Successful Orthograde Treatment of Teeth with External Inflammatory Root Resorption and Perforation Using a Tricalcium Silicate-Based Material.

One possible consequence of dentoalveolar trauma is the development of external inflammatory root resorption (EIRR), which represents an anatomic and microbiologic challenge for clinicians. This case report describes different strategies implemented for successful endodontic management of teeth with multiple EIRR lesions, highlighting the orthograde root canal filling using a tricalcium silicate-based material (Biodentine, Septodont, Saint-Maur-des-Fossés, France). A 17-year-old female patient presented with severe pain in the anterior maxillary teeth and a history of trauma. Two- and three-dimensional radiographic exams confirmed EIRR in three teeth, with a total of 11 EIRR lesions, three exhibiting communication with the root canal. Therefore, chemo-mechanical preparation complemented by ultrasonic activation of irrigants and some changes of intra-canal dressing with calcium hydroxide were performed to reduce the microbiologic load of the affected teeth as much as possible. Then, the canals were entirely filled with Biodentine to interrupt the root resorption process and strengthen the remaining root structure. A 60-month follow-up showed the disappearance of bone rarefactions and the complete repair of the 11 EIRR lesions. The favorable long-term response indicates the feasibility of using tricalcium silicate-based putty as part of orthograde endodontic treatment of teeth with EIRR and root perforations.

Intra- and Interobserver Agreement during the Assessment of the Different Stages of Root Development Using 4 Radiographic Classifications.

INTRODUCTION: This study analyzed intra- and interobserver agreements during radiographic assessment of the different stages of root development using the dichotomous, Moorrees, Demirjian, and Cvek classifications, as well as the effect of the observer's level of experience on the result. METHODS: Two hundred eighty-five digital periapical radiographs were examined via visual inspection by 3 experienced and 3 nonexperienced observers (n = 6) under strict technological and viewing conditions. After observer calibration, determination of the presence or absence of an open apex and the assignment of a root development stage according to the different subdivisions of the 4 indexes were performed. This evaluation was carried out by each observer in duplicate in the first round (n = 8) and repeated in the second round (n = 8). The 16 examinations performed by each observer (N = 96) were analyzed to determine the percentage of concordance followed by intraobserver, interobserver, and global observer agreement using the kappa coefficient and a weighted kappa. Additionally, to determine the level of concordance between the visual determination of an open or closed apex and the apical foramen width measured in millimeters, a dichotomized kappa coefficient was applied. RESULTS: A good level of global observer agreement was found for the dichotomous, Demirjian, and Cvek classifications. However, a significantly low percentage of total concordance and global observer agreement (6.66% and 0.498, respectively) was obtained using the Moorrees classification, which was more pronounced among nonexperienced observers (0.247). Apical foramen width measurements indicated the presence of 143 roots with an open apex (50.2%) and 142 with a closed apex (49.8%), and the dichotomized kappa coefficient test revealed a good level of agreement during the visual determination of an open or closed apex (range, 0.611-0.636). CONCLUSIONS: The classifications of Cvek and Demirjian provided reliable results when determining the different stages of root development. In contrast, the Moorrees classification provided the lowest agreement values, with a significant negative effect among nonexperienced observers. Finally, the visual estimation of the presence (or absence) of an open apex provided a good level of concordance with the radiographic apical foramen width.

The MB3 canal in maxillary molars: a micro-CT study.

OBJECTIVES: To assess the internal and external morphologies of the mesiobuccal (MB) root of maxillary molars presenting a third root canal (MB3), using micro-computed tomography (micro-CT). MATERIAL AND METHODS: Two-hundred and sixty-five extracted maxillary first and second molars with different root configurations were imaged in a micro-CT scanner at 19.6-µm pixel size. Sixteen teeth presenting MB3 canal were selected and evaluated regarding root configuration, minimal dentine thickness 2 mm under the furcation area, canal configuration of the MB root, MB3 canal morphology (location, independent or confluent orifice, and anatomy types), and the apical anatomy (aspect ratio, number of accessory canals and foramina, presence of isthmus, and independent MB3 foramen). RESULTS: Overall, a high variability in canal configuration was detected in the MB root. MB3 canal was observed in 10 maxillary first molars and 6 maxillary second molars (n = 16). Minimal dentine thickness related to the MB3 canal at the coronal third was smaller than that of the MB1 canal. A complex internal anatomy comprising 13 different root canal configurations was observed. A high number of independent MB3 orifices at the pulp chamber floor was observed in the first molars (7 out of 10 teeth), while most of the specimens (n = 14) showed a confluent anatomy of the MB3 canal. A varied number of accessory canals and foramina were observed. At the apical third, isthmus could be observed in 6 specimens, while an independent MB3 foramen was present in 37.5% of the MB roots. CONCLUSIONS: MB3 canal is a rare anatomical variation present in maxillary first and second molars. Its presence can be associated to a complex internal anatomy of the MB root which includes the presence of isthmuses and multiple accessory canals and foramina at the apical third, but also a thin dentine thickness at the coronal third and a confluent anatomy of the MB3 with the other main canals.

Non-Surgical Endodontic Management of Type II Dens Invaginatus with Closed and Open Apex.

Dens invaginatus (DI) is a developmental anomaly that poses a significant challenge to the clinician if endodontic treatment is required. The type II (as per Oehlers) form exhibits complex internal anatomy and is frequently associated with incomplete root and apex formation. The purpose of this study is to present two cases of type II DI in the maxillary lateral incisors. In the first case, non-surgical endodontic therapy was performed utilizing calcium hydroxide as an intracanal dressing, showing significant periapical healing of the apical radiolucent area at the six month follow-up. In the second case, the development of the root and apex were affected by pulp necrosis, and the revascularization procedure was performed. Complete resolution of the pre-existing apical radiolucency, apical closure, thickening of the root canal walls, and increase in root length, after 32 months was observed. Early detection of teeth with DI type II and proper exploration of their internal anatomy are key factors for their successful management. As demonstrated in this report, conservative non-surgical endodontic treatment should be the first line of treatment for these cases. The use of revascularization protocols in teeth that develop pulp necrosis and exhibit early stage of root development could be a better alternative than traditional apexification techniques.

Micro-CT study of the root canal anatomy of maxillary canines.

BACKGROUND: This study aimed to describe the anatomy of maxillary canines from a Western Mexican sub-population using micro-computed tomography (micro-CT). MATERIAL AND METHODS: Maxillary canines (n=32) were scanned at 19.6µm voxel resolution. Number and location of canals, the distance between the cemento-enamel junction and apex, occurrence of accessory and lateral canals, presence of oval canals, number of foraminas as well as two- (area, perimeter, roundness, aspect ratio, major and minor diameters) and three-dimensional (volume, surface area, and SMI) analysis were performed. Data of two-dimensional analyses at 5 different apical levels was statistically compared using Kruskal-Wallis tests (α=0.05). RESULTS: Overall, 31 specimens had one root with a main canal (Vertucci type I). Mean distance from the apex to the cemento-enamel junction was 16.32±2.27. Apical foraminas were present in 14 specimens (43.75%). No statistical differences were found in the two-dimensional analyses between the foramen and the 1 and 2mm apical levels (P >0.05). CONCLUSIONS: Maxillary canines presenting one root canal were present in a high percentage of cases (96%). The prevalence of long oval canals was <12% at the apical third and at least 37% of the sample showed more than one point of exit in the last apical 3mm. Key words:Maxillary canine, micro-computed tomography, root canal anatomy.

Mandibular Canines with Two Roots and Two Root Canals: Case Report and Literature Review.

Usually, the mandibular canine only has one root and one root canal. However, there has been a noticeable increment in evidence showing variations in its morphology, such as the presence of two roots and two root canals. The aim of this article was to present a case of a mandibular canine with two roots and two root canals and to review the available literature on this anatomic variation. Root canal treatment of tooth #43 with such morphology was performed in a 47-year-old woman. Careful inspection of the preoperative radiograph indicated the presence of more than one canal. The 12-month follow-up showed normal periapical tissues, with no pain or tenderness. Literature review revealed that the overall prevalence of such root canal configuration is 5.7%, with a strong preference for female sex (87.5%). Although mandibular canines with two roots and two root canals are not common, clinicians should always anticipate the presence of possible variations. Therefore, timely diagnosis and meticulous exploration of such mandibular canines allow for planning of an individualized treatment protocol, tailored to their peculiar morphology, focused on avoiding excessive weakening or even perforation of the roots.

Management of permanent teeth with necrotic pulps and open apices according to the stage of root development.

BACKGROUND: This paper analyzed the distribution of treatments for permanent teeth with necrotic pulps and open apices according to the stage of root development. MATERIAL AND METHODS: Dental records from all root canal procedures performed in permanent teeth with necrotic pulps and open apices over a period of 14 years by residents of the Speciality of Endodontics, University of Guadalajara, Mexico, were analized. RESULTS: Records from 206 treatments were mainly divided into the following 3 different stages according to criteria described by Cvek: stage IV (n = 79, 38.3%), stage V (n = 66, 32%) and stage III (n = 53, 25.7%). Few cases involved the initial stages of root development (stages I and II) (n = 8, 3.8%). Such teeth were submitted to four different treatments: MTA apical barrier (n = 69), Ca(OH)2 replacements (n = 34), gutta-percha (n = 67) and a plug of Ca(OH)2/gutta-percha (n = 36). The teeth with intermediate root development (Cvek stage III) showed a predilection for the MTA apical barrier and Ca(OH)2 replacement techniques (P ≤ 0.001). Furthermore, the stage of root development did not influence the apical extent of the root filling. CONCLUSIONS: The finding of permanent teeth with necrotic pulp and open apices is not exclusive to young patients with an open apex. Moreover, teeth with fragile, irregular and divergent apical morphologies, such as Cvek's stages´ I and II, were not common and may be considered to be unusual findings. The diverse endodontic procedures were reliable regardless of the stage of root development. Key words:Incomplete root formation, Open apex, Epidemiological studies, Root development.

Root Canal Filling after Revascularization/Revitalization.

INTRODUCTION: Revascularization/revitalization therapy is considered an alternative procedure for management of teeth with an immature apex and necrotic pulp, mainly when root development is interrupted in the early phases of formation. However, this clinical treatment protocol should be considered a permanent procedure? METHOD: A maxillary central incisor with a previous and successful RR treatment was intentionally filled with a biocompatible material with the periapical tissues due to the patient's lack of adherence to the follow-up protocol. RESULTS: The 20-month follow-up showed absence of clinical, radiological and tomographic signs and symptoms of an endodontic re-infection. CONCLUSION: This case demonstrates that once the increased thickening of the canal walls, incrementing the root length, apical closure and the total resolution of the apical lesion are observed, the main canal of a previously treated tooth with an RR procedure can be filled.

Accidental Contamination with Oil during Endodontic Surgery.

The modern surgical endodontic treatment is a safe and predictable procedure with high success rate. However, several factors can retard or impede the proper healing process. Use of a high speed handpiece during hard tissues management (osteotomy and apical resection) can potentially be one of these factors. Formation of metallic debris from the surgical diamond burs, production of necrotic local tissue due to overheating and the direct liberation of air from conventional handpiece into the working area are potential irritants able to delay the tissue healing. The aim of the present article is to report the histopathological findings of the trans-operational accidental contamination with oil in the surgical area during an endodontic surgery.

Iatrogenic displacement of a foreign body into the periapical tissues.

The presence of a foreign body in the periapical tissues can cause endodontic failure by triggering an inflammatory response and a subsequent foreign body reaction. This inflammatory response, which can occur to varying degrees, appears radiographically as a radiolucency that can remain asymptomatic for many years. A foreign object can reach the apical region by accident or iatrogenic procedures during dental procedures. The aim of the present case report is to describe the endodontic surgical treatment of an iatrogenic displacement of a foreign body (a metal fragment) into the periapical tissues and to describe its clinical and radiographic follow-up over a period of 52 months.