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Hidden internal resorption

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From: Terry Pannkuk
To: ROOTS
Sent: Friday, May 21, 2010 6:10 AM
Subject: [roots] Hidden Internal Resorption

I just packed this case a few moments ago.  GP in the buccal systems and MTA packed completely through
the palatal with an esthetic bonded resin surface/core placed afterwards.   The CT was helpful in showing
the internal resorption defect clearly ahead of time.  The dentin walls are amazingly thin at the level
of the defect seen on transverse sections.

Interesting history on this one but since it has some dark elements, I’ll refrain from discussing them,
no educational value.

Take home point on this case. You need adequate coronal flaring on the palatal to get good access to the
apex past the resorption defect, clean, shape, and fill with MTA densely.  I usually like to make sure
the smallest plugger fits to length before packing MTA. If it doesn’t fit to length you are likely
to fill short and get voids -  Terry




what made/lead you to do a CT on this case as a pre-op? - Craig Barrington

I could BS you and say I saw the shadow on the PA (which is subtly visible) but I didn’t.   It’s a long
story which will bore people, especially those who are already sick of me. J  Let’s just say the patient
didn’t believe she needed endo and travelled around town for a few second/third opinions before she finally
circled back to me and I took a CT to show her why she needed endo.  The internal resorption defect was
a surprise finding that validated the need for endo.    I wouldn’t’ have normally ordered a CT on a case
like this unless I had been perceptive enough to see the defect.   The CT didn’t provide a COD, it was a
validating CT for the patient.   If I hadn’t seen the internal resorption defect preoperatively it would
have been obvious after access and the result/treatment would have been the same.  It’s just that knowing
it ahead of time provided easier communication and planning up front without confusing the patient - Terry

Terry, Why have you decided to fill buccal canals with gutta, if you filled the problematic canal with
internal resorbtion entirely with MTA ? What was your logic behind such approach ? Why not all of them
with MTA ? - Valeri

Good question especially since George Bogen’s article in the JOE showed that routine obturation of MTA
is practiced by some.

What would be the point of obturating  with MTA unless it is a special case with gross irregular anatomy
with an irregular terminus that cannot be sealed adequately with gp/sealer?  It took me quite a few
compaction cycles to get the MTA adequately to the apex past the defect.  It simply has poor flow is
isn’t going fill in secondary and tertiary anatomy as well as gp/sealer.  The buccal systems were
narrower and had routine form, filling with MTA wasn’t a consideration.  Sometimes I’ll fill with MTA
if I know I’m going to have to perform endo surgery.  That didn’t seem to be an issue with this case,
and even if  surgery was necessary on the palatal root, it would have to be approached from the palatal.
It would be next to impossible to bevel the palatal root down and eliminate the resorption defect without
completely obliterating  the buccal roots to access it from the buccal approach.

The buccal roots seemed best obturated conventionally.    I know where this argument might be heading;
if you are presuming that obturation is not important and that a coronoapical seal would be better
achieved by packing MTA in the buccal systems even though you don’t fill apical anatomy; I can’t argue
with you; I simply view obturation as important, especially on necrotic cases. -  Terry

thanks...i was hoping you would say that the preop film was such an odd and "not very diagnostic" angle
that you knew you would get the "angle" you needed with the cbct.....

not every patient is built to fit the one size fits all XCP rinns or other instruments........
sometimes you can help but get a high angle shot on a flat palatal vault type patient. i have actually
learned that a pedo film in the rinn instrument will give a pretty good look in most of these patients
but it would certainly take away a lot of diagnostic delimma guess work by simply recogonizing the
existing patient anatomical limations for the one size fits all factor and simply go to a cbct......
rambling..........summed up: thanks - Craig barrington