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The Endo Blog - 5 new articles
Retreatment & MTA Save a Perforated ToothThe 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 ToothHere'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.  Dens in DenteDens in Dente literally means "a tooth within a tooth". It is a developmental anomaly caused by an epithelial invagination during the development of the tooth. Enamel is laid down on the internal surface of the tooth. This is most frequently seen in maxillary lateral incisors.  A thin layer of enamel can be seen internally. An amalgam restoration was previously placed at some point to try and seal off the development groove into the dens in dente.  Access for endodontic treatment reveals the internal layer of enamel.  Endodontic treatment is completed.
 This peg lateral incisor also shows the internal and external layers of enamel of a dens in dente. The large dens in dente has also affected the overall development of the tooth.
Submitted by: Dr. Rico D. Short of Smyrna, GA.  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.
 Removing a Broken Endodontic FileAnyone performing endodontics occasionally has a separated instrument. This case was referred for removal of a separated instrument.  The file is in the MB#2 canal. Since it is in the upper third of the canal, good visualization with a microscope and proper ultrasonic technique will make this file removal possible.  After finding the file, careful ultrasonic instrumention is used to remove dentin around the file - opening up the MB groove. This is done carefully without touching the file itself. We want to expose 2-3 mm of the file before we begin vibrating the file itself. Too much contact with the file in this early stage can cause a coronal piece of the file to break off, making it more difficult. Once the coronal coronal 2-3mm of the file has been accessed, the ultrasonic is placed on the most apical part of the file to begin vibrating it. This should loosen the file and vibrate it out. If the file breaks again, then repeat step one.  The file was removed and the MB#2 canal instrumented.  Removal of the separated instrument complete. Use of an operating microscope is essential in effective removal of a separated instrument. 
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