Wednesday, May 28, 2008

Surgical Repair of Post Perforation

This patient presented without pain but presence of draining sinus tract in the buccal attached tissue over #7. The position of the draining sinus tract directly at the level of the post, normal periodontal probings and evaluation of the radiograph made me suspicious of a post perforation. (note the widened ligament to the level of the post, and completely normal appearance at the periapex)
Options discussed included retreatment or apical surgery. Since the crown is all porcelain, we decided to treat surgically.

Ochsenbein-Luebke surgical flap was selected to prevent recession of marginal gingival, and minimal loss of crestal bone. The periodontal attachment was still in tact following flap reflection despite the loss of buccal bone adjacent to the perforation.

Metal tip of the post was visible without any removal of any buccal bone.

The post was counter-sunk using a high speed handpiece.

Preparation of the root. Note that this was not the apex of the root. This repair was being done on the mid-root surface.

Geristore was selected as the restorative material. Since Geristore is a bonded material, moisture control is important. Astringedent was used for hemostasis and the root was acid etched, primed and bonded.

Geristore placed in the preparation and cured.

Geristore was contoured to the root surface.

Final film. This will be an interesting case to follow. Expect a good result and repair of boney defect. We'll continue to monitor this tooth over time. Endodontic surgery has provided a valuable service to this patient prolonging the life of this tooth, the crown and hopefully regenerating the boney defect. Stay tuned for updates!

Monday, May 19, 2008

Vertical Root Fracture

This 92 year old patient came into our office for evaluation of #7. She reported no pain, but had a sinus tract between #6 & #7. Probing around #7 appeared normal.

The radiograph appeared to show some lateral radiolucency at the level of the post. The post also appeared slightly off angle with the root canal obturation. Despite the lack of narrow probing depths, I suspected a root fracture.

At this point, we decided to verify that fracture by disassembling the restoration. The patient was informed that if the root was fractured, then she we would not be able to save the tooth.

After simultaneous removal of the post and crown, multiple vertical root fractures were identified. A lingual, and distal fracture are seen in this image.

A mesial root fracture is seen in this angle.

Visualizing a fracture is the only certain way to diagnose a root fracture. This procedure is not well reimbursed, if at all. It will certainly require time that could be used for more productive treatment. However, if it was my tooth, I would want to know it is fractured before extracting it.

I suspect that a possible application of the new cone beam dental CT's will help with diagnosis of vertical root fracture.

Wednesday, May 7, 2008

Placement of MTA

Mineral Trioxide Aggregate (MTA) is a great material for retrofills, root perforation repair, direct pulp capping, apexification & apexogenesis. This material is mostly used by specialists, under a microscope. However, new applications, such as direct pulp capping, will make this material more commonplace.
Unlike most dental materials, MTA requires moisture to set up. Since moisture control is one of the largest challenges in working with most dental materials, this actually is a positive characteristic of this material.

Using this material is like playing with wet sand. You can add or remove water to the consistency that you like. If you put too much water in it, it runs. If you put too little water in it or it dries out, it crumbles. If you put just the right amount of water in it, it becomes packable, just like wet sand.  It takes a little practice, but once you learn how to manage the moisture, it's great to work with. The material does dry out while you use it, so additional water can be added to return it to your desired consistancy.

There are few specialized instrument that aid in the placement of MTA. Carriers are made in all shapes and sizes. These work just like an amalgam carrier on a much smaller scale.

Another useful carrier is made from a plastic block and a simple hand instrument.

Handling MTA will take a little practice, but once you learn how to mix and handle it, you will find it is a great material to work with.

The following video clip shows the placement of MTA as a retrofill during an apicoectomy surgery.