Endodontic Case Reports– a

review

Presented by

Dr. Syed.k.Aliuddin

B.D.S,(M.Sc.D—

Endodontics)

Retrieval of a foreign object from

the palatal root canal of

a permanent maxillary first molar:

Ujwal M, Nadkarni, MDSVAmila Munshi, MDSVSatyawan

G, Damie, MDS^/Riîesh R. Kalaskar, (Quintessence Int

2002:33:609-612)

Endodontic treatment in children can be a demanding

task and, occasionally, a clinician may encounter bizarre

situations that require both skill and patience.

Many children are in the habit of placing various objects

in the oral cavity.

So this case report describes successful retrieval of a

sewing needle that fractured within the palatal root canal

of a permanent maxillary first molar followed by

endodontic

treatment and placement of a stainless steel crown.

A 12-year-old boy reported to the hospital with pain in the

right maxilla.

His intraoral examination revealed a large occlusal cavity

in the tooth.(16)

All permanent teeth except the maxillary and mandibular

second molars had erupted.

The dental history revealed that spontaneous pain,

followed by swelling, had occurred in relation to the same

tooth approximately 6 months earlier. The patient had

visited a private dental clinic but was unable to recollect

the exact treatment procedure that had been carried out.

Preoperative radiograph revealed the presence of an

unusual radiopaque object in the palatal root canal of the

permanent

maxillary molar.

When asked, the patient initially denied having inserted

any object within the tooth. His mother was also unaware

of any such occurrence.

However, after detailed questioning, the patient admitted

that he often placed a sewing needle in the tooth to

relieve discomfort associated with it. When the needle

eventually fractured inside the root canal, the patient did

not disclose the incident to anyone.

The tooth did not respond to

thermal stimuli (cold test) or

electric pulp testing.

It was decided that an

attempt would be made to

retrieve the foreign object and complete the endodontic

treatment.

After administration of L.A, and placing rubber dam.

It was observed that an attempt had been made,

probably by the dentist who had been consulted earlier.

Management:

A conventional access cavity was prepared, and the pulp

chamber was irrigated with normal saline.

The foreign body was visible as a discolored object near

tbe orifice of the palatal canal.

A thin, tapering, diamond fissure bur was used to slightly

widen the orifice of the palatal canal and to facilitate

access for instrumentation.

Care was taken not -- remove too much internal tooth

material --weaken the tooth,

A No, 8 K-type file was slowly worked on the mesial and

distal sides of the foreign body.This procedure was

repeated 5 or 6 times with No, 10 and No, 15 K-type files.

Copious irrigation with normal saline and 2.5% hypo was

used to remove the debris around the foreign object to

loosen it.

An attempt was made to engage the object with a No. 15

H-type file and remove it with a pull-back motion, but did

not succeed.

To check for loosening of the broken needle, an attempt

was made to grasp the object with a tweezers that had

long narrow beaks.

Because it could be grasped adequately with the

tweezers, the object was removed from the root canal

with a slow, careful motion the retrieved foreign object

was confirmed to be a

fractured part of a sewing needle, which was discolored

and measured 8 mm in length.

Conventionalroot canal treatment was then completed

Because the maxillary second molar had not erupted, the

tooth was restored with a stainless steel crown.

discussio

nIn this case, a child used a sewing needle to relieve

discomfort associated with a maxillary molar. The needle

fractured within the palatal root canal and remained there,

asymptomatic, for about 5 months.

Several techniques for the retrieval of foreign objects from

teeth.

Fors and Berg‘ described a method that involved removal

of a considerable amount of internal tooth structure prior

to removal of foreign objects from the root canal.

Roig-Greene‘ demonstrated a simple device, comprising a

disposable 25-gauge dental needle, a thin segment of

steel wire, and a small mosquito forceps, to remove

broken silver cones.

Williams and BjorndaF used the Masseran kit to remove

fractured posts from root canals.

The ultrasonic scaler and the Cavi-Endo instrument have

also been used to remove such objects from the root

canal.

McCullock suggested that a small amount of tooth

structure be removed to improve access to the foreign

object..

Therefore, in the present case, a thin, tapering diamond

bur was used to widen the palatal root canai orifice

slightly, to promote better visualization of the foreign

object.

CONCLUSION

The present case report also highlights the importance of

both careful radiographic evaluation and the ability to

manage unexpected situations.

Non-surgical root canal treatment

of dens invaginatus 3 in a

maxillary lateral incisor

Saeed Moradi1* DDS, MS, Zakyeh Donyavi2 DDS, and

Mohammad Esmaealzade3 DDS

Dental School, Mashad University of Medical Sciences

Dens invaginatus also called dens in dente, dilated

composed odontoma or gestant odontoma.

developmental disturbance -- invagination of the enamel

organ toward the dental papilla before mineralization; it

may be limited to the tooth crown or invade the root to

affect the periapical region.

According to Pindborg---etiology—unknown

But the followingexplanations have been proposed:

(i) Delayed focal growth,

(ii) stimulation in the area of the tooth bud

(iii) abnormal pressure on tissues surrounding the dental

organ

Mostly effect permanent dentition, especially maxillary

lateral incisor.

Clinical appearance:

Thus, there may be greater buccolingual diameter peg-

shaped or barrel-shaped teeth or a talon cusp.

Mild invaginations exhibit only a lingual pit--- often

clinically unnoticed

According to the extent of the invagination

Oehlers proposed the following classification

Type I)a small invagination limited to the crown not

extending

beyond the cej.

Type II) line delineating enamel invagination invades the

root, yet is limited to it as a ‘cul-desac’ configuration,

without reaching the pdl . it may communicate with pulp

Type III)a severe form of invagination extending through

the root andending at the apical region without direct

communication with pulp

Radiographically, the roots present smaller dimensions

with presence of a radiopaque formation with density

similar to that of enamel.

‘tooth within a tooth’

Histologically, the structure of dens invaginatus is

composed of internal enamel, dentine, connective tissue

nucleus and blood supply.

The internal enamelhypo mineralized but dentine is

uniformly mineralized .

The purpose of the present article is to describe a case

of apical periodontitis associated with a tooth containing

a dens invaginatus healed successfully after non-surgical

root canal treatment.

A 15-year-old girl was referred by her general dental

practitioner.

She reported

throbbing pain and swelling from a week before,

but at the time of examination, there were no symptoms.

Clinical examination

revealed the maxillary lateral incisor to be

unusually greater buccolingual diameter.

Preoperative palatal inspection of maxillary lateral incisor

confirmed the large enamel projection.

There was no evidence of swelling or sinus tract;

however the tooth was slightly tender to percussion.

The tooth was not responsive to CO2 stimulation, whilst

adjacent teeth respond normally. Periodontal probing

was within normal limit.

Radiographic examinationrevealed an apical radiolucency of approximately 6 mm in

diameter and an anomalous internal structure consistent

with class III dens invaginatus.

The diagnosis

was pulp necrosis with chronic apical

periodontitis.

The contralateral lateral incisor was also checked for

clinical and radiographic sign of the same abnormality,

but none was detected

The treatment

presented was to perform RCT.

After rubber dam isolation

and gaining access into the pulp chamber, two

distinctly

separate areas of pulp tissue were found.

A central component was surrounded by internal hard

tissue; the lateral component appeared to form a c-

shaped extending from the mid labial towards the

mesial and palatal surface.

determination of working length

biomechanical preparation complemented by irrigation

with 5.25% sodium hypochlorite, calcium hydroxide paste

was applied.

and temporarily sealed with Cavit

After one week, patient returned without any symptoms.

At this appointment, the tooth was not tender to

percussion and the soft tissue in the area was not tender

to palpation.

The canal was irrigated with 1% sodium hypochlorite

and dried with paper point

The invagination was obturated by lateral condensation

of gutta-percha and AH-26

primary root canal was obturated using an injection-

moulded thermoplasticized guttapercha delivery system

At one-year follow up, the patient reported no symptoms,

the tooth was not tender to percussion and the labial

mucosa related to the area was not tender to palpation.

The radiography showed reduction in size of the apical

radiolucency

Discussion

Clinicians should be aware of the incidence and

methods for treating dens invaginatus.

Failure to locate, debride and obturate complex root

canal spaces will lead to failure in some cases.

The etiology of the periapical pathosis in this case was

due to the infected primary root canal. However, it is not

known how long the root canal had been infected prior to

the patient developing symptoms.

Mechanical debridement of the primary root canal was

difficult.

The combination of chemomechanical instrumentation

and the use of calcium hydroxide were sufficient without

resorting to surgery.

As calcium hydroxide has been reported to successfully

eliminate bacteria and stimulate hard tissue repair , it

was

decided to treat the primary root canal with this

medicament before obturating the root canal with gutta-

percha.

The use of a warm gutta-percha technique helped to

obturate the root canal system,

Conclusion

Despite complex anatomy and diagnosis of dens

invaginatus, non-surgical root canal treatment was

performed successfully

Management of cracked teeth - a

case report

Neelam Mittal ,Vishal Sharma ,Anshu Minocha

INTRODUCTION

Gibbs in 1954 was the first to describe cracked teeth

using the term ‘Cuspal fracture odontalgia’.

The term ‘cracked tooth syndrome’ was coined by

Cameron

in 1964.

Cameron’s cracked tooth syndrome described fractures

that were not easily visible but the teeth responded

painfully to cold or pressure applications and became

necrotic despite an

apparent healthy pulp and periodontium.

The most common cause of an incomplete fracture is

masticatory or accidental trauma.

Unintentional biting with physiologic masticatory force on

a small and very hard object may suddenly generate an

excessive load that may cause the tooth to split.

Other factors like extensive tooth preparation, unrestored

deep carious lesions, teeth endodontic cells treated

teeth, deep grooves or pronounced radicular grooves or

bifurcation also make teeth susceptible to fracture.

Overzealous condensation of amalgam, excessive lateral

condensation of Gutta percha and placement of friction

lock or self threading pins may also contribute to tooth

fractures.

Mandibular molars (67%) were more prone to incomplete

fractures than maxillary molars.

Diagnosis is a difficult task, sharp pain on chewing hard

substances is important diagnostic evidence. It is

speculated that this short and sharp pain is generated by

an alternating stretching and compressing of

odontoblastic processes located in the crack.

Magnifying glasses, transillumination, staining with

methylene

blue are useful in visualizing cracks.

Now a days ultrasound imaging system is being used for

crack detection

The use of radiographs to detect cracks is controversial.

Radiographs may reveal the fracture line if it is in direct

alignment with the central rays

The primary goal is to splint and stabilize a cracked tooth

to prevent further extension or complete fracture of the

tooth.

A 35 years old female patient came to the faculty of

Dental Sciences, Banaras Hindu University, Varanasi,

India with the chief compliant of pain and sensitivity in

right maxillary posterior region.

The pain was sharp, intermittent in nature which

increased on chewing hard substances.

Noncontributing medical history.

Dental history revealed that she had undergone RCT of

the right maxillary first molar 1 year ago.

Clinical examination

revealed fractured right maxillary first molar with the fracture

line running buccolingually in the crown region.The tooth was not restored with a crown restoration after

therapy

and occlusal loading may be the cause of fracture.

Radiographic examination

revealed adequate root canal filling with no signs

of periodontal involvement. A tooth slooth was used to confirm

the diagnosis.

Orthodontic steel band was fabricated and cemented to

the tooth and the tooth was disoccluded. After a month,

the crack was reinforced with bonded composite

restorative material and was finally restored with a full

coverage metal crown

restoration.

Tiny cracks are common and usually do not cause problems.

Various treatment modalities are available and the choice depends on the location, direction and extent of the crack.

Cracks may be superficial, affecting the cusp of a tooth or deep involving the root of the tooth. Some affect only the enamel; others may involve the dentin or the pulp.

Before the treatment, reduction or elimination of occlusal

contacts to avoid an overload of a split tooth is done.

Erhmann and Tyas suggested the use of orthodontic steel bands for this purpose.

A high success rate has been reported when full-

coverage acrylic provisional crowns were used to

stabilize the compromised tooth

after 2-4 wks the tooth should be examined and if

symptoms of irreversible pulpitis are evident, endodontic

treatment should be performed. About 20% of teeth with

cracked tooth syndrome need root canal treatment.

Permanent stabilization can be achieved with an

adhesive intracoronal restoration

however,if the cusp is left unprotected, there is probably

enough movement to allow microleakage and a

continuation of symptoms. Some clinicians recommend the

use of reinforced glass ionomer cement (GIC) to hold the

cusps together.

The bond strength of the GIC to hard tissue is inadequate

to withstand the forces to which the tooth is subjected.

Cracks extending subgingivally often require a

gingivectomy to

expose the margin, however, an unfavourable crown–root

ratio may render the tooth unrestorable.

Where vertical cracks occur or where the crack extends

through the pulpal floor or below the level of the alveolar

bone, the prognosis is hopeless and the tooth should be

extracted followed by replacement with an implant or a

fixed bridge restoration.

CONCLUSION

Fractures are the third most common cause of tooth loss.

Thus, it is of outstanding importance to avoid or eliminate

risk factors which contribute to tooth fracture. The key

factor is early diagnosis and treatment of the crack,

However, a cracked tooth is a compromised tooth even

with propertreatment.

Healing of external inflammatory

root resorption

Mithra N. Hegde ,Deepak Pardal

INTRODUCTIONFacial trauma often results in the complete avulsion of a

maxillary permanent incisor.

These teeth may be replanted.

It is well known that the fate of a replanted tooth can

cover

various healing categories such as; normal periodontal

healing, surface resorption, inflammatory resorption and

replacement

Resorption.

When extensive damage occurs to the innermost layer of

the periodontal ligament, competitive healing events take

place

Healing from the socket wall and healing from adjacent

pdl occurs simultaneously.

If less than 20% of the root surface is involved, a

transient ankylosis may occur, which can later be

resorbed due to functional stimuli, provided the tooth in

the healing period.

But if the trauma is extensive involving more than 20% of

root

surface, an abnormal attachment can occur after healing.

After the initial inflammatory response to remove debris

resulting from the injury, a root surface devoid of

cementum results. Cells in the vicinity of the denuded

root now compete to repopulate it.

Often cells that are precursors of bone will move across

from the socket wall and populate the damaged root

rather that slower moving periodontal ligament cells.

Bone resorbs and reforms physiologically through out

life. The osteoclasts in

contact with the root resorb the dentin.

In the reforming phase, osteoblasts lay down bone in the

area that was previously root, eventually replacing it.

This progressive effect of ankylosis on the avulsed tooth

is termed replacement resorption.

A healthy 22-year-old patient visited the Department of

Conservative Dentistry and Endodontics, A.B Shetty

Memorial Institute of Dental Sciences, Mangalore, with a

chief compliant of broken tooth in the right upper front

region of the oral cavity.

History revealed

that the patient had a fall about three months back,

following which avulsion of tooth number 21 and fracture

of 22 occurred.

The patient visited a hospital where the avulsed tooth

was replanted after an extra-oral time of more than 1

hour.

During this period avulsed tooth was not stored in any

suitable medium, instead was held in hand.

The replanted tooth was then nonphysiologically splinted

for a period of 15 days. No root canal therapy was done

at this period.

Although patient did not complain of any pain but on

clinical examination it was found that tooth number 21

was tender on percussion and had mobility.

An intra-oral periapical radiograph revealed areas of

radiolucency along the apical and lateral surface of root

and surrounding bone with loss of lamina dura

suggesting external root resorption in relation to 21.

Tooth number 11 and 22 also showed periapical

radiolucency.

Electric and thermal pulp testing gave a negative

response in relation to tooth number 11, 21 and 22.

Access opening and a complete canal debridement was

undertaken for all the three teeth.

Tooth number 11 and 21 were filled with Vitapex and 22

was obturated(Gp)

.

Tooth number 11 was obturated (GP)at 6 month recall.

It was only after a 12 month recall that the intra-oral

periapical radiograph showed sufficient healing of

external root resorption in relation to 21 with replacement

resorption and so a permanent root canal filling in form of

GP was placed

There was no mobility and tenderness on percussion in

relation to tooth number 21 at the 12 month recall.

DISCUSSIONUnlike bone, which undergoes resorption and apposition

as part of a continual remodeling process, the roots of

permanent teeth are not normally resorbed. Only the

resorption of deciduous teeth are considered

physiological.

In clinical studies, teeth replanted within 5 minutes after

avulsion had the best prognosis.

The avulsed tooth should be replanted immediately or

should be stored in a suitable medium before

replantation.

The replanted tooth should be splinted flexibly to the

adjacent teeth for 7 to 10 days to enhance periodontal

healing.

If the tooth apex is closed or almost closed, prophylactic

rct

should be carried out on the day of splint removal to

prevent the onset of inflammatory root resorption.

Inflammatory resorption is a mechanism of eliminating

infected calcified tissue from the body.

osteoclasts acting as specialized macrophages actively

participate in the healing process to repair traumatized

tooth and bone.

It has been emphasized that endodontic therapy should be

undertaken within 7-10 days after replantation so as to

remove the necrotic pulp tissue which could get infected

and initiate inflammatory root resorption.

In this case with extensive external inflammatory root

resorption on the first visit, long term calcium hydroxide Rx

was planned using Vitapex.(viscous mix of caoH and

iodoform)

CaoH is one of the most effective materials for the Rx of

external root resorption because of mainly two properties

high calcium ion concentration and alkaline pH.

mechanism of action of calcium hydroxide

One theory discusses its high alkaline pH, which is

important in stimulating matrix formation by the formative

cells.

Another theory postulates that a high pH neutralizes the

acidic products of the resorptive cells, creating an

unfavorable environment for them.

Seltzer and Bender stated that the presence of Ca2+

ions may activate ATPase, which may then enhance

dental tissue

remineralization

According to Andersen replacement resorption can take

place once inflammatory resorption has been arrested

by endodontic therapy.

Though there is no treatment for replacement

resorption, it is worth an effort to try slow down the

resorption process and maintain the tooth as long as

possible in the arch for esthetics, mastication, and

natural space maintenance

Thank you