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Cystic change at the site of a root fracture is an unusual sequelae. A case report of such an occurrence in a horizontal root fracture involving the apical third of a permanent central incisor in a 22-year-old man is presented and management of these injuries is discussed in brief.
AIM: To determine the five-year success rates, site or sites of failure, prognostic indicators and lower lip morbidity associated with molar apicectomy using amalgam root-end filling. DESIGN: Multicentre, prospective study. SETTING: The departments of oral and maxillo-facial surgery in two district general hospitals. METHOD: One thousand and seven molar apicectomy procedures, combined with amalgam root-end filling were expedited during the period 1974-1995. A five-year review of each operated tooth was carried out or attempted between 1979-2000. RESULTS: Of the 790 (78%) operated molars successfully reviewed at 5 years or later 451 (57%) exhibited 'complete healing' and 39 (5%) 'uncertain healing'. Three hundred (38%) were classified as 'unsatisfactory healing' (failures), and these included 12 which were assumed to be of periodontal origin. Whilst longitudinal root fracture, perforation and/or infection in the furcation, periodontal disease or a non-restorable crown accounted for treatment failure and often the need to remove teeth subsequently, the study probably pointed to the apical ends of the roots rather than the furcation as being the major sites at which 'unsatisfactory healing' occurred. Mandibular first molars attracted the highest 'complete healing' rate (60%) and mandibular second molars the lowest (46%). 'Good' root canal treatment (RCT) at the outset improved the prognosis of a root-end filling (REF) whilst the absence of RCT compromised it. Cystic change pointed to a better prognosis than apical granulomatous change as did a deep compared with a shallow 'bone cuff'. Disease at the furcation suggested a worse prognosis. Teeth which showed 'complete healing' at 1 year had a 75% probability of maintaining this outcome at 5 years. Sensory disturbance of variable duration occurred in the lower lip following 20-21% of mandibular molar procedures. In the majority of cases (79-80%) this had remitted within 3 months. A permanent deficit occurred in 8 patients (1%) where the apicectomy could definitely be incriminated as causative. Four were associated with first molar apicectomy and four with second molar apicectomy. CONCLUSIONS: Molar apicectomy with amalgam root-end filling attracts an overall 'complete healing' rate at 5 years of 57%, the results being best with mandibular first molars and worst with mandibular second molars. The prognosis is also better where there is 'good' initial orthograde root filling, an associated radicular cyst as compared with granulomatous change and where the buccal sulcus is deep rather than shallow. It is worse when orthograde root filling is absent and when there is disease in the furcation. 'Complete healing' at 1 year can be expected to be maintained at 5 years in 75% of cases. The commonest site of subsequent periradicular rarefaction seems to be 'apical' whilst failure at the furcation is probably comparatively rare. There is a threefold increase in the occurrence of permanent lower lip sensory impairment following second molar surgery in comparison with first molar surgery, the overall incidence being 1%.
Root canal treatment usually fails because infection remains within the root canal. An orthograde attempt at re-treatment should always be considered first. However, when surgery is indicated, modern microtechniques coupled with surgical magnification will lead to a better prognosis. Careful management of the hard and soft tissues is essential, specially designed ultrasonic tips should be used for root end preparation which should ideally be sealed with MTA. All cases should be followed up until healing is seen, or failure accepted, and should form a part of clinical audit.
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The complex anatomy of invaginated teeth make their root canal treatment difficult. Moreover, this treatment may compromise the future of the tooth if it is destined to support a post-retained coronal restoration. This case reports the successful surgical root canal treatment of an invaginated tooth using a retrograde filling with gutta-percha. After surgical exposure of the root-end and cleaning of the root canal, the gutta-percha was compacted in the root canal which had been coated previously with a zinc oxide-eugenol cement. The gutta-percha was then cold-burnished. Periapical radiographic examination after 1, 2, 3, 6 and 12 months showed periapical healing with osseous formation. This procedure, resulting in minimal loss of hard tissues, permitted subsequent restoration of the tooth.
It is often difficult to achieve realistic simulation in teaching endodontic surgery. There is relatively little material available to students other than animal tissue or human cadavers. We propose a working model for the teaching of this discipline, constructed from casts of a natural skull which reproduce anatomical features such as gingiva, maxillary sinus, or mandibular canal, for example. This model, made of polyurethane resin containing mineral particles, which closely simulates the radiological and tactile differences of the relative densities of spongy bone, cortical bone and teeth, permits close simulation of the conditions under which endodontic surgery may be performed.
The introduction of microinstruments for root-end cavity preparation has clearly improved the surgical technique in periradicular surgery with apicectomy. The new generation of sonic and ultrasonic root-end preparation devices, usually termed 'retrotips', has simplified the preparation of a sufficiently deep cavity that follows the original path of the root canal. The present paper describes the use of a new set of diamond-surfaced retrotips driven by a sonic handpiece. For clinical evaluation a prospective study was carried out, with assessment of pre-, intra- and postoperative data in 50 teeth (43 patients). This paper analyses: (i) the applicability of the new retrotips; (ii) the quality of the root-end filling assessed radiographically; (iii) the immediate postoperative course. Access with the retrotips to the resected root-end was found to be excellent in 80% of the treated teeth. The postoperative radiographs showed a root-end filling of at least 3 mm in 70% of the resected teeth. Healing was uneventful in all cases and most patients presented without any symptoms after 5 days and 10 days. The long-term treatment outcome will be reported in a future paper.
CLINICAL TECHNIQUE: Effective apical sealing in endodontic surgery requires a dry root-end cavity to insert the filling material. A number of procedures for controlling haemorrhage have been described in the literature. An improvement of these techniques is proposed in this paper: by using a mixture of surgical wax and fibres of calcium alginate. This device, easy to place, sterile and non-toxic, permits placement of a root-end filling under more favourable conditions.
AIM: The objective of this study was to evaluate the healing of the periradicular tissues when exogenous growth factors were delivered to the respected root-end. The healing response was compared with that when Diaket was used as a control. METHODOLOGY: Non-surgical root canal treatment was performed on mandibular teeth in mongrel dogs. Surgical treatment followed and included root-end resection and root-end cavity preparation. Insulin-like growth factor in combination with platelet-derived growth factor, or fibroblast growth factor alone, were then placed in the root-end preparations on a polylactic acid carrier (Atrisorb) with or without the incorporation of the carrier tetracalcium phosphate. The healing was evaluated at 60 days with regard to presence of inflammatory response, bone regeneration, periodontal ligament formation and cementum formation. RESULTS: Osseous regeneration in the excisional would and periodontal formation were significantly greater when Diaket was used as the root-end filling material. Likewise, cementum deposition occurred significantly more frequently in the Diaket group (P < 0.05). The polylactic carrier Atrisorb remained in the surgical sites for the duration of the study. CONCLUSIONS: The use of specific growth factors, FGF and a combination of IGF/PDGF, delivered to the prepared root end in a collagen carrier did not initiate the desired periradicular tissue response of regeneration. Diaket, as used in this study, did stimulate a periradicular tissue response compatible with regeneration.
AIM: The aim of this study was to compare traditional and newly developed root-end filling materials for resistance to bacterial microleakage. METHODOLOGY: Sixty extracted single-rooted teeth were randomly divided into five groups for root-end filling with mineral trioxide aggregate, Super-EBA, TPH composite resin with ProBond dentine bonding agent, Dispersalloy amalgam with and without ProBond, and positive and negative control groups. Root canals were instrumented using the step-back technique and simulated root-end resections performed. Root-end filling materials were placed in 3 mm ultrasonic retropreparations. Nail varnish was applied to all external root surfaces to the level of the resected root ends to prevent lateral microleakage. Samples were sterilized in an ethylene oxide sterilizer for 12 h. Using a newly designed model system, the apical 3-4 mm of the roots were immersed in BHI culture medium with phenol red indicator within culture chambers. The coronal access of each specimen was inoculated every 48 h with a suspension of Streptococcus salivarius. Culture media were observed every 24 h for colour change indicating bacterial contamination. Media demonstrating colour change were plated for S. salivarius. Samples were observed for 12 weeks. RESULTS: At 4 weeks 10% of specimens from each experimental group had evidence of leakage. At 8 weeks 20% of specimens filled with amalgam without dentine bonding agent, Super-EBA and MTA had evidence of leakage. At 12 weeks minor differences between materials were noted. CONCLUSIONS: Under the conditions of the study, despite some variations, there were no statistically significant differences in rate of microleakage among the five groups tested at either 4, 8 or 12 weeks.
This clinical report describes an apexification procedure on a maxillary left central incisor in a 34-year-old male who was also receiving active orthodontic treatment. The pulp of the tooth had become necrotic following a traumatic injury when the patient was 8 years of age. Despite the tooth undergoing active orthodontic repositioning with fixed appliances, root-end closure occurred uneventfully and within 3 years.
AIM: The purpose of this prospective study was to evaluate the prognosis of periradicular surgery using well-defined case selection and a rigorous surgical protocol. METHODOLOGY: Teeth to be treated surgically demonstrated a periradicular lesion of strictly endodontic origin with or without clinical signs and symptoms of inflammation. A total of 114 teeth were treated. Following the reflection of a full mucoperiosteal tissue flap, residual soft tissues were curetted, root ends were resected with a fine high-speed diamond bur, root-end cavities were prepared ultrasonically with diamond tips, and IRM root-end fillings were placed. Cases were followed clinically and radiographically for a period ranging from 1 to 4 years. RESULTS: The results of this study showed 91.2% success out of a total of 102 teeth available for follow-up, based on accepted parameters of evaluation. Cases were considered successful if there were no clinical signs or symptoms present and there was radiographic evidence of complete or incomplete healing (scar tissue). Factors related to case selection, parameters of healing and surgical technique are discussed in relation to the success rate identified in this prospective study. CONCLUSIONS: Adherence to a strict endodontic surgical protocol and the use of contemporary techniques and materials will result in a predictably successful outcome in a wide range of teeth.
AIM: To analyse the healing response to gutta-percha and Diaket when used as root-end filling materials in periradicular surgery. METHODOLOGY: Periradicular surgery was completed using the mandibular second, third and fourth premolar teeth from nine male mongrel dogs. The six roots on one side of the mouth were randomly allocated to one of the following groups: group A: a resected root end and a burnished gutta-percha root filling; group B: cavities were prepared to a depth of 4.0 mm, using ultrasonic root-end preparation and filled with Diaket. The response was evaluated histologically at 55 (nine specimens) and 150 (three specimens) days post operatively. RESULTS: The data for the 55-day period was analysed statistically using Wilcoxon's Signed Ranks test. No statistical analysis was carried out on the 150-day group due to the small number of specimens. The level of significance was set at P < 0.05. No statistical significance was observed in the healing response between Diaket and gutta-percha in the following categories at 55 days: inflammatory response, angiogenesis, root-end resorption, and cementum deposition. Statistically significant differences were observed in the healing categories: bone apposition (P < 0.05) and periodontal ligament formation (P < 0.05). CONCLUSIONS: At both time intervals, Diaket had a better healing response that was characterized by hard tissue formation adjacent to the root-end filling material bordered by occasional multinucleated giant cells. The nature of both the hard tissue formation and the adjacent cells, however, remains undetermined. Diaket displayed the best healing of either material used in this study.
AIM: This study compared the radiopacity of tetracalcium phosphate (TTCP) and 11 root-end filling materials relative to human dentine. METHODOLOGY: Specimens of 2 mm thickness and a graduated aluminium stepwedge were placed on dental X-ray films and exposed to an X-ray beam. The optical densities of the specimens and aluminium steps were measured. The optical densities of the specimens were correlated to the equivalent thickness of aluminium with a regression analysis equation. The equation was used to calculate the equivalent aluminium thickness of each of the specimens. RESULTS: Nine of the materials were found to be of acceptable radiopacity (at least 2 mm Al more radiopaque than dentine). TCCP and two of the glass-ionomer compounds were found to have insufficient radiopacity to be radiographically distinguishable from human dentine. CONCLUSIONS: All the materials were found to be distinguishable radiographically from dentine, except for Vitrebond, TTCP and Ketac-Fil. Amalgam was the most radiopaque material and Ketac-Fil was the least radiopaque material tested.
AIM: This randomized, controlled, clinical study was designed to evaluate the adjunctive effect of calcium sulphate grafts on the surgical treatment of through and through periradicular lesions. METHODOLOGY: Twenty patients each with one tooth showing evidence radiologically of a periradicular lesion wider than 10 mm, with lack of both buccal and lingual cortical bony plates and an indication for surgery were selected for the study. Ten teeth were treated with apicectomy, root-end filling and grafting of the bone defect with calcium sulphate prior to suturing (test group). The other 10 teeth received the same surgical therapy but no grafting with calcium sulphate (control group). The outcome of the healing process was evaluated at 6 and 12 months radiographically following the criteria reported by Rud and Andreasen. RESULTS: At the six- and 12-month evaluation the test group had seven teeth with complete healing and two with incomplete healing, whilst the control group showed three teeth with complete healing, five with incomplete healing and one with unsatisfactory healing. One tooth in each group had to be extracted because of a vertical fracture that occurred during the follow-up period. CONCLUSIONS: The results of the study demonstrate that the addition of calcium sulphate as a bone graft during the conventional surgical treatment of through and through lesions improves the clinical outcome. Histological analysis is desirable to investigate the quality of tissues formed using the two surgical procedures.
AIM: The purpose of this prospective clinical study was to evaluate the outcome of periradicular surgery of molars after one year. METHODOLOGY: The material consisted of 25 molars with 39 roots demonstrating periradicular lesions of endodontic origin. Surgical treatment included root-end resection, root-end preparation with sonic microtips, and root-end filling with Super-EBA cement. At the one-year follow-up examination, healing was evaluated clinically and radiographically. Healing was assigned to three categories: (i) success (ii) improvement, and (iii) failure using well defined criteria. RESULTS: Eighty-eight per cent of the surgically treated molars showed successful healing. In 8%, the healing was rated as improved and only 4% were failures. CONCLUSIONS: The outcome of the present study and data of recently published studies show that periradicular surgery may result in a predictable treatment outcome in molars with persistent periradicular lesions.
AIM: To present two clinical cases and demonstrate that occlusal trauma may affect healing of periapical pathoses. SUMMARY: Two teeth with periradicular disease did not respond successfully to conventional root canal treatment or endodontic surgery. Occlusal adjustment was finally performed on both cases. After occlusal adjustment, uncomplicated healing and periapical repair occurred in both cases. The findings in these two cases suggest that occlusal trauma may play a role in the healing of periapical pathoses. KEY LEARNING POINTS: Occlusal trauma is positively correlated with changes in periodontal tissues. Although experiments in animals have shown that application of forces to teeth will not induce further periodontal destruction, we believe that some failures of root canal treatment may be due to the presence of occlusal trauma modulating the responses of inflamed periapical tissues or apical pathoses with persistent infection.
AIM: The aim of this investigation was to assess the marginal adaptation of Super-EBA (EBA) and Pro Root MTA (MTA) root-end fillings and the occurrence of microcracks in resected root-ends of extracted teeth before and after occlusal loading for a five-year equivalent period in a computer-controlled masticator. METHODOLOGY: Twenty-four molar teeth were root-filled using lateral condensation and their root-ends resected. Root-end cavities were prepared and either EBA or MTA root-end fillings were placed. All surgical procedures were completed in vitro under an operating microscope. Replicas taken of the root-end fillings and resected root-ends were examined using an SEM before and after they were subjected to in vitro chewing cycles in a computer-controlled chewing simulator for the equivalent of 5 years. Marginal adaptation and integrity of the two root-end filling materials were evaluated and the presence of microcracks recorded. RESULTS: Before loading, a continuous margin was observed with 99.4 +/- 2.4% of EBA and 99.2 +/- 1.6% of MTA root-end fillings. After loading, the percentage of continuous margin decreased to 93.1 +/- 6.6% and 98.9 +/- 3.2% for EBA and MTA, respectively. After occlusal loading, 39.5% of the EBA root-end fillings were overfilled, whilst 52.6% of the MTA root-end fillings were underfilled. In total, 12.5% of the resected root-end surfaces showed microcracking before loading and 25% after occlusal loading. CONCLUSIONS: Both EBA and MTA displayed excellent marginal adaptation before masticatory loading. After loading, the amount of continuous margin for both root-end filling materials decreased slightly but was still high.