Diagnosis and management of a rare case of a maxillary second molar with two palatal roots - Supported by conventional radiography and CBCT / A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material
Diagnosis and management of a rare case of a maxillary second molar with two palatal roots - Supported by conventional radiography and CBCT
01 - 04 viewA combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material
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endo tribune 1D
Dental Tribune Middle East & Africa Edition | September-October 2015
Diagnosis and management of a rare case of a maxillary
second molar with two palatal roots - Supported by
conventional radiography and CBCT
By Ass. Prof. Katarina
Beljic-Ivanovic, Serbia
B
ENDO TRIBUNE
esides adequate knowledge of root canal morphology in general, it is of
utmost importance to evaluate
each individual case for aberrant anatomy and to identify any
morphological variation before
performing and during an endodontic procedure on such teeth.
In clinical practice, conventional
radiography with the assistance
of an operating microscope is
the most common method for
evaluating root canal anatomy.
However, it has been shown that
their use does not reveal all anatomical details. Recently introduced and developed cone beam
computed tomography (CBCT)
for dental use has proved to be
more accurate in detecting root
canal morphology, especially in
maxillary posterior teeth. One
of the most unusual and rare
aberrations of tooth anatomy is a
maxillary second molar with two
separated palatal roots. This article presents the case of such a
patient, who presented ten years
after another such patient had
been recorded.
canal therapy had been performed on the same tooth several years before.
- He also recalled that two teeth
on the same side of the upper
jaw had been extracted at least
ten years before.
- partly obturated palatal and
mesiobuccal (MB) root canals
and an unfilled distobuccal (DB)
root canal;
- slight radiolucency around the
palatal root apex; no distinctive
border towards the surrounding
maxillary bone structure.
The World’s Endodontic Newspaper Middle East & Africa Edition
Case report
A 26-year-old male patient
sought treatment at the Department of Restorative Odontology
and Endodontics at the University of Belgrade with the following
chief symptoms, which had persisted for several weeks already:
- spontaneous dull, mild and intermittent pain in the region of
the left maxillary molar;
- moderate sensation of pain
when biting hard food.
Additional information was acquired from further anamnesis:
- There were no other symptoms, and no irradiation of existing pain.
- The patient recalled that a root
Furthermore, clinical examination confirmed the following:
- only the second molar, #27,
with an extensive amalgam restoration, was present in the left
maxilla;
- moderate sensitivity on vertical
percussion of the buccal cusps,
and painful response to percussion of the mesiopalatal cusp;
- no sensitivity on digital palpation on the vestibular or palatal
side;
- both hot–cold and electric vitality tests were negative;
- no pathological mobility of the
tooth.
The diagnostic periapical radiograph (bisecting angle technique) showed:
The necessity of an endodontic
retreatment of the tooth was explained in detail to the patient,
who accepted the suggested
therapeutic procedure and the
general schedule for further appointments.
Treatment procedure
The old amalgam restoration
and the phosphate cement base
were completely removed, and
the cavity walls were additionally prepared to enable clear
visibility and straight-line access
to all root canal orifices. The orifices of the palatal and MB root
canals had been blocked with
obturation material, presumably
iodine phosphate cement and
a gutta-percha cone. Approximately 3 mm distal from the
orifice of the obturated palatal
root canal, another oval, cracklike orifice could be seen, with
the appearance of a perforation.
Further assessment of the pulp
chamber floor was performed
with 4.5 x magnifying loupes and
the Endodontic Probe Orifice
Opener (DENTSPLY Maillefer).
Using the probe and a #10 K-file
to negotiate the flat oval orifice,
the presence of a second palatal
(distopalatal, DP) root canal was
detected.
The orifice of the DB root canal
was hidden under brownish deposits of tertiary dentine, located
about 2 mm distal from the obturated MB canal orifice and approximately 2 mm buccal from
the DP canal orifice. The DB
canal orifice was negotiated and
> Page 4D
3D efficiency_
mechanical cleaning in areas previously impossible to reach
Oval, caverns, double canal, C, 8, isthmus shape.
FKG Dentaire SA
www.fkg.ch
[2] =>
2D endo tribune
Dental Tribune Middle East & Africa Edition | September-October 2015
A combined surgical and non-surgical approach
to repair an external root resorption utilizing
a nano-particulate bioceramic root repair material
Figure 1. Radiograph of tooth #9 shows extensive root resorption in the mid root region.
Figure 2. An apical barrier of EndoSequence
BioCeramic RRM Putty was condensed down
at the apex prior to back filling the rest of the
canal with EndoSequence RRM Syringeable BioCearamic material.
Figure 5. After raising a full thickness mucoperiosteal flap, a large resorptive defect was noted
on the distobuccal aspect of the root of tooth #9.
Figure 6. Using a high speed round bur and copious amounts of water, the defect was prepared and all visible resorptive soft tissue in the root was
drilled out until the root canal was reached, exposing the set EndoSequence RRM Material inside the non-surgically filled root canal.
By Allen Ali Nasseh, DDS. MMSc
I
ntroduction
The applications of bioceramic compounds in endodontic therapy range all the way
from their non-surgical use as
a root canal sealer, a pulp capping agent, and a perforation
repair material to their surgical
applications for root repair and
apiecoectomy procedures. The
first bioceramic compound introduced, MTA (Tulsa Dentsply,
OK,) was derived from Portland
cement and has proven to be a
valuable root repair material for
surgical applications1-3. More
recently, medically pure nanoparticulate bioceramic formulations (that have been engineered
from the ground up) have improved on some notable shortcomings of MTA by addressing
the clinical handling challenges
associated with this first generation material4-15. In addition, the
removal of heavy metals, that
can cause tooth staining in MTA
repaired cases, has also been
addressed with these newer 2nd
generation formulations.
This new family of compounds
known as EndoSequence BC
Sealer, Root Repair Material
(RRM), and Fast Set Putty (BUSA/
Brasseler USA, Savannah GA)
has shown significant clinical
handling advantages over MTA
for both non-surgical and surgical applications. Due to their
nano-particulate size and viscosity, these materials can now
be used as a sealer and/or filler
for root canal obturation, as well
as for the surgical repair of root
defects and apicoectomies.
This clinical case report demonstrates the use of EndoSequence
Bioceramic formulations
for
both the non-surgical root canal treatment and the surgical
repair of an extensive external
root resorption defect in a single
central incisor.
Case Report
A 26 year old female presented
with a chief complaint of discomfort and swelling around
her front tooth (Figure 1.) She
explained that she was seeking
a third opinion after being told
twice that tooth #9 was not salvageable and had to be extracted. Clinical testing and evaluation revealed erythematous
gingival tissues on the buccal aspect of tooth #9 with deep probing (+6mm with BOP on the buccal and normal probing on the
lingual.) Testing also revealed
that all anterior teeth were
within normal limits to thermal
and percussion test except for
tooth #9, which was positive to
percussion with severe and lingering response to cold. Upon
radiographic examination, tooth
#9 was diagnosed with extensive external root resorption. A
history of protracted orthodontic
therapy ten years ago was noted
in the patient’s dental history.
A pulpal diagnosis of symptomatic irreversible pulpits was
made and the prognosis, given
the large extent of the resorptive
defect was deemed guarded to
questionable at best. Extraction
was deemed the most predictable option. The patient, however, was very motivated and
wanted to attempt to save her
tooth despite the guarded prognosis.
The non-surgical endodontic
therapy was completed in a
single visit using a combination
of EndoSequence Root Repair
Material (RRM) Putty (BUSA/
Brasseler USA, Savannah GA) in
a barrier technique and EndoSequence Root Repair Material
(RRM) Syringeable formulation
(BUSA/Brasseler USA, Savannah GA) to fill the entire canal in
the following manner:
Following cleaning and shaping
to a size 70/.04 EndoSequence
File (BUSA/Brasseler USA, Savannah GA) the tooth was fur-
Figure 3. The access was restored with Fuji IX
after backfilling the root canal with EndoSequence RRM Syringeable BioCeramic material.
ther disinfected with full strength
(7%) Sodium Hypochlorite. This
was accomplished by using a
negative irrigation system (EndoVac Macro-Canula (SybronEndo, Orange, CA) and a Forza V3
Ultrasonic unit with an E11 tip/
size 20 U-blade insert (BUSA/
Brasseler USA, Savannah GA).
Thereafter, a size 70/.04 EndoSequence BC Gutta Percha
Cone (BUSA/Brasseler USA,
Savannah GA) was fitted to the
apex with tug back. The cone
was then trimmed with a scalpel
blade so that it would fit 4mm
short of the apex. A 4mm plug
of EndoSequence BC Putty was
then condensed to the apex using the fitted cone so that a 4mm
plug of putty filled the apex, creating a barrier (Figure 2.) The
apical barrier technique has
been described previously16,17.
The cone was then removed
and the entire remaining canal
was filled with Syringeable BCRRM. The access was restored
with Fuji IX (Figure 3). The patient was reschedule for surgical repair of the external defect
2 weeks later. The surgical appointment was not scheduled
concurrently in order to allow
time for the intra-radicular cement to set and to evaluate patient response.
The patient returned for the surgical root repair visit and a sinus
tract was noted on the buccal
aspect of the tooth pre surgically (Figure 4.) A large external
resorption defect was noted on
the buccal aspect of the root after a full thickness intra-sulcular
flap was raised (Figure 5.) Using a high speed round bur and
copious amounts of water, the
defect was prepared and all visible resorptive soft tissue in the
root was drilled out until the
root canal was reached, exposing the set EndoSequence RRM
Material inside the root canal
(Figure 6.) Once all the soft tissue was removed, the remaining preparation and the exposed
Figure 4. During the surgical visit, a sinus tract
was noted on the buccal gingiva.
root surfaces were conditioned
with citric acid. The remaining
root defect was then repaired
with an equivalent amount of
bioceramic putty trying to keep
the natural curvature of the root
(Figure 7) and the flap was sutured closed.
The immediate post operative
radiographs show the extent of
the root repair with the Putty in
this tooth (Figure 8.) Following
normal post operative healing
the patient was evaluated at 6
months and two years, where
the gingival tissue was observed
to be fully healed and probing
was found to be within normal
limits (Figure 9). At this point,
the surgical repair procedure
was deemed successful. The
post operative esthetics were
completely acceptable to the patient and no tooth staining was
noted as a result of the material
used to repair this tooth internally or externally.
Conclusion
Extensive external root resorption and other aggressive forms
of cervical root resorption are
challenging when they cause
significant root damage. These
lesions can sometimes be monitored requiring no intervention
at all. However, when endoperio involvement results in
pulpits and later infection of the
resorption defect, extraction of
the tooth or surgical repair of the
root are the only viable options.
In cases where direct surgical
access with good visualization
of the defect can be achieved,
the use of modern bioceramic
formulations (which are easy to
apply to the site and have demonstrated excellent biocompatibility, bonding, and hydrophilic
qualities) may be an excellent
clinical choice. In this clinical
case, the use of nano-particulate
premixed bioceramic formulations, both EndoSequence
Syringeable BC Root Repair
Material (RRM) & Putty (BUSA/
Brasseler USA, Savannah GA)
were demonstrated. Long term
follow up of the healing of the
gingival tissues and acceptable
esthetics were achieved in a
tooth that was otherwise deemed
unsalvageable. The ease of clinical handling during surgery and
a lack of dentin staining were
noted. Further studies in this
area are warranted in order to
explore the true potential of this
family of compounds in root
repair applications, as well as
all other aspects of endodontic
therapy, where direct contact
between biological tissues and
biocompatible repair material is
essential to success.
References
1. Parirokh M, Torabinejad M.
Mineral trioxide aggregate: a
comprehensive literature review — Part I — chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27.
2. Torabinejad M, Parirokh M.
Mineral trioxide aggregate: a
comprehensive literature review — Part II — leakage and
biocompatibility investigations.
J Endod. 2010;36(2):190-202.
3. Parirokh M, Torabinejad M.
Mineral trioxide aggregate:
a comprehen- sive literature
review —Part III – clinical applications,
drawbacks,
and
mechanism of action. J Endod.
2010;36(3):400-413.
4. Zhang W, Li Z, Peng. Ex vivo
cytotoxicity of a new calcium
silicate-based canal filling material. International Endodontic
Journal. 2010; 43(9): 769. DOI:1
0.1111/j.1365-2591.2010.01733.
5. Jingzhi M, Shen Y, Stojicic S,
Haapasalo M. Biocompatibility
of Two Novel Root Repair Materials. JOE. 2011; 37(6): 793-8
6. AlAnezi AZ, Jiang J, Safavi KE,
Spangberg LSW, Zhu Q. Cytotoxicity evaluation of EndoSequence Root Repair Material.
Oral Surgery, Oral Medicine,
> Page 3D
[3] =>
Dental Tribune Middle East & Africa Edition | September-October 2015
endo tribune 3D
< Page 2D
Figure 7. After removal of the resorptive cells in the defect, the cavity was restored with the EndoSequence RRM Putty material. The material was manipulated gently to the shape of the original root
structure.
Figure 8. The immediate suture placement and post operative radiograph shows the extent of defect
after it was filled with the BioCeramic RRM Putty.
Figure 9. 6 months and two year recall visits show excellent esthetics and bony healing in the area with reattachment and no dentinal staining.
Oral Pathology, Oral Radiology, and Endodontology. 2010;
109(3): 122-5. DOI:10.1016/j.tripleo.2009.11.028
7. Ciasca M, Aminoshariae A, Jin
G, Montagnese T, Mickel A. A
Comparison of the Cytotoxicity
and Proinflammatory Cytokine
Production of EndoSequence
Root Repair Material and ProRoot MTA in Human Oseoblast
Cell Culture Using ReverseTranscriptase Polymerase Chain
Reaction. JOE. 2012; 38(6); 486-9
8. AlAnexi A, Jiang J, Safavi K,
Spangberg L, Zhu Q. Cytotoxicity evaluation of endosequence
root repair material. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2010;109;e122-e125
9. Hirschman W, Wheater M,
Bringas J, Hoen M. Cytotoxicity
Comparison of Three Current
Direct Pulp-capping Agents with
a New Bioceramic Root Repair
Putty. JOE 2012; 38(3);385-8.
10. Zhang S., Yang X., Fan M.
Bioagreggate and iRoot BP Plus
optimizes the proliferation and
mineralization ability of human
dental pulp cells. International
Endodontic Journal. 2013; TBP
11. Zhang W, Li Zhi, Peng, B. Effects of iRootSP (aka BC Sealer)
on Mineralization-related Genes
Expression in MG63 Cells. JOE.
2010; 36(12); 1978-1982
12. Zhang H, Shen Y, Ruse ND,
Haapasalo M. Antibacterial activity of endodontic sealers by
modified direct contact test
against enterooccus faecalis.
JOE. 2009; 35(7): 1051-5
13. Lovato, K, Sedgley, M. Antibactieral Activity of EndoSequence Root Repair Material
and ProRoot MTA against Clinical Isolates of Enterococcus faecalis JOE. 2011; 37(11); 1542-6.
14. Candeiro G, Correia F, Duarte M, Ribeiro-Sigueira D, Gavini, G. Evaluation of Radiopacity,
pH, Rlease of Calcium Ions, and
Flow of a Bioceramic Root Canal
Sealer. JOE. 2012; 38 (6); 842-5
15. Zhang W, Zhi L, Peng B.
Assessment of a new root canal sealer’s apical sealing ability. Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology
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16. https://realworldendo.com/
videos/one-step-apexificationusing-endosequence-bioceramic-putty-and-root-repair-material
17. https://realworldendo.com/
videos/cbl-7-case-review-ofapical-barrier-technique
[4] =>
Dental Tribune Middle East & Africa Edition | September-October 2015
endo tribune 4D
< Page 1D
of the apical portion of the roots.
Fig. 1: Straight-line access to all four root
canals of tooth #27
Fig. 4: Intra-oral radiograph of tooth #27
lacking periapical information
Fig. 2: Intra-oral radiograph indicating
all four root canals of tooth #27
Fig. 5: Axial view of the middle level, axial view of the apical level, and sagittal
detailed view of tooth #27
Fig. 8: PAN detail, volume-rendered view
and Multi-Planar Reformat view of treatment check-up of tooth #27
Fig. 7: Axial view of the middle level, axial view of the apical level, and sagittal
detailed view of tooth #27
Fig. 3: Obturated root canal orifices of
tooth #27
Fig. 6: Axial view of the middle level, axial view of the apical level, and sagittal
detailed view of tooth #27
Fig. 9: PAN detail, volume-rendered view
and Multi-Planar Reformat view of treatment check-up of tooth #27
root canals was removed using rotating NiTi files, ProTaper
D1, D2 and D3 files (DENTSPLY
slightly widened with the Orifice Maillefer), and manual H-files
Opener, ensuring that it could be (DENTSPLY Maillefer). Further
easily detected in a further pro- instrumentation of those canals
cedure. The second MB root ca- was performed using WaveOne
nal could not be found with me- files (DENTSPLY Maillefer) with
ticulous searching under loupes reciprocating motion: the MP caand the application of a decalci- nal with black (#40) and the MB
canal with red (#25). The workfying solution (17% EDTA).
After consultation and receiving ing length was determined and
the approval of the patient, it was checked throughout the entire
decided to conduct the entire pro- procedure using an electronic
14ER3194 Dental
Tribune_A4_Layout
1 12/2/14
4:15 PM
Pagelocator
1
apex
(RomiApex A-15,
cedure
in at least two
sessions.
Romidan).
First, the root filling material in
the MB and mesiopalatal (MP) The DP root canal was then ne-
gotiated and a glide path was
created approximately 1–1.5 mm
shy of the apical foramen using
#10 and 15 K-files. The coronal
portion was flared successively
with #3 and 2 Gates–Glidden
drills. The same procedure was
performed at the DB root canal.
Clear visibility and straightline
access were established for all
four canals (Fig. 1).
Two intra-oral radiographs were
captured from two different horizontal angles with an inserted Kfile in each root canal, but only
one revealed all four root canals
(Fig. 2), showing vague contours
A calcium hydroxide dressing
was applied at the MP root canal
and a paper point, soaked with
a 2% solution of chlorhexidine
(R4, Septodont), was left in the
MB root canal. A cotton pellet
with chlorhexidine was left in
the pulp chamber and the cavity
was then sealed with a temporary filling material.
In the second session, two weeks
later, the DP and DB root canals
were carefully prepared, applying the same WaveOne technique as used for the MP and
MB root canals: the DP canal
with WaveOne black (#40) and
the DB canal with WaveOne red
(#25). The working length was
determined and checked using
the same electronic apex locator.
Throughout the entire endodontic procedure, 2.2% sodium
hypochlorite and 10% citric acid
solutions were used as irrigants,
successively, in all four root canals. Each of the four canals was
finally irrigated with 40 ml of a
2.2% NaOCl solution, dried and
obturated using Acroseal (Septodont) and a single gutta-percha
cone with an adequate taper
(DENTSPLY Maillefer; Fig. 3).
The intra-oral, retro-alveolar
radiograph captured post-treatment was of relatively poor quality owing to superimposition and
interference of the infrazygomatic arch and adjacent bone
structures, and failed to show the
most important apical portions
of the roots with the correct root
canal fillings (Fig. 4).
In agreement with the patient,
a CBCT scan was obtained, primarily to check the treatment
outcome, but also to document
this extremely rare case with
much more accurate and reliable images. The small field of
view (50 x 50mm) was recommended, and the data was acquired by SCANORA 3Dx (SOREDEX) immediately after the
treatment and at the six-month
recall.
The edited images (OnDemand3D, Cybermed) clearly
visualized two distinctive palatal roots, their relation to the
two buccal roots, the adjacent
anatomic structures and, most
importantly, the quality of the
obturation of all four root canals
(Figs. 5–9, arrows).
Conclusion and key learning
points
A careful assessment of the internal anatomy of the pulp chamber
is essential for detecting all root
canals.
A maxillary second molar with
two separate palatal roots is a
rare anatomical variation and,
according to our records, is detected only once in a decade.
CBCT images provide more accurate and reliable information
regarding roots and the root
canal morphology than conventional radiographs are able
to provide. Furthermore, concerning the treatment outcome,
CBCT images enable a much
more predictable and successful endodontic treatment procedure.
Editorial note: This article is
based on the work presented at
the 16th congress of the European
Society of Endodontology in Lisbon in Portugal in 2013 and was
published in cone beam – international magazine of cone beam
dentistry No. 02/2015.
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)
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[title] => Diagnosis and management of a rare case of a maxillary second molar with two palatal roots - Supported by conventional radiography and CBCT
[page] => 01
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[title] => A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material
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Table of contents
-
Diagnosis and management of a rare case of a maxillary second molar with two palatal roots - Supported by conventional radiography and CBCT
01 - 04
view
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A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material
02 - 03
view
[toc_titles] => Diagnosis and management of a rare case of a maxillary second molar with two palatal roots - Supported by conventional radiography and CBCT
/ A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material
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