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HELP with rubber dam clamp problem

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lilodent

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Hi so today i was doing an endodontic treatment on a patient. I easily put the rubber dam on in maybe less than 5 minutes. However the tooth was a lower second premolar and the whole crown was basically a big filling as the patient had kept getting caries on each side and the caries also went pretty deep below gingiva. So what happened was maybe 15 minutes after i had placed the rubber dam on with clamp suddenly the tooth broke off around margo gingiva.

I had to ask the patient to bite on something until i went and asked what to do. We ended up restoring the tooth with a copper ring and build it up with plastic / composite and i redid the thing.


My question is as follows:

1. Is it normal what happened considering the whole crown was one big restoration or did i do something wrong?

2. Is the prognosis of the tooth now worse as the rubber dam fell off since the tooth crown fell of while i was doing the treatment?

Thank you all in advance.
 
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lemoncurry

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It's not uncommon at all. Considering that you were in the midst of treatment, the prognosis should be fine IMO because you are still irrigating with NaOCl.
 

lilodent

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It's not uncommon at all. Considering that you were in the midst of treatment, the prognosis should be fine IMO because you are still irrigating with NaOCl.


I am a dental student and this was my 2nd root canal treatment so you can really imagine the horror i felt when the whole tooth simply broke off. Especially because the first one i did went pretty smoothly. Also my teacher seemed a bit stressed on time as i hadnt used a copper ring before so she build the tooth up again in plastic fastly. So i did not get the time to ask her weather this was something normal or something i just had ended messing up.

But does this happen often? I don't think they ever mentioned this while we got the course on endodontics in class. They did mention that when you do root canal treatments on teeth they tooth will be less strong compared to a normal tooth and might break. But i understood it as it might break AFTER the treatment like maybe months or years after, just because it cant be compared to a normal healthy tooth.

During the treatment i had never heard of it so i guess you can say my heart really went in overdrive when it happened under my own hands.
 

TanMan

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Hi so today i was doing an endodontic treatment on a patient. I easily put the rubber dam on in maybe less than 5 minutes. However the tooth was a lower second premolar and the whole crown was basically a big filling as the patient had kept getting caries on each side and the caries also went pretty deep below gingiva. So what happened was maybe 15 minutes after i had placed the rubber dam on with clamp suddenly the tooth broke off around margo gingiva.

I had to ask the patient to bite on something until i went and asked what to do. We ended up restoring the tooth with a copper ring and build it up with plastic / composite and i redid the thing.


My question is as follows:

1. Is it normal what happened considering the whole crown was one big restoration or did i do something wrong?

2. Is the prognosis of the tooth now worse as the rubber dam fell off since the tooth crown fell of while i was doing the treatment?

Thank you all in advance.

If the tooth broke with the force of the rubber dam clamp, the restorative prognosis of the tooth was not good in the first place.

The answer to your first question depends on the following variables:
- Pre-operatively, what was the restorative prognosis of the tooth? Did you have sufficient ferrule or tooth structure to place a rubber dam? If the tooth had almost no natural tooth structure and was essentially a 5 surface amalgam/composite crown, then you really have to think about long term prognosis. If there wasn't enough tooth structure or ferrule, then next time, clamp on the tooth behind, slit dam, and use opal dam around the tooth if you feel that a root canal can save the tooth (maybe need CL/posts to retain a crown in the future). So... if you were to think what you may have done wrong, I'd say assessing the restorability of the tooth should've been first, especially if it broke at the gumline.

Second question: Prognosis is worse, not because the rubber dam fell off, but because of the amount of remaining tooth structure. There's only a few times that I'd do endo on a non-restorable tooth, mostly when there are contraindications for extraction such as long term IV bisphosphonate use.

Another thing to consider, if the patient kept getting caries, you have to think whether rctbucrown would have been an appropriate option if OH is bad.
 

lilodent

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If the tooth broke with the force of the rubber dam clamp, the restorative prognosis of the tooth was not good in the first place.

The answer to your first question depends on the following variables:
- Pre-operatively, what was the restorative prognosis of the tooth? Did you have sufficient ferrule or tooth structure to place a rubber dam? If the tooth had almost no natural tooth structure and was essentially a 5 surface amalgam/composite crown, then you really have to think about long term prognosis. If there wasn't enough tooth structure or ferrule, then next time, clamp on the tooth behind, slit dam, and use opal dam around the tooth if you feel that a root canal can save the tooth (maybe need CL/posts to retain a crown in the future). So... if you were to think what you may have done wrong, I'd say assessing the restorability of the tooth should've been first, especially if it broke at the gumline.

Second question: Prognosis is worse, not because the rubber dam fell off, but because of the amount of remaining tooth structure. There's only a few times that I'd do endo on a non-restorable tooth, mostly when there are contraindications for extraction such as long term IV bisphosphonate use.

Another thing to consider, if the patient kept getting caries, you have to think whether rctbucrown would have been an appropriate option if OH is bad.


The patient has a full upper jaw denture and in the lower jaw he has i think i remember it as being his second molar in the forth quadrant, and then the second premolar in the third quadrant and a premolar in the 4th quadrant. So something like 7,5+5 are holding the whole partial denture. He always comes in with terrible oral hygiejne despite it basically being only 3 teeth he needs to take care of, and there is lots of plaque and residue especially around the tooth i did the root canal treatment on.

The 7+ he had problems with a month ago with it breaking and they did an emergency treatment simply building up the whole tooth crown in composite, as it was exam time and someone else had to do it. The premolar i was doing the root canal treamtent on he had also had numerous caries problems with. Whenever he came i would notice there was caries, and usually always around margo gingiva. It was typically very hard to put a matrix bond on and even my teacher could not succed in placing it and it resulted in gingival tear. We ended up dropping the matrix band and instead retraction cord and improvise with a cervical matrix half cut. So as you see in the end there was no real tooth left above the margo gingiva. Only composite filling. The filling was sufficient enough and shaped in size as a normal tooth. But i guess from this experience it means that a composite crown isnt ever strong enough to use a rubber clamp on? Does it mean we cant ever use a rubber clamp on the teeth with crowns that are t5 surface composite fillings or can you please explain to me what you meant by that i have to consider the prognosis when its a 5 surface composite? Because the suggestion in this forum is that i could place the clamp on other teeth but there were none others close by as you see.

The reason for the root canal treament was pulpa necrosis, and we wanted to do it because he wanted to do everything to save his last 3 teeth as they were holding the whole lower jaw prothesis and if anything happened to those he would have to get a new prothesis made which he didnt want. After the crown fell off my teacher also discussed that we will probably have to put a post on and then later put a crown on it, however as there is metal from the denture around that premolar i was told it will be hard to make the crown fit perfectly.

But so i do you guys think i messed up too much? The thing is that it was my teacher who put it up for a root canal treatment so i think the prognosis is was ok or else she wouldnt have choosen that and instead just asked it be fully extracted. Now the whole game changed though as he cracked his 7+ so maybe we will anyway need to redo the denture .

Its my 1st year at the dental clinical with real patients after simulation lab so as i saw my teacher seeming stressed about it a bit in the end i started wondering if she thought im not good enough or something. She is probably too nice a woman to say it, but i still would like to find out for my own sake anyway instead of walking around thinking everything is fine and get the shock once i graduate. Thats why i choose to ask here wanting to find out if the process was ok or weather i messed up badly.

I really had prepared very well in advance and knew every step just fine, and came half an hour before to get stuff ready. Everything went well despite him arriving half an hour too late, from giving him Infiltration anesthesia to placing the rubber dam, so i felt i had plenty of time as usually we have 3 hours for it and students have a hard time with placing the rubber dam, while i got it on in 5 minutes. However once it broke off suddenly the whole protocol was changed and it ended up lasting 4,5 hours instead of the maximum 3 as i had to find the canal again i got scared of drilling because i did not want risking the crown falling off again, so she came to help me find it. Then when i had to take the x ray to check the length of the file he was jumping in the chair whenever i pressed down to with the film and wasnt having it. She came again and while i couldnt get apex on the x ray my teacher didnt even get anything of the tooth on the first x ray she took but her 2nd try was just perfect. I think i had taken maybe 6-7 with no apex until i gave up.

I managed to rinse with all xfiles and then place calciumhydroxide, and fuji triage in the end and got him sent home with no more help from her.

Can you guys please tell me if it was ok or if you think i am to bad compared to you when you had had your first year at the clinic and on your 2nd root canal treatment.

Im really sorry the reply got this long and also about my english as im no english native speaker.
 

lemoncurry

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It sounds as though you have an uphill battle with this tooth. Frankly, if I were the clinical professor in this case, I would have referred this to prosths or insisted upon extraction based on what you are saying. I wouldn't have let a student take that case. Case selection is one of the most difficult things to master when it comes to dentistry. In terms of your technique, it sounds like you're doing things the right way, so I wouldn't worry about that.

In a situation like this where you have a tooth with a poor to guarded prognosis, the important thing is to not set your patient's expectations too high. Let them know that you will try your best but that it may not be enough to give this tooth any significant life extension. I also tell them that given the cost of RCT, post/core and crown and possibly crown lengthening, it may not be worth it to spend that kind of money for a tooth that may break down within a year or two of doing the work.

I wouldn't fret too much, though. You're not doing anything wrong; you didn't maltreat the patient, you didn't screw up. This sort of thing happens and the benefits of a case like this is that you learn how to adapt and what to do when everything isn't a slam dunk. You're going to get that sort of thing fairly often and you have to keep your cool and be flexible. Keep your head up and keep on plugging away!
 

lemoncurry

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It is also possible to place the rubber dam clamp on gingiva if there isn't enough tooth. You're not going to permanently damage the tissue by doing that. Next time, use an IAN block as infiltration for a second molar is very difficult to get profound anesthesia on its own.

This patient has a less than ideal setup and has very high expectations, so it's going to be difficult to get everything just right. I would think it would be possible, however, to add the second molar to the existing denture if he were to lose that tooth. Also, it is more than possible to get a crown retrofitted to an existing partial. It isn't always a slam dunk, but most labs can handle it.
 
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