endomontreal

case: 430646

Resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images, the modified foramen in distal root is positioned farther from the radiographic apex and gutta percha appears in overextension. A large and circumbscribed radiolucency involves both roots as well as the furcation. This indicates an important periradicular tissues destruction. Tooth mobility level 2 goes along with this tissue loss.

This case is definitly a controversial one, meaning that it is possible for different practitionners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity. As stated by John I. Ingles, a senior lecturer in endodontics: "The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one's own abilities. Being able to practice using a great variety of techniques and not being "married" to a single approach in every case will greatly enhance one's capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence."

Endododontic retreatment and MTA root-end fillings have been performed with a Zeiss Pro Ergo Microscope in september 2008. Last displayed X ray film on this post shows a 3 years post operative clinical outcome. Radiographic examination shows a complete regeneration of the periradicular tissues and a resoptive defect healing. 

Should an implant have been put there? maybe, maybe not!

Read more about MTA Precision placement with the microscope (.pdf)

Case study number: 461716

Patient came to our office with spontaneous intermittent pain on maxillary right side. He can readily identify the tooth, he is showing the first molar. Patient is taking many Aspirin tablets per day and is tired of suffering.

Tooth history: first attempt of root canal treatment which ended up with a broken instrument.The patient was then seen two years ago by another practitioner who succeeded in the broken instrument surgical retrieval. Even thought, at the time, a complete retreatment has been performed, the tooth remained sensitive. Since then, painful episodes became more and more frequent with a growing pain intensity. 

Tooth is sensitive to palpation with a mobility of level 2. A new crown is protecting the cusps and occlusion looks fine. Pre operative Xray shows an apical periodontitis on mesio vestibular root and something that might be a perforation with a bunch of wispy gutta percha points into it. Patient is informed of this concern prior to starting anything. Patient is informed of the high incidence rate of a fourth canal in those first maxillary molars (Studies shows up to a whopping 92% rate). He is also made aware that this fourth canal may have been omitted. After the exam, patient knows that at least two concerns have to be addressed in order to solve his problem. Implant is suggested but patient is reluctant, he is 25 years old and he wants to keep his real tooth. 

The two first X Rays are preoperative

Third X rays show the recovered MB2 with a first instrument (number 08 ISO file) reaching its apex, the fourth X ray film shows the repaired perforation with MTA and intracanal medication (Ca(OH)2 dressing) in MB2. 

Fifth image shows immediate post operative outcome with the Pulp Canal sealer overfill which has no impact on the overall prognosis. An amalgam has been placed as a long term provisional for one year. Symptoms subsided almost immediately after the intra canal dressing. The monitored tooth has been fine all along for one year. The last Xray is a one year post operative control with a brand new crown in place.

Access made through crown makes the treatment much more difficult in that the landmarks that direct the clinician to the pulp chamber are removed. Our microscope integrated video camera recorded a short movie showing treated MB2 and the MTA repair, the position of the repaired perforation site (dark grey shade) in relation to the real position of the MB2, clearly stresses out what can happen while you are looking for the MB2 with external contour of the tooth being altered by a PFM crown. 

Patient has been advised of bad tooth prognosis because of external apical resorptive defect and suspected huge amount of tooth decay in root canal. Nevertheless patient refused implant supported crown on maxillary first premolar. An attempt has been made to save this tooth.

Teeth 12, 13 and 17 are existing 17XXX13,12 bridge abutments. Previous bridge done by a prosthodontist lasted 12 years. Lack of bone structure precluded implants surgery in number 16,15 and 14 and patient did not want any sinus lift surgery.  Tooth number 12 became a key abutment to save without shortening its root lenght. Root canal performed 12 years ago on tooth number 12, a casted post has to be removed, broken Hedstrom file number 45 ISO also has to be removed in apical third of root canal. Tooth decay surrounded the file fragment and apical root canal size diameter had to be enlarged to 80 ISO diameter file. After re-endo, casted posts on teeth number 12,13 and a new 17XXX13,12 bridge are planned. Last Xray is a post operative X ray with cemented post and abutment 12 of 17XXX13,12 bridge.

A Left side X Ray film:

(1)Iatrogenic defect

(2)3 mm short gutta percha obturation

B Right side X Ray film:

(1)MTA repair (iatrogenic defect)

(2)New gutta percha obturation

C 12 month follow up X Ray

1:Pre and post MTA repair of an external resorption defect

In response to a Canadian collegue concern about this MTA repair :”The overextension of the material behond external root contour seems not to affect the prognosis of the repair”

Ref. : Pathway to the pulp, Ninth edition, Chapter 25, page 1000.

Legend #1 is an MTA Apical plug + Gutta Percha obturation performed seven years ago. Last image to the right is a 5 years follow up X ray dental film. Today the tooth is still asymptomatic. So far so good! This MTA material is amazing!