UNIVERSITY OF OSLO FACULTY OF DENTISTRY
Department of Endodontics
Postgraduate Program in Endodontics
Case Book Trude Handal
Autumn Semester 2014
1 Table of contents Endodontic treatment guidelines ...... 1 Non-surgical cases Case 1 ...... 6 Endodontic treatment of the mandibular right second molar with irreversible pulpitis and cracked tooth syndrome Case 2 ...... 12 Endodontic treatment of the mandibular right second molar with irreversible pulpitits and iatrogenic furcal perforation Case 3 ...... 17 Endodontic treatment of a mandibular right first incisor in a patient with DiGeorge Syndrome (velo-cardio-facial-syndrome) Case 4 ...... 22 Endodontic retreatment of the maxillary right second molar Case 5 ...... 28 Endodontic treatment of the maxillary left first molar Case 6 ...... 3Error! Bookmark not defined. Endodontic retreatment of the maxillary right first incisor Case 7 ...... Error! Bookmark not defined.8 Endodontic retreatment of the maxillary left first molar Case 8 ...... 42 Endodontic retreatment of the mandibular left first molar Case 9 ...... 47 Endodontic retreatment of the maxuíllary left first incisor Case 10 ...... 52 Endodontic treatment of a maxillary anterior tooth Case 11 ...... 56 Patient with persistent pain maxilla left side Surgical cases Case 12 ...... 62 Endodontic retreatment and apical surgery of the maxillary right canine Case 13 ...... 69 Endodontic retreatment in conjunction with apical surgery of the mandibular right first molar with a separated instrument Case 14 ...... 76 Explorative surgery of the maxillary left second incisor with sinus tract Case 15 ...... 82 Endodontic retreatment of the maxillary left first molar and surgical retreatment of the maxillary left first and second premolar Case 16 ...... 88 Endodontic treatment and apical surgery of the mandibular left first molar Case 17 ...... 94 Surgical retreatment of the maxillary right first incisor Case 18 ...... 99 Evaluation of a root-filled mandibular right first molar and surgical retreatment of the maxillary left first molar with a sinus tract Case 19 ...... 106 Endodontic retreatment of the maxillary right first molar with a sinus tract Case 20 ...... 112 Treatment of multiple idiopathic cervical root resorption
Endodontic Treatment Guidelines
Treatment of Tooth with Apical Periodontitis
Pre-operative radiograph. Anaesthesia. Removal of plaque, caries and leaking fillings. Pre-endodontic tooth build-up if required for isolation. Access cavity preparation. Localization of canal orifices. Application of rubber dam. Disinfection of the working field with 0.5% chlorhexidine in 70% ethanol. Measurement of working length, using apex locator and working length radiograph. Instrumentation to desired apical length and size: . Goal: 0.5-1mm short of the anatomic apex Frequent irrigation with: . 0.5% sodium hypochlorite (NaOCl) . Alternative: 0.5 % chlorhexidine (from 2013) . Final irrigation with 17% ethylenediamine tetraacetic acid (EDTA) Drying of the canals with paper points. Mastercone radiograph. Root filling: Obturation techniques: . Lateral compaction, warm vertical compaction, apical plug with MTA Sealers: . AH Plus Seal Core materials: . Gutta-percha Temporary IRM top filling with a 2 mm IRM plug in the canal orifice . Alternatively a final composite restoration Removal of rubber dam. Post-operative radiograph.
1
Treatment of Tooth with Apical Periodontitis
The same treatment as for teeth without apical periodontitis, but two-appointment treatment is the standard procedure: 2-3 weeks between 1st and 2nd appointment is the standard, mainly due to practical reasons:
. Intra-canal dressing with Ca(OH)2 . Two-layered temporary top filling: Cavit G and IRM In retreatment cases: Final irrigation with 17% EDTA and 2% chlorhexidine-di- gluconate. The periapical index (PAI) (Ørstavik et al. 1986) is used for radiographic evaluation.
Emergency treatment
Acute irreversible pulpitis: . Pulpotomy . Eugenol pellet in pulp chamber . IRM top filling . NSAIDs when severe pain Acute apical periodontitis: . Incision and drainage of abscess/pus if applicable . Preparation of canals and intracanal dressing (Ca(OH)2) as the optimal treatment . NSAIDs when indicated . Systemic antibiotics if systemic complaints and disseminating infection
2 Endodontic files for instrumentation of canals
Hand files: . K-files . Stainless steel files (SS) . Hedstrøm files . Nickel-titanium files (NiTi files)
NiTi rotary files: . Biorace . Reciproc
Endodontic surgery
All relevant radiographs mounted on viewer or screen. Anaesthesia. 1 minute mouth rinse with Corsodyl®(Chlorhexidine 2mg/ml). Incision: . A horizontal incision extending one to several teeth mesial and distal of the involved tooth and one vertical-releasing incision, usually placed at the mesial end of the prospective flap. Retraction: . To hold the flap away from the surgical site, providing maximum access and visibility, without causing harm to the flap or the surrounding tissues. Osteotomy: . Involves removal of cortical and cancellous bone to gain direct access to the apical portion. This is achieved routinely by using burs/rotary instruments. Surgical curettage: . To remove all pathologic tissue, foreign bodies, and root and bone particles from the periradicular area. Biopsy: . Any soft tissue lesion removed during the surgical procedure should be submitted for biopsy. Microbiological sample: . With paper point directly in the periapical sample, placed in pre-reduced anaerobic transport medium, or periapical tissue placed in 4% formalin for scanning electron microscopy.
3 Root end resection: . By sectioning the apical segment of the root and/or bevelling it to the line of sight/3 mm. Ultrasonic root end preparation: . To provide a clean, well-shaped class I cavity. Haemorrhage control: . Local anaesthetic solutions possessing vasoconstrictor properties; Stryphnon
gauze (Adrenalonchlorid 0,33 mg/cm2); Ferric sulphate (Fe2[SO4]3 with 15.5% astringent and 21% stasis). Root-end filling: . Using either IRM or MTA. Use of the MAP system (Micro-Apical Placement) or the MTA pellet-forming block will ease the application of MTA. Cleaning of surgical site: . Saline solution to remove debris, and tissue edges are re-approximated in their correct position to promote healing by primary intention. Compression of the repositioned tissue with a saline-moistened piece of gauze will reduce the coagulum to a thin fibrin layer between the repositioned tissue and cortical bone. Tissue margins should rest passively in the desired place before suturing. Wound closure: . Using nonabsorbable suture material in sizes 4-0 and 6-0. Post-operative radiograph is taken for control of procedures and as reference for follow- up. Postsurgical care: . A disposable ice pack is covered with a soft towel, and the patient instructed on where and how to hold the ice pack firmly in position against the facial tissues approximating the surgical site. . Unless contraindicated for some reason, the patient is instructed to take Ibuprofen 400mg every 4 to 6 hours for the first 48hours. The patient is advised to rinse with Corsodyl® twice a day until suture removal. Suture removal: . The epithelial seal at the wound edges is evident within 2 days-suture removal can take place earliest after 48h but nor later than 6-7 days.
4 Abbreviations
. Nd: not determined. . V&h: vertical and horisontal.
5 Case 1
Endodontic treatment of the mandibular right second molar with irreversible pulpitis and cracked tooth syndrome persisted, another temporary IRM filling, with concomitant reduction of cusp heights but without cuspal coverage was placed.
Fig. 1. Frontal view.
Patient 43-year-old Caucasian female. Fig. 2. Craze lines are visible at the buccal and distal aspect of the tooth. Chief complaint The patient complained about pain in th Clinical findings September 15 2010 the posterior region in the lower right Soft tissue: Normal findings. jaw. She felt sudden pain and tenderness Dental: when chewing and biting She also . Tooth 45: Sound. complained about increased sensitivity Tooth 46: Missing. to thermal changes (both cold and warm Tooth 47: Occlusal temporary filling; stimuli) and discomfort during tooth several craze lines/fracture lines can be brushing. The pain started after seen in the enamel (Fig 2.) When using a placement of a filling in the molar tooth FracFinder on the different cusps of in this jaw. tooth 47, the patient felt sharp pain when the distal cusps were tested. Medical record The patient had recurrent headaches Clinical tests September 15th2010 and was medicated with Sarotex. 44 45 47 EPT 16 16 43 Dental history Cold + + + The patient was referred to the post- Percussion - - +(v)∗ graduate clinic from the student clinic Palpation - - - for evaluation and treatment of the PPD 4 4 4 mandibular right second molar. The Mobility - - - tooth had previously been treated with Biting - - + an occlusal composite restoration due to ∗v, vertical occlusal caries three years earlier (2007), followed by a temporary restoration (IRM) in 2010 due to post- restoration pain. Since the pain
6 Radiographic findings September Mechanical: Bur, NiTi hand 15th2010 instrumentation #20, Biorace: Dental: Tooth 47 has a radiopaque MB: #40/0.04 (BR5) /16mm occlusal filling. ML: #40/0.04 (BR5) /16mm Periodontal: Marginal bone loss. D: #60/0.02 (BR7) /15 mm Periapical: Teeth 45 and 46 have a Chemical: 1% NaOCl, 17% EDTA. continuous PDL space. Intracanal medicament: Ca(OH)2. Temporary filling: Cavit, IRM.
Fig. 3. Periapical radiograph 15.09.2010.
Fig. 4. Working length radiograph. th Diagnosis September 15 2010 Intra-pulpal injection of anaesthetic was applied during the session due to pain Diagnosis when negotiating the canals. Pulpal K04.01 acute irreversible pulpitis The patient was told that the tooth would have a less favourable prognosis Periodontal K05.03 chronic marginal periodontitis unless a dental crown was made.
Periapical Within normal limits Treatment September 29th2010 Dental S02.50A cracked tooth The patient experiences fewer
symptoms. The tooth is slightly tender to percussion, and the last two days she felt some tenderness when biting and Treatment plan Treatment of the inflamed pulp tooth 47. tooth brushing. Several other teeth are also tender to percussion. Anaesthesia: 2 carpules of Problem list Xylocaine/adrenaline. Cracked tooth. The canals were obturated using gutta- percha (0.04 and 0.02 taper) and AH Plus and the tooth was sealed with IRM. Treatment September 15th2010 2 carpules of Xylocaine/adrenaline was applied to establish anaesthesia. Access opening and localisation of three canal orifices. Bleeding from all canals. The distal fracture line extended through the distal marginal ridge.
7 Discussion The term “cracked tooth syndrome” (CTS), was first introduced by Cameron in 1964 (1). He defined a cracked tooth as an ”incomplete fracture in a vital posterior tooth that involves the dentine and occasionally extends into the pulp.” Diagnosis of incompletely fractured teeth with symptoms is time consuming and may represent a diagnostic Fig. 5. Master cone radiograph. problem. The discomfort or pain can mimic that arising from other pathologies, such as sinusitis, temporomandibular joint disorders, headaches, ear pain, or atypical orofacial pain (2). There may be a history of a course of extensive dental treatment involving repeated occlusal adjustments or replacement of restorations, which fail to eliminate symptoms. The American Association of Endodontists Fig. 6. Post-obturation radiograph 29.09.2010. (AAE) categorized longitudinal tooth fractures into 5 major classes: craze line, Prognosis fractured cusp, cracked tooth, split Endodontic: Good. tooth, and vertical root fracture (VRF) Tooth: Uncertain due to cracks. (3). The diagnosis of CTS has been based in the past exclusively on tooth Follow up examination October 11th2011 symptomatology. Common patient (1 year) subjective findings with incompletely A dental crown has been made at the fractured teeth include: student clinic. She still feels 1. Sustained pain during biting some sensitivity to biting and tooth pressures, 2. Pain only upon release of brushing. TMD symptoms. biting pressure, 3. Occasional, momentary, sharp pain during mastication, 4. Sensitivity to thermal changes, 5. Sensitivity to mild stimuli, such as sweet or acidic foods, and 6. Persistent dull pain. Common clinical objective findings with incompletely fractured teeth: 1. Pain to selective percussion on specific tooth margins or cusps. The percussion may be in the long axis of the tooth or angled against a labial or cuspal
Fig. 7. Follow-up radiograph 1 year. slope, 2. Generalized discomfort to percussion, 3. Presence of craze or fracture lines on the facial or lingual surfaces or marginal ridges, 4.
8 Significant gaps between old (33.8% in first molar, 23.4% in second restorations and tooth structure, 5. molar), followed by mandibular molars Cracked restorations, and 6. Evidence of (20.1% in first molar, 16.2% in second the initial vertical loss of alveolar bone molar). 96.1% of the cracked teeth adjacent to the proximal root surface responded to the bite test, and 81.1% of (4). the cracked teeth were observed in the A variety of protocols have been mesiodistal direction. described in the contemporary In a material from Krell & Rivera (9) 796 literature for the definitive management out of 8175 cases seen in an endodontic of incomplete posterior tooth fractures, practice during a six-year period were ranging from the application of directly diagnosed as cracked teeth (9.7%). bonded intra-coronal restorations and Mandibular second molars (243/796, directly bonded extra-coronal 30%) had the largest incidence followed restorations (5) and indirect extra- by mandibular first molars (231/796, coronal restorations with varying 29%) and maxillary first molars amounts of tooth coverage (6). (167/796, 21%). Of 127 patients Seo et al. (7) analysed the specifically diagnosed with reversible characteristics, distribution, and pulpitis (RP), 27 converted to associated factors of longitudinal irreversible pulpitis (N=21) in 58 days fractures in 107 teeth from 103 patients. or to necrotic pulp (N=6) in 149 days. Eighty-seven teeth were diagnosed with The outcomes of this study suggested a cracked tooth (81.3%), 14 were that if a crack is identified early enough diagnosed with vertical root fracture in cases with a diagnosis of RP and a (VRF, 13.1%), 4 had a split tooth (3.7%), crown is placed, root canal treatment and 2 had a fractured cusp (1.9%). I will be necessary in about 20% of these In 82.2% teeth showed a sensitive cases within a 6-month period. reaction on the bite test. The upper first Tan el al. (10) assessed the survival rate molar (28.0%) was most frequently of root filled cracked teeth over a 2-year cracked, followed by the lower first period in a tertiary institute. Forty-nine molar (25.2%), the lower second molar patients who had root canal treatment (20.6%), and the upper second molar completed on their cracked teeth at the (16.8%). Longitudinal tooth fractures National Dental Centre (Singapore) were occurred mainly in restored teeth and in recalled for a 2-year review. The patients in their 40 years of age. Out of survival rate of the root-filled cracked 107 of longitudinal fractured teeth, 33 teeth was 85.5%. Cracked teeth that (30.8%) were treated endodontically were the terminal teeth in the dental and 74 (69.2%) were not. VRF was arch, teeth with pre-root filling associated with endodontic treatment. periodontal pocketing and teeth with Roh et al. (8) reported on 154 cases of multiple cracks were more likely to be teeth with cracks. In their study cracked extracted. teeth were observed most frequently in Opdam et al. (5) performed a seven-year the teeth with no restorations (60.4%) clinical evaluation of painful cracked and with class I restorations (29.2%). teeth restored with a direct composite The most prevalent age was in those restoration. Twenty teeth were restored over 40 years of age (31.2% in their 40s, without and 21 with cuspal coverage. 26.6% in their 50s) and the prevalence After 7 years, 40 teeth could be was similar in men (53.9%) and women evaluated. Three teeth without cuspal (46.1%). Cracked teeth were found most coverage needed an endodontic frequently in the maxillary molars treatment, of which 2 failed as a result of
9 fracture. No failures in restorations with 3. American Association of cuspal coverage occurred. They Endodontists. Cracking the suggested that a direct bonded cracked tooth code: Detection composite resin restoration could be a and treatment of various successful treatment for a cracked tooth. longitudinal tooth fractures. In a study by Brynjulfsen et al. (11), 32 Endodontics: Colleagues for patients with poorly localised orofacial Excellence 2008; summer: 1-8. pain were finally diagnosed with 46 4. Gutmann JL, Rakusin H. incompletely fractured teeth. In cases Endodontic and restorative with incompletely fractured mandibular management of incompletely teeth, the pain was felt throughout the fractured molar teeth. Int Endod J arch and in tissues including neck, ear, 1994; 27: 343-348. chewing muscles and TMJ on the same 5. Opdam NJ, Roeters JJ, Loomans side. The longer the duration of pain BA, Bronkhorst EM. Seven-year before the diagnosis of an incompletely clinical evaluation of painful fractured tooth was established, the cracked teeth restored with a more diffuse was the distribution of direct composite restoration. J pain. Often symptoms projected to both Endod. 2008; 34(7): 808-811. jaws. Headaches occurred in the group 6. Signore A, Benedicenti S, Covani of patients with symptoms for more U, Ravera G. A 4–6 year than 5 years prior to treatment. retrospective clinical study of Endodontic or restorative treatment cracked teeth restored with relieved the symptoms in 90% of the bonded indirect resin composite patients during a two-year follow-up, onlays. Int J Prosthodontics 2007; whilst persisting symptoms in 10% 20: 609–616. were considered as part of an orofacial 7. Seo DG, Yi YA, Shin SJ, Park JW. pain complex of unknown aetiology. Analysis of factors associated with cracked teeth. J Endod 2012; The patient in the present case had an 38(3): 288-292. incomplete fractured tooth. Although 8. Roh BD, Lee YE. Analysis of 154 treatment will succeed in many cases, cases of teeth with cracks. Dent some cracked teeth may eventually Traumatol 2006; 22(3): 118-23. evolve into split teeth and require 9. Krell KM, Rivera EM. A Six Year extraction. Placement of a cuspal- Evaluation of Cracked Teeth reinforced restoration, in this case a Diagnosed with Reversible crown, providing optimum protection Pulpitis: Treatment and for the tooth, does not guarantee Prognosis, J Endod 2007; 33(12): success, but is thought to be beneficial in 1405-1407. most cases. 10. Tan L, Chen NN, Poon CY, Wong HB. Survival of root filled cracked teeth in a tertiary institution. Int References Endod J 2006; 39(11): 886-889. 1. Cameron CE. Cracked-tooth 11. Brynjulfsen A, Fristad I, Grevstad syndrome. J Am Dent Assoc 1964; T, Hals-Kvinnsland I. 68: 405-411. Incompletely fractured teeth 2. Türp JC, Gobetti JP. The cracked associated with diffuse tooth syndrome: an elusive longstanding orofacial pain: diagnosis. J Am Dent Assoc 1996; diagnosis and treatment 127(10): 1502-1507.
10 outcome. Int Endod J 2002; 35: 461-466.
11 Case 2
Endodontic treatment of the mandibular right second molar with irreversible pulpitis and iatrogenic furcal perforation
46: Composite restoration ODB, occlusal temporary filling. 47: Dental crown, occlusal temporary filling (Fig. 2).
Fig. 1. Frontal view.
Patient 59-year-old Caucasian male.
Chief complaint The patient complained of severe Fig. 2. Buccal/occlusal view. permanently pain which got worse in the evening/at night. He was th suppressing the pain with analgesics Clinical tests January 28 2014 (NSAIDs). 45 46 47 EPT nd∗ nd 80 - - + Medical record Cold Percussion - - +(v,h)∗ Non-contributory. Palpation - - - PPD 4 3 3 Mobility - - - Dental history Biting - - - The patient was referred to the post- ∗nd, not graduate clinic from a general dental determined practitioner for endodontic treatment of ∗v, vertical the mandibular right second molar. The ∗h, horizontal tooth had previously, and recently, been accessed by the referring dentist with Radiographic findings January 28th2014 the result of an iatrogenic furcal Dental: Tooth 45: Radiopaque coronal perforation. restoration, poorly fitted crown with possible caries at the distal aspect, a post in the canal and a radiopaque root Clinical findings January 28th2014 filling material. A radiolucency is seen Soft tissue: Normal findings. between the post and the root filling. Dental: Tooth 45: Dental crown.
12 Tooth 46: Radiopaque coronal Treatment January 28th2014 restoration and a radiopaque root filling Two carpules of Xylocaine/adrenaline material. was applied to establish anaesthesia. Tooth 47: Radiopaque coronal Intrapulpal injection was necessary. restoration, a radiolucency can be seen Access opening and localisation of in the floor of the pulp chamber in the perforation and undiscovered MB canal furcation area. orifice (Fig. 5). Periodontal: Marginal bone loss. Mechanical: Bur, NiTi hand files #20, Periapical: Tooth 47 has a continuous RECIPROC one file endo: PDL space (PAI I). Tooth 46 has a MB: #40/18mm widened PDL space and an apical ML: #40/18mm radiolucency mesial root (PAI 3). Tooth D: #50 /18mm 45 has an apical radiolucency (PAI 4). Chemical: 0.5% chlorhexidine, 17% EDTA. Reparation of furcal perforation with MTA seal. Intracanal medicament: Ca(OH)2. Temporary filling: Moistened cotton pellet, cavit, IRM.
Fig. 3 Periapical radiograph 28.01.2014.
Diagnosis January 1st2014
Diagnosis Pulpal K04.01 acute irreversible pulpitis Fig. 4. Working length radiograph.
Periodontal K05.03 chronic marginal periodontitis
Periapical Within normal limits
Treatment plan Treatment of the inflamed pulp. Reparation of furcation perforation.
Problem list Fig. 5. Furcal perforation. Communication of perforation to oral cavity. Weakened tooth.
13 Discussion Perforations from the pulp to the surrounding periodontium may occur from resorptive defects, caries or iatrogenic events during endodontic treatment. Perforations create an artificial communication between the root canal system and the supporting tissues of the teeth (1). Ingle (2) Fig. 6. Reparation of furcal defect with grey MTA. reported that perforations were the second greatest cause of endodontic nd failure and account for 9.6% of all Treatment February 2 2014 No symptoms, filled with gutta-percha unsuccessful cases. and AH Plus, sealed with composite. Factors that affect treatment prognosis of perforation repair include the level, location and size of the perforation, the time delay before perforation repair and the material used to seal the perforation (3). The location of the perforation is of crucial importance. Close proximity to the gingival sulcus may lead to endodontic-periodontal problems through contamination of the perforation with bacteria from the oral Fig. 7. Master cone radiograph. cavity through the sulcus (4). Perforations near the crestal bone are susceptible to epithelial migration and rapid pocket formation and treatment of these has a low success rate (5). The purpose of treating furcal perforation is to seal the artificial communication between the endodontic space and the periradicular tissue to prevent alveolar bone resorption and damage to the periodontal ligament. These complications are not infrequent Fig. 8. Post-obturation radiograph. in cases of furcal and/or old perforations, which show a worse Prognosis prognosis than fresh, small, coronal, and Endodontic: Uncertain. apical perforations. Mineral trioxide Tooth: Uncertain aggregate (MTA) is widely used to seal perforations because of its biocompatibility and sealability. Follow-up examination September 2014 Lodiene et al. (6) created furcation Not able to reach the patient for a perforations in 82 extracted human scheduled control. maxillary and mandibular molars, and sealed them with either mineral trioxide aggregate (MTA), glass ionomer cement or resin composite. The bacterial
14 leakage method was used with In a case series (9) MTA was used as Enterococcus faecalis as microbial tracer. repair material for furcal perforation They found that the percentage of Ten cases of furcal perforation were leaking samples was significantly higher selected at the department of in the resin composite group. Scanning Endodontics, University of Florence. All electron microscopy (SEM) inspection the perforations were cleaned with revealed the presence of bacteria in all NaOCl, EDTA, and ultrasonic tips and leaking specimens. Bacteria were sealed with MTA without internal observed along the filling-dentine matrix. Finally, the teeth were interface as well as in dentinal tubules at endodontically treated and coronally some distance from the filling. The restored. Clinical and radiographic authors concluded that teeth repaired follow-ups were done at 6 months, 1 with MTA were more resistant to year, 2 years, and 5 years. After 5 years, bacterial leakage. the absence of periradicular radiolucent Ford et al. (7) investigated the histologic lesions, pain and swelling along with response to intentional perforation in functional tooth stability indicated a the furcations of 28 mandibular successful outcome of sealing premolars in seven dogs. In half the perforations in 9 out of 10 teeth. One teeth, the perforations were repaired patient dropped out of the study after immediately with either amalgam or the 1-year follow-up and could not be MTA; in the rest the perforations were contacted for further recalls. The results left open to salivary contamination confirmed that MTA provides an before repair. All repaired perforations effective seal of root perforations and were left for 4 months before histologic clinical healing of the surrounding examination of vertical sections through periodontal tissue. the site. In the immediately repaired group, all the amalgam specimens were associated with inflammation, whereas References only one of six with MTA was; further, 1. Fuss Z, Trope M. Root the five non-inflamed MTA specimens perforations: classification and had some cementum over the repair treatment choices based on material. After 4 months, all the prognostic factors. Endod Dent amalgam specimens were associated Traumatol 1996; 12: 255–264. with inflammation; in contrast only four 2. Ingle JI. A standardized of seven filled with MTA were inflamed. endodontic technique utilizing The authors suggest that MTA is a far newly designed instruments and more suitable material than amalgam filling materials. Oral Surg Oral for perforation repair, particularly when Med Oral Pathol 1961; 14: 83-91. used immediately after perforation. 3. Tsatsas DV, Meliou HA, Another study (8) assessed the ability of Kerezoudis NP. Sealing Portland cement, white Angelus-mineral effectiveness of materials used in trioxide aggregate (MTA), and MTA Bio furcation perforation in vitro. Int to seal furcal perforations in extracted Dent J 2005; 55: 133–141. human molar teeth. Leakage existed in 4. Simon J H, Glick D H, Frank A L. every sample and was very variable in The relationship of endodontic- all the experimental groups. The sealing periodontic lesions. J Periodontol ability promoted by the 3 cements was 1972; 43: 202–208. similar; no cement was able to produce 5. Petersson K, Hasselgren G, a fluid-tight seal. Tronstad L. Endodontic treatment of experimental root
15 perforations in dog teeth. Endod Dent Traumatol 1985; 1: 22–28. 6. Lodiene G, Kleivmyr M, Bruzell E, Ørstavik D. Sealing ability of mineral trioxide aggregate, glass ionomer cement and composite resin when repairing large furcal perforations. British Dent J 2011; 210: 1-6. 7. Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Jun;79(6):756-63. 8. De-Deus G, Reis C, Brandão C, Fidel S, Fidel RA. The ability of Portland cement, MTA, and MTA Bio to prevent through-and- through fluid movement in repaired furcal perforations. J Endod. 2007 Nov; 33(11): 1374- 1377. 9. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate as repair material for furcal perforation: case series. J Endod. 2008; 34(9): 1130-1133.
16 Case 3
Endodontic treatment of a mandibular right first incisor in a patient with DiGeorge Syndrome (velo-cardio-facial syndrome)
Fig. 1. Frontal view
Fig. 2. Fractured crown, tooth 42. Patient instruments (Biorace) and treatment 21-year-old Caucasian male. with intracanal dressing of Ca(OH)2.
Chief complaint Clinical findings September 20th2011 Non-contributory. Soft tissue: Gingivitis. Dental: Medical record Tooth 41: Composite build-up IP. The patient was diagnosed with Tooth 42: Fractured crown, occlusal DiGeorge Syndrome. He was quite temporary filling (Fig. 2). anxious in new situations. Due to Tooth 43: Buccal enamel caries. asthma he was medicated with Symbicort, Ventoline and Serevent. th Because of congenital heart disease he Clinical tests September 20 2011 was in need of prophylactic antibiotics 41 42 43 before dental treatment. EPT 25 80 15 Cold + - + Percussion - - - Dental history Palpation - + - The patient was referred to the post- PPD 3 3 3 graduate clinic from the public dentistry Mobility - - - for endodontic treatment of the Biting - - - mandibular right lateral incisor. The mandibular right lateral incisor presented with a history of persistent Radiographic findings September fistula; tooth 42 had previously been 20th2011 treated endodontically, including Dental: Tooth 31 has a radiopaque root cleaning/shaping to size #50 with rotary filling material. Teeth 41, 42 and 43 have radiopaque restorations related to the crowns.
17 Periodontal: Within normal limits. Treatment October 18th2011 Periapical: A lateral radiolucency is seen Two carpules of Xylocaine/adrenaline between the roots of teeth 42 and 43 was applied to establish anaesthesia (PAI 4). (mandibular block and infiltration). Mechanical: Bur, NiTi hand files: B: #50/0.02/16mm L: #40/0.02/16.5mm Chemical: 1% NaOCl, 17% EDTA, 2% chlorhexidine-di-gluconate. Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
Fig. 3. Periapical radiograph 20.09.2011.
Diagnosis September 20th2011
Diagnosis Pulpal K04.11 necrotic pulp K04.19 endodontically treated
Periodontal K05.01 chronic gingivitis
Periapical K04.51 chronic lateral periodontitis
Fig. 4. Working-length radiograph.
Treatment plan Treatment November 8th2011 Tooth 42: Endodontic treatment. No symptoms. Filled with gutta-percha (0.02 taper) and AH Plus, sealed with IRM. Problem list Cooperation/anxiety.
Treatment September 20th2011 Two carpules Xylocaine/adrenaline was applied to establish anaesthesia (infiltration). Access opening and localisation of untreated lingual canal orifice (bleeding from canal).
Due to challenges with poor anaesthesia Fig. 5. Master cone radiograph. and patient hyperventilation (due to anxiety) treatment had to be ended. Chemical: 1% NaOCl, 17% EDTA. Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
18 Furthermore, cleaning narrow flattened canals or roots with a high degree of curvature is extremely ineffective (3). If accurate data on the size of the apex of root canals could be obtained, it might provide reliable standards for the amount of instrumentation normally required in this region. In an attempt to provide such data, Kerekes and Tronstad (4, 5, 6) measured the diameter of root canals by taking sections of anterior, premolar, and Fig. 6. Post-obturation radiograph. molar teeth at 1, 2, 3, 4, and 5 mm from the apex. Based on these data, they then estimated the smallest size of Prognosis instruments that would ensure, with Endodontic: Good. 90% probability for each tooth type, Tooth: Uncertain due to loss of tooth adequate preparation of the circular- substance. shaped canals at the various distances from the apex. Follow-up examination October 15th2013 The internal anatomy of the mandibular (2 years) incisors has been described in several No symptoms. A crown has been made. studies that used clearing or cross- Lateral radiolucency has healed. sectional methods (7-14). The results of these studies show that mandibular incisors with single canals are the most common reported anatomy. The second most prevalent anatomic variation includes the presence of 2 canals that ends in a single foramen (Vertucci type III) (7, 11, 15). In their study of one hundred freshly extracted central and lateral incisors, Kartal and Yanikoglo (15) concluded that the chance of a second canal in mandibular incisors is 50%. They also described two additional root canal
Fig. 7. Follow-up radiograph 2 years. types that are not defined in Vertucci´s classification (7). Despite the presence of single canals at Discussion the apical third of the mandibular One of the most important factors in incisors, the prevalence of oval canals is endodontic therapy is the mechanical not uncommon (9). preparation of the root canal. Despite Several studies have shown the difficulty the high success rates seen for to achieve efficient cleaning of the appropriate endodontic procedures (1, mandibular incisors with oval root canal 2), cleaning of complex root canals such anatomy by using hand or rotary as to those with lateral branches or instruments (16-19). apical ramifications is difficult.
19 Miyashita el al. (13) investigated canal premolars. J Endodon 1991; configuration, thickness and curvature 17(1): 1-7. of the root canals, condition of any 4. Kerekes K, Tronstad L. accessory canals, and location of the Morphometric observations on apical foramina in 1085 extracted root canals of human anterior mandibular incisors with no visual teeth. J Endodon 1977; 3: 24-29. abnormalities. They found that more 5. Kerekes K, Tronstad L. than 85 % of the root canals possessed a Morphometric observations on single canal (Type I). The majority of the root canals of human premolars. J lateral branches were small (>80% Endodon 1977; 3: 74-79. <#15 reamer, none >#30 reamer and 50 6. Kerekes K, Tronstad L. % of apical foramina were located distal Morphometric observations on to the apex. Based on data on the root canals of human molars. J thickness of the root and main canal in Endodon 1977; 3: 14-18. the apical portion and curvature of the 7. Vertucci FJ. Root canal anatomy root canal the authors suggested that for of the human permanent teeth. adequate apical preparation, a #40 Oral Surg Oral Med Oral Pathol reamer must be able to reach the apical 1984; 58: 589–599. constriction. 8. Vertucci FJ. Root canal anatomy Milanezi de Almeida et al. (20) analysed of the mandibular anterior teeth. root canal anatomy and prevalence of J Am Dent Assoc 1974; 89: 369– oval canals in 340 mandibular incisors 371. by micro CT scanning. The occurrence of 9. Wu MK, R’Oris A, Barkis D, a single canal and Vertucci type III Wesselink PR. Prevalence and configuration represented 92% of the extent of long oval canals in the mandibular incisors studied. Within apical third. Oral Surg Oral Med these anatomic configurations, oval- Oral Pathol Oral Radiol Endod shaped canals in the apical third were 2000; 89: 739–743. not uncommon and were more 10. Mauger MJ, Schindler WG, Walker prevalent in the type III anatomy. WA. An evaluation of canal morphology at different levels of root resection in mandibular References incisors. J Endod 1998; 24: 607– 1. Grossman LI, Shepard LI, Pearson 609. LA. Roentgenologic and clinical 11. Pineda F, Kuttler Y. Mesiodistal evaluation of endodontically and buccolingual treated teeth. Oral Surg 1964; 17: roentgenographic investigation 368-374. of 7,275 root canals. Oral Surg 2. Yamamoto A, Sawada S, Ono Y, Oral Med Oral Pathol 1972; 33: Beppu K, Yamada H, Takeuchi H, 101–110. Yagasaki T, Takahashi T, 12. Madeira MC, Hetem S. Incidence Kasahara E, Yasuda E. Clinical of bifurcations in mandibular long-term observation on incisors. Oral Surg Oral Med Oral endodontically treated teeth. J Pathol 1973; 36: 589–591. Conserv Dent 1986; 29: 74-84. 13. Miyashita M, Kasahara E, Yasuda 3. Kasahara E, Yasuda E, Yamada H, E, et al. Root canal system of the Miyazawa A. An evaluation of mandibular incisor. J Endod guidelines for the apical 1997; 23: 479–484. enlargement of maxillary
20 14. Boruah LC, Bhuyan AC. Morphologic characteristics of root canal of mandibular incisors in North-East Indian population: an in vitro study. J Conserv Dent 2011; 14: 346–350.
15. Kartal N, Yanikoglu FC. Root canal morphology of mandibular incisors. J Endod 1992; 18(11): 562–564. 16. Katz A, Tamse A. A combined radiographic and computerized scanning method to evaluate remaining dentine thickness in mandibular incisors after various intracanal procedures. Int Endod J 2003; 36: 682–686. 17. Wu MK, Wesselink PR. A primary observation on the preparation and obturation of oval canals. Int Endod J 2001; 34: 137–141. 18. Wu MK, van der Sluis LW, Wesselink PR. The capability of two hand instrumentation techniques to remove the inner layer of dentine in oval canals. Int Endod J 2003; 36: 218–224. 19. De-Deus G, Barino B, Zamolyi RQ, et al. Suboptimal debridement quality produced by the single- file F2 ProTaper technique in oval-shaped canals. J Endod 2010; 36: 1897–1900. 20. Milanezi de Almeida M, Bernardineli N, Ordinola-Zapata R, Villas-Bôas MH, Amoroso-Silva PA, Brandão CG, Guimarães BM, , Gomes de Moraes I, Húngaro- Duarte MA. Micro–Computed Tomography Analysis of the Root Canal Anatomy and Prevalence of Oval Canals in Mandibular Incisors. J Endod 2013; 39: 1529– 1533.
21 Case 4
Endodontic retreatment of the maxillary right second molar
Fig. 1. Frontal view. Fig. 2. Occlusal view.
Patient Clinical tests September 8th2010 56-year-old Caucasian male. 14 15 17 EPT 34 39 80 Chief complaint Cold + + - Non-contributory. Percussion - - - Palpation - - - PPD 4 4 6 Medical record Mobility - - - Ritalin, Paracetamol/codein due to back Biting - - I pain. Heavy smoker.
Dental history Radiographic findings September 8th2010 The patient was referred to the post- Dental: graduate clinic from the student clinic Tooth 17: Radiopaque MOD restoration. for endodontic retreatment of the Tooth 16: Missing. maxillary right second molar. A post and Tooth 15: Radiopaque MOD restoration. crown was planned as restoration. The A retained root corresponding to the tooth had been treated endodontically wisdom tooth is seen. for more than 10 years ago. Periodontal: Generalized attachment loss. Clinical findings September 8th2010 Periapical: Tooth 17 has an apical Soft tissue: Gingivitis in the region 15 to radiolucency (PAI 4). Tooth 15: A 17. An aphthous lesion is seen at the normal PDL space is seen around the buccal aspect between tooth 17 and 15. root. Dental: Tooth 15: MOD amalgam filling. Tooth 16: Missing. Tooth 17: MOD amalgam filling, buccal cuspal fracture (Fig. 2).
22
Diagnosis September 8th2010
Diagnosis Pulpal K04.11 necrotic pulp K04.19 endodontically treated
Periodontal K05.03 chronic marginal periodontitis
Periapical K05.40 chronic apical periodontitis Fig. 3. Access cavity.
Treatment plan Non-surgical endodontic retreatment. The patient is told that the prognosis for the tooth is uncertain due to considerably loss of tooth substance.
Problem list Fig. 4. Copper ring assortment. Proper tooth isolation and aseptic due to severely damaged tooth (Fig. 2).
Fig. 5. Placement of copper ring.
Treatment September 15th2010 1 carpule of Septocaine was applied. Fig. 3. Periapical radiograph 08.09.2010. Mechanical: Burs, prerace and biorace rotary files: Treatment September 8th2010 MB: #50/0.04 (BR6)/18mm 1 carpule of Xylocaine/adrenaline was DB: #50/0.04 (BR6)/18mm applied. The access cavity was refined P: #60/0.02 (BR7)/17mm with burs and all the caries and the Chemical: Chloroform, 1% NaOCl, 17% former amalgam coronal restoration EDTA. material was removed. Three orifices Intracanal medicament: Ca(OH)2. with gutta-percha were localised (Fig. Temporary filling: Cavit, IRM. 4). A pre-endodontic copper ring was adjusted and semented using IRM (Fig. 5).
23
Fig. 6. Working length radiograph. Fig. 9. Follow-up radiograph 1 year.
Treatment November 17th2010 No symptoms, filled with gutta-percha Discussion and AH Plus, sealed with IRM. Endodontic therapy is a predictable treatment, resulting in up to 97% retention rate for the treated teeth (1, 2, 3). However, about 3% of endodontically treated teeth require further treatment, including extraction of the tooth. Long- term predictability of restored endodontically treated teeth is important for the decision of tooth retention versus extraction and implant
Fig. 7. Master cone radiograph. placement. A distinction has to be made between a general treatment outcome and endodontic treatment outcome. Depending on the evaluation criteria used, a general treatment outcome of either natural tooth or dental implant may address retention, functionality, restorative, and, if applicable, periodontal and endodontic success (4). Endodontic treatment success is Fig. 8. Post-obturation radiograph. Sealerpuff is noted, DB root. considered to be achieved by its objective of preventing or eliminating apical periodontitis (5, 6). Prognosis Healing or continuation of periapical Endodontic: Good. disease is widely regarded to be Tooth: Uncertain. dependent on the absence or presence of microorganisms and thus on the antimicrobial debridement of the root Follow-up examination November th canal system by cleaning, shaping, and 29 2011 subsequent root filling (7, 8). No symptoms. Radiograph shows Nevertheless, additional factors have evidence of healing of the periapical been found to influence the long-term radiolucency. endodontic outcome of a tooth. Sjögren et al. (9) suggested various factors, such
24 as pre-existing apical periodontitis or highest endodontic success (15). Hence, adequate length and level of the root an intact coronal restoration has been canal filling. A variety of other found indispensable for the long-term endodontic treatment parameters, general treatment outcome of the restorative factors, and biological endodontically treated tooth (16). variables are considered to influence the Fuss et al. (17) studied 147 extracted endodontic outcome (10). teeth. The most common reason for In a patient cohort with 200 teeth extraction (44%) was a restorative investigated by Chugal et al. (11), consideration, with endodontic, preoperative pulp and periapical endorestorative, and vertical root diagnosis, periapical radiolucency size, fracture (VRF) the next most frequent and the patient’s sex were significantly reasons (21%, 19%, and 11%, correlated to the outcome of the respectively). endodontic treatment. The strongest Vire (18) found that 59% of 116 influence on postoperative healing was extractions of endodontically found to be by the presence and treated teeth were due to prosthetic magnitude of preoperative apical reasons, 32% to periodontal reasons, periodontitis. and 9% to endodontic failures. The apical limit of the obturation has Zadik et al. (19) also analysed factors also been identified as a parameter related to extraction of endodontically significantly influencing the true treated teeth. In this retrospective study endodontic outcome by Bergenholtz et 547 endodontically treated permanent al. (12). teeth that were extracted in a In terms of the general treatment multidisciplinary clinic in a 2-year outcome, according to Ng et al. (10), four period were analyzed. The most variables could improve the survival of common reason for ectraction was endodontically treated teeth: a crown nonrestorable caries (61.4%). Other restoration after endodontic therapy, reasons were: endodontic failure the presence of mesial and distal (12.1%), VRF and iatrogenic perforation approximal contacts, that the tooth will or stripping (8.8% each), periodontal not be used as an abutment for disease (4.6%), unrestorable cusp removable or fixed partial dentures, and fracture (2.4%), orthodontic (1.3%) and if the tooth itself was not a molar. prosthetic (0.2%) reasons, and trauma A definitive restoration is necessary (0.5%). because the root canal filling itself may Setzer et al. (4) investigated not provide the necessary coronal seal preoperative factors that potentially can that can prevent bacterial penetration provide more information about the and the invasion of oral microorganisms long-term survival and predictability of into the root canal system (13). endodontically treated teeth, including A retrospective investigation of age, sex, and restorative, periodontal, complete-mouth radiographs of patients and endodontic factors. The authors seen in a university setting found the found that significant positive definitive coronal restoration to be more correlations existed between ‘‘untoward important for a successful endodontic events’’ (any form of retreatment or outcome than the quality of the extraction) and ‘‘prognostic value endodontic filling (14). Nevertheless, according to periodontal status’’. They different studies showed that both a concluded that the only preoperative good coronal restoration and a good factors significant for the prognosis of endodontic treatment provided the restored endodontically treated molars
25 were related to periodontal prognostic outcome of endodontic treatment value and attachment loss. of teeth with apical periodontitis. Int Endod J 1997; 30: 297–306. 9. Sjögren U, Hagglund B, Sundqvist References G, et al. Factors affecting the long- 1. Salehrabi R, Rotstein I. term results of endodontic Endodontic treatment outcomes treatment. J Endod 1990; 16: in a large patient population in 498–504. the USA: an epidemiological 10. Ng YL, Mann V, Gulabivala K. study. J Endod 2004; 30: 846– Tooth survival following non- 850. surgical root canal treatment: a 2. Chen SC, Chueh LH, Hsiao CK, et systematic review of the al. An epidemiologic study of literature. Int Endod J 2010; 43: tooth retention after nonsurgical 171–189. endodontic treatment in a large 11. Chugal NM, Clive JM, Spangberg population in Taiwan. J Endod LS. A prognostic model for 2007; 33: 226–229. assessment of the outcome of 3. Fonzar F, Fonzar A, Buttolo P, et endodontic treatment: effect of al. The prognosis of root canal biologic and diagnostic variables. therapy: a 10-year retrospective Oral Surg Oral Med Oral Pathol cohort study on 411 patients Oral Radiol Endod 2001; 91: with 1175 endodontically treated 342–352. teeth. Eur J Oral Implantol 2009; 12. Bergenholtz G, Lekholm U, 2: 201–208. Milthon R, et al. Influence of 4. Setzer FC, Boyer KR, Jeppson JR, apical overinstrumentatio and Karabucak B, Kim S. Long-Term overfilling on retreated root Prognosis of Endodontically canals. J Endod 1979; 5: 310–314. Treated Teeth: A Retrospective 13. Torabinejad M, Ung B, Kettering J. Analysis of Preoperative Factors In vitro bacterial penetration of in Molars. J Endod 2011; 37: 21- coronally unsealed 25. endodontically treated teeth. J 5. Strindberg LZ. Dependence of the Endod 1990; 16: 566–569. results of pulp therapy on certain 14. Ray HA, Trope M. Periapical factors. An analytical study based status of endodontically treated on radiographic and clinical teeth in relation to technical follow-up examinations. Acta quality of the root filling and the Odont Scand 1956; 14: 1–175. coronal restoration. Int Endod J 6. Ørstavik D. Reliability of the 1995; 28: 12–18. periapical index scoring system. 15. Tronstad L, Asbjornsen K, Døving Scand J Dent Res 1988; 96:108– L, et al. In- fluence of coronal 111. restorations on the periapical 7. Byström A, Happonen R-P, health of en- dodontically treated Sjögren U, et al. Healing of teeth. Endod Dent Traumatol periapical lesions of pulpless 2000;16: 218–221. teeth after endodontic treatment 16. Iqbal MK, Johansson AA, Akeel with controlled asepsis. Endod RF, et al. A retrospective analysis Dent Traumatol 1987; 3: 58–63. of factors associated with the 8. Sjögren U, Figdor D, Persson S, et periapical status of restored, al. Influence of infection at the time of root filling on the 26
endodontically treated teeth. Int J Prosthodont 2003; 16: 31–38. 17. Fuss Z, Lustig J, Tamse A. Prevalence of vertical root fractures in extracted endodontically treated teeth. Int Endod J 1999; 32: 283-286. 18. Vire DE. Failure of endodontically treated teeth: classification and evaluation. J Endod 1991; 17: 338-342. 19. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related to extraction of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(5): 31- 35.
27
Case 5
Endodontic treatment of the maxillary left first molar
Fig. 1. Frontal view.
Patient 57-year-old Caucasian male.
Fig. 2. Buccal view. A sinus tract is seen at the Chief complaint distal aspect of tooth 27. Non-contributory.
Clinical tests January 19th2011 Medical record Non-contributory. 25 26 27 EPT 50 80 80 Cold + - - Dental history Percussion - - - The patient was referred to the post- Palpation - - - graduate clinic from the student clinic PPD 4 4 12 for endodontic treatment of the Mobility - - - maxillary left first molar. Biting - - -
th Clinical findings January 19 2011 th Soft tissue: Sinus tract at the buccal Radiographic findings January 19 2011 aspect of tooth 27, normal findings Dental: Tooth 27 has a around tooth 26. radiopaque MOD restoration, the root Dental: canal is filled with a weakly radiopaque Tooth 25: MOD amalgam restoration. filling material. Teeth 25 and 26 have Tooth 26: Fractured composite MOD radiopaque filling materials. restoration, caries. Periodontal: Moderate attachment loss. Tooth 27: A mixture of amalgam, Periapical: Apical radiolucencies teeth composite, and temporary filling 26 (PAI 3) and 27 (PAI 4). A normal PDL material is seen. space is seen around the root of tooth 25.
28
Fig. 3. Periapical radiograph 19.01.2011. Fig. 4. Working-length radiograph.
th 2011 th Diagnosis January 19 Treatment February 9 2011 No symptoms. Obturation tooth 26: Diagnosis Buccal roots filled with gutta-percha and Pulpal K04.11 necrotic pulp AH Plus; Palatal root filled with MTA plug and thermoplastisised gutta-percha Periodontal K05.03 chronic marginal periodontitis and AH Plus. Sealed with IRM.
Periapical K05.40 chronic apical periodontitis
Treatment plan Pre-endodontic treatment restoration and endodontic treatment tooth 26, extraction of tooth 27.
Problem list Fig. 5. Master cone radiograph. Obliteration, loss of tooth substance due to caries.
Treatment January 19th2011 1 carpule of Xylocaine/adrenaline was injected. Access opening and removal of caries and former restoration materials. Pre-endodontic composite restoration. Mechanical: Burs, Gates glidden, NiTi handfiles #20, Biorace rotary files: MB: #40/0.04 (BR5) /18mm Fig. 6. Post-obturation radiograph. MB2: #40/0.04(Br5)/20mm DB: #40/0.04 (BR5) /19mm Prognosis P: #50/0.04 (BR6) /18mm Endodontic: Good. Chemical: 1% NaOCl, 17% EDTA. Tooth: Good. Intracanal medicament: Ca(OH)2. Temporary filling: Cavit, IRM.
29 Follow-up examination January 27th2012 Discussion (1 year) The presence of microorganisms in a No symptoms. Tooth 26 has been root canal is the main etiologic factor in restored with a post and a dental crown. the development and continuation of The patient has postponed the periapical lesions (1, 2, 3). extraction of tooth 27 since he had no Immunological reactions, in this case subjective complaints. periapical lesions, are established in the Re-informed about the infection related periapex to combat the infectious agent to tooth 27 and recommended to have it and promote the repair of the affected extracted as soon as possible. Periapical region (4). These pathologies cause radiograph shows no sign of regression bone lysis to make room for their of apical radiolucency related to tooth organisation and growth. The 26. differential diagnosis of periapical pathologies is confirmed only by means of histological processing (5). Several authors disagree about the prevalence of these pathologies: the prevalence of cystic lesions ranges from 6% (6) to 54% (7), and that of granuloma, from 45% (8) to 97.0% (6, 9). A number of chemical mediators of Fig. 7. Follow-up radiograph 1 year. inflammation, including the cytokines IL- - LPS, seem to be related to the Follow-up examination June 24th2014 (3.5 pathogenesis1α, IL 1β, TNFα, of periapical prostaglandins lesions and years) (10,11, 12, 13). These substances may No symptoms. Tooth 27 was extracted stimulate root resorption in the same after the last follow-up examination. The way that they stimulate bone resorption apical periodontitis lesion on tooth 26 (14). Irregular resorbed areas are seems to have healed well. frequently situated in sites that are not within the reach of root-canal instruments or medication and may act as niches for extraradicular bacterial colonization (15, 16), besides causing technical problems for rootcanal treatment (17, 18). Radiographic examination is not always helpful in the diagnosis of small areas of external root Fig. 8. Follow-up radiograph 3.5 years. resorption associated with teeth having apical periodontitis. Vier and Figuereido (19) examined 104 root apices from extracted teeth with periapical lesions by means of hematoxylin-eosin (HE) staining and scanning electron microscopy (SEM). Cysts accounted for 24.5% of the samples, 84% of which were associated with marked inflammation. The most prevalent
30 diagnosis was noncystic periapical periapical tissues of monkeys. abscess with varying degrees of severity Scand J Dent Res 1982; 90: 200– (63.7%). Periapical granuloma was not a 206. frequent finding. SEM analysis showed 3. Lin L, Pascan EA, Skribner J et al. that 42.2% of the root apices had Clinical, radiographic, and periforaminal resorption extending over histologic study of endodontic 50% of their circumference. When the treatment failures. Oral Surg Oral foraminal resorption was evaluated, Med Oral Pathol 1991; 71: 603– 28.7% had resorption affecting >50% of 161. the periphery. Only 8.9% of the samples 4. Torabinejad M, Bakland L. showed no periforaminal or foraminal Immunopathogenesis of chronic resorption. In a similar study periapical lesion. A review. Oral examinating internal apical resorption Surg, Oral Med Oral Pathol 1987; the authors found that apical internal 46: 685–699. resorption was present in 74.7% of 75 5. Linenberg W, Waldron C, Delaune examined roots associated with Jr G (1964) A clinical periapical lesions (20). roentgenographic and Normally, the failure of root-canal histopathologic evaluation of treatment is related to the persistence of periapical lesions. Oral Surg, Oral infection in the root-canal system Med Oral Pathol 1964; 17: 467– (21, 22). The presence of root resorption 472. in teeth with periapical lesions is 6. Block R, Brushell A, Rodrigues H important for infection control since et al. A histopathologic, these areas are niches for bacteria. histobacteriologic, and Moreover, the apical limit of radiographic study of periapical instrumentation may be altered in teeth endodontic surgical specimens. with widely resorbed apices, since the Oral Surg, Oral Med Oral Pathol cementum-dentine junction at the 1976; 42: 656–678. constriction can be missing (17, 18). In 7. Priebe W, Lazansky J, such circumstances, sealing the canal Wuehrmann A. The value of the may be difficult and overflling is likely. roentgenographic film in the Bacteria may also be found in the differential diagnosis of external surface of the root, forming a periapical lesions. Oral Surg, Oral periapical bioflm (23, 24), thus Med Oral Pathol 1954; 7: 979– confirming the importance of 983. appreciating the existence of 8. Lalonde E, Luebke R. The periforaminal root resorption. frequency and distribution of periapical cysts and granulomas. Oral Surg, Oral Med Oral Pathol References 1968; 25: 861–868. 1. Kakehashi S, Stanley H, Fitzgerald 9. Nair P. Light and electron R. The effects of surgical microscopic studies of root canal exposures of dental pulps in flora and periapical lesions. J germ-free and conventional Endod 1987; 13: 29-39. conventional laboratory rats. 10. Schein B, Schilder H. Endotoxin Oral Surg, Oral Med Oral Pathol content in endodontically 1965; 20: 340–349. involved teeth. J Endod 1975; 2. Fabricius L, Dahlen G, Holm S, 1(1): 19-21. Möller A (1982) Influence of combinations of oral bacteria on
31 11. Schonfeld SE, Greening AB, Glick apical external root resorption. DH, Frank AL, Simon JH, Herles Int Endodo J 2002; 35: 710-719. SM. Endotoxic activity in 20. Vier FV, Figueiredo JAP. Internal periapical lesions. Oral Surg Oral apical resorption and its Med Oral Pathol. 1982; 53(1): 82- correlation with the type of 87. apical lesion. Int Endod J 2004; 12. Wang CY, Stashenko P. 37: 730–737. Characterization of bone- 21. Sjögren U, Figdor D, Persson S, resorbing activity in human Sundqvist G. In£uence of periapical lesions. J Endod. infection at the time of root filling 1993;19(3): 107-111. on the outcome of endodontic 13. Wang CY, Stashenko P. The role treatment of teeth with apical of interleukin-1 alpha in the periodontitis. Int Endod J 1997; pathogenesis of periapical bone 30: 297-306. destruction in a rat model 22. Sundqvist G, Figdor D, Persson S, system. Oral Microbiol Immunol. Sjögren U. Microbiologic analysis 1993; 8(1): 50-56. of teeth with failed endodontic 14. Hammarström L, Lindskog S. treatment and the outcome of Factors regulating and modifying conservative re-treatment. Oral dental root resorption. Proc Finn Surg Oral Med Oral Pathol 1998; Dent Soc. 1992; 88 Suppl 1: 115- 85: 86-93. 123. 23. Sunde PT, Olsen I, Debelian GJ, 15. Tronstad L, Barnett J, Cervone F. Tronstad L. Microbiota of Periapical bacterial plaque in periapical lesions refractory to teeth refractory to endodontic endodontic therapy. J Endod treatment. Endod and Dent 2002; 28: 304–310. Traumatol 1990; 6: 73-77. 24. Wang J, Jang Y, Cheng W, Zhu C, 16. Lomcali G, Sen B, Cancaya H. Liang J. Bacterial flora and Scanning electron microscopic extraradicular biofilm associated observations of apical root with the apical segment of teeth surfaces of teethwithapical with post-treatment apical periodontitis. Endod Dent periodontitis. J Endod 2012; Traumatol 1996; 12: 70-76. 38(7): 954-959. 17. Delzangles B. Scanning electronmicroscopic study of apical and intracanal resorption. J Endod 1989; 15: 281-285. 18. Malueg L,Wilcox L, JohnsonW.
Examination of external apical root resorption with scanning electron microscopy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82: 89-93. 19. Vier FV, Figueiredo JAP. Prevalence of different periapical lesions associated with human teeth and their correlation with the presence and extension of
32 Case 6
Endodontic treatment of the maxillary right first incisor
Medical record The patient had a pronounced dental anxiety. He was not using any medicaments.
Dental history The patient was referred to the post- graduate clinic from private practice for Fig. 1. Frontal view. evaluation and treatment of the maxillary right first incisor. Patient 34-year-old Caucasian male. Clinical findings November 3rd2010 Soft tissue: Normal findings Dental: Chief complaint Tooth 12: Sound He complained about tenderness when Tooth 11: Discoloration, incisal chewing and biting on his upper right composite filling. front tooth. He also had a sensation of Tooth 21: Composite filling ID. slight mobility of this particular tooth. Periodontal: A periodontal pocket of He could not remember any specific 6mm was probed at the buccal aspect of trauma to his front teeth. tooth 11 (Fig. 5).
Clinical tests November 3rd2010
12 21 11 EPT 20 80 10 Cold + - + Percussion - +(v) - Palpation - + - Fig. 2. Buccal view. Discoloured tooth 11. PPD PPD 3 6 3 6mm. Mobility - I - Biting - + -
Radiographic findings November 3rd2010 Dental: Tooth 11has an incisal radiopaque restoration. Periodontal: Marginal periodontitis. Periapical: Tooth 11 has a periradicular Fig. 3. Palatal view. radiolucency at the midroot to cervical level. Apically there is a continuous PDL space.
33 canal orifice, pulp chamber obliteration. Bleeding from canal below the fracture line. Mechanical: Burs, Gates glidden, NiTi handfiles: #45/19mm Chemical: 1% NaOCl, 17% EDTA Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
Fig. 4. Periapical radiograph.
Fig. 6. Working-length radiograph.
Fig. 5. PPD 6mm. Treatment November 24th2010 No symptoms. Tooth feels different, but Diagnosis November 3rd2010 is not tender on percussion compared to neighbouring teeth. Diagnosis Filled with gutta-percha and AH Plus, Pulpal K04.11 necrotic pulp sealed with composite.
Periodontal K05.03 chronic marginal periodontitis
Periapical K04.51 chronic lateral periodontitis
Treatment plan Tooth 11: Endodontic treatment of infected pulp.
Fig. 7. Master cone radiograph. Problem list Calcification. Root fracture?
Treatment November 3rd2010 2 carpules of Xylocaine/adrenaline was applied, intrapulpal injection was necessary during the treatment session. Access preparation and localisation of
34
Fig. 10. Periapical control radiograph 2.5 years.
Fig. 8. Post-obturation radiograph. Discussion An intra-alveolar fracture in the cervical Prognosis part of the root is a rare injury; reported Endodontic: Uncertain. frequencies vary between 6% and 19% Tooth: Uncertain. of intra-alveolar root fractures (1-5). The prognosis is considered to be poor due to a short mobile coronal fragment,
th with less probability of healing with Follow-up examination July 4 2011 (7 hard tissue, and possible bacterial months) contamination of necrotic pulp tissue Asymptomatic. Reduction of periodontal from the gingival crevice (6, 7). pocket (4mm). Less mobility. However, it has also been shown that cervical fractures may heal and a conservative approach, including a relatively long splinting period, has been recommended (8-11). Type of fracture healing was classified by Andreasen & Hjörting-Hansen (8): 1) Healing with interposition of hard tissue: healing with hard tissue, fragments are in close contact and the fracture line is not visible or indistinctly outlined; 2) Healing with interposition Fig. 9. Periapical control radiograph 04.07.2011. of bone and soft tissue (PDL) between the fragments: fragments are separated Follow-up examination March 18th2013 by ingrowth of hard tissue surrounded (2.5 years) by periodontal ligament-like tissue; 3) Asymptomatic. Periodontal pocket Healing with interposition of soft tissue unchanged (4mm). Lateral radiolucency (PDL): fragments are close but is seen in relation to fracture line. separated by a distinct radiolucent line Observation. and there is rounding-up of the fracture edges; 4) No healing: persistent or a widened space between the fragments and the presence of a radiolucency in the alveolar bone adjacent to the root fracture.
35 Cvek et al. (12) evaluated 94 cervical (30%) than the incidence in the middle root fractures .The teeth were divided (86%) and apical thirds (96%) (14). into two groups according to type of In the present case, the tooth required fracture: 1: transverse fractures limited endodontic treatment, probably because to the cervical third of the root (51 of infection via the periodontal pocket incisors) and 2: oblique fractures that resulted in necrosis of the coronal involving both the cervical and middle fragment. parts of the root (43 incisors). Healing of Clinical examination of root fractures the fracture with hard tissue formation should evaluate tooth colour, sensitivity was observed in 17 teeth (18%), healing to percussion, mobility, and sensitivity with interposition of periodontal to thermal stimulation (15). ligament (PDL) and, in some cases, hard tissue between the fragments in 62 teeth This case showed slight mobility (grade (66%), and fifteen teeth (16%) showed 1), which can be explained by the no healing and a radiolucency adjacent cervical location of the fracture line. to the fracture. Neither the frequency There was no response to the cold test, nor the type of fracture healing differed one can argue that this could be significantly between the two groups explained by the obliteration of the (transverse versus oblique). coronal pulp space; the dental crown Andreasen et al. (13) analysed the long- showed yellow discoloration, which also term tooth loss after root fractures and may be a clinical sign of mineralization assessed the influence of the type of of the pulp chamber. Although in most healing and the location of the root cases of horizontal root fracture, testing fracture in 492 root-fractured teeth in the pulp elicits a positive response, a 432 patients. The location of the root negative response may be recorded (16) fracture had a strong significant effect when there is calcification. This negative on tooth survival. The 10-year tooth response does not necessarily indicate a survival of apical root fractures was need for endodontic therapy. However, 89%, of mid-root fractures 78%, of in this case, a radiolucency in the cervical-mid-root fractures 67%, and of alveolar bone adjacent to fracture was cervical fractures 33%. The fracture- evident, indicating the need for healing type offered further prognostic endodontic treatment. information. No tooth loss was observed In the study by Cvek et al. (14) no in teeth with hard tissue fracture healing healing, i.e. pulp necrosis and regardless of the position of the fracture. appearance of radiolucency in the For teeth with interposition of periradicular bone, next to the root connective tissue, the location of the fracture, with or without widening of fracture had a significant influence on the space between fragments, occurred tooth loss. For teeth with connective in 109 (20%) of the 534 intra-alveolar tissue healing, the estimated 8-year root fractured teeth. survival of apical, mid-root, and cervical- mid-root fractures were all more than 80%, whereas the estimated 8-year References survival of cervical fractures was 25%. 1. Lindahl B. Transverse intra- Horizontal root fractures due to dental alveolar root fractures. Roentgen trauma generally do not result in pulp diagnosis and prognosis. Odontol necrosis (14). The incidence of tooth Revy 1958; 9: 10–24. survival in the cervical third is lower 2. Austin LT. A review of forty cases of retained fractured roots of
36 anterior teeth. J Am Dent Assoc root. Dent Traumatol 2002; 18: 1930; 17: 1930–1932. 57–65. 3. Zachrisson BU, Jacobsen I. Long- 13. Andreasen JO, Ahrensburg ss, term prognosis of 66 permanent Tsilingaridis G. Root fractures: anterior teeth with root fracture. the influence of type of healing Scand J Dent Res 1975; 83: 345– and location of fracture on tooth 354. survival rates – an analysis of 492 4. Ravn JJ. En klinisk og radiologisk cases. Dent Traumatol 2012; 28: undersögelse af 55 rodfrakturer i 404–409. unge permanente incisiver. 14. Cvek M, Tsilingaridis G, Tandlaegebladet 1976; 80: 391– Andreasen JO. Survival of 534 396. incisors after intra-alveolar root 5. Andreasen FM, Andreasen JO, fracture in patients aged 7–17 Bayer T. Prognosis of years. Dent Traumatol 2008; 24: rootfractured permanent incisors 379–387. - prediction of healing modalities. 15. S. Patel, D. Ricucci, C. Durak, F. Endod Dent Traumatol 1989; 5: Tay. Internal root resorption: a 11–22. review. J Endod 2010; 36: 1107– 6. Feiglin B. Clinical management of 1121. transverse root fractures. Dent 16. Andreasen FM, Andreasen JO, Clin North Am 1995; 39: 53–78. Cvek M. Root fractures. In: 7. Andreasen FM, Andreasen JO. Andreasen JO, Andreasen FM, Root fractures. In: Andreasen, JO, Andersson L, editors. Textbook Andreasen, FM, editors. Textbook and color atlas of traumatic and color atlas of traumatic injuries to the teeth, 4th edn. injuries to the teeth, 3rd edn. Kopenhagen: Blackwell Copenhagen: Munksgaard; 1994: Munksgaard; 2007: 337–371. 301–314. 8. Andreasen JO, Hjörting-Hansen E. Intraalveolar root fractures. radiographic and histologic study of 50 cases. J Oral Surg 1967; 25:
414–426. 9. Andreasen JO. Treatment of fractured and avulsed teeth. ASDC J Dent Child 1971; 38: 29– 48 10. Benati FW, Biggs JT. Management of traumatized incisor teeth with horizontal fractures. Okla Dent Assoc J 1994; 85: 30–3. 11. Yates JA. Root fractures in permanent teeth: a clinical review. Int Endod J 1992; 25:150–157. 12. Cvek M, Mejàre I, Andreasen JO. Healing and prognosis of teeth with intra-alveolar fractures involving the cervical part of the
37 Case 7
Endodontic retreatment of the maxillary left first molar
Fig. 1. Frontal view.
Fig. 2. Occlusal-palatal view. Patient 29-year-old Caucasian male. Clinical tests October 25th2011
Chief complaint 25 26 27 Non-contributory. EPT Nd Nd Nd Cold + - + Percussion - - - Medical record Palpation - - - Non-contributory. PPD 3 3 3 Mobility - - - Biting - - - Dental history The patient was referred to the post- th graduate clinic from the student clinic Radiographic findings October 25 2011 for endodontic retreatment of the Dental: Tooth 26 has an MOD maxillary right first molar. A crown is radiopaque filling material. The root planned. canals seem poorly filled with a weakly radiopaque material. Periodontal: Within normal limits. Clinical findings October 25th2011 Periapical: Widening of PDL space tooth Soft tissue: normal findings 26, apical radiolucencies mesiobuccal Dental: and palatal root (PAI 3). Normal PDL 25: Sound. space around tooth 25 and 27. 26: Discoloured and leaking composite filling (ODP) with underlying cavity/caries (Fig. 2). 27: Sound.
Fig. 3. Periapical radiograph 25.10.2011
38 Diagnosis October 25th2011 Treatment November 2nd2011 1 carpule of Xylocaine/adrenaline was Diagnosis applied to establish anaesthesia. Gutta- Pulpal K04.11 necrotic pulp percha was removed. Prepared the K04.19 endodontically treated canals using NiTi hand files and BioRace rotary files: Periodontal within normal limits MB: #40/0.04 (Br5)/19.5mm DB: #40/0.04 (Br5)/19mm (step) Periapical K05.40 chronic apical periodontitis P: #50/0.04 (Br6)/19.5mm Chemical: 1% NaOCl, 17% EDTA. Intracanal medicament: Ca(OH)2. Temporary filling: Cavit, IRM. Treatment plan Non-surgical retreatment. A crown is planned after endodontic retreatment.
Problem list Obliteration.
Treatment October 25th2011 Fig. 5. Working-length radiograph MB and P 1 carpule of Xylocaine/adrenaline was canals. applied to establish anaesthesia. Access preparation, caries removal and locating the untreated MB canal (MB2). Mechanical: Burs, NiTi handfiles #20, Biorace rotary files: MB2: #40/0.04 (Br5)/18mm Chemical: 1% NaOCl, 17% EDTA. Intracanal medicament: Ca(OH)2. Temporary filling: Cavit, IRM.
Fig. 6. Working length radiograph DB canal.
Treatment November 9th2011 No symptoms. Master cone radiograph. The canals were filled with AH Plus and gutta-percha with a cold lateral condensation technique. A small sealer puff is noted at the apex of the palatal root (Fig. 8). Fig. 4. Working-length radiograph MB2.
39 Follow-up examination April 15th2013 (2 years) No symptoms. Radiograph shows healing of the periapical radiolucency.
Fig. 7. Master cone radiograph.
Fig. 10. Follow-up radiograph 2 years.
Discussion Successful root canal therapy requires a thorough knowledge of root and root canal morphology. Root canal anatomy Fig. 8. Post-obturation radiograph 09.11.2011. variations present a constant challenge in successful diagnosis and endodontic Prognosis treatment, especially the multirooted Endodontic: Good. teeth. A classic study by Hess (1) Tooth: Good. showed pulp spaces to be complex systems. Numerous studies since then have continued to help define the Follow-up examination March 8th2012 (1 anatomy, morphology, and dimension of year) the human dentition, with the common No symptoms. The tooth had been denominator being that certain root restored at the student clinic with a systems are more complex than others. crown. Radiograph shows evidence of One such system is found in the healing of the periapical radiolucency. mesiobuccal (MB) root of maxillary molars (2-5). The broad buccolingual dimension of the mesiobuccal root and associated concavities on its mesial and distal surface is consistent with the majority of the mesiobuccal roots having two canals while there is usually a single canal in each of the distobuccal and palatal roots (6, 7). In a literature review of the root canal
Fig. 9. Follow-up radiograph 1 year. morphology of the human permanent maxillary first molar (8399 teeth from 34 studies) the incidence of two canals in the mesiobuccal root was 56.8% and of one canal was 43.1% in a weighted
40 average of all reported studies. The Human Teeth (2nd ed.) Iowa incidence of two canals in the City: University of Iowa Press. mesiobuccal root was higher in 3. Vertucci FJ. The endodontic laboratory studies (60.5%) compared to significance of the mesiobuccal clinical studies (54.7%). Less variation root of the maxillary first molar. was found in the distobuccal and palatal US Navy Med 1974; 63: 29–31. roots and the results were reported 4. Weine FS, Healey, Gerstein H, et from fourteen studies consisting of 2576 al. Canal configuration in the teeth. One canal was found in the mesiobuccal root of the maxillary distobuccal root in 98.3% of teeth first molar and its endodontic whereas the palatal root had one canal significance. Oral Surg Oral Med in over 99% of the teeth studied (8). Oral Pathol 1969; 28: 419–425. The use of operating microscopes has 5. F.J. Vertucci FJ. 1984. Root canal facilitated the localization and handling anatomy of the human of additional canals, especially the permanent teeth. Oral Surg Oral second mesiobuccal canal (MB2) in Med Oral Pathol 1984; 58: 589– maxillary first molars. Buhrley et al. (9) 599. investigated the effect of magnification 6. Walton R, Torabinejad M. 1996. on locating the MB2 canal in maxillary Principles and practice of molars. The participating endodontists endodontics (2nd ed). W.B. documented 312 cases of root canal Saunders Co, Philadelphia. therapy on maxillary first and second 7. Ash M, Nelson S. 2003. Wheeler’s molars. Participants that used the dental anatomy, physiology and microscope or dental loupes located the occlusion (8th ed) Saunders, MB2 canal with a frequency of 57.4% Philadelphia. and 55.3%, respectively. Those using no 8. Cleghorn BM, Christie WH, Dong magnification located the MB2 canal CC. Root and Root Canal with a frequency of 18.2% (9). Morphology of the Human Failure to detect and treat the second Permanent Maxillary First Molar: MB2 canal system will result in a A Literature Review. J Endod decreased long-term prognosis (10). 2006; 32(9): 813-821. Stropko (11) observed that by 9. Buhrley LJ, Barrows MJ, BeGole scheduling adequate clinical time, by EA, Wenckus CS. Effect of using the recent magnification and magnification on locating the detection instrumentation aids and by MB2 canal in maxillary molars. J having thorough knowledge of how and Endod 2002; 28: 324–327. where to search for MB2, the rate of 10. Wolcott J, Ishley D, Kennedy, location can approach 93% in maxillary Johnson S, Minnich S. Clinical first molars. investigation of second mesiobuccal canals in endodontically treated and References retreated maxillary molars J 1. W. Hess. 1925. The Anatomy of Endod 2002; 28: 477–479. the Root Canals of the Teeth of 11. Stropko JJ. Canal morphology of the Permanent Dentition. John maxillary molars: clinical Bale, Sons and Danielson, Ltd, observations of canal London. configurations. J Endod 1999; 25: 2. Bjorndal AM, Skidmore AE. 1987. 446–450. Anatomy & Morphology of
41 Case 8
Endodontic retreatment of the mandibular left first molar
Fig. 1. Frontal view.
Patient Fig. 2. Occlusal view. 34-year-old Asian male.
Clinical tests April 21st2010 Chief complaint 35 36 37 Non-contributory. EPT 22 80 66 Cold + - + Percussion - - - Medical record Palpation - - - Non-contributory. PPD 3 3 3 Mobility - - - Biting - - - Dental history The patient was referred to the postgraduate clinic from the student clinic for retreatment of the mandibular Radiographic findings April 21st2010 left first molar prior to prosthetics Dental: Tooth 36 has an MOD (crown). The tooth had been root filled radiopaque filling material. The tooth approximately 15 years ago. Previous has an insufficient root filling. The root attempts to retreat the tooth had been canals seem to be calcified apically. made at the student clinic. Periodontal: Within normal limits. Periapical: Normal PDL space around
st tooth 35, 36 and 37. Clinical findings April 21 2010 Soft tissue: Normal findings. Dental: Tooth 35: Occlusal amalgam restoration. Tooth 36: Leaking amalgam restoration (MODL) with caries and occlusal temporary filling material. Tooth 37: Composite filling (MO).
42
Fig. 3. Periapical radiograph.
Fig. 4. Working length radiograph. st Diagnosis April 21 2010
Diagnosis Pulpal K04.11 necrotic pulp Treatment September 7th2010 K04.19 endodontically treated 1 carpule of Septocaine was injected. Access preparation and localisation of D Periodontal Within normal limits canal, bleeding from canal. Attempt to
Periapical Within normal limits negotiate mesial canals using ultrasound was unsuccessful. Mechanical: Burs, NiTi hand files: D: #50/0.02 23mm Treatment plan Chemical: 1% NaOCl, 17% EDTA. Non-surgical endodontic retreatment. Intracanal medicament: Ca(OH)2. Temporary filling: Cavit, IRM.
Problem list Negotiation of obliterated root canals.
Treatment April 21st2010 1 carpule of Septocaine was applied to establish anaesthesia. Access preparation and localisation of 3 canal orifices. Partially removing the old gutta-percha. Obliterated canals. Mechanical: Burs, Gates glidden, Fig. 5. Working length radiograph. D canal. Hedstrøm hand files. : Chloroform, 1% NaOCl, 17% th Chemical Treatment September 12 2010 EDTA. No symptoms. : Ca(OH) . Intracanal medicament 2 1 carpule of Septocaine was injected. MB : Cavit, IRM. Temporary filling and ML canals were filled with ProRoot
MTA, D canal was filled with gutta-
percha and AH Plus using a cold lateral condensation technique. Moistened cotton pellet applied over MTA. Temporary filling: Cavit, IRM.
43
Fig. 6. Master cone radiograph. Fig. 10. Tooth restored with composite.
Prognosis Endodontic: Uncertain. Tooth: Uncertain.
Follow-up examination February 6th2012
Fig. 7. MTA in mesial canals. No symptoms. A crown with a post was made at the student clinic. No visible apical pathology on periapical radiograph.
Fig. 8. Filled with GP/AH+ distal canal.
Treatment November2nd2010 IRM plugs mesial canals, tooth filled with composite.
Fig. 11. Follow-up radiograph 2 years.
Discussion Strindberg (1) stated in 1956 that the highest success rate is obtained when the root filling is confined to 1 mm from the radiographic apex. In the ideal endodontic case, the root canal is patent Fig. 9. IRM plugs. from the orifice to the apical foramen. However, this is not always the case. Canals may be obliterated by denticles or secondary dentin formation, or the anatomy of the root may prevent
44 proper instrumentation. There are usually extending horizontally from the various opinions in the literature main root canal (4). Ramifications can regarding the prognosis for endodontic be observed anywhere along the length treatment of such canals. According to of the root, but they occur more Strindberg (1) the prognosis is good commonly in the apical portion and in even in teeth with nonvital pulps. posterior teeth (5). In 73.5% of the Molven (2) studied, in vitro, forty-six cases, ramifications are found in the root canals in which the pulps had been apical third of the root, in 11% in the amputated or partially root filled 5 years middle third, and in 15% in the coronal or more previously and in which no root third (6). Ricucci et al. (7) reviews and canals were visible in intraoral reports on the histopathologic and radiographs apical to the amputation or histobacteriologic status of the tissue in end of the root fillings. On radiographs lateral canals and apical ramifications taken after extraction, twenty-nine (LC/AR) in diverse clinical conditions as canals could be traced partially or for well as in response to endodontic their whole length. When the canals treatment. Serial sections from 493 were instrumented in the laboratory, human tooth specimens obtained by using a standardized procedure, ten extraction or apical surgery. They found canals were found to be penetrable, that LC/AR were observed in about 75% twenty-six were diagnosed as non- of the teeth. Chemo mechanical penetrable, and complications occurred preparation partially removed necrotic in ten canals (breakage of tissue from the entrance of LC/AR, instrument/obstruction caused by filling whereas the adjacent tissue remained material). A complete obliteration in the inflamed, sometimes infected, and total length was not found in any canal. associated with periradicular disease. In In a study by Åkerblom et al. (3), looking cases in which lateral canals appeared at the outcome of obliterated root-filled radiographically ‘‘filled,’’ they were teeth that were root-filled only one third actually not obturated, and the of the root length, clinical and remaining tissue in the ramification was radiographic follow-up examinations inflamed and enmeshed with the filling were performed for 2 to 12 years. The material. criteria for obliteration were: (a) The root canal was not patent for more than one-third of the root length, (b) No root References canal lumen was visible on the radiographs apical to the instrumented 1. Strindberg LZ. The dependence of portion. Teeth with obliterated root the results of pulp therapy on canals were treated endodontically certain factors. An analytic study without any surgical procedure. The based on radiographic and overall success rate was found to be clinical follow-up examinations. 89%. When the preoperative periapical Acta Odontol Scand 1956; status was taken into consideration, the 14(Suppl 21). success rate for roots with an intact 2. Molven O. Nonpenetrable root periapical contour was 97.9%. canals as assessed by a An accessory canal is any branch of the standardized instrumentation main pulp canal that communicates with procedure. Oral Surg Oral Med the external surface of the root. A lateral Oral Pathol 1973: 95(2): 232- canal is an accessory canal located in the 237. coronal or middle third of the root, 3. Akerblom A, Hasselgren G. The Prognosis for Endodontic
45 Treatment of Obliterated Root Canals J Endod 1988; 14: 565- 567. 4. DeDeus QD. Frequency, location, and direction of the lateral, secondary, and accessory canals. J Endod 1975; 1: 361–6. 5. Vertucci FJ. Rootcanal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984; 58: 589–599.
6. Vertucci FL. Root canal morphology and its relationship to endodontic procedures. End topics 2005; 10: 3-29. 7. Ricucci D, Siqueira JF. Fate of the Tissue in Lateral Canals and Apical Ramifications in Response to Pathologic Conditions and Treatment Procedures. J Endod 2010; 36: 1–15.
46 Case 9
Endodontic retreatment of the maxillary left first incisor
Fig. 1. Frontal view. Fig. 2. Buccal view.
Patient 15-year-old Caucasian male.
Chief complaint Non-contributory. Fig. 3. Palatal view.
Medical record th Non-contributory. Clinical tests August 24 2011
22 21 11 12 Dental history EPT 43 80 66 45 The patient was referred to the post- Cold + - - - graduate clinic from the public Percussion - - - - dentistry for retreatment of the Palpation - - - - 2 3 2 2 maxillary left first incisor. The tooth had PPD Mobility - - - - recently been rootfilled but the referring Biting - - - - dentist was unhappy with the result. The patient had a trauma to his upper front teeth 7 years earlier (2004). Radiographic findings August 24th2011 Dental: Tooth 21 has a radiopaque th coronal restoration and a radiopaque Clinical findings August 24 2011 root filling material. Soft tissue: Normal findings. : Within normal limits. Dental: Teeth 11 and 21 have coronal Periodontal composite build-ups. Tooth 21 has a Periapical: Tooth 21 has an apical radiolucency (PAI 3). palatal temporary filling.
47
Fig. 4. Periapical radiograph 24.08.2011. Fig. 5. Working-length radiograph.
Diagnosis August 24th2011
Diagnosis Mechanical: Bur, Hedstrøm handfiles, Pulpal K04.19 endodontically treated NiTi handfiles, root-canal enlargement: #90/23.5mm (Fig. 6). Periodontal within normal limits Chemical: 1% NaOCl, 17% EDTA.
Periapical K05.40 chronic apical periodontitis Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
Treatment plan Endodontic retreatment.
Problem list Apical resorption?
Treatment August 24th2011 Access opening and localization of gutta- percha. Iatrogenic push-out of gutta- percha during removal (Fig. 5).
Mechanical: Bur, Gates Glidden, Fig. 6. Removal of GP with iatrogenic protrusion Hedstrøm handfiles, DeRace rotary files, apically. NiTi handfiles:
#60/24mm adjusted to 23.5mm th Chemical: Chloroform, 1% NaOCl, 17% Treatment November 11 2011 EDTA. Asymptomatic. Filled with gutta-percha and AH Plus, sealed with IRM. Intracanal medicament: Ca(OH)2.
Temporary filling: IRM.
Treatment September 28th2011 Asymptomatic. Access and removal of remaining gutta-percha.
48
Fig. 7. Master cone radiograph.
Fig.9. Follow-up radiograph 2 years.
Follow-up examination April 7th2014 (3 years) The patient is still asymptomatic. Radiograph shows improved, but uncertain healing.
Fig. 8. Post-obturation radiograph.
Prognosis Endodontic: Uncertain. Tooth: Good.
Follow-up examination March 18th2013 (2 years) The patient is asymptomatic.
Radiograph shows uncertain healing. Fig. 10. Follow-up radiograph 3 years.
Discussion Several follow-up studies (1-6) have concluded that apical overfilling is associated with an impaired prognosis. This opinion has been based on studies that include observation periods mostly in the range of 2-4 years. Strindberg (1) however, followed up some cases for up to 10 years, and he occasionally noticed a reduction in the volume of excess fillings over the longer periods.
49 Halse & Molven (7) re-examined 239 References root-filled teeth after 10-17 years and 1. Strindberg LZ. The dependence of concluded that apical overfilling per se the results of pulp therapy on had little influence on the long-term certain factors. An analytic study healing result as judged based on radiographic and radiographically. In about 80% of the clinical follow-up examinations. cases of overfilling, no excess root filling Acta Odontol Scand material could be traced at the 1956;14(suppl 21). reexamination. In a few cases 2. Grahnen H, Hansson L. The only, the appearance of the excess prognosis of pulp and root canal material was nearly identical to that at therapy. A clinical and the time of treatment, whereas the radiographic follow-up remaining overfillings (18%) showed a examination. Odontol Rev 1961; reduced size. Among the recorded 12: 146-165. variables only one seemed to have a 3. Storms JL. Factors that influence major impact on the prognosis-namely, the success of endodontic the presence or absence of an apical treatment. J Can Dent Assoc radiolucency at the time of treatment, 1969; 35: 83-97. indicating that infection was the 4. Seltzer S, Bender IB, Turkenkopf important factor when failures occurred. S. Factors affecting successful Yusuf (8) found in his study of periapical repair after root canal therapy. J granulomas that “foreign” material was Am Dent Assoc 1963; 67: 651- present in 96/284 specimens. Whilst 662. dentin and cementum chips often was 5. Kerekes K, Tronstad L. Long-term associated with active inflammation, results of endodontic treatment extruded root-filling materials were performed with a standardized generally associated with the formation technique. J Endodont 1979; 5: of scar tissue. Healing of the periapical 83-90. lesion may occasionally occur by means 6. Bergenholtz G, Lekholm U, of fibrous scar tissue, which appears as a Milthon R, Engstrom B. Influence periapical radiolucency of apical overinstrumentation indistinguishable from that seen in and overfilling on re-treated root failed endodontic treatment (9). canals. J Endodont 1979; 5: 310- In one study (10) scar tissue healing was 314. observed at the apices of teeth that had 7. Halse A, Molven O. Overextended previously undergone periapical gutta-percha and Kloroperka N-O curettage; it was concluded that a root canal fillings. Radiographic periapical scar develops only after findings after 10-17 years. Acta periapical surgery. However, in another Odontol Scand. 1987; 45(3): 171- histopathologic study, 2.5% of 2308 177. specimens were diagnosed as periapical 8. Yusuf H. The significance of the scars, most of which occurred at the presence of foreign material apices of conventionally rootfilled periapically as a cause of failure teeth (11). In the study by Nair et al. (9), of root treatment.. Oral Surg Oral the observation of scar tissue in 2 Med Oral Pathol. 1982; 54(5): specimens indicated that after root canal 566-574. treatment the periapical lesions healed 9. Nair PNR, Sjögren U, Figdor D, with soft connective tissue with no signs Göran Sundqvist G. Persistent of inlammation. periapical radiolucencies of root-
50 filled human teeth, failed endodontic treatments, and periapical scars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 617-627. 10. Seltzer S, Bender IB, Smith J, Freedman I, Nazimov H. Endodontic failures: an analysis based on clinical, roentgenographic, and histologic findings. Oral Surg Oral Med Oral Pathol 1967; 23: 500-530. 11. Bhaskar SN. Periapical lesion: types, incidence, and clinical features. Oral Surg Oral Med Oral Pathol 1966; 21: 657-671.
51 Case 10
Endodontic treatment of a maxillary anterior tooth
Fig. 1. Frontal view. Fig. 2. Buccal view.
Patient 61-year-old Caucasian female.
Chief complaint Pain in the mucosa above the maxillary left front tooth, sometimes-unprovoked radiating pain.
Fig. 3. Palatal view. Medical record The patient has dental fear. She explains Clinical tests May 27th2014 about traumatic experiences related to treatment of the upper front teeth after 23 22 21 11 a trauma in childhood. EPT Nd Nd Nd Nd Cold + - - - Percussion - - +,h Dental history Palpation - - - - The patient was referred to the post- PPD 3 3 3 3 graduate clinic from private practice for Mobility - - - endodontic treatment of the maxillary Biting - - - - left first incisor. She had a trauma (traffic accident) to her anterior teeth as a child and the teeth were restored with Radiographic findings May 27th2014 aluminium crowns until the age of 18. Dental: Teeth 21 and 11 have After that the metallic-ceramic dental radiopaque dental crowns. crowns (Fig. 1-3) were made. Periodontal: Within normal limits. Periapical: Tooth 21 has an apical radiolucency (PAI 3). Widened PDL th Clinical findings May 27 2014 space around the apex of tooth 11. A Soft tissue: Normal. continuous PDL space is seen around the Dental: Teeth 21 and 11 have dental root of tooth 22. crowns (Fig. 2, 3).
52
Fig. 4. Periapical radiograph 27.05.2014. Fig. 5. Locating the canal orifice.
Diagnosis May 27th2014
Diagnosis Pulpal K04.11 necrotic pulp Treatment June 3rd2014 Periodontal K05.01 chronic gingivitis 1 carpule of Xylocaine/adrenaline was injected. Access opening and Periapical K04.50 chronic apical periodontitis relocalization of canal orifice. Mechanical: Bur, NiTi hand instrumentation #20, RECIPROC one file endo: Treatment plan #40/0.04/23.5mm Endodontic treatment of tooth 21. Chemical: 0.5% chlorhexidine, 17% EDTA. Problem list Intracanal medicament: Ca(OH)2. Dental anxiety. Temporary filling: IRM. Pulp canal obliteration in the coronal half of the canal space.
Treatment May 27th2014 The patient cried during the first visit. She was afraid that the crown would be destroyed, however, she wanted to treat the tooth due to pain. 1 carpule of Xylocaine/adrenaline was injected. Access opening and careful localisation of the canal orifice with the aid of radiographs (Fig. 5). Mechanical: Burs, LN burs. Chemical: 17% EDTA. Fig. 6. Working-length radiograph. Temporary filling: IRM.
53 Treatment June 17th2014 Discussion No symptoms. Crown fractures of the permanent Filled with gutta-percha and AH Plus, dentition comprise the most frequent sealed with composite. form of traumatic dental injuries. Since enamel-dentin crown fractures expose a large number of dentinal tubules, pathways to the pulp are established for a variety of noxious agents present in the oral environment including bacteria and toxins (1-4). Therefore, to prevent pulpal injury, coverage of the exposed dentin would seem important. However, the effect of length of dentin exposure on pulpal response has been controversial. On the one hand this assumption is supported by a clinical study where pulpal necrosis (PN) was significantly increased in Fig. 7. Master cone radiograph. untreated crown fractured teeth with extensive dentin exposure (5). But, in teeth with functional, vital pulp tissue, dentin provides considerably resistance to bacterial ingress. Classical studies (6- 8) suggest that persistent bacterial provocation of exposed dentin, even in conjunction with resin restoration (9), tends to result in pulpal inflammatory lesions of limited duration. Cavalleri and Zerman (10) did a follow- up study of 84 crown fractured permanent incisors with incomplete root formation over a 5-year period. Four of 67 teeth (6%) with fracture of Fig. 8. Post-obturation radiograph. the enamel and dentine without pulpal involvement showed PN and 1 tooth showed pulp canal obliteration (PCO) Prognosis (1.5%). Eight of 14 teeth (57%) with : Good. Endodontic fractures of the enamel and dentine with : Good. Tooth pulp involvement showed PN. Robertson (11) did a retrospective Follow-up examination (phone call) evaluation of patients with September 9th2014 (3 months) uncomplicated crown fractures and The patient has no symptoms; no longer luxation injuries. A total of 241 patients tender when palpating over the root. with 545 injured teeth were available for clinical examination. In addition, 82 permanent incisors presenting with pulp canal obliteration were followed for a period of 7 to 22 years (mean 16 years). The findings showed little pulpal
54 response to crown fracture and 5. Ravn JJ. Follow-up study of subsequent restorative procedures as permanent incisors with enamel- long as there was no concomitant dentin fractures after acute periodontal injury (15-year follow-up). trauma. Scand J Dent Res 1981: PCO was found in all luxation categories. 89: 355-365. According to the survival curve the 20- 6. Lundy T, Stanley HR. Correlation year pulp survival rate diagnosed of pulp histopathology and radiographically was 84%. Although the clinical symptoms in human teeth risk of PN increased with time, routine subjected to experimental endodontic intervention of teeth with irritation. Oral Surg 1969; 27: on-going PCO of the root canal did not 187-201. seem justified (11). 7. Lervik T, Mjör IA. Evaluation of Robertson et al. (12) investigated pulp- techniques for the induction of healing responses following crown pulpitis. J Biol Bucc 1977; 5: 137- fracture in 455 teeth with or without 148. pulp exposure and luxation. The 8. Warfvinge J, Bergenholtz G. observation period ranged from 6 Healing capacity of human and months to 17 years (mean 2-3 years). monkey dental pulps following Crown fractures without luxation experimentally induced pulpitis. showed pulp survival (PS) in 99 %, PCO Endod Dent Traumatol 1986; 2. in 1 % and PN in 0 % of the cases. With 256-262. concomitant luxation PS was observed 9. Felton D, Bergenholtz G, Cox CF. in 70 %, PCO in 5 % and PN in 25 %. Inhibition of bacterial growth Their findings support the idea that in under composite restorations teeth with an intact pulpal circulation, following CLUMA pretreatment. dentin can provide considerable Dent Res 1989; 68: 491-495. resistance to bacterial invasion (13). 10. Cavalleri G, Zerman N. Traumatic crown fractures in permanent incisors with immature roots: a follow-up study. Endod Dent References Traumatol 1995; 11(6): 294-296. 1. Hørsted-Bindslev P, Simonsen A- 11. Robertson A. A retrospective M, Larsen MJ. Monkey pulp evaluation of patients with reactions to restorative uncomplicated crown fractures materials. Scand J Dent Res 1986; and luxation injuries. Endod Dent 94: 154-163. Traumatol 1998; 14(6): 245-256. 2. Bergenholtz G, Cox CF, Loesche 12. Robertson A1, Andreasen FM, WJ, Syed SA. Bacterial leakage Andreasen JO, Norén JG. Long- around dental restorations: its term prognosis of crown- effect on the dental pulp. Oral fractured permanent incisors. Pathol 1982; 11: 439-450. The effect of stage of root 3. Brännström M, Nyborg H. Pulpal development and associated reactions to composite resin luxation injury. Int J Paediatr restorations. J Prosth Dent 1972; Dent. 2000; 10(3): 191-199. 27: 181-189. 13. Bergenholtz G. Pathogenic 4. Brännström M, Vojinovic O. mechanisms in pulpal disease. J Response of the dental pulp to Endod 1990; 16: 98-101. invasion of bacteria around three filling materials. ASCD J Dent for children 1976; 43: 15-21.
55 Case 11
Patient with persistent pain maxilla left side
Clinical findings April 11th2014 Soft tissue: Normal findings. Dental: Tooth 25: Composite fillings. Tooth 26: Large composite restoration (MODP), temporary occlusal filling, chronic caries. Fig. 1. Frontal view. Tooth 27: Composite fillings, chronic caries.
Patient
32-year-old Caucasian male.
Chief complaint The patient is complaining about occasional throbbing pain (once a week) in the left side of maxilla. The pain mainly arises after consumption of red wine and the tooth pain often comes with a temporary headache. He describes the pain as ”nerve pain”. The pain started after a root canal treatment Fig. 2. Occlusal view. of the maxillary left first molar. The pain persisted after endodontic treatment and the tooth was later retreated two Clinical tests April 11th2014 times without any relieve of symptoms. He is not using any pain medications. 26 27 EPT Nd Nd Cold - + Medical record Percussion + + Non-contributory. Palpation - - PPD 3 3 Mobility - - Dental history Biting - - The patient was referred to the post- graduate endodontic clinic from private th practise for apicoectomy of the Radiographic findings April 11 2014 maxillary left first molar. Tooth 26 had Dental: Teeth 25, 26, 27 have been treated endodontically several radiopaque restoration materials. Tooth times. 26 has a radiopaque root filling material.
56 Periodontal: Normal findings. endodontically treated maxillary left Apical: Teeth 25 and 27 have continuous first molar. PDL spaces. Tooth 26 uncertain findings mesial root; flush root canal filling. Based on uncertain clinical and Problem list radiographic findings, the patient was Neuropathic pain. referred for cone-beam CT (CBCT).
Prognosis Tooth: uncertain
Radiologic description (in Norwegian) from the Department of Maxillofacial Radiology, May 6th2014
Fig. 3. Periapical radiograph.
Fig. 4. Periapical radiograph.
Diagnosis April 11th2014
Diagnosis Pulpal K04.19 endodontically treated
Periodontal within normal limits
Periapical within normal limits
Nerve disorders G50.10 atypical facial pain?
Treatment plan CBCT referral. Treatment alternative: Surgical retreatment of the mesial root of the
57 periapical radiographs may reflect limitations of the diagnostic method rather than an absence of an osteolytic lesion (3, 4). Superimposition of adjacent anatomical structures over the suspect tooth may further obscure the view. Conversely, residual periapical disease may be truly absent and the pain may be nonodontogenic. Nonodontogenic dentolalveolar pain is often difficult to diagnose because it is poorly understood (5, 6). Nonodontogenic pain in the dentoalveolar region can arise from four potential processes: 1) referred musculoskeletal pain disorder, 2) neuropathic pain disorder, 3) headache disorders presenting in the dentoalveolar region, and 4) a pathological process outside the Fig. 5. CBCT. immediate dentoalveolar region that refers pain to that area, such as sinus Follow-up examination May 27th2014 disease, salivary gland disorders, brain Information about CBCT findings. The tumors, angina, throat cancer, and patient is advised to have a permanent craniofacial vascular disorders (7, 8). filling in tooth 26, preferably a dental Pain in a tooth site of neurogenic origin crown, and a general caries check. has been reported in the literature (9, 10) but only a few published studies (9- 14) have investigated the occurrence of Follow-up examination (phone call) neuropathic pain after dental treatment. September 30th2014 Evidence of the association between Fewer symptoms from the tooth. He dental treatment and chronic feels some ”discomfort” approximately neuropathic pain has been presented by once a month. He has not decided if he Marbach (11), Schnurr & Brooke (12) wants to keep the tooth and have a and Vicker et al. (13), who reported that crown made. At present, he is waiting most patients diagnosed with atypical for his dentist to return after maternity odontalgia related the onset of the pain leave. to dental treatment, dental infection or dental trauma. Only three epidemiological studies (9, Discussion 10, 14) have investigated the prevalence Persistent pain associated with teeth of chronic neuropathic pain after dental after nonsurgical or surgical endodontic treatment. treatment has been used as an indicator The study by Marbach et al. (9) was of treatment failure (1, 2). However, conducted by a single endodontist, who pain may be experienced in a tooth or mailed questionnaires to patients 1 adjacent site in the absence of clinical or month following nonsurgical endodontic radiographic signs of dental disease. treatment. Only female patients were Failure to detect pathological change on included in their analyses because the
58 male sample was considered too small. a systematic review of prospective Of the 256 female patients assessed, 20 studies that reported the frequency of (9%) reported persistent pain during nonodontogenic pain in patients who the period of survey but only 11 female had undergone endodontic procedures. patients attended for clinical and In their study, 3.4 % of patients radiographic examination to exclude an experienced persistent pain of odontogenic cause of pain. Of the 11 nonodontogenic origin for 6 months or patients, eight (3% of 256 female more after root canal therapy. patients) were diagnosed with ‘phantom In rare cases, chronic persistent tooth toothache’. pain does not respond to dental Campbell et al. (10) carried out a similar treatment. Some of these cases might be survey of patients who had undergone due to neuropathic pain disorders surgical endodontic treatment 2 years induced by nerve injuries sustained previously and found that 59 (5%) of during endodontic procedures. the 118 patients suffered from chronic Neuropathic pain is defined as a pain pain that divided equally into two initiated or caused by a primary lesion groups; post-traumatic stress in or dysfunction of the nervous system. dysaesthesia (absence of pain Clinically, neuropathic pain is preoperatively) and phantom tooth pain characterized by partial or complete (presence of pain preoperatively). somatosensory change in the In contrast, Berge (14) found none of the innervation territory of a specific part 1035 patients in their survey suffered of the peripheral or central nervous from chronic neuropathic pain following system along with the paradoxical surgical removal of third molars 5–6 presence of pain and hypersensitivity years previously. phenomena (18). Several studies have Polycarpou et al. (15) investigated the reported that endodontic procedures prevalence of persistent pain after are related to the development of endodontic treatment and factors neuropathic tooth pain (NTP) (9, 10, 19- affecting its occurrence in cases with 23). NTP is also known as atypical complete radiographic healing. 175 odontalgia (21) and phantom tooth pain patients/teeth were reviewed 12–59 (PTP) (9, 20). Some cases of chronic months following treatment. The tooth pain related to endodontic prevalence of persistent pain after procedures have been reported in which successful root canal treatment was repeated dental treatments failed to 12% (21/175). A positive history of provide pain relief (20, 21). previous chronic pain experience or One study reported that the incidence of painful treatment in the orofacial region, NTP after endodontic procedures was and female gender were important risk greater than that after any other dental factors associated with persistent pain treatment such as tooth extraction and after successful endodontic treatment. trauma (23). Marbach (16) has suggested that a Furthermore, 3 retrospective studies deafferentation pain syndrome may be have reported that 3%–12% of patients triggered by pulp amputation. Support developed NTP after endodontic for this theory comes from the work of procedures (9, 10, 15). Hu & Sessle (17) who showed that Oshima et al. (18) conducted another somato-sensory pathways alter as a retrospective study of 271 patients who result of removal of pulp tissue in cats. had chronic persistent tooth pain that Nixdorf et al. (7) conducted did not respond to endodontic procedures despite the absence of
59 ”major pathology”. Pain predominantly 7. Nixdorf DR, Moana-Filho EJ, Law occurred in the maxilla (14 patients). In AS, McGuire LA, Hodges JS, John 10 patients (62.5%), NTP developed MT. Frequency of after retreatment. The majority of Nonodontogenic Pain after patients were female. Daily application Endodontic Therapy: A of tricyclic antidepressants produced Systematic Review and Meta- pain relief in 11 patients (68.8%). Analysis. JOE 2010; 36 (9): 1494- 1498. 8. Mattscheck D, Law AS, Nixdorf References DR. Diagnosis of nonodonogentic 1. Rahbaran S, Gilthorpe MS, toothache. In: Hargreaves KM, Harrison SV, Gulabivala K. Cohen S, eds. Cohen’s pathways Comparison of clinical outcome of the pulp. 10th ed. St. Louis, of periapical surgery in MO: Mosby Inc. 2011: 49–70. Endodontic and Oral Surgery 9. Marbach JJ, Hulbrock J, Segal AG. units of a teaching Dental Incidence of phantom tooth pain. Hospital: a retrospective study. Oral Surg, Oral Med, Oral Pathol. Oral Surg, Oral Med, Oral Pathol, 1982; 53: 190–193. Oral Radiol, Endod 2001; 91: 10. Campbell RL, Parks KW, Dodds 700–709. RN. Chronic facial pain associated 2. Hoskinson SE, Ng Y-L, Moles D, with endodontic therapy. Oral Hoskinson AE, Gulabivala K. Surg, Oral Med, Oral Pathol. Comparison of outcome or root 1990; 69: 287–290. canal treatment using two 11. Marbach JJ. Phantom tooth pain. J different protocols. Oral Surg, Endod 1978; 4: 362–372. Oral Med, Oral Pathol, Oral 12. Schnurr RF, Brooke RI. Atypical Radiol, Endod 2002; 93: 705– Odontalgia. Update and comment 715. on long term follow up. Oral Surg, 3. Bender IB, Seltzer S. Oral Med, Oral Pathol 1992; 73: Roentgenographic and direct 445–448. observation of experimental 13. Vicker ER, Cousins MJ, Walker S, lesions in bone. Part I. J Am Dent Chisholm K . Analysis of 50 Assoc 1961; 62: 152–160. patients with atypical odontalgia: 4. Shoha RR, Dowson J, Richards AG. a preliminary report on Radiographic interpretation of pharmacological procedures for experimentally produced bony diagnosis and treatment. Oral lesions. Oral Surg 1974; 38: 294– Surg, Oral Med, Oral Pathol, 303. Endod 1998; 85: 24–32. 5. Israel HA, Ward JD, Horrell B, et 14. Berge TI. Incidence of chronic al. Oral and maxillofacial surgery neuropathic pain subsequent to in patients with chronic orofacial surgical removal of impacted pain. J Oral Maxillofac Surg 2003; third molars. Acta Odont Scand 61: 662–667. 2002; 60: 108–112. 6. deSiqueira SRDT, Nobrega JCM, 15. Polycarpou N, Ng YL, Canavan D, Valle LBS, et al. Idiopathic Moles DR, Gulabivala K. trigeminal neuralgia: clinical Prevalence of persistent pain aspects and dental procedures. after endodontic treatment and Oral Surg Oral Med Oral Path Oral factors affecting its occurrence in Rad Endod 2004; 98: 311–315. cases with complete radiographic
60 healing. Int Endod J. 2005; 38(3): 169-178. 16. Marbach JJ. Is Phantom tooth pain a deafferentation (neuropathic) syndrome? Part 1 Evidence derived from the pathophysiology and treatment. Oral Surgery, Oral Medicine, Oral Pathology 1993; 75. 95–105. 17. Hu JW, Sessle BJ. Effects of tooth pulp deafferentation on nociceptive neurons of the feline trigeminal subnucleus caudalis. Journal of Neurophysiology 1989; 61: 1197–1206. 18. Oshima K, Ishii T, Ogura Y, Aoyama Y, Katsuumi I. Clinical Investigation of Patients Who Develop Neuropathic Tooth Pain After Endodontic Procedures. J Endod 2009; 35: 958–961. 19. Vickers ER, Cousins MJ. Neuropathic orofacial pain: part 1—prevalence and pathophysiology. Aust Endod J 2000; 26: 19–26. 20. Battrum DE, Gutmann JL. Phantom tooth pain: a diagnosis of exclusion. Int Endod J 1996; 29: 190–194. 21. Lilly JP, Law AS. Atypical odontalgia misdiagnosed as odontogenic pain: a case report and discussion of treatment. J Endod 1997; 23: 337–339. 22. Matwychuk MJ. Diagnostic challenges of neuropathic tooth pain. J Can Dent Assoc 2004; 70: 542–546. 23. Lynch ME, Elgeneidy AK. The role of sympathetic activity in neuropathic orofacial pain. J Orofac Pain 1996; 10: 297–305.
61 Case 12
Endodontic retreatment and apical surgery of the maxillary right canine
Fig. 2. Buccal view. Fig. 1. Frontal view.
Clinical tests May 18th2011 Patient 65-year-old Caucasian female. 11 12 13 EPT 80 80 80 Cold + - - Chief complaint Percussion - +(v) - Tender to palpation. Palpation + + - PPD 3 3 3 Mobility - - Medical record Biting - - - Non-contributory.
Radiographic findings May 18th2011 Dental history Dental: Tooth 13 was endodontically treated by Teeth 13 and 12 have radiopaque dental general practitioner 5 years ago (due to crowns. A radiopaque root filling apical periodontitis). History of a sinus material is seen in both teeth. tract. Tooth 12 is going to be extracted Periodontal: Attachment loss. and an implant or a dental bridge is Apical: An apical radiolucency is seen planned. around the root of tooth 13 (PAI 4). The patient was referred to the post- Widened PDL space apically around the graduate endodontic clinic for root of tooth 12. retreatment and complementary apical surgery of tooth 13.
Clinical findings May 18th2011 Soft tissue: A sinus tract is evident apically region 13. Dental: Teeth 11, 12 and 13 have dental crowns.
62
Fig. 3. Periapical radiograph. Fig. 4. Working length radiograph.
Treatment August 31th2011 th The patient is asymptomatic. Access Diagnosis May 18 2011 opening and attempt to remove GP in
Diagnosis the apical part of the canal. Apical Pulpal K04.19 endodontically treated perforation and bleeding at the tip of paper point. Adjustment of working Periodontal K05.03 chronic marginal periodontitis length and enlargement. Mechanical: Burs, Hedstrøm- and Periapical K05.40 chronic apical periodontitis NiTi hand files: #70/21.5mm Chemical: Chloroform, 1% NaOCl, 17% EDTA. Treatment plan Orthograde retreatment and Filled with gutta-percha and AH Plus complementary apical surgery tooth 13. Sealed with IRM plug and composite.
Problem list Gingival recession and aesthetics.
Treatment May 18th2011 1 carpule of Septocaine was injected. Access opening and localization of gutta- percha (GP). Not able to remove all GP apically. Mechanical: Burs, Gates glidden, Prerace,
NiTi hand files: Fig. 5. Master cone radiograph. #60/23mm adjusted to 22.5 mm Chemical: Chloroform, 1% NaOCl, 17% EDTA. Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
63
Fig. 8. Osteotomy. Extruded GP is visible.
Fig. 6. Post-obturation radiograph.
Surgery September 28th2011 The patient was given a chlorhexidine mouth rinse and local anaesthetic was injected. A marginal incision was made running from tooth 11 to tooth 14 with a vertical releasing incision on the distal Fig. 9. Root end resection 3mm. aspect of 14. Elevation of the mucoperiosteal flap revealed pathological fenestration and extruded GP. Osteotomy and curettage of granulation tissue. Biopsy. Root-end resection 3mm and retrograde preparation with ultrasonic instruments. Haemostasis using resorbable surgicel and ferric sulphate. Fig. 10. Periapical radiograph, root-end A retrograde filling of white MTA was preparation. applied. The operation site was rinsed with sterile saline and the flap sutured in place with supramide 4.0. Administration of Ibux 400mg. Postoperative instructions.
Fig. 11. Root-end filling using white MTA.
Fig. 7. Marginal incision. Pathologic fenestration apically, tooth 13.
64
Fig.12. Periapical radiograph to see placement of root-end filling.
Fig. 15. Periapical control radiograph 4 months.
Follow up examination May 14th2013 (2 years) Asymptomatic. The apical radiolucency seems to have healed well.
Fig. 13. Suturing.
Prognosis Endodontic/surgery: Good. Tooth: Good.
Follow-up examination October 11th2011 (2 weeks) The patient had no postoperative complaints. Suture removal. Fig. 16. Periapical control radiograph 2 years.
Radiograph from general practitioner September 4th2013
Fig. 14. Follow-up (2 weeks).
Follow up examination January 26th2012 (4 months) Asymptomatic. Healing of apical radiolucency. Fig. 17. Periapical radiograph 04.09.2013.
65 Discussion Post-treatment disease has been Non-surgical endodontic treatment is a demonstrated to be highly associated predictable and reliable treatment with with intraradicular infection by studies high success rates ranging from 86%– using microscopy (12-14), culture (15, 98% (1, 2). Nevertheless, for a variety of 16) or molecular methods (17, 18, 19). reasons, endodontic failure still occurs, The outcome of treatment has been and presence of clinical signs and shown to be poorer when bacteria symptoms along with radiographic persist in the root canals at the time of evidence of periapical bone destruction filling (20, 21). This may indicate that indicates the need for retreatment (3, 4). residual bacteria can survive in treated Etiologic factors of endodontic failure canals for many years and induce or can be placed into 4 groups (5): (1) sustain periradicular tissue persistent or reintroduced inflammation. intraradicular microorganism, (2) Extraradicular infections are usually extraradicular infection, (3) foreign associated with acute inflammation, body reaction, and (4) true cysts. Among clinically characterised by an abscess those, many studies reported that with accompanying pain and swelling, microorganisms in the root canals or or a sinus tract. However, it has been periradicular lesions play a major role in suggested that in some cases an the persistence of apical periodontitis extraradicular infection may be after a root canal treatment (6-8). Non- associated with chronic inflammation microbial factors have also been and lead to endodontic treatment suggested as a potential cause of post- failure. This condition may be associated treatment disease (9), but evidence is with a biofilm formation on the external relatively weak as it comes from a few root surface (22), sometimes showing case reports. calculus-like calcifications (23), or Endodontic failure related to forming cohesive actinomycotic colonies microorganisms can be caused by within the body of the lesion (24). procedural errors such as root There are some few case reports that perforation, ledge formation, separated suggest that some lesions may not heal instruments, and missed canals, as well because of endogenous or exogenous as anatomical difficulties such as apical non-microbial factors (25). Endogenous ramification, isthmuses, and other causes include cholesterol crystals and morphologic irregularities (8, 10). true cysts, whereas exogenous causes Song et al. (11) examined the clinical comprise foreign-body reactions to causes of failure and the limitation of apically extruded filling materials, paper previous endodontic treatment by points or food (14, 26). Nevertheless, in examining the root apex and resected most of these cases it is difficult to rule root surface at 26x magnification during out the concomitant presence of endodontic microsurgery. A total of 493 infection as the cause of the disease. roots were analysed. The most common possible cause of failure was a leaky canal (30.4%), followed by a missing References canal (19.7%), under filling (14.2%), 1. Friedman S, Abitbol S, Lawrence anatomical complexity (8.7%), HP. Treatment outcome in overfilling (3.0%), iatrogenic problems endodontics: the Toronto (2.8%), apical calculus (1.8%) and apical Study—phase 1: initial cracks (1.2%). treatment. J Endod 2003; 29: 787–793.
66 2. Setzer FC, Boyer KR, Jeppson JR, apical periodontitis. Brit Dent J Karabucak B, Kim S. Long-term 2014; 216: 305-312. prognosis of endodontically 10. Lin LM, Rosenberg PA, Lin J. Do treated teeth: a retrospective procedural errors cause analysis of preoperative factors endodontic treatment failure? J in molars. J Endod 2011; 37: 21– Am Dent Assoc 2005; 136: 187– 25. 193. 3. Barbizam JV, Fariniuk LF, 11. Song M, Kim HC, Lee W, Kim E. Marchesan MA, Pecora JD, Sousa- Analysis of the Cause of Failure in Neto MD. Effectiveness of manual Nonsurgical Endodontic and rotary instrumentation Treatment by Microscopic techniques for cleaning flattened Inspection during Endodontic root canals. J Endod 2002; 28: Microsurgery. J Endod 2011; 11: 365–366. 1516-1519. 4. De Cleen MJ, Schuurs AH, 12. Nair P N, Sjögren U, Krey G, Wesselink PR, Wu MK. Periapical Kahnberg K E, Sundqvist G. status and prevalence of Intraradicular bacteria and fungi endodontic treatment in an adult in root-filled, asymptomatic Dutch population. Int Endod J human teeth with therapy- 1993; 26: 112–119. resistant periapical lesions: a 5. Nair R. Pathology of apical long-term light and electron periodontitis. In: Ørstavik D, Pitt microscopic follow-up study. J Ford TR, eds. Essential Endod 1990; 16: 580–588. Endodontology: Prevention and 13. Ricucci D, Siqueira J F Jr. Biofilms Treatment of Apical and apical periodontitis: study of Periodontitis, 2nd ed. Boston, prevalence and association with MA: Blackwell Science; 2008: 68– clinical and histopathologic 88. findings. J Endod 2010; 36: 1277– 6. Sundqvist G, Figdor D, Persson S, 1288. Sjogren U. Microbiologic analysis 14. Ricucci D, Siqueira J F Jr., Bate A of teeth with failed endodontic L, Pitt Ford T R. Histologic treatment and the outcome of investigation of root canal- conservative re-treatment. Oral treated teeth with apical Surg Oral Med Oral Pathol Oral periodontitis: a retrospective Radiol Endod 1998; 85: 86–93. study from twenty-four patients. 7. Gomes BPFA, Pinheiro ET, Jacinto J Endod 2009; 35: 493–502. RC, Zaia AA, Ferraz CCR, Souza- 15. Sundqvist G, Figdor D, Persson S, Filbo FJ. Microbial analysis of Sjögren U. Microbiologic analysis canals of root-filled teeth with of teeth with failed endodontic periapical lesions using treatment and the outcome of polymerase chain reaction. J conservative re-treatment. Oral Endod 2008; 34: 537–540. Surg Oral Med Oral Pathol Oral 8. Lin LM, Skribner JE, Gaengler P. Radiol Endod 1998; 85: 86–93. Factors associated with 16. Pinheiro E T, Gomes B P, Ferraz C endodontic treatment failures. J C, Sousa E L, Teixeira F B, Souza- Endod 1992; 18: 625–627. Filho F J. Microorganisms from 9. Siqueira JF, Rocas IN, Ricucci D, canals of root-filled teeth with Hülsmann N. Causes and periapical lesions. Int Endod J management of post-treatment 2003; 36: 1–11.
67 17. Siqueira J F Jr, Rôças I N. 25. Nair P N. Pathogenesis of apical Polymerase chain reaction-based periodontitis and the causes of analysis of microorganisms endodontic failures. Crit Rev Oral associated with failed endodontic Biol Med 2004; 15: 348–381. treatment. Oral Surg Oral Med 26. Koppang H S, Koppang R, Solheim Oral Pathol Oral Radiol Endod T, Aarnes H, Stolen S O. Cellulose 2004; 97: 85–94. fibres from endodontic paper 18. Rôças I N, Siqueira J F Jr. points as an etiological factor in Characterization of microbiota of postendodontic periapical root canal-treated teeth with granulomas and cysts. J Endod posttreatment disease. J Clin 1989; 15: 369–372. Microbiol 2012; 50: 1721–1724. 19. Schirrmeister J F, Liebenow A L, Pelz K et al. New bacterial compositions in root-filled teeth with periradicular lesions. J Endod 2009; 35: 169–174. 20. Fabricius L, Dahlén G, Sundqvist G, Happonen R P, Möller A J R. Influence of residual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth. Eur J Oral Sci 2006; 114: 278–285. 21. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997; 30: 297–306. 22. Tronstad L, Barnett F, Cervone F. Periapical bacterial plaque in teeth refractory to endodontic treatment. Endod Dent Traumatol 1990; 6: 73–77. 23. Ricucci D, Martorano M, Bate A L, Pascon E A. Calculus-like deposit on the apical external root surface of teeth with post- treatment apical periodontitis: report of two cases. Int Endod J 2005; 38: 262–271. 24. Happonen R P. Periapical actinomycosis: a follow-up study of 16 surgically treated cases. Endod Dent Traumatol 1986; 2: 205–209.
68 Case 13
Endodontic retreatment in conjunction with apical surgery of the mandibular right first molar with a separated instrument
Clinical findings September 28th2010 Soft tissue: Normal findings Dental: Tooth 44 has an occlusal amalgam filling and a buccal composite filling. Buccal caries is noted along the composite margins. A craze line is seen at the Fig. 1. Frontal view. buccal aspect, running in an occlusal- cervical direction. Tooth 45 has a dental crown. Patient Tooth 46 has a composite restoration 54-year-old Caucasian male. with a small buccal amalgam filling, and there is caries along the margins of the restorations. Chief complaint He has no symptoms at present, but he complains about several episodes of pain and swelling in the lower right mandible. His dentist/doctor has prescribed antibiotics (AB) at several occasions due to tooth pain.
Medical record The patient is diagnosed with Bechterev. Fig. 2. Buccal view. He has dental fear. Medicaments: Celebra, Prednisolone.
Dental history Concomitant with the last AB regimen the patient was referred to the postgraduate clinic from private practice for retreatment of the mandibular right first molar. Tooth 46 was endodontically treated Fig. 3. Lingual view. many years ago. At several occasions the last year, the patient received dental emergency treatment consisting of AB prescriptions for tooth pain related to the specific tooth.
69 th Clinical tests September 28 2010 Treatment plan Non-surgical retreatment of the 44 45 46 endodontically treated right mandibular 25 12 80 EPT first molar and observation. Cold + + - Percussion - - - Palpation - - - Problem list 3 3 3 PPD Instrument removal and negotiation of Mobility - - - apical third. Biting - - -
Treatment September 28 th2010 1 carpule of Septocaine was injected. Radiographic findings September th Access opening and localization of old 28 2010 GP and of untreated DL canal. : Tooth 46 has a radiopaque filling Dental Mechanical: Burs, Gates glidden, material. A radiopaque root canal filling Hedstrøm files, NiTiFlex hand files: material and a separated instrument in MB: #40/18.5mm the mesial root is seen. Tooth 45 has a ML: #40/20.5 radiopaque dental crown and a DB: #40 /18.5mm radiopaque root filling material. DL: #40/21.5mm : Within normal limits Periodontal Chemical: Chloroform, 1% NaOCl, 17% Apical: An apical radiolucency around EDTA. the root of tooth 46 is seen (PAI 4). A Intracanal medicament: CaOH2 normal PDL space is seen around the Temporary filling: Cavit, IRM root of tooth 45.
Fig. 4. Periapical radiograph 28.09.2010. Fig. 5. Working length radiograph.
th Diagnosis September 28th2010 Treatment October 26 2010 History: The patient experienced a flare- Diagnosis up three days ago during physical Pulpal K04.19 endodontically treated workout. Emergency treatment at the student Periodontal Within normal limits clinic: Prescription of phenoxymethylpenicillin and Periapical K04.50 chronic apical periodontitis paracetamol/codein. At present: Tooth is tender on biting only.
70
Fig. 6. Periapical radiograph 26.10.2010. Fig. 8. Post-obturation radiograph 23.11.2010.
Mechanical: NiTiFlex hand files, Prognosis adjusting working lengths according to Endodontic: Uncertain. apex locator: Tooth: Uncertain. MB: #40/18.5mm
ML: #40/21mm rd DB: #40 /21mm Follow-up examination August 23 2011 DL: #40/23mm (8 month) Chemical: 1% NaOCl, 17% EDTA, 2% The patient describes another history of chlorhexidine-di-gluconate. flare-up and antibiotic treatment in June Intracanal medicament: Chlorhexidine- 2011 at private practice. : di-gluconate /CaOH2. Radiographic findings 23.08.2011 Temporary filling: Cavit, IRM. Radiolucency seemed unchanged from November 2010. Treatment plan: Surgical retreatment of Treatment November 23rd2010 the endodontically treated mandibular The patient has no symptoms. Tooth 46 right first molar. filled with gutta-percha and AH Plus. Sealed with IRM.
Fig. 9. Periapical radiograph 23.08.2011.
Fig. 7. Master cone radiograph.
Fig. 10. Orthopanthogram 23.08.2011.
71 Surgical treatment September 21th2011 The patient was given a chlorhexidine mouth rinse and local anaesthetic was injected. A marginal incision was made running from tooth 43 to tooth 46 with vertical releasing incisions at the distal aspect of 46 and mesial aspect of 43. Elevation of the mucoperiosteal flap. Osteotomy and curettage of granulation tissue. Biopsy. Root-end resection and Fig. 13. Root resection 3mm. retrograde preparation with ultrasonic instruments. Fractured instrument in mesial root removed simultaneously with resected root. Adrenalin and ferric sulphate haemostasis. Retrograde filling of IRM was applied. The operation site was rinsed with sterile saline and the flap sutured in place with supramide 4.0 and 5.0. Postoperative instructions.
Fig. 14. Root-end preparation.
Fig. 11. Buccal view of operation site.
Fig. 15. Root-end filling with IRM.
Prognosis Surgery: Good. Tooth: Good. Fig. 12. Enucleation of lesion.
Follow up examination September 27th2011 (1 week) The patient experienced mild post- operative discomfort. Suture removal. A secondary healing pattern was observed in the posterior region and the patient was advised to rinse with chlorhexidine for another week.
72 Follow up examination October 8th2013 elevated number of teeth to be retreated (2 years) resulting in periapical radiolucencies Asymptomatic, a crown is now planned. from poor root-canal therapies (10). Radiograph shows healing of apical Gorni & Gagliani (11) studied 254 radiolucency. molars, 107 premolars, and 91 single- root anterior teeth and found that the success rate was significantly lower in teeth with altered root canal morphology (47%) compared with teeth in which no significant anatomical changes were made by the former endodontic treatment (86,8%). Formerly treated teeth with persistent periapical lesions might be preserved with nonsurgical retreatment, assuming Fig. 16. Periapical control radiograph 2 years. the tooth is restorable and periodontally sound. Bergenholtz et al. (12) reported a success rate of 78% in teeth with Discussion periapical pathologies and 94% in teeth Procedural accidents have a negative without. Sundqvist et al. (13) reported effect on healing and might contribute to an overall success rate of 74% of 50 the persistence of infections in cases examined after retreatment. They inaccessible apical areas, requiring found that the success rate in bacteria- surgical intervention. free canals was almost 80%; whereas in The failure of nonsurgical root canal teeth with particular bacterial species treatment is commonly related to the the outcome was significantly lower presence of residual bacteria (persistent (66%). In a study by Sjögren et al. (14), infection) or the reinfection of a similar results were achieved and previously disinfected root canal further considerations were made environment (secondary infection) (1). regarding the size of the lesions: the Unsuccessful outcomes can be greater the lesion, the lower the success attributed to persistent intraradicular rate. Chugal et al. (15) confirmed these infections found in previously un- results. instrumented canals, dentinal tubules, Some authors have reported better or the complex irregularities of the root clinical results with surgical procedures canal system (2, 3, 4). The extraradicular compared with orthograde retreatment causes of endodontic failures include (16), although others have reported periapical actinomycosis, a foreign-body similar clinical outcomes using both reaction caused by extruded endodontic techniques with slight differences materials, the accumulation of related only to the time element. Kvist & endogenous cholesterol crystals in the Reit (17) did a randomized clinical study apical tissues, and an unresolved cystic comparing surgical and nonsurgical lesion (5-8). Previous procedural procedures. They failed to show any accidents may have a negative effect on systematic difference in the outcome of healing. Besides, they might contribute surgical and nonsurgical endodontic to the establishment of infections at retreatment. Surgical retreatment inaccessible apical areas, requiring a seemed to result in more rapid surgical intervention (9). periapical bone fill, but also might imply In different European countries, a higher risk of ”late failures”. epidemiological studies have shown an
73 Torabinejad el al. (18) performed a human periapical lesions systematic review to compare the obtained with extracted teeth. outcomes of nonsurgical and surgical Oral Surg Oral Med Oral Pathol retreatment. They concluded that while Oral Radiol Endod 1996; 81: 93– endodontic surgery demonstrates more 102. favourable initial healing, this declines 9. Wu MK, Dummer PM, Wesselink with increasing recall periods. PR. Consequences of and Conversely, nonsurgical retreatment strategies to deal with residual shows improved outcomes with post-treatment root canal increasing recall time. infection. Int Endod J 2006; 39: 343–356. 10. Eriksen HM. Endodontology- References epidemiological considerations. 1. Siqueira JF Jr. Reaction of Endod Dent Traumatol 1991; 7: periradicular tissues to root canal 189–195. treatment: benefits and 11. Gorni FGM, Gagliani MM. The drawbacks. Endod Topics Outcome of Endodontic 2005;10: 123–147. Retreatment: A 2-yr Follow-up. J 2. Stropko JJ. Canal morphology of Endod 2004; 30: 1-4. maxillary molars: clinical 12. Bergenholtz G, Lekholm U, observations of canal Milthon R, et al. Retreatment of configurations. J Endod 1999; 25: endodontic fillings. Scand J Dent 446–450. Res 1979; 87: 217–224. 3. Nair PN. On the causes of 13. Sundqvist G, Fidgor D, Persson S, persistent apical periodontitis: a et al. Microbiologic analysis of review. Int Endod J 2006; 39: teeth with failed endodontic 249–281. treatment and the outcome of 4. Ricucci D, Siqueira JF Jr. conservative retreatment. Oral Anatomic and microbiologic Surg Oral Med Oral Pathol Oral challenges to achieving success Radiol Endod 1998; 85: 86–93. with endodontic treatment: a 14. Sjögren U, Hagglund B, Sundqvist case report. J Endod 2008; 34: G, et al. Factors affecting the 1249–1254. longterm results of endodontic 5. Tronstad L, Barnett F, Cervone F. treatment. J Endodon 1990; 16: Periapical bacterial plaque in 498–504. teeth refractory to endodontic 15. Chugal NM, Clive JM, Spångberg treatment. Endod Dent LS. A prognostic model for Traumatol 1990; 6: 73–77. assessment of the outcome of 6. Nair PN, Sjögren U, Krey G, endodontic treatment: effect of Sundqvist G. Therapy-resistant biologic and diagnostic variables. foreign body giant cell granuloma Oral Surg Oral Med Oral Pathol at the periapex of a root-filled Oral Radiol Endod 2001; 91: human tooth. J Endod 1990; 16: 342–352. 589–595. 16. Danin J, Stromberg T, Forsgren H, 7. Nair PN. Cholesterol as an et al. Clinical management of aetiological agent in endodontic nonhealing periradicular failures: a review. Aust Endod J pathosis. Surgery versus 1999; 25: 19–26. endodontic retreatment. Oral 8. Nair PN, Pajarola G, Schroeder HE. Types and incidence of
74 Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82: 213–217. 17. Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study comparing surgical and nonsurgical procedures. J Endodon 1999; 25: 814–817. 18. Torabinehad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod 2009: 35: 930-937.
75 Case 14
Explorative surgery of the maxillary left second incisor with sinus tract
Patient Clinical tests October 19th2011 72-year-old Caucasian male. 22 EPT Nd Chief complaint Cold Nd The patient complains about Percussion +v,h spontaneous pain and tenderness when Palpation + chewing in the front region of the upper PPD left maxilla. The pain is worse in the Mobility I morning. Biting +
Medical record Radiographic findings October 19th2011 Non-contributory. Dental: Tooth 22 has a non-radiopaque distal filling and a radiopaque coronal filling material. The root canal is filled Dental history with a homogeneous radiopaque The patient was referred to the material. postgraduate clinic from a specialist in Periodontal: Moderate attachment loss. endodontics for apicoectomy of the Periapical: Tooth 22 has an apical maxillary left lateral incisor. The tooth circumferential radiolucency (PAI 5). was root filled one year ago (2010) by the referring specialist due to apical periodontitis. One year later (2011) the patient presented with pain and a sinus tract was evident.
Clinical findings October 19th2011 Soft tissue: A draining sinus tract was evident at the distal aspect of tooth 22. Dental: Tooth 22 had a distopalatal composite filling. Fig. 1. Periapical radiograph 19.10.2011.
76
Fig. 2. Sinus tract. Fig. 3. Draining sinus tract.
Diagnosis October 19th2011 An incomplete vertical root fracture was evident in the apical part of the root; Diagnosis resection was done at the mid-root level Pulpal K04.19 endodontically treated (Fig. 3.). Tooth 22 was kept in place as temporary restoration and the tooth
Periodontal K05.03 chronic marginal periodontitis was stabilized with a dentine adhesive and a composite restoration to the Periapical K04.69 chronic apical periodontitis neighbouring teeth. with sinus tract
Treatment plan Explorative surgery tooth 22.
Problem list Root fracture?
Surgery October 19th2011 1. Local anaesthetic (xylocaine/adrenaline), 2. Sulcular flap from tooth 24 to tooth 11D, vertical Fig. 4. Root resection. "Sulphur granules" is seen releasing incision 11D, 3. Curettage of in the soft tissue lesion. granulation tissue and removal of ”sulphur granules”, 4. Biopsy and microbiological sample, 5. Root resection mid-root level due to incomplete root fracture (visualized with the aid of methylene blue), 6. Haemostasis, and 7. Suturing. A sinus tract draining through the alveolar bone incisally between tooth 22 and tooth 23 was evident (Fig. 3).
77
Fig. 7. Periapical radiograph 29.08.2014. Fig. 5. Dissected "sulphur granules".
Bacteriological findings (with DNA-DNA hybridization); Diagnostic service, Institute of Oral Biology • Porphyromonas gingivalis in high concentrations. • Gram-negative enteric bacilli in high concentrations • Additional findings: o Treponema socranskii subsp. socranskii o Eubacterium saburreum o Prevotella nigrescens Fig. 6. Suturing. o Fusobacterium nucleatum subsp. vincentii Campylobacter rectus Follow-up treatment October 25th2011 o o Actinomyces viscosus Suture removal. The patient was Actinomycis gerenceriae asymptomatic. o o Streptococcus intermeduíus Fusobacterium nucleatum Prognosis o subsp. polymorphum The tooth has to be extracted. o Porphyromonas endodontalis Follow-up examination August 29th2014 The patient has a well-functioning brigde replacing tooth 22.
78 Results SEM (scanning electron Wang et al. (5) evaluated the presence of microscopy); Institute of Oral Biology, extraradicular biofilm on the external Steinar Stølen surface of the root apex in teeth with different pulp and periapical pathological conditions. They found that teeth with vital pulp and pulp necrosis without radiographically visible periapical lesions did not have exposed apical root cementum or extraradicular bacteria. The detection rates of extraradicular biofilm in teeth with primary chronic periapical periodontitis and persistent periapical periodontitis were 30% and 100%, respectively.
Fig. 8. SEM photo shows Gram-negative bacilli on Actinomycosis is a chronic, root cementum. granulomatous infectious disease characterized by suppuration, abscess formation, and draining sinus tracts. In tissues, Actinomyces species grow in microscopic or macroscopic clusters, that sometimes exude from soft tissues through sinus tracts, and because of their yellowish appearance, they are commonly referred to as sulphur granules, even though there is no clear evidence that they contain sulphur at all (1, 6). It has been recognized that granules can provide the bacteria with protection against phagocytosis or other Fig. 9. SEM of cut surface of sulphur granule. The immunologic mechanisms. granule consists of an abundance of bacteria. Rod- The patient in the present case had a like organisms are prominent. persistent sinus tract. A sinus tract is defined as a passage of pus from an Discussion abscess cavity to and external Microorganisms are able to survive and environment through a tissue induce persistent infection in membrane such as the oral extraradicular areas (1, 2). mucosa or the skin. The reason that a The endodontic treatment of teeth with sinus tract develops is not fully periapical lesions is less successful than understood. that of teeth with vital pulp or with pulp Mortensen et al. (7) investigated 1600 necrosis without radiographically teeth with periapical lesions; 136 (9.0%) visible periapical lesions (3). Some teeth had sinus tracts. They found that studies have revealed that bacteria can the size of the radiolucency seemed to form a biofilm surrounding the apical matter, because teeth with periapical foramina and external root surfaces that lesions smaller than 5 mm had sinus is associated with persistent periapical tracts in 5% of cases, whereas teeth with infections (4). periapical lesions greater than or equal to 5 mm had sinus tracts in 19%.
79 Some studies have suggested that the filled asymptomatic human odontogenic sinus tract is lined with tooth: Scanning electron epithelium (8, 9). Valderhaug (10) microscopic analysis and studied experimentally induced sinus microbial investigation after tracts in monkeys. He found that most of apical microsurgery. J Endod the sinus tracts were completely or 2011; 37: 1696–1700. partly lined with epithelium. However, 5. Wang J, Jiang Y, Chen W, Zhu C, studies by Grossman (11) and Bender Liang J. Bacterial Flora and and Seltzer (12) state that the sinus tract Extraradicular Biofilm Associated is not lined with epithelium, but lined with the Apical Segment of Teeth with granulation tissue. According to with Post-treatment Apical Grossman (11) sinus tracts can heal and Periodontitis. J Endod 2012; 38: closure occur after root-canal treatment. 954–959. In this case the sinus tract persisted 6. Happonen RP. Periapical after treatment of the tooth. It was an actinomycosis: a follow-up study indication of treatment failure and a of 16 surgically treated cases. surgical approach had to be done. Endod Dent Traumatol 1986: 2: For non surgical endodontic treatment, 205-209. it has been shown that the presence of a 7. Mortensen H, Winther JE, Birn H. sinus tract will not influence the long- Periapical granulomas and cysts. term outcome of endodontic treatment Scand J Dent Res 1970; 78: 241– (13-17). However, another study fond 250. that the presence of a sinus tract was 8. Harrison JW, Larson WJ. The found to be a significant prognostic epithelized oral sinus tract. Oral indicator (18). In surgical endodontic, Surg 1976; 42: 511–517. studies have reported a comparable 9. Baumgartner JC, Pickett AB, treatment outcome (19, 20). Muller JT. Microscopic examination of oral sinus tracts and their associated periapical References lesions. J Endod 1984; 10: 146- 1. Sunde PT, Olsen I, Debelian GJ, 152. Tronstad L. Microbiota of 10. Valderhaug J. A histologic study periapical lesions refractory to of experimentally produced endodontic therapy. J Endod intra-oral odontogenic fistulae in 2002; 28: 304– 310. monkeys. Int J Oral Surg 1973; 2: 2. Tronstad L, Sunde PT. The 54–61. evolving new understanding of 11. Grossman LI. Endodontic endodontic infections. Endod Top practice. Philadelphia: Lea & 2003; 6: 57–77. Febiger. 1965; 78 –92. 3. Sjogren U, Figdor D, Persson S, 12. Bender IB, Seltzer S. The oral Sundqvist G. Influence of fistula: its diagnosis and infection at the time of root filling treatment. Oral Surg 1961; 14: on the outcome of endodontic 1367– 1376. treatment of teeth with apical 13. Strindberg LZ. The dependence of periodontitis. Int Endod J 1997; the results of pulp therapy on 30: 297–306. certain factors. Acta Odont Scand 4. Signoretti FG, Endo MS, Gomes 1956; 14(Suppl 21): 1–175. BP, Montagner F, Tosello FB, 14. Sjögren U, Hagglund B, Sundqvist Jacinto RC. Persistent G, Wing K. Factors affecting the extraradicular infection in root-
80 long-term result of endodontic treatment. J Endod 1990; 16: 498-482. 15. Chugal NM, Clive JM, Spångberg LSW. A prognostic model for assessment of the outcome of endodontic treatment: effect of biologic and diagnostic variables. Oral Surg Oral Med Oral Path Oral Radiol Endod. 2001; 91: 342-352. 16. Farzaneh M, Abitol S, Friedman S. Treatment outcome in endodontics: the Toronto study. Phases I and II: Orthograde retreatment. J Endod 2004; 30: 627-633. 17. Ricucci D,Russo J, Rutberg M, DMD,c Burleson JA, Spångberg LSW. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112: 825-842. 18. Ng YL, Mann V, gulabivala K. A prospective study of the factors effecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J 2011; 344: 583-609. 19. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics-The Toronto Study. Phases I and II: apical surgery. J Endod. 2004; 30: 751- 761. 20. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 91: 700-709.
81 Case 15
Endodontic retreatment of the maxillary left first molar and surgical retreatment of the maxillary left first and second premolar
Fig. 1. Frontal view. Fig. 2. Buccal view.
Patient 66-year-old Caucasian female. Clinical tests November 16th2010
24 25 26 Chief complaint EPT Nd Nd Nd The patient reported of previous pain Cold - - - and antibiotic regiments related to tooth Percussion h v&h V 25. She also complains that several teeth Palpation - - - in the left maxilla are tender when PPD 4 4 4 biting. Mobility - I - Biting + + +
Medical record The patient was diagnosed with Radiographic findings November fibromyalgia and was medicated with 16th2010 Ibuprofen. Dental: Teeth 24 and 25 have radiopaque dental crowns, a post in the canal and radiopaque root filling Dental history materials. Tooth 26 has a radiopaque The patient was referred to the post- dental crown and a radiopaque root graduate clinic from the student clinic filling material. for apicoectomy of the maxillary left Periodontal: Moderate attachment loss. second premolar. Periapical: An apical radiolucency is seen around the root of tooth 25 (PAI 4). Clinical findings November 16th2010 Widened PDL space around the root of tooth 24, flush root filling. Discontinued Soft tissue: Normal findings. Dental: Teeth 24, 25 and 26 have dental lamina dura around the buccal roots of crowns. tooth 26; apical radiolucency MB root (PAI 3).
82 NiTiFlex hand files: MB: #45/18mm DB: #45 /18.5mm P: no treatment Chemical: 1% NaOCl, 17% EDTA, 2% clorhexidine-di-gluconate. Intracanal medicament: CaOH2 Temporary filling: Cavit, IRM.
Fig. 3. Periapical 16.11.2010.
Fig. 5. Working length radiograph.
Fig. 4. Periapical radiograph 16.11.2010. th Treatment December 14 2010 Diagnosis November 16th2010 Filled with thermoplasticized gutta- percha (Beefill) and AH Plus. Sealed with Diagnosis IRM. Pulpal K04.19 endodontically treated 24, 25, 26
Periodontal K05.03 chronic marginal periodontitis
Periapical K05.40 chronic apical periodontitis 25, 26
Treatment plan Endodontic retreatment of tooth 26.
Surgical retreatment of tooth 25 and Fig. 6. Master cone radiograph. inspection of tooth 24.
Problem list Post removal 26. Apical lesion 24? Root fracture.
Treatment November 16th2010 1 carpule of Xylocaine/adrenaline was applied to establish anaesthesia. Access opening and localization of gutta-percha Fig. 7. Post-obturation radiograph. and a post in the palatal root canal. Mechanical: Burs, Gates Glidden,
83 Prognosis: Endodontic: Good. Tooth: Good.
Surgery April 6th2011 Anaesthetic, mucoperiosteal flap, osteotomy, surgical curettage, biopsy, root-end resection, ultrasonic root-end Fig. 10. Root-end preparation. preparation. Haemorrhage control: adrenalin, ferric sulphate. Root-end filling using MTA Wound closure using non-absorbable suture material in sizes 4-0 and 5-0. Postoperative radiograph. Postsurgical care.
Fig. 11. Root-end filling with white MTA.
Fig. 8. Pathologic fenestration/extruded GP tooth 24.
Fig. 12. Root-end filling checked on periapical radiograph.
Fig. 9. Root-end resection 3mm.
Fig. 13. Suturing.
Histologic findings (Laboratorium of pathology, HS Koppang) Granulation tissue with moderate to intense chronic inflammation.
84 Prognosis source of infection that may allow Surgery: Good. inflammation to continue after surgical Teeth: Good. endodontics. The surgical intervention aims thus to remove the infected root- end and seal any remaining bacteria in th Follow-up examination April 13 2011 (1 the root canal system from the week) periradicular tissues. It has been Few post-operative complaints. Suture discussed whether a root-end filling removal. after root-end resection is necessary, or if the root canals are sufficiently filled with GP (2, 3). Some studies have found that healing occurs whether or not a root-end filling is placed (2, 4). However, ex vivo studies have suggested that a root-end filling is necessary to prevent leakage from the root canal and dentinal tubules (5, 6). In the last 10 years, mineral trioxide Fig. 14. One week post-operatively. aggregate (MTA) has received special attention. MTA was introduced in the early 1990s as a new root-end filling Follow-up examination September material (7). MTA has showed in leakage 21th2011 (5month´s) studies that the material provides a The patient is asymptomatic. No pain to remarkable seal (7, 8) and a favourable percussion. The radiograph shows that endodontic response with the potential the lesion is healing. to induce or attach to the newly regenerating periodontal ligament (8,9). Two randomized clinical trials (RCTs) comparing MTA and intermediate restorative material (IRM) have reported success rates of 84–92% for MTA and 76– 86% for IRM after 1 year (11, 12) and 92% for MTA and 87% for IRM after 2 years (11). Christiansen el al. (13) performed a randomized clinical to compare healing
Fig. 15. Periapical control radiograph 5 months after root-end resection with a root-end post-operatively. filling of mineral trioxide aggregate (MTA) or smoothing of the orthograde gutta-percha (GP) root filling. Teeth Discussion treated with MTA had significantly Surgical endodontic treatment has better healing (96%) than teeth treated historically been considered as an by smoothing of the orthograde GP root alternative to root canal treatment, or filling only (52%). the preferred choice when root canal Wälivaara el al. (14) investigated the treatment is difficult or impossible (1). periapical tissue response of 4 different However, unless the root canal space is retrograde root-filling materials: effectively cleaned, shaped and filled intermediate restorative material (IRM), during preliminary root canal treatment thermoplasticized gutta-percha, or root-end preparation, it remains as a
85 reinforced zinc oxide cement (Super- mineral trioxide aggregate when EBA), and mineral trioxide aggregate used as a root end filling (MTA), in conjunction with an ultrasonic material. J Endod 1993; 19: 591- root-end preparation technique in an 595. animal model. New root cement on the 8. Torabinejad M, Smith PW, resected dentin surfaces was seen on all Kettering JD, Pitt Ford TR. sections regardless of the used material. Comparative investigation of The IRM and MTA produced fewer marginal adaptation of mineral signs of leakage, less unhealed periapical trioxide aggregate and other tissue, and a concomitant decreased commonly used root-end filling inflammatory infiltration. New hard materials. J Endod 1995; 21(6): tissue formation, directly on the surface 295-299. of the material, was seen only in the 9. Torabinejad M, Hong CU, Lee SJ, MTA sections. There was, however, no Monsef M, Pitt Ford TR. statistical difference in outcome Investigation of mineral trioxide among the tested materials. aggregate for root-end filling in dogs. J Endod 1995; 21(12): 603- 608. References 10. Torabinejad M, Pitt Ford TR, 1. Gutmann JL & Harrison JW. McKendry DJ, Abedi HR, Miller Posterior endodontic surgery: DA, Kariyawasam SP. Histologic anatomical considerations and assessment of mineral trioxide clinical techniques. Int Endod J. aggregate as a root-end filling in 1985; 18(1): 8-34. monkeys. J Endod 1997; 23(4): 2. Nordenram A, Svärdström G. 225-228. Results of apicectomy. Sven 11. Chong BS, Pitt Ford TR, Hudson Tandlak Tidskr. 1970; 63(9): MB. A prospective clinical study 593-604. of Mineral Trioxide Aggregate 3. Johnson BR. Considerations in and IRM when used as root-end the selection of a root-end filling filling materials in endodontic material. Oral Surg Oral Med Oral surgery. Int Endod J. 2003 Pathol Oral Radiol Endod 1999; Aug;36(8):520-526. 87(4): 398-404. 12. Lindeboom JA, Frenken JW, 4. Rapp EL, Brown Jr CE, Newton Kroon FH, van den Akker HP. A CW. An analysis of success and comparative prospective failure of apicoectomies. J randomized clinical study of MTA Endodontics 1991; 17: 508–512. and IRM as root-end filling 5. Beatty RG, Vertucci FJ, Zakariasen materials in single-rooted teeth KL. Apical sealing efficacy of in endodontic surgery. Oral Surg endodontic obturation Oral Med Oral Pathol Oral Radiol techniques. Int Endod J 1986; Endod. 2005 Oct;100(4):495- 19(5): 237-241. 500. 6. Vignaroli PA, Anderson RW, 13. Christiansen R, Kirkevang LL, Pashley DH. Longitudinal Hørsted-Bindslev P, Wenzel A. evaluation of the microleakage of Randomized clinical trial of root- dentin bonding agents used to end resection followed by root- seal resected root apices. J Endod end filling with mineral trioxide 1995; 21(10): 509-512. aggregate or smoothing of the 7. Torabinejad M, Watson TF, Pitt orthograde gutta-percha root Ford TR. Sealing ability of a
86 filling--1-year follow-up. Int Endod J 2009; 42(2): 105-114. 14. Wälivaara DÅ, Abrahamsson P, Isaksson S, Salata LA, Sennerby L, Dahlin C. Periapical tissue response after use of intermediate restorative material, gutta-percha, reinforced zinc oxide cement, and mineral trioxide aggregate as retrograde root-end filling materials: a histologic study in dogs. J Oral Maxillofac Surg 2012; 70(9): 2041-2047.
87 Case 16
Endodontic treatment and apical surgery of the mandibular left first molar
Fig. 1. Frontal view.
Fig. 2. Occlusal view.
Patient th 70-year-old Caucasian male. Clinical tests January 12 2011
34 35 36 Chief complaint EPT 28 80 Nd The patient complains about occasional, Cold + - + sporadic pain in the posterior region in Percussion - - +,v lower left mandible. The posterior molar Palpation - - - 3 3 3 tooth is tender when biting. PPD Mobility - - - Biting - - + Medical record Non-contributory. Radiographic findings January 12th2011 Dental history Dental: Tooth 36 has radiopaque coronal The patient was referred to the post- restoration. Tooth 35 has a radiopaque graduate clinic from private practise for MOD restoration and a radiopaque root endodontic treatment of the mandibular filling material. left first molar. Periodontal: Moderate attachment loss. Tooth 35 was treated 2 years earlier Apical: Tooth 46 has an apical (2009) at the Department of Oral and radiolucency mesial root (PAI 3). Tooth Maxillofacial Surgery; apicoectomy 35 has an apical radiolucency (PAI 3). without root-end filling.
Clinical findings January 12th2011 Soft tissue: Normal findings. Dental: Tooth 34 is sound. Tooth 35 has a MODL composite restoration. Tooth 36 has a dental crown (Fig. 2).
88 Treatment February 2nd2011 No symptoms. Tooth filled with gutta- percha and AH Plus. Sealed with IRM.
Fig. 3. Periapical radiograph 12.01.2011.
Diagnosis January 12th2011
Diagnosis Pulpal K04.11 necrotic pulp Fig. 5. Master cone radiograph.
Periodontal K05.03 chronic marginal periodontitis
Periapical K05.40 chronic apical periodontitis
Treatment plan Non-surgical endodontic treatment of tooth 36.
Treatment January 12th2011 2 carpules of Xylocaine/adrenaline was Fig. 6. Post-obturation radiograph. applied to establish anaesthesia. Access opening, bleeding from DB and MB Prognosis canal, ML necrotic. Endodontic: Good. Mechanical: Burs, NiTiFlex hand files Tooth: Good. #20, Biorace MB: #40/0.04 (BR5)/18mm ML: #40/0.04 (BR5)/18mm Follow-up examination February 29th D: #50/0.04 (BR6) /19mm 2012 (1 year) Chemical: 1% NaOCl, 17% EDTA. Control at 1 year with x-ray indicated Intracanal medicament: CaOH2. that the tooth was healing. Temporary filling: Cavit, IRM.
Fig. 7. Periapical control radiograph 1 year. Fig. 4. Working length radiograph.
89 Follow-up examination April 2nd2014 (3 years) The patient contacted the clinic due to a small discomfort and swelling of the gingiva next to tooth 36 (Fig. 8).
Fig. 10. OPG 02.04.2014.
Surgery April 22nd2014 5 carpules of Xylocaine/adrenalin was applied to establish anaesthesia. Marginal incision from 34-36 with vertical releasing incisions 34 mesially
Fig. 8. Gingival swelling. and 36 distally. Enucleation of granuloma overlying mesial root Clinical examination revealed a buccal /surgical curettage. Detection of a swelling over the mesial root of tooth vertical root fracture (VRF) mesial root. 36. Normal probing depths. Discussion of treatment alternatives. The patient is reluctant upon extracting X-ray showed apical radiolucency. the tooth immediately. Root resection of An OPG was ordered. mesial root was discussed as a treatment alternative with the Medications: 8 months ago the patient conclusion that unfavourable occlusal started taking Calcigran Forte loading could weaken the prognosis of 1000mg/day and Alendronat 70mg once the remaining distal root. It was decided a week. to postpone the extraction and leave the tooth until symptoms. Treatment plan: Apical surgery tooth 36. Wound closure using non-absorbable suture material in sizes 4-0. Postsurgical care.
Fig. 9. Periapical radiograph 2 years.
Fig. 11. Clinical photo showing VRF mesial root.
90 Follow-up examination April 29th2014 (1 usually located at the buccal side of the week) tooth or the root involved. Other signs No symptoms. Suture removal. and symptoms were sensitivity to percussion, mobility, and a coronally located fistula. There was a combination th Follow-up examination May 13 2014 (1 of both a deep pocket and a fistula in 22 month) cases (23.9%). The most significant Recurrent swelling at the buccal aspect finding of bone rarefaction was that a over the mesial root. Tender on biting. lateral radiolucency plus the Referred to Department of Maxillofacial combination of periapical and lateral Surgery, Ullevål hospital the same day radiolucency was present in 58 cases for removal of tooth 36. (63%). Radiographic features of vertical root fractures vary widely. These may be Discussion observed on radiographs as diffuse Vertical root fracture (VRF) is a widening of periodontal ligament, longitudinally oriented fracture of the dislodgement of retro-filling material, root that originates from its apical end vertical bone loss, separation of root and propagates coronally and is defined fragments or displacement of apical as one of the crack types (1). The portions of root. Presence of prevalence of VRFs is reported to range “radiographic halo” has been shown as a from 11%–20% in extracted major finding in cases of vertical root endodontically treated teeth (2). fractures (12). According to the literature, vertical root A VRF might also be observed directly fracture is the third most common on a conventional radiograph in the reason for extraction of an event the x-ray beam is in the same endodontically treated tooth (3). plane as the fracture to be observed (13, The final diagnosis of VRF can be 17). complicated due to lack of specific signs, In a systematic review by Tsesis et al. symptoms, and/or radiographic features (14), the authors concluded that and because several etiologic factors evidence-based data concerning the might be involved. Thus, the differential diagnostic accuracy and clinical diagnosis from other pathologic entities effectiveness of clinical and radiographic might be difficult (4, 5, 6, 7, 8, 9, 10, 11). dental evaluation for the diagnosis of Tamse et al. (4) did an evaluation of 92 VRF in endodontically treated teeth are endodontically treated VRF teeth. They lacking. found that premolars were the Often, exploratory surgery is resorted in predominant group (52%), and the order to visualize the fracture. Raising a maxillary second premolar accounted full thickness flap to directly visualize for 27%. In the mandible, the fracture the root(s) under light, magnification, was found in the mesial root in 17 of 22 and with methylene blue staining does molars (77%), whereas the distal root this. There is no substitute for direct was fractured in only five teeth. In the visualization if the diagnostic and maxillary molars, the fracture was in the prognostic assessments remain mesiobuccal root (55.5%) and palatal questionable (15). root (33.3%). Only one distobuccal root The inability of conventional imaging was fractured. Pain (51%) or abscess techniques to consistently visualize (31%) was the major complaint. VRFs precisely necessitates the The most predominant clinical sign was development of alternative imaging deep pockets in 62 cases (67.4%),
91 modalities to improve their detection fractures in extracted (16). Cone-beam computed tomography endodontically treated teeth. Int (CBCT), also called digital volume Endod J 1999; 32: 283–286. tomography (DVT), is a relatively new 3. Toure B, Faye B, Kane AW, Lo CM, imaging modality in maxillofacial Niang B, Boucher Y. Analysis of imaging, which involves three- reasons for extraction of dimensional (3D) slice acquisition at endodontically treated teeth: A significantly reduced radiation doses. prospective study. J Endod 2011; Presently CBCT has been shown to be 37: 1512-1515. promising in the early detection of 4. Tamse A, Fuss Z, Lustig J, Kaplavi vertical root fractures. J. An evaluation of endodontically Edlund et al. (17) designed a clinical treated vertically fractured teeth. pilot study to determine the diagnostic J Endod 1999; 25: 506–508. accuracy of CBCT for detection of 5. Fuss Z, Lustig J, Katz A, Tamse A. suspected VRFs in endodontically An evaluation of endodontically treated teeth by using exploratory treated vertical root fractured surgery to confirm the presence or teeth: impact of operative absence of a fracture. Thirty-two teeth procedures. J Endod 2001; 27: in 29 patients with clinical signs and 46–48. symptoms suggestive of VRF were 6. Cohen S, Blanco L, Berman L. included in the study. Sensitivity of Vertical root fractures: clinical CBCT for detection of VRF was 88%, and and radiographic diagnosis. the specificity was 75%. Positive J Am Dent Assoc 2003; 134: 434– predictive value (PPV), the proportion of 441. teeth with fractures that were correctly 7. Meister F Jr, Lommel TJ, Gerstein diagnosed, was determined to be 91%, H. Diagnosis and possible causes and negative predictive value (NPV), the of vertical root fractures. Oral proportion of teeth with no fractures Surg Oral Med Oral Pathol 1980; that were correctly diagnosed, was 67%. 49: 243–25. The overall accuracy was 84%. Similar 8. Moule AJ, Kahler B. Diagnosis and findings have been published in a few management of teeth with case reports (18, 19, 20). vertical root fractures. It has been shown that the presence root Aust Dent J 1999; 44: 75–87. canal filling does not significantly 9. Sedgley CM, Messer HH. Are influence the accuracy but reduces endodontically treated teeth specificity in detection of vertical root more brittle? J Endod 1992; 18: fracture by CBCT (21, 22). 332–335. 10. Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent References Traumatol 1988; 4: 190–196. 1. Colleagues for excellence. 11. Tamse A, Fuss Z, Lustig J, Ganor Cracking the cracked tooth code: Y, Kaffe I. Radiographic features detection and treatment of of vertically fractured, various longitudinal tooth endodontically treated maxillary fractures. Chicago: American premolars. Oral Surg Oral Med Association of Endodontics; Oral Pathol Oral Radiol Endod 2008. 1999; 88: 348–352. 2. Fuss Z, Lustig J, Tamse A. Prevalence of vertical root
92 12. Khasnis SA, Kidiyoor KH, Patil two cases. Dent Traumatol 2011; AB, Kenganal SB. Vertical root 27: 484-488. fractures and their management. 20. Metska ME, Aartman IHA, J Conserv Dent 2014; 17(2): 103- Wesselink PR. Ozok AR. Detection 110. of vertical root fracture in vivo in 13. Rud J, Omnell KA. Root fractures endodontically treated teeth by due to corrosion: diagnostic cone beam computed aspects. Scand J Dent Res 1970; tomography scans. J Endod 2012; 78: 397–403. 38: 1344-1347. 14. Tsesis I, Rosen E, Tamse A, 21. Hassan B, Metska ME, Ozok AR, Taschieri S, Kfir A. Diagnosis of Stelt PV, Wesselink PR. Detection Vertical Root Fractures in of vertical root fracture in Endodontically Treated Teeth endodontically treated teeth by Based on Clinical and cone beam computed Radiographic Indices: A tomography scan. J Endod 2009; Systematic ReviewJ Endod 2010; 35: 719-722. 36: 1455–1458. 22. Hassan B, Metska ME, Ozok AR, 15. Cohen S, Blanco L, Berman L. Stelt PV, Wesselink PR. Vertical root fractures: clinical Comparison of five cone beam and radiographic diagnosis. computed tomography systems J Am Dent Assoc 2003; 134: 434– for detection of vertical root 441. fractures. J Endod 2010; 36: 126- 16. Nair MK, Nair UDP, Grondahl HG, 129 Webber RL, Wallace JA. Detection of artificially induced vertical radicular fractures using tuned aperture computed tomography. Eur J Oral Sci 2001; 109: 375– 379. 17. Edlund M, DDS, Nair MK, Nair PN. Detection of Vertical Root Fractures by Using Cone-beam Computed Tomography: A Clinical Study. J Endod 2011; 37: 768–772. 18. Zou X, Liu D, Yue L, Wu M. The ability of cone beam computed tomography to detect vertical root fracture s in endodontically treated and non endodontically treated teeth: A report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111: 797-801. 19. Tang L, Zhou XD, Wang Y, Zhang L. Detection of vertical root fracture using cone beam computed tomography: Report of
93 Case 10
Surgical retreatment of the maxillary right first incisor
Fig. 1. Frontal view. Fig. 2. Buccal view.
Patient 18-year-old Asian female.
Chief complaint Non-contributory.
Medical record Non-contributory. Fig. 3. Palatal view.
nd Dental history Clinical findings February 2 2011 A specialist in pedodontics Soft tissue: Gingivitis. endodontically treated tooth 11 in 2009 Dental: Tooth 11 has a dental crown. due to a large apical radiolucency. Teeth 12 and 21 have palatal erosive There was a trauma in childhood. The tooth loss, otherwise sound. tooth had a crown cemented soon after finishing of the root filling. The patient nd Clinical tests February 2 2011 was referred to the postgraduate clinic from the public dentistry for surgical 12 11 21 retreatment due to a persisting apical EPT 32 80 22 lesion. Cold + - + Percussion - - - Palpation - + - PPD 2 3 2 Mobility - - - Biting - - -
94 Radiographic findings February 2nd2011 Surgical treatment May 25th2011 Dental: Tooth 11 has a radiopaque At the day of surgery, clinical inspection dental crown and a radiopaque root- showed a sinus tract tooth 11. filling material. Periodontal: Gingivitis. Apical: Tooth 11 has an apical radiolucency (PAI 4), and overfilling of gutta-percha is suspected. Normal PDL space around teeth 12 and 21.
Fig. 5. A sinus tract was present apically around tooth 11, 25.05.2011. The patient was given a chlorhexidine mouth rinse and local anaesthetic (Xylocaine/adrenaline) was injected. A papilla-base incision was made running from tooth 22 to tooth 13 with a vertical releasing incision on the distal aspect of 13. Elevation of the mucoperiosteal flap Fig. 4. Periapical radiograph. revealed pathologic fenestration and extruded gutta-percha. Osteotomy and
nd curettage of granulation tissue. Biopsy. Diagnosis February 2 2011 Root-end resection and retrograde preparation with ultrasonic Diagnosis instruments. Haemostasis with ferric Pulpal K04.19 endodontically treated sulphate. A retrograde filling of white MTA was applied. The operation site Periodontal K05.01 chronic gingivitis was rinsed with sterile saline and the
flap sutured in place with supramide Periapical K04.50 chronic apical periodontitis and dafilon 5.0 and 6.0. Prescription of Apocillin 660mg x4 for 7 days. Postoperative instructions. Treatment plan Apicoectomy with retrograde filling of Complications during surgery: Flap- tooth 11. tearing and difficulties in suturing. Treatment alternative: non-surgical retreatment and observation.
Problem list Thin gingival biotype. Gingival recession and aesthetics.
95
Fig. 9. Suturing.
Prognosis Fig. 6. Photo after root-end preparation. Endodontic: Good. Tooth: Good. Surgery: Unpredictable tissue healing.
Follow-up examination May 31th2011 (one week) Suture removal. The patient had not experienced any postoperative problems. The sinus tract was closed but secondary healing was observed in the midline.
Fig. 7. Photo showing retrograde filling with MTA. Follow-up examination June 8 th2011 (2 weeks) The wound healing was good. There was a small gingival recession. The patient had not noticed any changes in gingival levels.
Fig. 10. Photo 2 weeks post-operatively. Fig. 8. Post-operative radiograph before suturing.
Follow-up examination January 19th2012 (7 months) No further gingival recessions. The tooth was asymptomatic. Radiographic signs of healing with a continuous PDL space surrounding the apex.
96 height as a result of the surgical or healing process (2). In 2003 Velvart et al. (3) investigated papilla healing in twelve patients after apical surgery in anterior and molar teeth using the PBI and sulcular full- thickness flap. After 1- and 3- months the PBI allowed recession-free healing whilst complete mobilization of the Fig. 11. Photo 7 months post-operatively. papilla led to a marked loss of the papilla height. Velvart et al. (4) compared the long- term loss of papilla height when using either the PBI or the standard papilla mobilization incision in marginal full thickness flap procedures. They found a significant difference between the two incision techniques for all recall appointments (1-, 3-, and 12-months). Von Arx et al. (5) evaluated gingival recession following apical surgery of 70 anterior teeth (central and lateral incisors, canines, and first premolars).
Fig. 12. Periapical control radiograph 7 months They concluded that gingival biotype, after surgery. pre-treatment periodontal pocket, and type of incision might significantly influence changes in gingival margin Discussion (GM) and clinical attachment level When designing a tissue flap, various (CAL). In their study the submarginal modes of incision can be selected, incision showed significantly less including horizontal, sulcular, gingival recession compared with the submarginal, and vertical releasing intrasulcular incision, papilla-base incisions. The tissue flap in its entirety incision or papilla-saving incision. can be a full-thickness or a combination In a study by von Arx et al. (6) long-term of a full- and a split-thickness flap (1). changes in periodontal parameters were Certain basic principles must be evaluated after apical surgery of 186 considered before deciding on the type teeth. Significant changes in GM and CAL of incision and the flap design: regional were observed at facial sites during the anatomy, proper access to the periapical first year after surgery. However, none pathosis, periodontal conditions, state of of the periodontal parameters changed coronal tooth structure, the nature and significantly between 1 and 5 years after extent of coronal restorations and apical surgery. The type of incision operators choice. technique was found to be the major The papilla base incision (PBI) for the factor affecting changes in GM and CAL marginal mucoperiosteal flap was between baseline and 1 year after suggested to prevent loss of interdental surgery. Age, smoking, and type papilla height. This incision allows the of periapical healing were the variables preservation of the entire papilla, thus influencing the periodontal parameters eliminating any substantial loss of
97 over the longer observation period of up 6. von Arx T, Alsaeed M, Giovanni to 5 years. ES. Five-year changes in It has been demonstrated that the periodontal parameters after gingival biotype could be related to apical Surgery. J Endod 2011: 37: complications following flap- 910-918. procedures. The thin biotype is more 7. Kao RT, Fagan MC, Conte GJ. prone to gingival recession and an Thick vs. thin gingival biotypes: a unpredictable tissue healing should be key determinant in treatment expected (7). The type of incision may planning for dental implants. be a predictor for complications J Calif Dent Assoc. 2008; 36(3): following surgery of a tooth with a thin 193-198. biotype: higher probability of recession 8. Tsesis I, Beitlitum I, Rosen E. for intra-sulcular incision, more scarring Prevention and management of for submarginal incision, more soft tissue complications in complications during flap elevation endodontic surgery. In: susch as flap tearing, and dehiscence Complications in endodontic and difficulties in suturing (8). surgery. 2014; Springer-Verlag Berling Heidelberg (eBook).
References 1. Velvart P, Peters CI, Peters OA. Soft tissue management: flap design, incision, tissue elevation and tissue retraction. Endod Topics 2005: 11: 78–97. 2. Velvart P. Papilla base incision: a new approach to recession-free healing of the interdental papilla after endodontic surgery. Int Endod J 2002: 35: 543-460. 3. Velvart P, Ebner-Zimmermann U, Ebner JP. Comparison of papilla healing following sulcular full- thickness flap and papilla base flap in endodontic surgery. Int Endod J 2003: 36: 653–659. 4. Velvart P, Ebner-Zimmermann U, Ebner JP. Comparison of long term papilla healing following sulcular full thickness flap and papilla base flap in endodontic surgery. Int Endod J 2004: 37: 687–693. 5. von Arx T, Salvi GE, Janner S, Jensen SS. Gingival recession following apical surgery in the esthetic zone: a clinical study with 70 cases. Eur J Esthet Dent 2009: 4: 28–45.
98 Case 18
Evaluation of a root-filled mandibular right first molar and surgical retreatment of the maxillary left first molar with a sinus tract.
Tooth 46 was root-filled by the referring dentist 2 years ago and has a history of pain, swelling and sinus tract. Tooth 26 was root-filled by a specialist in endodontics 4 years ago and a crown has recently been made.
Fig. 1. Frontal view. Clinical findings February 7th2014 Soft tissue: Sinus tract region 26. Patient Dental: Tooth 46 has an ODL composite 45-year-old Asian male. restoration. Tooth 26 has a dental crown, tooth 27 has a composite restoration with poor margins and Chief complaint caries. The patient complains about previous Generalized erosive tooth surface loss. pain and sinus tract related to a mandibular left molar tooth. He tells that the tooth was root-filled in 2012 and that his dentist has prescribed antibiotics at several occasions after finishing the root filling. At present the tooth is tender when chewing. He also complains about tenderness when chewing in the posterior region in the upper left maxilla. He has noticed a draining sinus tract in this area.
Fig. 2. Occlusal view tooth 46. Medical record Podagra (hyperuricaemia), allergy (pollen), sleeping disorder. He has mild dental fear. Medications: Ritalin, Zyrtec.
Dental history The patient was referred to the postgraduate clinic from private Fig. 3. Buccal view tooth 26; sinus tract. practice for endodontic evaluation and treatment of the mandibular right first molar and the maxillary left first molar.
99 Clinical tests February 7th2014
25 26 27 46 EPT 25 Nd Nd Nd Cold + - - - Percussion - + - + Palpation - + - + PPD 3 4 4 4 Mobility - - - - Biting - + - + Fig. 6. Periapical radiograph.
Radiographic findings February 7th2014 Dental: Tooth 46 has a radiopaque MOD filling and a radiopaque root filling material. Tooth 26 has a radiopaque dental crown and a radiopaque root- filling material. Periodontal: Chronic marginal periodontitis. Fig. 7. A sinus tract originating from tooth 26. Apical: Tooth 46 has apical radiolucencies mesial and distal root (PAI 4) and a lateral radiolucency distal Diagnosis February 7th2014 root. Tooth 26 has apical radiolucencies Diagnosis mesial and distal root (PAI 3) and an Pulpal K04.19 endodontically treated 26,46 interradicular radiolucency. Periodontal K05.03 chronic marginal periodontitis
Apical 26 K04.62 chronic apical periodontitis with sinus tract Apical 46 K04.50 chronic apical periodontitis
Dental 46 S02.50 cracked tooth
Fig. 4. Periapical radiograph. Treatment plan Access preparation and visual inspection with magnification of tooth 46; longitudinal fracture? Surgical retreatment of the buccal roots of the endodontically treated maxillary left first molar.
Fig. 5. Periapical radiograph.
100 Problem list Surgery March 25th2014 Anxiety. The patient was given a chlorhexidine Longitudinal fracture tooth 46? mouth rinse and local anaesthetic was Interradicular radiolucency tooth 26. injected. A marginal incision was made running from tooth 27 to tooth 25, with vertical releasing incisions 25 mesially th Treatment February 7 2014 and 27 distally. Elevation of the Rubberdam was applied. Access mucoperiosteal flap. Osteotomy and preparation and identification of a crack curettage of granulation tissue. affecting the distal marginal ridge of the Adrenaline and ferric sulphate mandibular right first molar; the crack haemostasis. A retrograde filling of has propagated into the distal root. The white MTA was applied. The operation patient is told that the prognosis is poor site was rinsed with sterile saline and and removal of the tooth is the flap sutured in place with supramide recommended. 4.0 and 5.0. Postoperative instructions. Paracetamol.
Complications during surgery: Large defect in furcation area. Limitations to visibility and accessibility of the root tips.
Fig. 8. Occlusal view of the cracked tooth affecting the distal marginal ridge and extending into the distal root.
Fig. 10. Retro-preparation radiograph. Follow-up April 29th2014 (by phone) The patient postponed the removal of tooth 46 and sent a photo showing a fracture of the tooth (Fig. 9). He was advised to contact his dentist for removal of 46.
Fig. 11. Retro-filling.
Prognosis Endodontic: Uncertain. Tooth: Uncertain.
Fig. 9. Propagation of crack resulted in a split tooth 46.
101 Follow-up examination March 27th2014 (2 days) The patient experienced post-operative discomfort; swelling and mild pain/malaise and fever. He contacted us due to a planned flight abroad the same day. Clinically: heat, pain, redness, and swelling are noted in the cheek at the Fig. 13. Periapical radiograph 3 months. operation site. Secondary healing region 25. Prescription of phenoxymethylpenicillin Follow-up examination September (660mgx4 for 7 days). 5th2014 (6 months) No symptoms. Tooth 26 not tender to percussion or palpation. PPD 4mm at th Follow-up examination April 1 2014 (1 the buccal aspect. Interradicular week) radiolucency seems unchanged on the Asymptomatic. Suture removal. Minor periapical radiograph. swelling in the cheek.
Follow-up examination April 11th2014 (10 days) No swelling. Satisfactory healing at the operation site.
Follow-up examination June 17th2014 (3 months) Fig. 14. Periapical control radiograph 6 months. The patient has no complaints. Radiograph shows initial healing of apical radiolucencies. Interradicular Discussion radiolucency seems unchanged. The persistence of microorganisms plays a significant role in endodontic treatment failures (1). Although several factors might be involved with endodontic treatment failure, this usually results from the presence of bacteria in the apical portion of the root canal (2-4). The absence of coronal sealing, micro leakage, failures in chemo mechanical preparation, and limit and quality of Fig. 12. Photo region 26; 3 months post- operatively. root filling favour the survival of microorganisms after endodontic treatment or reinfection of the canal and may lead to endodontic treatment failure (2, 4, 5). There is great variation in the composition of the microbiota
102 associated with endodontic failure and preparation to ensure complete the levels of the bacterial species disinfection when this particular detected in root canals, which may occur organism is suspected. CHX is a broad- as a result of the different diagnostic spectrum antimicrobial agent that has techniques used (6-10). been reported to be an effective This microbiota has been described as medicament in endodontic therapy. It being mainly composed of facultative has been recommended as a final anaerobic gram-positive species. irrigating solution in view of its Enterococcus is the genus most antimicrobial action (20), proven frequently described, and Enterococcus substantivity (21), and capacity to faecalis is the species more commonly inhibit the adherence of certain bacteria found in these lesions (6-10). to dentin (22). However, recent studies have Basrani et al. (23) studied the efficacy of questioned the hypothesis that E. CHX and calcium hydroxide (Ca(OH)2- faecalis is the main species associated containing medicaments against E. with endodontic failures (11-16). faecalis in vitro. They concluded that Murad et al. (17) investigated the CHX was significantly more effective composition of the root canal microbiota against E. faecalis than Ca(OH)2. from 36 root canals with persistent In another study by Zamany et al. (23), endodontic infection. The presence, the authors demonstrated that an levels, and proportions of 79 bacterial additional rinse with 2% chlorhexidine species were determined by resulted in enhanced disinfection of the checkerboard DNA-DNA hybridization. root canal system. The highest mean levels were found for the following species: E. faecium, Dialister pneumosintes, Staphylococcus References epidermidis and Helicobacter pylori. No 1. Sjögren U, Fidgor D, Persson S, et correlation was found between any of al. Influence of infection at the the species tested and clinical findings; time of root filling on the however, periapical lesions with the outcome of endodontic treatment largest areas presented higher counts of of teeth with apical periodontitis. gram-negative and rod species. The Int Endod J 1997; 30: 297–306. levels of gram-negative species were 2. Sjögren U. Siqueira Jr JF. statistically significantly higher than Aetiology of root canal treatment those of the gram-positive species. failure: why well treated teeth can fail. Int Endod J 2001; 34: 1– Sodium hypochlorite (NaOCl) is the 10. main irrigating solution used in root 3. Wu MK, Dummer PM, Wesselink canal preparation to dissolve vital and PR. Consequences of and necrotic tissue and eliminate the strategies to deal with residual bacteria of instrumented root canals post-treatment root canal (18, 19). infection. Int Endod J 2006; 39: Concomitant with the focus on E. faecalis 343–356. as a key organism in persistent 4. Sundqvist G, Fidgor D, Persson S, infections, modifications like the et al. Microbiologic analysis of addition of chlorhexidine (CHX) were teeth with failed endodontic introduced. Many authors have stressed treatment and the outcome of the importance of using antimicrobial conservative re-treatment. Oral irrigants during chemo mechanical Surg Oral Med Oral Pathol 1998; 85: 86–92.
103 5. Siqueira Jr JF, Rôças IN, Uzeda M, with periradicular lesions. J et al. Comparison of 16S rDNA- Endod 2009; 35: 169–174. based PCR and checkerboard 13. Fujii R, Saito Y, Tokura Y, et al. DNA-DNA hybridization for Characterization of bacterial flora detection of selected endodontic in persistent apical periodontitis pathogens. J Med Microbiol 2002; lesions. Oral Microbiol Immunol 51: 1090–1096. 2009; 24: 502–505. 6. Molander A, Reit C, Dahlen G, et 14. Rocas IN, Siqueira JF Jr. al. Microbiological status of root- Characterization of microbiota of filled teeth with apical root canal-treated teeth with periodontitis. Int Endod J 1998; posttreatment disease. J Clin 31:1–7. Microbiol 2012; 50: 1721–1724. 7. Hancock HH, Sigurdsson A, Trope 15. Wang J, Jiang Y, Chen W, et al. M, et al. Bacteria isolated after Bacterial flora and extraradicular unsuccessful endodontic biofilm associated with the apical treatment in a North American segment of teeth with port- population. Oral Surg Oral Med treatment apical periodontitis. J Oral Pathol 2001; 91: 579–585. Endod 2012; 38: 954–959. 8. Fouad AF, Zerella J, Barry J, et al. 16. Hong BY, Lee TK, Lim SM, et al. Molecular detection of Microbial analysis in primary and Enterococcus species in persistent endodontic infections root canal therapy-resistant by using pyrosequencing. J Endod endodontic infections. Oral Surg 2013; 39: 1136–1140. Oral Med Oral Pathol Oral Radiol 17. Murad CF, Sassone LM, Faveri M, Endod 2005; 99: 112–118. Hirata Jr R, Figueiredo L, and 9. Gomes BP, Pinheiro ET, Jacinto Feres M, DDS, MSc, PhDMicrobial RC, et al. Microbial analysis of Diversity in Persistent Root Canal canals of toot-filled teeth with Infections Investigated by periapical lesions using Checkerboard DNA-DNA polymerase chain reaction. J Hybridization. J Endod 2014; 40: Endod 2008; 34: 537–540. 899–906. 10. Rocas IN, Jung II-Y, Lee CY, et al. 18. Bystrom A, Sundqvist G. The Polymerase chain reaction antibacterial action of sodium identification of microorganisms hypochlorite and EDTA in 60 in previously root-filled teeth in a cases of endodontic therapy. Int South Korean population. J Endod Endod J 1985; 18(1): 35–40. 2004; 30: 504–508. 19. Siqueira JF Jr, Rôças IN, Santos SR 11. Blome B, Braun A, Sobarzo V, et al. Efficacy of instrumentation Jepsen S. Molecular techniques and irrigation indentification and quantification regimens in reducing the of bacteria from endodontic bacterial population within root infections using real-time canals. J Endod 2002; 28(3): 181– polymerase chain reaction. Oral 184. Microbiol Immunol 2008; 23: 20. Mohammadi Z, Abbott PV. The 384–390. properties and applications of 12. Schirrmeister JF, Liebenow AL, chlorhexidine in endodontics. Int Pelz K, et al. New bacterial Endod J 2009; 42(4): 288–302. compositions in rootfilled teeth 21. Mohammadi Z, Abbott PV. Antimicrobial substantivity of
104 root canal irrigants and medicaments: a review. Aust Endod J 2009; 35(3): 131–139. 22. Kishen A, Sum CP, Mathew S et al. Influence of irrigation regimens on the adherence of Enterococcus faecalis to root canal dentin. J Endod 2008; 34(7): 850–854. 23. Basrani B, Tjaderhane L, Santos JM, Pascon E, Grad H, Lawrence HP, Friedman S. Efficacy of chlorhexidin- and calcium hydroxide-containing medicaments against Enterococcus faecalis in vitro. Oral Surg Oral Med Oral Pathol Oral Rsdiol Oral Endod 2003; 96(5): 618-624. 24. Zamany A, Safavi K, Spangberg LS. The effect of chlorhexidine as an endodontic disinfectant. Oral Surg Oral Med Oral Pathol Oral Radiol Oral Endod 2003; 96(5): 578-581.
105 Case 19
Endodontic retreatment of the maxillary right first molar with a sinus tract
Fig. 1. Frontal view.
Patient Fig. 2. Photo showing sinus tract tooth 16. 60-year-old Caucasian female. Clinical tests January 31st2014 Chief complaint She had noticed a swelling on the 14 16 Nd Nd gingiva in the molar region in the right EPT maxilla. Cold + - Percussion - - Palpation - + Medical record PPD 3 6 Medical condition: Hypothyroidism. Mobility - - - - Medications: Esidrex, Levaxin. Biting
Dental history st Tooth 16 had been treated Radiographic findings January 31 2014 endodontically more than 10 years ago. Dental: A radiopaque dental bridge In 2012 she had a bridge made at the abutment teeth 14 and 16, and student clinic, keeping the pre-existing replacement tooth 15 is seen. Tooth 16 casted conus tooth 16. The patient was has a radiopaque root filling material. referred to the postgraduate clinic from Periodontal: Attachment loss. the student clinic for endodontic Apical: An apical radiolucency is seen retreatment of the maxillary right first surrounding the mesial root of tooth 16. molar. Normal PDL space around the root apex of tooth 14 (Fig. 3). The radiopaque gutta-percha point in the sinus tract can Clinical findings January 31st2014 be seen in Fig. 4. Soft tissue: A sinus tract in relation to tooth 16 was observed (Fig. 2). Dental: A dental bridge restoration comprising teeth 141516.
106 Treatment January 31st2014 Access opening and localisation of MB canal orifice with the old GP. Mechanical: Burs, NiTiFlex hand files MB: #55/18mm Not able to negotiate beyond the curvature. Unable to localize a second MB canal. Fig. 3. Periapical radiograph 31.01.2014. Chemical: 2% Chlorhexidine, 17% EDTA. Intracanal medicament: Ca(OH)2. Temporary filling: IRM.
Fig. 4. The sinus tract originates from tooth 16.
Fig. 5. Working length radiograph.
th Diagnosis January 31st2014 Treatment February 18 2014 Asymptomatic. Regression of sinus tract Diagnosis is seen (Fig. 6). Pulpal K04.19 endodontically treated
Periodontal K05.03 chronic marginal periodontitis
Apical K04.62 chronic apical periodontitis with sinus tract
Fig. 6. Photo showing recession of sinus tract. Treatment plan The tooth was filled with gutta-percha Non-surgical retreatment of the mesial and AH Plus. Sealed with composite. root of the endodontically treated maxillary right first molar Observation of sinus tract. If no healing apicoectomy is planned.
Problem list Previous transportation of mesiobuccal canal. Negotiating the apical third beyond the curvature. Fig. 7. Master cone radiograph. Sinus tract.
107 a vertical releasing incision on the mesial aspect of tooth 25. Elevation of the mucoperiosteal flap. Osteotomy and curettage of granulation tissue. Small sinus perforation. Gauze sponge sutured in place before root-end resection and retrograde preparation with ultrasonic instruments. Haemostasis using Fig. 8. Post-obturation radiograph. Xylocaine/adrenaline. A retrograde filling of white MTA was applied. The Prognosis operation site was rinsed with sterile Endodontic: Uncertain. saline and the flap sutured in place with Tooth: Good. supramide 4.0 and 5.0. Postoperative instructions.
Follow-up examination May 6th2014 (3 months) No symptoms but the patient noticed that the sinus tract is still there. Surgery is planned. Problem list: Reduced bone level.
Fig. 11. Gauze sponge sutured in place to protect sinus.
Fig. 9. Periapical radiograph 06.05.2014.
Fig. 12. Root resection.
Prognosis Surgery: Good. Tooth: Good. Fig. 10. Persisting sinus tract 3 months.
Surgery May 13th2014 Follow-up examination September The patient was given a chlorhexidine th mouth rinse and local anaesthetic was 5 2014 (4 months) injected. A marginal incision was made No symptoms. Closed sinus tract. running from pontic 25 to tooth 17 with
108 There is a very close anatomic relationship between the root tips of the maxillary posterior teeth and the sinus floor. Eberhardt et al. (3) measured the distances between maxillary molar and premolar roots and the maxillary sinus. Their findings showed that the mean distance of the maxillary posterior teeth to the floor of the maxillary sinus is 1.97
Fig. 13. Control 4 months. mm. Thus, endodontic surgery of premolars and molars can produce an accidental oroantral communication (2, 4, 5, 6, 7 and 8) referred to as OAC. The OAC may result in acute or chronic sinusitis through displacement of bacteria from the infected periapical tissue, resected root tips, or bony drilling dust into the sinus (2).
Fig. 14. Periapical control radiograph (4 months). Hauman et al. (9) addressed anatomic and clinical aspects of the maxillary sinus in their review article. A key Discussion finding was that the borders of the When planning periapical surgery in maxillary sinus are projected as a thin maxillary premolars and molars, the radio-opaque line on periapical proximity of the maxillary sinus has to radiographs. In some cases with chronic be considered. The maxillary sinus is an periapical periodontitis, this line can be osseous cavity with the shape of a well-defined and easy to trace, although pyramid, the base being the nasal antral in others the radio-opaque line appears wall and the rounded tip lying in the less defined or blurred. zygomatic bone (1). The maxillary sinus Oberli et al. (2007) attempted to find out is lined by a ciliary epithelium whether conventional periapical containing beaker cells. This lining radiographs can be used to determine transports bacteria and other possible the risk of creating an oroantral foreign material toward the maxillary communication (OAC) while performing ostium on a thin mucous layer. The periapical surgery on maxillary maxillary ostium represents the opening premolars and molars. Perforation of to the nasal cavity, lying below the the sinus membrane (also referred to as middle nasal concha. A healthy maxillary the Schneiderian membrane) occurred sinus is aseptic in 80 to 100% of the in 12 cases (9.6%). Exposure of the population, containing neither bacteria membrane without rupture occurred in nor any other foreign material (2). The 15 cases (12%). It was found that the main purposes of the maxillary sinus distance between the apex or the apical have been postulated as a space for lesion and the sinus floor did not serve conditioning of the breathing air, a as a predictor of a possible sinus means of reducing the weight of the membrane rupture. On the other hand, if skull, and a resonance chamber for the the radiograph showed a distinct human voice (1). It also functions as an distance between the lesion and the immunologic barrier (2). sinus floor, there was an 82.5% probability that OAC would not occur.
109 Additionally, a blurred radiographic References outline of the periapical lesion did 1. Waite DE. Maxillary sinus. Dent not indicate an increased risk of sinus Clin North Am 1971; 15: 349- membrane rupture. They concluded that 386. conventional periapical radiographs 2. Watzek G, Bernhart T, Ulm C. couldn’t be used as predictors for Complications of sinus perforation of the maxillary sinus perforations and their during periapical surgery. However, management in endodontics. radiographs with a specific distance Dent Clin North Am 1997; 41: between the periapical lesion and the 563-583. sinus floor point toward a very low risk 3. Eberhardt JA, Torabinejad M, of accidental sinus perforation during Christiansen EL. A computed periapical surgery (10). tomographic study of the Another issue is whether an OAC must distances between the maxillary be considered a “surgical accident” (6). sinus floor and the apices of the A review article of the literature on maxillary posterior teeth. Oral periapical surgery by Garcia et al. (11) Surg Oral Med Oral Pathol Oral confirms that none of the included Radiol Endod 1992; 73: 345-346. studies found a significant difference 4. Freedman A, Horowitz I. in the healing outcome or the Complications after apicoectomy postoperative sequel when in maxillary premolar and molar accidental OAC had occurred. However, teeth. Int J Oral Maxillofac Surg the importance of prevention of 1999; 28: 192-194. introduction of foreign bodies, drilling 5. Rud J, Rud V. Surgical dust, or bacteria into the maxillary sinus endodontics of upper molars: during the surgery is emphasised. relation to the maxillary sinus In case of OAC, Jerome and Hill (12) and operation in acute state of suggested protecting the OAC with a infection. J Endod 1998; 24: 260- gauze pad once the root tip had been 261. resected. Furthermore, magnifying 6. Lin L, Chance K, Shovlin F, surgical aids such as loupes, endoscopes, Skribner J, Langeland K. and microscopes permit the surgeon to Oroantral communication in make a precise diagnosis and perform periapical surgery of maxillary minimally invasive low trauma posterior teeth. J Endod 1985; surgery (13, 14). 11: 40-44. The occurrence of intraoperative OAC 7. Ericson S, Finne K, Persson G. during periapical surgery is not a Results of apicoectomy of severe surgical accident. A proper maxillary canines, premolars and operation technique avoiding molars with special reference to dislocation of drilling dust, root tips, oroantral communication as a infected tissue, and haemostatic and prognostic factor. Int J Oral Surg filling material into the maxillary 1974; 3: 386-393. sinus will allow healing without 8. Ioannides C, Borstlap WA. complications even if OAC should occur. Apicoectomy on molars: a clinical and radiographical study. Int J Oral Surg 1983; 12: 73-79. 9. Hauman CHJ, Chandler NP, Tong DC. Endodontic implications of
110 the maxillary sinus: a review. Int Endod J 2002; 35: 127-141. 10. Oberli K, Bornstein MM, vonArx T. Periapical surgery and the maxillary sinus: radiographic parameters for clinical outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103: 848-853. 11. Garcia B, Martorell L, Martí E, Peñarrocha M. Periapical surgery of maxillary posterior teeth. A review of the literature. Med Oral 2006; 11: 146-150. 12. Jerome CE, Hill AV. Preventing root tip loss in the maxillary sinus during endodontic surgery. J Endod 1995; 21: 422-424. 13. von Arx T, Montagne D, Zwinngi C, Lussi A. Diagnostic accuracy of endoscopy in periradicular surgery—a comparison with scanning electron microscopy. Int Endod J 2003; 36: 691-699. 14. von Arx T, Hunenbart S, Buser D. Endoscope- and videoassisted endodontic surgery. Quintessence Int 2002; 33: 255- 259.
111 Case 20
Treatment of multiple idiopathic cervical root resorption
no history of trauma or orthodontic treatment.
Clinical findings August 30th2013 Soft tissue: An aphthous lesion was observed at the buccal aspect between tooth 13 and tooth 14. A gingival pocket Fig. 1. Frontal view. of 5mm was probed at the mesiopalatal aspect of tooth 14. Sensitivity to airspray and explorer was noted on the Patient mesiobuccal side of tooth 37 and palatal 51-year-old Russian male. side of tooth 15. Dental: Tooth 13 has a composite filling. Tooth 14 has a dental crown and a Chief complaint Firstly, he complains about lots of past mesiopalatal subgingival cavity. Tooth problems with his teeth in the left 15 has a composite filling. Tooth 37 has maxilla that finally had to be extracted. an occlusal amalgam filling and a small At present he feels discomfort in the mesiobuccal. gingiva around tooth 14 as well as sensitivity to cold in this area. He thinks the problems started when a crown was made 4 years earlier, and that the gingival discomfort got worse as time went by. Secondly, he complains of sensitivity to cold in the posterior left side of the mandible. He further tells that he is grinding his teeth and that his dentist told him that he is a bruxist. Fig. 2. Buccal view tooth 14, 15.
Medical record Non-contributory.
Dental history The patient was referred to the post- graduate endodontic clinic from private practise because of suspicion of a Fig. 3. Buccal view tooth 37. resorption (internal) on tooth 14 below a crown made 4 years earlier. It was observed on a routine x-ray. There was
112 Clinical tests August 30th2013
13 14 15 37 EPT nd nd nd nd Cold + + + + Percussion - v&h - - Palpation - + - - PPD 3 5 3 3 Mobility - - - - Biting - - - - Fig. 5. Bite-wing to visualize suspected cavity 37m.
Radiographic findings August 30th2013 Dental: Tooth 14 has a dental crown and a radiolucency is seen in the cervical area of the tooth. Tooth 15 has a MOD composite filling. Tooth 37 has an occlusal radiopaque filling and a possible pathologic radiolucency is seen at the mesial aspect of the tooth. Periodontal: Chronic marginal periodontitis. Apical: Tooth 14 has a lateral Fig 6. Orthopanthogram. radiolucency, mesial aspect, in the coronal third of the root. Teeth 15 and 37 have a continuous PDL space. Radiologic description (in Norwegian) from the Department of Maxillofacial Based on clinical and radiographic Radiology findings, and with the suspicion of an additional resorptive lesion on tooth 37, the patient was referred for cone-beam CT. In addition to cervical resorption on teeth 14 and 37, a cervical resorption on tooth 15 was identified on the CT scans.
Fig. 4. Periapical radiograph with gutta-percha inserted in the periodontal pocket.
113 Surgery November 19th2013 Surgery tooth 37: Marginal incision from 37 to 35. Cleaning of resorption lacunae: topical application of a 90% aqueous solution of trichloroacetic acid and curettage. Placement of a composite restoration. Suturing. Fig. 7. CT scan; axial view of the maxillary right first and second premolar with cervical The lesion was more advanced in apical resorption. direction than observed on CT scans, displaying fibro-osseous characteristics with deposition of ectopic bonelike calcifications both within the resorbing tissue and directly on the dentin surface. No pulpal perforation.
Prognosis Fig. 8. CT scan; sagittal view of mandibular left Tooth: Uncertain. second molar with cervical resorption. The resorption has not perforated the pulp. Follow-up examination November th Diagnosis 26 2013 (1 week) The patient is having pain. He describes Diagnosis increased sensitivity to cold and warm Pulpal within normal limits drinks region 37. Clinically there is drainage of pus from a periodontal Periodontal K05.03 chronic marginal periodontitis pocket at the buccal aspect. Tooth 37 is sensitive to percussion. Periapical within normal limits Treatment: Sterile saline rinse, observation. Pathologic K03.38 cervical resorption resorption MIR Multiple idiopathic resorption
Follow-up and treatment December 6th2013 Treatment plan The patient complains about intense Flap-elevation to fill the defects in teeth pain and increased sensitivity region 37. 37 and 15 externally with composite The pain is worse in the evening; jaw Surgical extraction of tooth 14. pain that is radiating to the ear. He uses Treatment alternatives were thoroughly paracetamol/codein at a daily basis. discussed: pulpectomy tooth 37 before Clinically tooth 37 is hypersensitive to surgery? Root canal treatment and cold stimulus (endo ice), lingering pain. filling of resorption defect tooth 14? Optimal healing is noted after surgery. Diagnosis: K04.01 acute irreversible pulpitis. Problem list The patient is not interested in a root Extension of lesion tooth 37. filling. It was decided to extract the Preservation of bone tooth 14 prior to tooth non-surgically (Fig. 10, 11). implant therapy.
114 resorption lacunae and placement of composite filling. Tooth 14: Tooth/root sectioning and removal.
Fig. 9. Periapical radiograph tooth 37, 06.12.2013.
Fig. 12. Photo of resorption defects.
Fig. 10. Buccal view of extracted tooth 37.
Fig. 13. Suturing.
Prognosis Tooth 15: Uncertain.
Follow-up examination February 11th2014 Fig. 11. Palatal view of extracted tooth 37. (1 week) Removal of sutures. Healing. No Histological findings tooth 37 symptoms. (Laboratorium of pathology, AK Goplen)
Diagnosis: “Changes consistent with th resorption of cementum and with Follow-up examination May 27 2014 virtually empty pulp”. The patient describes mild sensitivity to cold in the right maxilla. Two implants are placed in region 14 and 36. Surgery February 4th2014 Clinically: Teeth 15 and 16 are sensitive Surgery teeth 14 and 15: to air spray, more pronounced on tooth A palatal marginal incision was made 16. PPD 4mm tooth 15, palatal aspect. from the canine to the molar region (13- No symptoms on palpation and 16). Tooth 15: Small resorption defect, percussion. minimal osteotomy required, cleaning of A new recall is planned in 6 months.
115 external resorption from another type of inflammatory resorption called external inflammatory resorption, which is continued by necrotic pulp tissues and an infected root canal content (5). The aetiology of invasive cervical resorption is inconclusive, however, several potential predisposing factors have been identified (1):
Fig. 14. Periapical radiograph 27.05.2014. A. Physical trauma a) Orthodontic treatment b) Orthognathic surgery c) Transplanted teeth d) Trauma e) Bruxism f) Guided tissue regeneration B. Chemical Agents a. Intracoronal bleaching b. Secondary bone grafting in unilateral complete cleft palate patient. Fig. 15. Periapical radiograph 27.05.2014. c. Tetracycline conditioning of root
The clinical presentation of invasive Discussion cervical resorption varies considerably Invasive cervical resorption (ICR) is depending on the extent of the defined as ‘a localized resorptive resorptive process. The condition is process that commences on the surface usually painless and while a pink of root below the epithelial attachment discoloration of the crown indicates the and the coronal aspect of the supporting resorptive process, some teeth give no alveolar process, namely the zone of the visual signs and diagnosis is usually the connective tissue attachment’ result of a routine or sometimes a (1). Characterized by its cervical chance radiologic examination. Multiple location and invasive nature, this resorptions can occur, particularly when resorptive process leads to the there has been a history of orthodontic progressive and usually destructive loss treatment and a full mouth radiographic of tooth structure. The resorbed tissue is examination should follow the replaced by highly vascular tissue that identification of any tooth showing may become visible through thin evidence of invasive cervical resorption. residual enamel as pinkish discoloured Based on the invasiveness of the lesion, tooth (2). Heithersay (4) introduced a clinical Clinically, invasive external resorption is classification of invasive cervical associated with inflammation of the resorption (6): periodontal tissues and does not have Class 1- Denotes a small invasive any pulpal involvement (3). The pulp resorptive lesion near the cervical area remains protected by a thin layer of with a shallow penetration into dentine predentin until late in the process and it Class 2- Denotes a well-defined has been postulated that bacteria in the resorptive lesion that has penetrated sulcus sustain the inflammatory close to the coronal pulp chamber but response in the periodontium (1, 4). This feature differentiates cervical
116 shows little or no extensions into the restorations with glass-ionomer cement. radicular dentine The result was complete success in Class Class 3- Denotes a deeper invasion of 1 and Class 2 resorption. Of the 63 teeth dentine by resorbing tissue, not only classified with Class 3, 61 (96,8%) involving the coronal dentine but also showed resorption control. When all extending into the coronal third of the factors (resorption control, angular root bone loss, periapical changes and Class 4- Denotes a large invasive extraction) were included in the resorptive process that has extended assessment, the overall success rate of beyond the coronal third of the root Class 3 treatment was 77,8%. In Class 4 resorption 16 teeth were treated and Early defects are commonly detected as the results showed a survival rate of chance findings on radiographs. The 50% and a success rate as judged above severity of the lesion determines its 12,5%. This represents an radiographic appearance. The lesion unsatisfactory outcome for this classically presents as an asymmetrical treatment regimen when applied to radiolucency with ragged or irregular Class 4 resorption, and alternative margins in the cervical region of the prosthodontic replacement is generally tooth. Early lesions might be suggested (2). radiolucent; however, more advanced Multiple idiopathic cervical root lesions might have a mottled resorption (MICRR) is an uncommonly appearance caused by the osseous reported phenomenon that may affect nature of the advanced lesion. varying numbers of teeth. The condition The outline of the root canal should be was first identified 80 years ago by visible and intact, indicating that the Mueller who reported the first case of lesion lies on the outer surface of the idiopathic cervical root resorption in root (7). 1930 (11), and since that time It has been shown that conventional approximately 30 cases have been radiographic techniques reveal limited reported (12-25); the number of information on the true extent and involved teeth ranges from three to nature of the resorptive lesion (8). In more than 20 per subject (13). The recent literature, cone beam computed distribution varies from a single region tomography (CBCT), has been used to (e.g. mandibular incisors) to most teeth assess ICR lesions. The position, depth in within one arch or more generally relation to the root canal, and ultimately distributed throughout the entire the restorability of the tooth can be dentition. A similar condition involving assessed objectively before any apical resorption has also been treatment is carried out (8, 9). described (26). Most affected individuals are healthy, Heithersay (10) reported on a non- with non-contributory medical histories. surgical treatment regime that were A predilection for young females has applied to 101 teeth from 94 patients been reported (12, 27). displaying varying degrees of invasive An attempt has also been made to link resorption and followed up for a multiple idiopathic cervical root minimum of 3 years. It involved the resorption to feline invasive cervical topical application of a 90% aqueous resorption (14, 28). These studies raised solution of trichloroacetic acid to the the question of a possible role of a feline resorptive tissue, curettage, endodontic virus as an etiologic co-factor in MICRR. treatment where necessary, and
117 Liang et al. (12) reviewed the literature 4. Heithersay GS. Clinical, on MICRR. They reported the history, radiologic, and histopathologic clinical findings and radiographic features of invasive cervical appearance of four unreported cases of resorption. Quintessence Int multiple idiopathic cervical root 1999; 30: 27-37. resorption and did a systematic 5. Andreasen JO. External root literature review of this condition. resorption: its implication in MICRR was an incidental finding on dental traumatology, routine clinical and radiographic paedodontics, periodontics, examination. No correlation was seen orthodontics and endodontics. between this type of resorption and any Int Endod J 1985; 18(2): 109- medical or dental finding. 118. Radiographically, the lesions were found 6. Heithersay GS. Treatment of to begin at the cemento-enamel junction invasive cervical resorption: An and then either progress to involve the analysis of results using topical entire cervical region or, at some point, application of trichloroacetic spontaneously arrest. Those cases that acid, curettage, and restoration. progressed to involve the entire cervical Quintessence Int 1999; 30: 96- region required extraction. The number 110. of teeth that demonstrated this 7. Patel S, Kanagasingam S, Ford TP. condition ranged from 5 to 24 per External Cervical Resorption: A patient. More teeth became involved as Review. J Endod 2009; 35: 616– the condition was followed in time. 625. There was no detectable frequency of 8. Patel S, Dawood A, Whaites E, Pitt occurrence for any particular dental Ford T. The potential region or tooth among the involved applications of cone beam teeth. Of a total of 18 patients, 13 were computed tomography in the females whose ages ranged from 7 years management of endodontic to 68 years. Ten of the 18 patients were problems. Int Endod J 2007; 40: Caucasian. 818–830. 9. Cohenca N, Simon JH, Mathur A, In the present case, there was no Malfaz JM. Clinical indications for obvious etiologic factor identified, and digital imaging in dento-alveolar the lesion was considered to be trauma: part 2—root resorption. idiopathic form. Dent Traumatol 2007; 23: 105– 113. 10. Heithersay GS. Treatment of invasive cervical resorption: An References analysis of results using topical 1. Tronstad L. Root resorption: application of trichloroacetic etiology, terminology and clinical acid, curettage, and restoration. manifestations. Endod Dent Quintessence Int 1999; 30: 96- Traumatol 1988; 4: 241–252. 110. 2. Heithersay G. Invasive cervical 11. Mueller E, Rony HR. Laboratory resorption. Endod Topics 2004; studies of an unusual case of 7: 73–92. resorption. J Am Dent Assoc 3. Frank AL, Torabinejad M. 1930; 17: 326–334. Diagnosis and treatment of 12. Liang H, Burkes EJ, Frederiksen extracanal invasive resorption. J NL. Multiple idiopathic cervical Endod 1998; 24(7): 500-504.
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