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.

Endodontic Retreatment & MTA Preserve the Tooth

Here's a tooth that had endodontic treatment over 10 years ago. While the clinician had difficulty finding all the canals, the tooth has been functional for quite some time. A large furcal defect raises suspicion of a root fracture or perforation.

DX: Prior RCT w/ Symptomatic Apical Periodontitis.

There are many who would consider this hopeless and recommend extraction.

Let us consider the cause of this treatment failure:

1. Missed Canals

2. Furcal Perforation or Root Fracture?

Can these issues be addressed to preserve the natural tooth?

In my consultation with the patient, I explain these issues and that endodontic re-treatment may be able to save the tooth (as long as the root is not fractured). I also explain the alternative option of extraction.

Finding missing canals is a simple solution.

A perforated root can be repaired with guarded prognosis.

A fractured root will require extraction.

I tell the patient the only way to know for sure is to open the tooth and investigate. Considering the nice crown on the tooth, the cost of attempting to save the tooth is minimal, compared to the cost of removing and replacing. In this case the patient elected re-treatment.

Pre-operative radiograph.

Upon access, 2 additional canals are located and instrumented. A furcal perforation is also identified. No root fractures are found.

Re-treatment is complete. Canals obturated with gutta percha and furcal perforation repaired with MTA. Glass ionomer base is placed over MTA.

7 month recall shows a tooth that is fully functional with remarkable healing of the furcal defect. Endodontic re-treatment has preserved the natural tooth.

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.

The Evolution of Implant Success

The 7th Annual Spring into Dentistry seminar was held on March 6th, 2009 in Mesa, AZ. The guest lecturer was Dr. Robert London of Seattle, Washington. Dr. London is currently a clinical professor and director of graduate periodontics at the University of Washington. Prior to his work at UW, Dr. London was director of graduate periodontics at NOVA Southeastern and at University of Southern California.
Dr. London's presentation was entitled, "Enhancing Dental Outcomes".

While a good portion of his presentation had to do with implant treatment planning and preparation of implant sites, he made some comments that I found fascinating.

He used an analogy of a pendulum to describe the acceptance of dental implants into mainstream dentistry. Early on, there was some resistance to accepting them into everyday practice. Like the swinging of a pendulum, treatment with dental implants then became the solution to every situation. Now that the pendulum has swung to both extremes, we are now hopefully settling somewhere in the middle.

He also discussed the changing definition of success with implants. Early on, successful implant therapy meant osseointegration. If the implant was not loose, it was considered a success. In endodontics, success has always been defined very strictly as the complete resolution of signs and symptoms and complete healing of bone. With two such different definitions of success, it is no wonder that there has been misinterpretation regarding the treatment outcomes of the two different treatments.

Dr. London pointed out that what was once considered a successful implant (osseointegration alone) may no longer be an acceptable treatment outcome. Successful implant therapy now requires getting the implant to integrate in the right position, where it can support a prosthesis and look like a natural tooth. This is a major difference from simple osseointegration.

Dr. London stressed how important it was to have an interdisciplinary approach to dental treatment so all specialties are included in the best treatment approach for each patient.

We were pleased to have Dr. London come and share some of his expertise regarding periodontal bone grafting and implant treatment. We hope that the balanced approach to endodontics and implants which he described continues to gain momentum.

Endodontic Surgery in the Esthetic Zone

One of the big challenges with dental implants is working in the esthetic zone (anterior maxilla). Crestal bone loss, which often occurs with dental implants, can lead to loss of gingival papilla. Loss of the papilla will lead to dark triangles and long clinical crowns. In an areas as esthetically sensitive as the maxillary anterior, loss of crestal bone can become a big challenge.

Endodontic microsurgery may allow you to save a natural tooth and preserve the crestal bone. Since endodontic surgery is an advanced technique taught in specialty residencies, many dentists are not as familiar with the possibilities of endodontic surgery. In addition, the advancement of surgical techniques and instruments have completely changed the endodontic surgical technique and it's outcomes.

The following case is an example of endodontic microsurgery.

Pt presents with a draining sinus tract on #10. A periapical radiolucency is noted. While pt reports the RCT was completed "eons ago", the post and crown are only a year old. The silver cone obturation, while past the apex, has served this patient well for many years. Options were discussed and the patient elected to have endodontic surgery.

An Ochsenbein-Luebke flap was used to help preserve the marginal gingiva. The silver point was removed and the canal was retrofilled with MTA (Mineral Trioxide Aggregate).

Post-op radiograph


3 month recall finds complete function, significant radiographic healing & preservation of the crestal bone.

Endodontic Retreatment or Implant?

This patient is wondering if she would be better off having tooth #10 extracted and an implant placed.

This is her situation. She had this silver point root canal done back in the 70's. A new crown was placed about a month ago and then the crown broke off. She came to my office for an evaluation. I recommended that we retreat the root canal, and place a new post for retention of the build-up/crown.

Since the crown broke off the remaining tooth structure supporting it, the ideal situation would be to make a new crown and improve the ferrrule effect.

I explained to her that as long as the tooth is not fractured, the retention of the natural tooth will actually help maintain the bone in the esthetic zone and give her the most natural appearance.

The silver point root canal is almost 40 years old. There is no sign of failure of the endodontics. This is actually a restorative failure. Any disturbance of the silver point can jeopardize it's seal. In retrospect, it would have been best to have retreated the RCT and placed a new post and core prior to the new crown.

Would you implant or do RCT?

I work with some great oral surgeons & periodontists. I was recently asked to evaluate tooth #31 by my periodontist colleague. This patient had been referred to him for extraction and placement of an implant.

The periodontist realized that the bone loss around this root was not caused by periodontal disease. The patient reported no pain or swelling. He has no senstivity to percussion, normal probing depths (4mm depth on the buccal was the deepest) and when proper vitality testing was completed, the tooth was found to be necrotic. The tooth was diagnosed: Necrotic Pulp w/ Chronic Apical Periodontitis. The patient was given the option of endodontic therapy to retain the natural tooth.

Pulpal access revealed a necrotic pulp chamber.

Endodontic therapy completed and a 6 month recall scheduled to evaluate the periapical healing.
Please feel free to share your thoughts about these cases. The purpose of this blog is to generate discussion. What would you have done?

Horizontal Root Fracture?

This tooth was referred to an oral surgeon for extraction and immediate implant placement on #11. A void between the post and the root canal filling is noted and it appears there may be some widening of the periodontal ligament adjacent to that void. There was purulence noted from the sulcus and the attached gingival tissue was inflammed. The tooth was otherwise asymptomatic. I was asked to do a consultation to confirm the horizontal fracture before the tooth was extracted. As I have mentioned in previous posts, root fractures are very difficult to diagnose.

A second radiograph of the tooth appears normal. No sign of fracture or change in the periodontal ligament from this view. It does appear that there may be some coronal leakage on the distal margin of the crown.

Another radiographic shift reveals that the post preparation was off center slightly with the canal. I explained to the patient and my oral surgeon colleague that the only way to know for sure would be to examine the tooth surgically or by removing the post and examining the tooth internally using the microscope.

When given the option to evaluate the tooth microscopically and potentially retain the natural tooth, the patient elected to disassemble the post & crown and evaluate it. Microscopic examination as well as additional radiographs revealed no sign of horizontal fracture. Endodontic retreatment was completed and a post and core build up was completed. There is plenty of supracrestal bone to get a good ferrule for the new crown.
Proper endodontic consultation allowed this patient to retain his natural tooth, save considerable time and money and be back to complete function in a matter of a few weeks.
The endodontic part of the "multi-disciplinary" approach to implant treatment planning is often lacking. Diagnosis of root fracture rarely can be made by looking at a single film. Endodontic consultation is an important part of implant treatment planning.

Research Update: Comparison of Nonsurgical Endodontics & Single Tooth Implants

A recent study published in the Journal of Endodontics is one of the first studies to directly compare the outcomes of nonsurgical endodontic therapy (NSRCT) with single tooth implants.
Implants have long been accepted as a predictable treatment option for the replacement of missing teeth. However, recently, there are those who have begun to indicate that extraction and an implant may be preferred over endondontic treatment. There are those who argue that implants have a higher long term survival rate than teeth treated with endodontics. This is not an evidence based argument.
Until recently, there was no research directly comparing the survival rate of endodontics and implants. The endodontic literature defined "success" as complete radiographic healing, absence of symptoms, & full function. (A tooth that had incomplete radiographic healing at the time of re-evaluation would not be considered a "success" by this definition even if it was asymptomatic and fully functional.) In contrast, the implant literature defines their success as "survival". An implant was categorized as "surviving" if it was still in the mouth at the time of re-evaluation. (An implant with a draining sinus tract that had not been removed would be considered "surviving".) This difference in definitions has caused much confusion and mis-interpretation of the endodontic & implant literature.
The recent study by Doyle et. al. directly compared the NSRCT with single tooth implants. The retrospective study compared 196 NSRCT cases and 196 single tooth implant cases for success, survival, survival with intervention & failure. This definition of outcomes allows a more accurate comparison of the outcomes of endodontics & implants.
Their results were very interesting.



Their study found that NSRCT (when restored properly) and single tooth implants have similar failure rates over time. They also found that the implant group has a longer average and median time to function.

This study directly comparing implants and endodontics, while one of the first of its kind, will not be the last. Dr. Walter Bowles, associate professor at the University of Minnesota, will be leading a team of researchers to conduct a similar retrospective study on a much larger scale. Dr. Bowles and his associates from the University of Alabama, University of California, San Francisco, & Ohio State University, will be evaluting 10,000 patients and use the data to provide a timeline for outcomes over a 10 year period. The project which recently began will take two and a half years to complete.

Evidence based dentistry helps us to make treatment decisions based on the best available clinical evidence, individual factors of each particular case, the clinician’s expertise & patient’s informed consent. The decision to restore a tooth with endodontic treatment or remove and place an implant should be based on other factors than long term survival rates.

References:

Doyle S, Hodges J, Pesun I, Law A, Bowles W. Retrospective Cross Sectional Comparison of Initial Nonsurgical Endodontics Treatment and Single Tooth Implants. J Endod 2006; 31.

Hoffman, J. AAE-Funded Study to Compare Implants, Endo. The Endo Tribune 2007; 2:8, 2-3.

Cracked Tooth?

This patient came in today complaining of pain on #31. I went through my typical diagnostics and diagnosed the tooth as: partially necrotic pulp with phoenix abscess. The patient elected to go ahead with endodontic treatment today, since she is leaving town tomorrow morning.

Once I opened up the tooth, I realized that there was a crack on the distal of the tooth. I proceeded with the access and removed all the distal amalgam to get a good look of the crack. I wanted to find out if the crack was just in the surface of the enamel or if it went all the way through the dentin. I found some purulence in the distal canal and bleeding in the mesial canals (confirming my diagnosis of partially necrotic). Once I got the access opened up, I could see that the crack ran down along the distal wall of the pulpal chamber. When I find cracks like this, I think that it changes the long term prognosis of the tooth. We all know that the research supports the survival rate of endodontically treated teeth (when properly restored) at very high levels (90+%). A crack in the tooth is a factor that will likely decrease that long term survival rate. However, I have found that even in a situation like this, when given the options, many patients still want to try and save their tooth.

This is what I found. At this point in the procedure, I stop and we have a little "heart to heart". I explain to the patient what I have found. Then I tell them that their options are:

1. Complete the RCT, restore, and recall. I explain the decreased prognosis. There is really no evidence/research (I am aware of) that would tell them how much a crack in the tooth will change the long term prognosis.

2. Extract the tooth. Replacement options are discussed. In this case, with a full complement of teeth, an implant would be the only practical replacement option.

In this particular case, the patient decided that she did not want to extract the tooth. With good informed consent we completed the case, reduced the occlusion & temporized the tooth. She will return to her G.P. for build-up & crown. You may see that I removed a little extra gutta percha from the distal canal, to allow the bonded restoration to seal off the distal a little better.

Here is how the final film turned out.

We will recall her in 6 months to re-evaluate the distal lesion. I really feel that the key to this type of treatment is informed consent. When presented the options & prognosis, some patients will elect to extract and move on. However, most patients want to try and save their natural tooth. Endodontics can help them retain their natural teeth for many years.

Here is another case where a cracked tooth was found and it was recommended that she extract the tooth and have an implant placed. The patient followed the recommendation and had tooth extracted, bone grafting, and an implant placed by a specialist.

4 years later, she returned for re-eavluation. The implant was loose, probed to the apex, and there was purulence. You have to wonder if it wouldn't have been better to have tried to save the tooth originally. I can't guarantee that the tooth would have lasted with endodontic treatment, but it is an option that shouldn't be left out of the treatment planning process.

Time for an Implant

This patient was referred to my office today to finish the RCT on #5. I was obviously a little concerned about the restorability of the tooth. Since she traveled quite far, and her referring dentist had sent her, I went ahead and opened it up to take a peek.





This is what I found. (not surprising)

We discussed the options:

OPTION #1

1. RCT $800

2. Build-up $250

3. Crown Lengthening $700

4. Crown $800

Total $2550 with guarded/poor prognosis



OPTION #2

1. Extract $200

2. Implant $1800

3. Crown $1000

TOTAL $3000 with excellent prognosis

OPTION #3

1. Extract $200

2. Bridge $2400

TOTAL $2600 with excellent prognosis

It is obvious that an implant or bridge will have a better long term prognosis than trying to save this tooth with endodontic therapy, perio therapy & restorative therapy. This is a situation where I made a recommendation for extraction. Since #4 has a nice crown and #6 is a virgin tooth, if it were me, I would personally go with the implant option.

In my practice, I always try to give my patients the same treatment that I would want for myself or my family. I think we owe it to our patients to give them all of the options.

Don't pull that tooth yet!

This patient came into our office complaining of pain on tooth #3. She reported that she had the RCT done within the last year, but it had never felt better. I'm sure that if she had walked into see an implant dentist, he would have pulled this tooth out faster than you can say "nobel biocare"! Fact of the matter, if we don't offer endodontic microsurgery in a case like this, we are doing our patients a real disservice.

After reviewing the apicoectomy and retrofill procedure, the patient wanted to try and save the tooth with an endodontic surgery. We resected the root, removed the extruded gutta percha, and placed an MTA retrofill.
















At the 3 month re-evaluation, complete apical healing of the osteotomy site is evident. The tooth is fully functional and asymptomatic.

For more case examples of endodontic surgery, including video of an apicoectomy - click here