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This paper briefly reviews the pros and cons of five methods used to treat a tooth with a necrotic pulp and an open apex (incompletely developed root), and presents representative treatments of open apex cases. These treatments include customized cone, short-fill, periapical surgery, apexification, and one-visit apexification.
OBJECTIVE: The objective of this study was to investigate the outcome of conventional root canal treatment in a general practice setting within the Royal Air Force dental service. Design Retrospective review. METHODS: Teeth that had been root-filled for 12 months or more by Royal Air Force dental practitioners in patients attending a large Royal Air Force dental centre were included in the study. Following clinical and radiographic review the root fillings were classified as 'definitely successful', 'probably successful' or 'failed' The effect on success of several variables on the outcome was investigated. RESULTS: Out of a total of 406 teeth, 59% were maxillary teeth and 41% were mandibular teeth. Sixty-nine per cent of the total sample had pre-existing periapical radiolucencies. Cold lateral condensation of gutta-percha was the most widely used filling technique (64% of all cases). Fifty per cent of the teeth had root fillings within 2 mm of the radiographic apex, 32% were greater than 2 mm from the radiographic apex and 18% were overfilled. Cold lateral condensation was the most successful (92% overall) filling technique. Maxillary anterior teeth had a better success rate (96%) than other tooth types. Teeth with pre-existing periapical radiolucencies had a higher success rate (87%) than those cases where there was no pre-existing periapical radiolucency (80%). Root fillings that were less than 2 mm from the radiographic apex of the tooth had a higher success rate (88% overall) than those that were greater than 2 mm from the radiographic apex (77% overall). Of the 406 cases, 57% (n=231) were classified as definitely successful, 28% (n=114) were classified as probably successful and 15% (n=62) were classified as failures. Thus, the overall success rate combining definitely successful and probably successful root fillings was 85% (n=344). CONCLUSIONS: Root fillings placed using cold lateral condensation of gutta-percha to within 2 mm of the radiographic apex of the tooth were associated with the best outcome.
Labial mucosal fenestration of the root apex is an uncommon occurrence. An unusual case involving a maxillary right first premolar is described. When presented, the tooth was nonvital with the buccal root apex readily seen through a soft tissue and bone fenestration. Conventional endodontic treatment with gutta percha failed to resolve the problem. Periodontal surgery with a laterally positioned pedicle flap was thus scheduled. At the 1-month recall, complete healing was evident in the surgical site, and the fenestrated area of the maxillary right first premolar was filled with healthy mucosal tissue. One-year postoperatively, the mucosa remained covered, and there was radiographic evidence of bone infilling in the periapical region.
Delineating the limits of orthodontic treatment in nongrowing individuals is important when making treatment decisions, especially in borderline orthodontic-surgical cases. The labial and lingual cortical plates at the level of the incisor apex may represent the anatomic limits of tooth movement. Cephalometric films of 107 adults were measured to determine the width of alveolar bone anterior and posterior to the incisor apex in each arch. Thin alveolar widths were found both labial and lingual to the mandibular incisors in groups of Class I, II, and III individuals with high SN-MP angle and in a group of Class III average SN-MP individuals. Thin alveolar widths were also found lingual to the maxillary incisors in a Class II high angle group. Clinical cases are presented showing that orthodontic tooth movement may be limited in patients with narrow alveolar bone widths and that these patients are likely to experience increased iatrogenic sequelae.
The purpose of this study was to compare the difference between the in vivo working length established by viewing a periapical radiograph and the in vitro measurement from the file tip to the apical foramen of the extracted tooth. Twenty-six canals from teeth that had been treatment planned for extraction were accessed under rubber dam isolation. The coronal portion of each canal was flared using Gates Glidden drills, and a K-type file was inserted down the canal until an electronic apex locator indicated that the file had reached the apex. A size 20 K-type file was locked into place with glass ionomer cement at this position. A radiograph was exposed and the tooth was extracted. Each tooth was viewed using a videomicroscope at 30x original magnification, and the distance from the file tip to the most coronal aspect of the major foramen was measured. Six examiners viewed each radiograph and assessed the working length of each canal. Chi(2) analysis of the data revealed a significant difference (p < 0.01) between the estimation of working lengths and the microscopic measurements. The examiners overestimated the distance between the file tip and the apical foramen of the tooth when the file was placed short, and underestimated the distance when the file was placed long. In conclusion, when the file is short it is actually closer to the apical foramen than it appears radiographically; when it is long it is actually longer than it appears radiographically.
The purpose of this in vitro study was to evaluate the accuracy of three apex locators in determining the working length during the retreatment process. Twenty extracted single-rooted human teeth with mature apices were used in this study. The root canal length of each tooth was measured placing a #15 file until the tip was visible at the apical foramen. The direct visual measurement was reduced by 0.5 mm and recorded. The root canals were instrumented and filled to the direct visual measurement using lateral compaction technique. After 7 days the teeth were retreated using three apex locators: ProPex, NovApex, and Root ZX, for determining the retreatment working length. Afterward, comparison between the visual working length and the retreatment working length were made. ProPex, NovApex, and Root ZX were accurate within 0.5 mm 80, 85, and 95% of the time, and within 1 mm 95, 95, and 100%, respectively. No significant differences were detected between the three apex locators (p > 0.05).
A case report of a developmental anomaly known as a radicular groove is presented. This case is unusual in that it is believed to be the first reported case of complex involvement of the entire facial aspect of a tooth root. An alveolar crest to apex facial root defect in a maxillary right lateral incisor of a 12-yr-old black female led to early pulpal necrosis and periapical rarefaction. Clinical and histologic findings as well as morphologic and treatment ramifications are discussed.
It has been reported that the amount of D-aspartic acid in dentin is highly correlated with age. However, further studies are necessary to determine the details of this correlation. We quantitatively determined L- and D-aspartic acids in dentin, and from the data calculated the D/L ratio. We did not find any statistically significant difference in the D/L ratio between the same type of left and right teeth from the same jaw, and between the vestibular and lingual sides of the root dentin. However, the D/L ratio was significantly higher on the lingual side than on the labial side of the dentin. Although the D/L ratio in young subjects was comparatively high in the tooth crown and decreased toward the apex of the root, we did not always observe such a tendency in middle- to advanced-age individuals. These results indicate that the ratio of D/L aspartic acid in dentin varies between the lingual side and vestibular side of the crown dentin. Therefore, it appears that the racemization rate of aspartic acid is not uniform but differs with the region of the dentin, and may be affected by differences in factors such as temperature.
Selected histomorphometric parameters were measured in alveolar bone adjacent to rat molars treated with a 40-gram tipping force designed to tip the molar mesially and with a sham procedure. Undecalcified parasagittal sections of teeth and surrounding tissues were prepared for static and dynamic histomorphometry at 1, 3, 5, 7, 10, and 14 days. Initial tooth displacement was assessed by measuring differences between groups in the widths of the day-1 periodontal ligaments (PDL) at various vertical locations and correlating these using linear regression analysis. All parameters were measured in the alveolar bone adjacent to four quadrants around the teeth (mesial-distal; occlusalapical). Means and standard errors for each parameter in each group were calculated and compared for time- and group-specific differences using ANOVA and pairwise comparisons with Scheffe's multiple comparison tests. In sham-treated rats, bone resorption predominated on the distal alveolar surface, but significant surface-related differences between mesial and distal surfaces in bone formation were not demonstrated. Time-specific effects in bone resorption were not evident on either surface in the shams. These findings suggested that molar distal drift in the sham rat is facilitated by resorption in the distal alveolar bone. PDL width changes in orthodontically-treated rats were greatest in the mesial occlusal half of the root and decayed linearly toward the apex indicating that the greater initial tooth displacement occurred in the occlusal half of the root surface. Histomorphometric parameters of alveolar bone turnover were also seen to be greater in these locations, suggesting that these processes were sensitive to the increased tooth displacement.(ABSTRACT TRUNCATED AT 250 WORDS)
The effect of resection of the apical part of the root before replantation upon periodontal and pulpal healing was studied in 7 green Vervet monkeys (Cercopithecus aethiops) using teeth with incomplete and complete root formation. Maxillary central incisors, mandibular lateral incisors and first and second mandibular molars were used in this experiment. On one side, the tooth was extracted and replanted with an intact root while the contralateral tooth had 2 mm of the apex resected for the purpose of facilitating pulpal repair and eliminating resorption in the resorption-prone region of the root. The replanted teeth were examined histologically 8 weeks after replantation. The histometric analysis revealed no significant difference in periodontal healing between teeth with or without apical resection. With regard to pulpal healing, apical resection was found to lead to significantly less vital pulp tissue in teeth with immature root formation. A similar, but not significant difference was found for mature teeth. Based on these findings, it could not be recommended that apices be resected prior to replantation in order to improve pulpal repair.
An algorithm was designed to automatically obtain information on the orientation of roots in dental radiographs aimed at localizing the periapical region. A curve was approximated mathematically by a cubic polynomial to intersect the boundary of the root at its apex. The performance was judged by comparing the location of this intersection with the actual location of the apex as determined by five expert observers. In an experiment with 262 roots of the eight tooth groups, the distance between these two points was less than 1 mm in 67.9% of all cases and less than 2 mm in 88.2%. The performance of the procedure appeared to depend on the tooth group (p < 0.01). The location of the intersection was reproducible within 1 mm in 86.4% of all cases. The reproducibility was, however, not equal for all tooth groups (p < 0.01). The experts were more consistent in localizing the apex than the system was (p < 0.01), although this difference was not confirmed for four of the tooth groups (p > 0.57), and was marginal for two others (0.01 < p < 0.02). It is concluded that the algorithm is promising in its capacity to track a majority of roots down to their apex. It could therefore add important knowledge to imaging procedures aimed at the digital analysis of the periapical region.
OBJECTIVE: To evaluate treatment decisions of general practitioners (GPs) and dental teachers (DTs) in cases of endodontically treated teeth and to test the hypothesis that dentists' treatment decisions are independent of their working sector and other practice characteristics. DESIGN: A questionnaire based on four endodontic cases was mailed to 400 GPs and 47 DTs. The GPs were selected by stratified randomisation by gender, and main occupation (public and private sector). Others were all full-time DTs, representing clinical disciplines other than surgery and orthodontics. The endodontic cases were described in detail: one with a radiograph enclosed, three with statements on radiographic examinations. For each case, respondents chose the optimal treatment from alternatives, later reclassified as 'no therapy now' (further examination within 3-12 months), and 'active treatment' (immediate retreatment or periapical surgery). RESULTS: For Case 1 (tooth 25, asymptomatic, in normal occlusion, the radiograph revealed an underfilled root canal and a crown with a post, widened periodontal ligament space around the apex but no radiolucency), active treatment was chosen more frequently by private than by public dentists (11% vs. 4%, P=0.01), but neither sector differed (P>0.05) from DTs (6%). Decisions in favour of active treatment were associated with higher share of adult patients (OR=2.8; 95%CI: 0.3, 1.0; P=0.01). Cases 2-4 showed no difference in treatment decisions by practice characteristics. CONCLUSION: Treatment decisions by GPs and DTs were quite similar for each case and in most cases independent of the dentist's work and practice related characteristics.
Dens invaginatus is an anomaly of the tooth formation of embryonic origin that presents itself in several morphologic types. The complex anatomy of these teeth makes nonsurgical endodontic treatment complex and more so when its apex is immature. The 2 cases reported illustrate the nonsurgical endodontic management of a dens invaginatus type II and type III with an immature apex and periapical lesions, in which mineral trioxide aggregate (MTA) in one case, and calcium hydroxide in the other one, were the materials used. A 5-year follow-up of both cases shows a complete periapical healing with bone formation at the site of the lesions.
The purpose of this study was to evaluate the effect of preparation taper using size #20 or size #40 ProFile GT files on the ability to introduce irrigant and remove debris from root canals. Forty-eight bilaterally matched pairs of extracted teeth were instrumented using.04-,.06-,.08-, and.10-tapered files with one tooth of each pair enlarged to size #20 and the other to size #40. The teeth were sectioned at 1 mm and 3 mm from the apex, and the amount of remaining debris was calculated as a percentage of the total lumen area. The following variables were evaluated: apical preparation size, preparation taper, total volume of irrigation, depth of irrigation needle penetration, and number of instrument changes needed to reach working length. Compared with the size #40 preparations, a significantly greater percentage of remaining debris was observed in the size #20 preparations at the 1-mm level for all tapers except the.10 taper group in which there was no significant difference (p = 0.982). There were no significant differences between any groups at 3 mm. Results suggest that debris is more effectively removed using.04,.06, and.08 ProFile GT instruments when the apical preparation size is larger (size #40) compared with size #20 apical preparations. When a taper of.10 can be produced at the apical extent of the canal, there is no difference in debris removal between the two preparations sizes.
AIM: To describe a case where a second orthograde retreatment was successful in the management of an infected mandibular right first molar that previously had received both orthograde and retrograde treatments. SUMMARY: Periapical surgery is unlikely to be successful unless the root canal system has been adequately debrided and sealed. A case is described where orthograde endodontic treatment, retreatment and apicectomy were unsuccessful in the management of and infected mandibular right first molar. The periapical radiolucency eventually disappeared following a second orthograde retreatment. Teh second retreatment included 12 months of intracanal calcium hydroxide placement to promote apexification, thus allowing subsequent controlled obturation with gutta percha and AH26. At a 5-year review following completion of treatment, the tooth remained asymptomatic and was in normal function. KEY LEARNING POINTS: Orthograde retreatment is a treatment option to manage refractory lesions in teeth that have previously received endodontic treatment, retreatment and apicectomy. Orthograde retreatment using long-term intracanal calcium hydroxide can help promote root-end closure of a resected apex.
A new method for studying leakage of root fillings using the bacterium Pseudomonas fluorescens ATCC 13525 is described. The presence of the microorganism is detected by fluorimetry and can thus be used to measure the depth of penetration from the root apex toward the crown of the tooth. This system, applied to a number of methods of root canal filling, showed that procedures involving compaction of the gutta-percha gave a more effective seal than the use of a paste sealer with uncondensed gutta-percha. There was no statistically significant difference between the leakage results from the lateral, vertical, and thermomechanical condensed techniques.
OBJECTIVE: To compare apical microleakage of MTA following reverse retrograde root filling with that following amalgam and EBA retrofilling. DESIGN: Prospective random control trial. SETTING: It was conducted at the University of Jordan in 1998. MATERIALS AND METHODS: The root canals of 79 extracted teeth were instrumented and obturated with vertically condensed gutta-percha. Each tooth was apically resected and the apex was prepared ultrasonically to 3 mm depth and the root surface isolated with nail varnish. Teeth were divided randomly into three groups of 25 teeth each. First group was retrofilled with amalgam, second group with EBA and the third group with MTA. Following immersion in 1% methylene blue dye for 72 hours, the roots were sectioned and the depth of dye penetration was evaluated by a stereomicroscope at x10 magnification. INTERVENTIONS: Super EBA is a reinforced zinc oxide cement based on a mixture of 32% eugenol and 68% ethoxy benzoic acid (EBA). MTA is a mineral trioxide aggregate cement (MTA) based on a mixture of sterile water. MAIN OUTCOME MEASURES: The sealing effectiveness of the retrograde filling materials used in this study was determined by their ability to inhibit dye penetration. RESULTS: 56% of the group filled with amalgam and 20% of the group filled with EBA showed dye leakage beyond the retrofilling material whereas the MTA group showed none, two samples from MTA group were eliminated because of their fractured roots. The chi-squared test revealed a statistically significant difference among all three groups (P < 0.05). CONCLUSION: MTA cement provides a better seal than amalgam and EBA cement when used as retrograde filling, but the extrapolation of this result into a clinical practice may be questionable.
This study investigated the effects of dental local anaesthetic solutions containing either 2% plain lignocaine or 2% lignocaine with 1:80,000 adrenaline. The duration of anaesthesia and the occurrence of a reduction in blood flow together with its duration were examined in the dental pulps of maxillary central incisor teeth in 10 human subjects. The local anaesthetic solution was injected into the soft tissues adjacent to the apex of the sound maxillary incisor tooth. The blood flow in the dental pulp was assessed by a laser Doppler flowmeter, and the effectiveness of pulpal anaesthesia was determined by an electric pulp tester, both at timed intervals. The injection of 1-2 ml of 2% plain lignocaine had no significant effect on blood flow in the pulp of the incisor tooth in eight of 10 subjects. In the other two, there was a small but significant increase. The duration of pulpal anaesthesia was 25.1 min (SD 6.23). Following injection of 1 ml of 2% lignocaine with 1:80,000 adrenaline, there was a significant reduction (31%) of pulpal blood flow in every subject (p < 0.05). The duration of reduced blood flow was 68.5 min (SD 9.73). The duration of pulpal anaesthesia was 100 min (SD 15.09), four times the duration of anaesthesia induced by plain lignocaine. The anaesthetic solution with vasoconstrictor produced far longer anaesthesia more consistently at a lower dose than the plain solution.