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.

Herodontics? - Revisited

In Aug 2009, an American Academy of Implant Dentistry press release stated, "...times have changed and patients should forego prolonged dental heroics to save failing teeth and replace them with long-lasting dental implants". While it universally accepted that implants are a great way to replace missing teeth, a more controversial topic is when to replace a diseased tooth with an implant. In my opinion, those promoting dental implants have become increasingly more aggressive about replacing natural teeth.

As a specialist, I am occasionally called upon to perform "heroic" procedures. This may be following some iatrogenic damage or by a patient who wishes to retain a natural tooth at any cost. While I would much rather treat a normal, straightforward endodontic case, the use of microscopes, ultrasonics and MTA have allowed us to preserve teeth that many would consider "hopeless". I am often amazed at the success that we have with some of these "heroic" cases.

The following case was previously posted, but the patient returned for a 4 year recall last month. Unfortunately, the patient was returning for another root repair perforation following endodontic access on a different tooth. This case would be considered a "heroic" case by anyone's standard! In this particular case, this patient has been pleased with his decision to retain the tooth.

Original Post
This root canal was done just over four years ago. The patient presented with pain to percussion, and an 8 mm buccal probing was present. The RCT had been completed 2 years previously and recently became symptomatic.
DX: Prior RCT w/ Symptomatic Apical Periodontitis.
Treatment recommended: Non-surgical retreatment, perforation repair with possible need for endodontic surgery. Prognosis: guarded.

As you can see, the MB canal is very calcified. Calcification of this kind would make this case a very high level of difficulty. The MB canal was missed and the furcation was found, instrumented & obturated. Proper case selection can help prevent this type of complication. However, if this does occur, one would expect to find bleeding and the tactile sensation of the pdl/cortical bone is very different from the canal. Length determination films, working films or final films should also identify the perforation. I would recommend immediate referral to an endodontist for treatment of an iatrogenic event such as this.

Retreatment completed. MB canal located and treated. Furcal perforation repaired with MTA. Patient placed on recall to watch the area and see if endodontic surgery will be required.

Recall at 2 years & 3 months. Patient reports complete function and no symptoms. The 8mm periodontal probing has dissappeared. This tooth is considered "healing", and scheduled for a 1 year recall.

You can call it "herodontics", but that tooth is functional, apical bone looks good, periodontal pocket has disappeared. This will be a fun case to watch over time.

4 Year Recall

Asymptomatic & fully functional.

NOTE: I have never said this is pretty. Actually, its pretty ugly. However, retaining the natural tooth has preserved the crestal bone, provided normal function, and cost much less in time and money than any replacement option available.

Retreatment & MTA Save a Perforated Tooth

The following case was submitted by Dr. Rico D. Short of Smyrna, GA.

Original endodontic treatment was done 15 years ago. The crowns on 8 & 9 were replaced 2 years earlier at which time the dentist placed post for retention. During post preparation, the root was perforated. A large lesion has developed.


DX: Prior RCT w/ Chronic Apical Abscess w/ root perforation. Pt was informed the prognosis was questionable due to the perforation. Pt understood and consented for treatment including perforation repair.

Retreatment on #8 completed with MTA root repair.

8 month recall

22 month recall finds patient asymptomatic and functioning with no mobility and normal probing depths.

While many clinicians would have deemed this tooth "hopeless" and recommended extraction, MTA, microscopes and a expert clinician can save teeth that otherwise would be extracted.

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.

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.

Root Perforation causing Tooth Loss

This patient came to our office for evaluation of tooth #3. He reported having a recent root canal and crown done by a general dentist. Since the time the work was completed, he was experiencing "burning & itching in the gums around that tooth". The patient was concerned that he was having an allergic reaction to the cement or materials of the crown.

Our examination found #3 sensitive to palpation, moderately sensitive to percussion. (Adjacent teeth WNL) The radiopacent material in the furcation area of the tooth was noted.

Retreatment was initiated to evaluate the area.


The crown was first removed. Upon first look, there appears to be mesial decay still present and an obvious void between the tooth and the post/core material.

Additional removal of the buildup material shows a surprise underneath.

It become obvious that the distal wall of the MB canal has been perforated.

At this point, we can understand where the symptoms have been coming from. An attempt could be made to try and repair this defect (with MTA), however, the long term prognosis would be guarded to poor. Considering the the cost of initial treatment, the cost of retreatment which would then require post & build-up and new crown, this patient elected to extract the tooth.

This then becomes an appropriate time to replace this missing tooth with an implant or bridge. I recommended an implant consultation.

Endodontic treatment did not fail on this patient. The treating doctor failed to put his patient's best interest first and failed to inform the patient of the treatment complication (perforation) that occurred during treatment.

In a case like this, the patient referred himself to our office for evaluation. Had his dentist properly evaluated the case difficulty and referred him to an endodontist for treatment, this tooth would likely not have been lost.

This is not endodontic failure. This is failure to do good endodontics. This failure to do quality endodontics may be part of the reason that some clinicians are questioning the success of endodontic treatment.

Endodontic Success

This patient presented today with a dull, radiating ache in the lower right quadrant. Clinical examination finds #29 sensitive to percussion, normal probings with prior RCT (30 years). A short obturation is evident. Adjacent teeth #30 & #28 have normal pulps . #29 is diagnosed with Prior RCT & Symptomatic Apical Periodontitis. Retreatment is recommended & completed.


I think that it is great that a root canal, done sometime in the late 70's, can be retreated, using modern techniques and equipment and be functional for another 30-40 years. Unless that root is fractured, there is nothing better than a natural tooth.

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.

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.

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.

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.

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.