Is That a Root Fracture?

Large J-shaped lesions are often associated with vertical root fractures. This tooth was asymptomatic to percussion, non responsive to thermal testing and surprisingly normal to probing. Diagnosis: necrotic pulp and asymptomatic apical periodontitis. It was was determined to be an endodontic problem.

The large radiolucency extends up the distal root into the furcation. Microscopic examination during endodontic therapy revealed no root fracture. In this case, the assumption of a root fracture, based on radiographs alone, would have been incorrect.

Without proper diagnosis, this tooth might easily be labeled a fractured root and extracted. A new crown is indicated to prevent coronal leakage.

Root Canal Treatment Saves a Perforated Tooth

This root canal was started in July '09. After having difficulty finding the canals, the tooth was referred to our office.

Upon opening the tooth, we found a supraboney perforation on the ML surface.

Canals were located using a operating microscope and the root canal completed.

The ML perforation was repaired using Geristore. (Since this perforation was above the crestal bone, a restorative material that would not wash out must be used. MTA is not the best material in this type of perforation)

A six month recall finds the lesions almost completely healed and the tooth pain free and functional.

Calcium Hydroxide as Intercanal Medicament

Ca(OH)2 pastes are used in endodontics as a temporary canal filling material for multiple purposes including:
1. Stimulate continue root development
2. Control exudate/disinfect the canal system
3. Prevention of external root resorption following traumatic injuries
4. Create an apical barrier following over instrumentation

Occasionally, I will use calcium hydroxide as a intracanal medicament to look for signs of initial healing prior to obturation. On this particular retreatment case, the distal canal was long and wide. I was concerned there may have been some resorption or possible an apical crack that I could not visualize.

Pre-Operative Radiograph

Calcium Hydroxide paste was placed (and extruded) in the canals.

3 month recall shows remarkable resorption of the extruded Ca(OH)2 and healing of the apical lesion.

Tooth was re-obturated and another tooth has been saved!

Source:
Cohen & Burns. Pathways of Pulp 6th ed. p.406-407.

Apexification with Calcium Hydroxide & MTA Fill

This 15 year old patient has a history of trauma to #8. Trauma occurred at an age before apical closure occurred. Tooth was diagnosed with necrotic pulp and symptomatic apical periodontitis. Note the large periapical lesion.

Traditional apexification using Ca(OH)2 was used.

Tooth debrided to the apex, NaOCl irrigation.

Ca(OH)2 placed.

3 month check shows resorption of Ca(OH)2, but apex still open. Apical lesion almost completely healed.

Ca(OH)2 placed again.

10 month re-evaluation. Apical barrier present, so it was time to obturate. This is a great view of the apical barrier that has formed.

Tooth was obturated with MTA. If this tooth ever needs apical treatment, a simple resection will be done without retropreparation or retrofilling.

Saving the Natural Tooth with Intentional Replantation

Intentional replantation is the intentional removal (extraction) and replantation of a tooth. This technique can be useful for teeth that cannot be treated with traditional endodontic surgery. This strategy can be particularly helpful in lower second molars where proximity to the mandibular nerve and thickness of the buccal bone make endodontic surgery difficult.


This patient presented for treatment of tooth #18. It had previous endodontic treatment 15 years earlier. The patient presented with some intraoral swelling and intermittent pain that was worsened with pressure and biting. Class II mobility and deep buccal probing were found along with the obvious periapical radiolucency and apical resorption. The tooth was diagnosed as: Prior RCT with chronic apical abscess. The large access cavity weakening the mesial tooth surface was noted and discussed as well as the possibility of a root fracture.

Treatment options discussed included:
1. Retreatment and look for fracture
2. Apicoectomy and look for fracture
3. Intentional replantation and look for fracture
4. Extraction

Due to the conical root structure, closeness to the mandibular canal, and probable root fracture, we decided to perform and intentional replantation.
Tooth was removed atraumatically and no root fractures were found.

Immediate root resection, retropreparation and retrofill with MTA was performed.
Patient was given PenVK 500mg for 5 days.
Patient was informed of the guarded prognosis following this procedure. Long term follow up will be required to determine the success.

6 year recall of the patient finds the tooth completely functional and asymptomatic. While there are many who would not have considered saving this tooth, the intentional reimplantation procedure has saved this patient thousands of dollars and allowed him to retain his natural tooth.

Resorption of Calcium Hydroxide Paste

Calcium Hydroxide is widely used in endodontics for a number of purposes. Its antimicrobial properties are attributed to its high pH (basic), destructive effects on bacterial cell walls and ability to dissolve organic tissue. It is used routinely as an intracanal medicament. It is also used for apexification, apexigenesis, treatment of root resorption.

Ca(OH)2 used in endodontics is made with Ca(OH)2 powder, a vehicle and a radiopacifier. Most common radiopacifiers are barium sulfate, bismuth or compounds containing iodine or bromine. While radiopacifiers make the calcium hydroxide more visible radiographically, some radiopacifiers are known to resorb at a slower pace, sometimes making it difficult to see the subtle changes.

While the control of a paste material at the apex of a canal can be very difficult, the resorptive properties of calcium hydroxide make it a very forgiving material. Extrusion of calcium hydroxide past the apex of a tooth is not uncommon. In fact, there are some who would recommend deliberate extrusion in the case of a large, chronic periapical lesion to help in the healing of such a lesion.



Calcium hydroxide (Ultracal - Ultradent - 35% Ca(OH)2 with barium sulfate) was used during treatment of this tooth to control exudate prior to obturation. A significant amount was extruded past the apex in close approximation to the maxillary sinuses during the endodontic treatment.




14 months later, the patient returned for treatment of #14. Our recall radiograph of #15 shows complete resorption of Ca(OH)2. The patient had no complaints and is in full function.



Sources:

Hasan Orucoglu, Funda Kont Cobankara, "Effect of Unintentionally Extruded Calcium Hydroxide Paste Including Barium Sulfate as a Radiopaquing Agent in Treatment of Teeth with Periapical Lesions: Report of a Case", Journal of Endodontics, July 2008 (Vol. 34, Issue 7, Pages 888-891)

Root Canals Save Your Natural Teeth

Occasionally I will use the images posted on the endo blog to aid in communication with patients. Whether trying to explain the healing of an abscess or show the patient how their tooth is cracked or fractured, a picture is worth a thousand words. Access to the internet in the operatory allows the endo blog to serve as a useful educational tool with patients. These images designed for patient education are written in lay terms will be labeled "patient education". Feel free to use them in your discussions with your patients. (click on the image for a larger, high resolution image)

Another Abscess Healed - At Least for Now!

This patient presented for treatment on #19. Tooth was diagnosed as necrotic with symptomatic apical periodontitis. Endodontic therapy recommended.


RCT completed. 6 month recall shows complete healing of the apical lesion. My concern is the distal leakage under the bridge. If this bridge is not replaced, the abscess will return. Some would then consider that endodontic failure, when in reality it would be a restorative failure.

Fantastic Endodontic Healing

This tooth #30 was diagnosed with a necrotic pulp with chronic apical abscess. Large periapical lesion noted, 4mm pocketing, class II mobility with large subgingival/subcoronal repair. Proper diagnosis indicated that this lesion is a true endodontic lesion. Therefore, endodontic therapy should yield good results.

Endodontic treatment completed.

3 year recall illustrates complete endodontic healing.  The tooth is completely asymptomatic and functional. A new coronal restoration to include the previous repair done on the distal is recommended to prevent coronal leakage.

Healing Following Apical Surgery

This patient came to our office for treatment in 2005. Tooth #30 was diagnosed with a necrotic pulp and chronic apical abscess. Periodontal probing around tooth #30 was normal. Despite the large lesion into the furcation, this was determined to be an endodontic lesion.

Endodontic treatment was completed.

16 months later, the patient returned with swelling. Orthodontic treatment was underway. The apical lesion had failed to heal, and even gotten worse. Surgery was recommended to evaluate the lesion for possible root fracture.

Large amount of granulation tissue removed from large boney defect.

Biopsy Dx: Periapical Cyst

Following the apicoectomy, a MTA retrofill was placed in all canals. No fractures were found. The orthodontic treatment was discontinued for a period to allow for healing.

The patient came in last week for a nine month recall. The patient is completely asymptomatic, the apical healing is almost complete.
As a review, this is a tooth that failed to heal with non-surgical endodontic therapy. This tooth while loaded occlusally, underwent orthodontic forces, endodontic surgery (without bone grafting) and had significant bone regeneration at nine months.
There are many dentists who would have extracted this tooth without considering the option of endodontic treatment or surgery. Modern endodontic microsurgery provides our patients with another option for maintaining their natural teeth. It should be considered when we are doing our treatment planning.

Endodontic Healing with Perforation Repair

This patient came to my office in March of 2003. She had two large "all porcelain" bridges done a year and a half earlier between #22-#27. Teeth #24 & #25 were diagnosed as necrotic with Chronic Apical Periodontitis. Endodontic therapy was initiated.

To my dismay, a suprabony perforation was created on the distal of #24.

After a little redirection, the canals were located and then instrumented and obturated.

Both teeth were obturated with gutta percha. Because the perforation was suprabony, Geristore was selected as the repair material. Since geristore is a resin, it will not wash out, making it ideal for a defect above the level of crestal bone. The patient was informed of the perforation defect and its repair.



Typically I would re-evaluate this case 6 months to a year following completion. This patient chose not to return until another tooth needed endodontic treatment.
The patient reported no symptoms and our recall film at 3 yrs 9 months shows complete healing of the apical radiolucencies.
Retaining these teeth with endodontic therapy allows for healing of the bone and maintains the crestal level of the bone as well as provides more life from the recently placed porcelain bridges.

Endodontic Healing

This is a typical case of endodontic healing. This tooth was diagnosed with a necrotic pulp & chronic apical periodontitis. The periodontal probings were normal. The apical lesion was very large and extended up the lateral side of the tooth. This could be described as a "J-shaped" lesion which is sometimes indicative of a vertical root fracture. Since the perio attachment is normal, this is diagnosed as purely an endodontic lesion.

Endodontic treatment complete.

At one year recall, the lesions is almost completely healed. The periodontal probings are normal and the patient is completely asymptomatic. Proper endodontic diagnosis & treatment not only saved this tooth, but saved this bridge as well.

Endodontic Retreatment

This patient came in with RCT #29 completed 7 years earlier. She reported dull ache, had a gold onlay and obvious apical lesion. Clinically, tooth was mildly sensitive to percussion, normal probing depths. Diagnosis: Prior RCT with Phoenix Abscess. Retreatment indicated.

During retreatment, a lateral canal was opened, irrigated & obturated. No fractures seen under the microscope.

At 3 months, the patient was asymptomatic and apical healing noted. This lesion is classified as "healing" due to the decrease in apical lucency since the retreatment.

At 15 month recall, the patient is asymptomatic and lesion is "healed", despite failure to place coronal restoration.

Swartz, Skidmore & Griffin (1983) in an evaluation of 1007 endodontically treated teeth found that the #1 reason for failure was inadequate restorations. They also found that overfills caused 4 times as many failures.

This patient was encouraged to get coronal coverage on this tooth ASAP.

Retreatment Success

This patient came in 18 months ago. Tooth #30 was diagnosed with Prior RCT & Phoenix Abscess. Retreatment was recommended. As you can see, there is an apical radiolucency on the mesial roots, which appear to be filled short of the apex.

An amalgam was placed into the canal orifaces for retention of the core build-up. During the treatment, some amalgam shavings were pushed apically. However, I was pleased that we were able to open the canals better and get to the apex.

This patient returned today for a 18 month recall. The lesion has healed. The tooth is asymptomatic, fully functional & with normal periodontal probings. Endodontic retreatment is a valuable (and economical) treatment option that has helped this patient retain this tooth and the bridge.

Wow - Nice Healing!

In a previous post I mentioned how a J-shaped lesion is often indicative of vertical root fracture? I also mentioned that thorough endodontic diagnostics must always be completed before condemning a tooth with a vertical root fracture. Here is a perfect example of a huge j-shaped lesion, that is not a vertical root fracture. This patient came in today, and I took a 4.5 yr recall on this tooth. Healing is complete.