RED&WHITE
P8. GUEST AUTHOR
INTERNAL RESORPTION CASE Article by: Stephen Martin
Treated with Bioroot RCSTM and BiodentineTM Case Presentation This case was referred from a General Dental Practitioner, and had presented with a labially draining sinus. The referring practitioner supplied a radiograph with a GP tracer in the sinus confirming the 22 as the source of the chronic infection, and appearing to show a large resorption defect in the mid third of the 22. After a discussion with the patient the decision was made to use CBCT in order to confirm if the resorption was internal or external, and to determine the extent of the defect, thus allowing a better assessment of treatment options for the tooth. According to the joint position statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology on the use of cone beam computed tomography in endodontics, 2015 Update, “Limited field of view CBCT is the imaging modality of choice in the localization and differentiation of external and internal resorptive defects and the determination of appropriate treatment and prognosis.1 CBCT was taken with a Sirona Orthophos XG, low volume and high definition image to allow accurate measurements to be taken from the 3D image
Axial Slice from CBCT At Largest Extent of Resorptive Defect Pre-op Radiograph
The CBCT image confirmed a diagnosis of internal resorption and periapical periodontitis. There was no apparent communication with the periodontal ligament, i.e. there was no perforation however the walls of the tooth were very thin. However a small perforation was strongly suspected due to the position of the draining sinus and the thin nature of the remaining walls of tooth.
BDS MSc(Endo) MJDF RCS (Eng) PG Dip (Primary Dental Care)
Meadows Dental Team
After a discussion with the patient about the compromised nature of the tooth and alternatives of extraction and potential methods of replacement it was agreed that attempts would be made to carry out endodontic treatment and repair the resorption defect. Treatment Planning Vertical root fracture is a risk for endodontically treated teeth, and this risk is obviously increased by the lack of remaining tooth structure in the mid third of the root. It was decided that the use of Gutta Percha and a traditional endodontic sealer would firstly not effectively seal the suspected perforation, and also would not provide any strengthening to the compromised tooth structure. Biodentine, (Septodont, Saint-Maur-des-Fosses, France), is a Calcium silicate based cement which has been shown to be highly biocompatible, and have excellent sealing ability, allowing for it’s use in repair of perforation. It’s physical properties such as flexural and compressive strength have been found to be similar to Dentine.2 Another key property of Biodentine when being used anteriorly is it’s improved colour stability when compared with other Calcium Silicate materials such as MTA.3 Bioroot RCS,(Septodont, Saint-Maur-des-Fosses, France) is a Calcium Silicate root canal sealing material which has very similar properties to Biodentine. It has been shown to be highly biocompatible and to induce hard tissue formation in contact with bone and dentine structure.4 As both of these materials share many common elements and a setting reaction they are highly compatible with each other and therefore ideal to use in combination in this case. In the apical part of the tooth a standard root canal required cleaning shaping and filling, the mid-third of the canal had a large resorptive defect which needed filled with a biocompatible material which had similar physical properties to dentine. It was therefore decided to use a single GP Cone matched to the preparation system used in the apical third with Bioroot RCS severed using a heated plugger and then to fill the defect and coronal part of the canal with Biodentine.
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CASE STUDY .P9 Treatment Measurements of the position and extent of defect as well as length of canal were taken from the CBCT. These showed that the resorptive defect began at approximately 13mm from the incisal edge. The apical part of the canal began at approximately 16mm. This information was used to accurately locate, then prepare and carefully irrigate the apical portion of the canal with 2 % Sodium Hypochlorite. This was carried out with the aid of an operating microscope, (Global Surgical Corporation, St Louis USA).
possible to produce a well condensed and effectively sealed obturation relatively easily in difficult circumstances. The final post-operative radiograph shows that there is some lateral extrusion of Biodentine mesially confirming the suspected small perforation, and further vindicating the decision to use a bioactive material to repair the defect. The patient is aware that the tooth although now repaired, is still compromised but her objective of trying to retain the tooth as long as possible has hopefully been achieved. At the recent 6 monthly review there had been no discolouration of the tooth and no return of the draining sinus. A radiographic review to assess bony healing is planned at one year.
Sagittal Slice of CBCT
References
The canal was prepared using WaveOne Gold Reciprocating files,(Dentsply Sirona, Ballaigues, Switzerland). The working length was determined using the Morita ZX Mini Electronic Apex Locator and found to correspond to the length determined from the CBCT.
3D Imaging in Endodontics: A New Era in Diagnosis and Treatment; M. Fayed and B.R. Johnson Springer International Publishing Switzerland 2016
A matched GP point was inserted into the canal to the prepared length and a master cone radiograph taken to ensure good adaptation and seating of the single cone. After further careful irrigation of the canal and defect with hypochlorite the apical protion of the canal was obturated with a matched GP Point and Bioroot RCS, (Septodont) The GP was severed at 16mm with a heated plugger, (Calamus Dual, Dentsply Sirona). The resorptive defect was packed with Biodentine using the known measurements of the defect from the pre-op cbct. A periapical radiograph was then taken to ensure that the defect had been adequately filled with Biodentine. The coronal part of the canal was then sealed with Biodentine and then the access cavity restored in composite.
GP and Bioroot RCS in Apical Portion of Canal, and Biodentine filling defect
Biodentine: Material Characteristics and Clinical Applications. A Review of the Literature. Rajasekharan et alEur Arch Paediatr Dent (2014) 15:147–158 Color Stability of Teeth Restored with Biodentine: A 6 month In Vitro Study. M Valles et al. Journal of Endodontics 2015 Volume 41:7 1157-1160 Biocompatibility of three new calcium silicate based endodontic sealers on human periodontal ligament stem cells. Gonzalez et al International Endodontic Journal 2016
Post-op Radiograph with coronal part of canal obturated with Biodentine, and coronal seal with composite.
Discussion The combination of cbct technology and the properties of advanced endodontic materials gave this compromised case the best possible chance of success. The cbct technology allowed accurate diagnosis and was an invaluable tool in treatment planning. Biodentine and Bioroot RCS material properties made them ideal to deal with this complex clinical situation. The two materials complement each other perfectly. The ease of handling of both materials meant that it was
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