Apical Surgery Saves the Bridge

This root canal was orginally done in 1982 and an instrument was separated at the time. Within the next two years, the tooth was treated with an apicoectomy to remove the separated instrument. This was "Old School" endo surgery. No microscope with an amalgam retrofill. Despite this, the tooth was retained (survived) for 25 years. You can tell that the amalgam retrofill came loose and the apical seal was jeopardized. An apical radiolucency is apparent.

We discussed with the patient the possibility of a root fracture, but that the most likely reason for the apical lesion was the lost retrofill. We recommended endodontic microsurgery to retreat the lost retrofill. The patient agreed and procedure was peformed.

A root end fracture was found. At this point, we decided to go ahead and resect the root to see how far the fracture went. (I decided that rather than remove more bone looking for the dislodged amalgam, I would leave it.)

Under the microscope we were able to remove the fractured portion of the root. We went ahead and placed a retrofill with MTA (Mineral Trioxide Aggregate).

Post-operative radiograph following placement of new apical retrofill.

A six month recall on the tooth reveals complete healing of the bone and full function of the tooth. No pain to percussion, normal probings. Despite a small root end fracture, this tooth was treatable with endodontic microsurgery. The endodontic microsurgery option has allow this patient to retain his natural tooth and keep his 3 unit bridge.

Finding the canal in a Md Incisor

This tooth was referred to my office today after the RCT had been started. I appreciate a dentist who is not afraid to stop during a procedure and refer if needed. Here's a tip to help you find these canals.

Look lingually. The natural access into a Md incisor always goes toward the buccal. If you cannot find the canal (or the second canal in 20-40% of these teeth), look lingually.

I used an ultrasonic tip under the microscope to cut from the current access back towards the lingual.

That's it. Remember to look lingually.

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.

Transillumination

Transillumination can be a useful diagnostic tool for identifying cracked teeth. As the light passes through the enamel, a crack will diffract the light and make the crack visible.

In this case, tooth #19 has visible cracks on the lingual, buccal and disto-marginal ridge.

This may be an important tool to help you identify a cracked tooth. Accurate pulpal and periapical diagnostics are most important to determine if endodontic therapy is needed before a crown is placed.
Transillumination helps the patient to see the stresses that the tooth is under and realize the importance of coronal coverage.

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.

Apexification after Avulsion

This 11 year old kid took a fall at the swimming pool and knocked out #8. It was out of his mouth for over an hour. It was re-implanted by his general dentist and splinted for some time.

When he came to my office the tooth was still sensitive to pressure, percussion & no response to pulpal testing. I diagnosed it with a necrotic pulp, acute apical periodontitis with immature apex. My recommended treatment was traditional apexification using Ca(OH)2. Apexification is done when the tooth is no longer vital and we are trying to create a calcific barrier at the root end, allowing us to obturate the canal.

Ca(OH)2 placed and repeated again 4 months later.

After one year of treatment with Ca(OH)2 paste, (you can see the paste resorbs over time) I was concerned that the calcific barrier at the root end had not formed. I planned to go in an obturate the whole canal with MTA, but found that a calcific barrier had formed and I was able to obturate the tooth in normal fashion.

This is the final film. As you can see, once the tooth has been obturated, the apex of the tooth looks completely normal. The next issue that this young guy will have to deal with is the possibility of ankylosis. When the tooth was originally reimplanted, it was fixated for too long of a time. For instructions on treating an avulsed tooth, click here.

Dental Pulp Tissue

This is neat image of a vital dental pulp. The tooth was diagnosed with irreversible pulpitis, acute apical periodontitis and cracked tooth syndrome. RCT was completed prior to crowning the tooth. Once in a while, the pulp will come out in one piece. This actually shows the tissue from the pulp chamber all the way down to the apical portion.