Regeneration of the periradicular tissues

A J shaped lesion is not pathognomonic of VRF

February 28, 2016 By Dr Pierre Pizem 2 Comments

On July the 29th 2009, we have been presented with this mandibular second molar. Patient was experiencing pain. This radiographic image showed a huge radiographic J-shaped lesion in the mesial aspect of the mesial root. Back then, according to some experts, this type of lesion along with a deep narrow probing was considered as a pathognomonic sign of a vertical root fracture. Since vertical root fracture has a hopeless prognosis, standards of care would have commanded its extraction. In the presence of such a periradicular tissues loss, extraction would have also been indicated in the event we were dealing with a periodontal infection.

Still, what if we were dealing we an endodontic infection? If this was the case, an endodontic revision (endodontic retreatment) would suffice to preserve this tooth. The decision of extracting or saving that tooth has been based on a foundation of sound diagnosis, as we opened the existing PFM crown to confirm the presence of a crack which we could not find.

An endodontic revision which implied an interim calcium hydroxide has proven to be the correct approach, no dental implant needed here.

Thinking Out of the Box 20 years Ago to Preserve a Tooth! An Early Ceramic Material Apical Filling

October 10, 2013 By Dr Pierre Pizem Leave a Comment

Wide apical foramen, thin canal walls, necrotic pulp would, in year 2000, condemn this tooth and have it replaced by an implant supported crown.

Thinking out of the box to preserve that tooth, this MTA (Mineral Trioxide Aggregate) apical plug also known as a ceramic material has been performed by the author back in 2001. Legend #1 on XRay dental film displays an MTA apical obturation. Last image to the right is a 5 years follow up X ray dental film showing perfect bone healing. Today, almost 13 years later, the tooth is still asymptomatic and functional. So far so good!

Back then, ceramic material MTA was not intended to be used as a a root canal filler material but as a perforation/resorption repair material or as a retrofill material. Thus using this ceramic material as an orthograde filler to create an apical barrier in this instance makes it most likely one of the earliest ceramic application procedure of this type ever attempted to preserve a tooth. Outcome success in this case is due to the ceramic following advantages:

Highly antibacterial due to its 12,8 pH, biocompatible, non inflammatory in case of material extrusion, has the ability to form hydroxyapaptite thus create a real bond to dentine, hydrophilic, does not shrink

The only drawback is that MTA has such a large particle size which limits its application as a filler to relatively wide canals such as this one.

Back then, MTA was not intended to be used as a filler and most certainly not as a sealer. Today, 20 years later, because of recent nanotechnology development, some researchers pushed the concept one step further and a new type of premixed root canal Bioceramic sealer material is being marketed by Brasseler USA: EndoSequence BC Sealer. According to the manufacturer, the particle size of BC Sealer is so fine (less than two microns), it can actually be delivered with a 0.012 capillary tip. A promising sealer that seems to offer all the benefits associated with bioceramic material. The only drawback is its non recommended use as a filler material in teeth that might one day need an endodontic revision. This material bond to the dentine and cannot be removed from canal, thus surgery is the only left available option for a tooth filled with a Bioceramic sealer.

Endo Sequence Root Canal Sealer. Brasseler USA
Photos/Provided by Real World Endo

A Root Canal Retreatment Involving a Crown and a Post Removal Alowed for This Painful Tooth to be Preserved

April 19, 2012 By Dr Pierre Pizem 1 Comment

An endodontist case report. MicroEndodontic. Case Study Number 505026

Twenty five years old patient presenting with an abscessed maxillary molar. Diagnosis: Persisting disease after root canal treatment. Etiology: untreated second mesio vestibular root canal (MB2).

Two appointments were required to preserve that tooth:

First appointment: Crown and post removals plus root canal filling retrieval, MB2 location and calcium hydroxide insertion as a medicament.

Second appointment: Calcium hydroxide removal, irrigation, drying, final canal obturation gutta percha and Pulp Canal Sealer. Provisional filling material: Cavit.

Abutment is now symptom free and it is now all set for a casted post and permanent crown replacement.

A 6 months follow up dental Xray film shows an impressive regeneration of periradicular tissues. Compared to its initial size, apical lesion on mesio vestibular root shrunk up to 80%. Tooth is asymptomatic and functional.

A complex root canal retreatment does not have to mean extraction and replacement by a dental implant. A research study by Farzaneh et al. on treatment outcome in endodontic found an orthograde root canal retreatment success rate of 93% .

(Farzaneh M., Abitbol S., Friedman S. Treatment outcome in endodontics: The Toronto Study. Phases I and II: Orthograde retreatment. J Endod 2004; 30(9):627-633)

Pushing Back the Limit to Save Teeth with Opmi Proergo Dental Operative Microscope. Dental Operating Microscope Assisted Root Canal Procedure on a Completely Stenosed Canal System.

April 6, 2012 By Dr Pierre Pizem Leave a Comment

MicroEndodontic. Case Study Number 449947

Pulp chamber and root canals are not visible on pre operating X Ray of second mandibular molar. Diffuse calcifications preclude easy canal entries location. Despite its highly calcified canals, this tooth must not be extracted, it can be saved with a dental operating microscope assisted root canal procedure.

Progressive abrasion of attached pulp chamber calcifications with ultrasonic tips led to the canal entries. Required state of mind: No pushing but resolution.

First mandibular molar has an apical external root resorption in distal root making it difficult to obturate because of the absence of apical constrictions

Post operative X ray dental film displaying final root canal obturation with gutta percha and Pulp Canal Sealer

Amalgam post and core build up.

This last X ray dental film is a three years post operative control and is showing a complete regeneration of periradicular tissues, teeth are still functional and symptoms free.

Should an implant have been put there in the first place to replace this second mandibular molar simply because this root canal procedure is extremely difficult to perform? Maybe, maybe not!

Both implant therapy and endodontics show excellent prognosis. To let the informed patient decide for himself whether or not he want’s to save his tooth instead of having a dental implant is simply common sense.

Endodontic Revision Procedure on Mandibular Molar, a 6 months Post Operative Outcome

February 10, 2012 By Dr Pierre Pizem Leave a Comment

Case Study Number 495336

Symptoms: Acute pain to pressure, patient is eating on the opposite side.
Root canal was done three years ago.

Tooth root canal system has been retreated (reshaping and cleaning) and calcium hydroxide paste inserted as an intracanal medication, symptoms subsided.

A week later, final root canal obturation with gutta percha and pulp canal sealer completed the root canal procedure, an amalgam post and core build up was done during the same appointment to seal coronal part of the tooth.

Six months recall shows a complete healing.
Patient’s dentist can prepare the tooth as an abutment to receive a crown.

Endodontic Treatment on Mandibular Molar with Calcified Canals and a “J” Type Lesion, a Five Years Follow Up

January 19, 2012 By Dr Pierre Pizem 1 Comment

Root Canal Procedure with Surgical Operative Microscope.
MicroEndodontic.
Case Study Number 156037.

Pre operative film shows a large bony defect reminding us the alleged pathognomonic “J” type lesion. Still, there was no deep and narrow pocket probing. Root canals are not visible neither in mesial or distal root (calcified canals)

First appointment post operative X ray dental film shows shaped and cleaned canal system with inserted intracanal calcium hydroxide.

Post operative control X ray film in December 2011 shows a nice healing of surrounding hard tissues. Endo treatment finished on 2007 with surgical operative microscope Opmi PROergo from Carl Zeiss.This root canal therapy attempt once more enlightens the huge advantages of microendodontics and calcium hydroxide therapy in order to save teeth with an apparent very bad prognosis.

Treatment protocol:

First appointment: Opening through metal bridge abutment, gaining access to pulp chamber, adherent pulpstones and embedded pulpstones removal, root canal entries locations, cleaning and shaping, rinsing, drying, intracanal medication insertion and provisional obturation material.

Second appointment: Intracanal medication removal, rinsing and final obturation with Pulp Canal Sealer from Kerr and gutta percha

Endodontic material and equipment:

Shaping and debridment instruments: Stainless steel ISO files, Pro taper files (Dentsply)
Rinsing solution: sodium hypochlorite 6%
Drying: sterile paper points
Calcium hydroxide
Obturation material: gutta percha lateral and vertical condensation, Pulp Canal Sealer
Dental operative microscope: OPMI PROergo microscope from Carl Zeiss

Sven-Erick Hamp Class III Furcation Defect? Parodontal Prognosis? A Seven years Follow Up

December 10, 2011 By Dr Pierre Pizem Leave a Comment

Preoperative X ray dental film shows a “furcation defect” encompassing the entire width of the tooth (no probing). A root canal treatment implying a few Calcium Hydroxyde dressings (and being patient) helped this patient in saving what appeared to be a hopeless tooth.

Last scan shows a seven years post operative control X ray dental film. The four units fixed bridge has been cemented shortly after complete regeneration of periradicular tissues.

To Save or Not To Save? That Was the Question. A Seven Years Post Endodontic Treatment Outcome Follow Up

December 2, 2011 By Dr Pierre Pizem Leave a Comment

Case Study Number 368745

Patient was told seven years ago to remove lower right premolar and replace this tooth by an implant supported crown. Lack of periradicular tissues implied a guided tissue regeneration which, in turn implied a bone curetage close to the mental foramen. Estimated health risk: A possible permanent nerve paresthesia caused by a curetage or by an implant surgery close to the mental foramen on a patient with a narrow crestal mandibular bone. A possible failure of guided tissue regeneration which in turn, would impair implant osseointegration (or simply make the implant surgery impossible). Clinical examination revealed a mobility level of 2 and a sinus tract. Our findings on radiographic appearance: a large but a localized bony defect and a tooth that needed a root canal re-treatment. Our suggestion to the patient: To put aside the implant surgery and to invest in a root canal re-treatment with a few Ca(OH)2 replacements. The patient had to be patient (and faithful) for a few months in order to monitor progressive periradicular tissue healing.

Results: Per and post operative control X ray films show a progressive, then complete healing of periradicular bone tissue. In this case, root canal retreatment proved to be a safe predictable way of saving that tooth at half the cost of an agressive implant surgery.
Now, 7 years later, the tooth has it’s own casted post, a PFM crown and it’s mobility level came back to zero. And above all, patient is now completely safe from any paresthesia risk.

Good Prognosis is in the eye of the beholder

September 23, 2011 By Dr Pierre Pizem 2 Comments

Case Study Number 430646

External root resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images (2008), the modified foramen in distal root is positioned farther from the radiographic apex and gutta percha appears in overextension. A large and circumbscribed radiolucency involves both roots as well as the furcation. This indicates an important periradicular tissues destruction. Tooth mobility level 2 goes along with this tissue loss.

Based both on this 2008 pre operative X ray dental image and clinical findings, should an extraction plus an implant have been an appropriate decision? most certainly not in my book, time has proven otherwise. Still, up until nowadays, this case is definitely a controversial one, meaning that it is possible for different practitioners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity.

Endododontic retreatment and MTA root-end fillings have been performed with a Zeiss Pro Ergo Microscope in september 2008. Last displayed X ray film on this post shows an 8 years post operative clinical outcome. Radiographic examination shows a complete regeneration of periradicular tissues and a resorptive defect healing. An implant would not have been indicated in this case.

As stated by John I. Ingles: “The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one’s own abilities. Being able to practice using a great variety of techniques and not being “married” to a single approach in every case will greatly enhance one’s capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence.”

When a “J” Type Lesion on an X Ray Image, as well as Probing a “Deep Narrow Periodontal Pocket” Could Have Missled the Dental Practioner to Conclude the Presence of a Cracked Tooth.

April 8, 2011 By Dr Pierre Pizem Leave a Comment

This is a case where, based on the X ray image of a “J” type lesion in combination with a deep narrow periodontal probing, one could easily think of a cracked tooth. However, when observing under high magnification, no crack could be seen from within the root canal mesial wall. This J shaped radiolucency was in fact a narrow desmodontal sinus tract originating from an endodontic infection. Saving that tooth implied a retreatment, a ledge bypass and a few calcium hydroxide dressings replacements. As shown on those control post operative X ray images, a slow but complete periradicular tissues regeneration occured. In this case study, even a CBCT 3D imaging would have shown a deep narrow bony defect that could have misled the practionner to conclude the presence of a cracked tooth. Direct observation under a dental operative microscope showed us otherwise, proving once more how micro dentistry is elevating endodontic care to a higher level.