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Endo tips    Better Endo    Endo abstracts    Endo discussions

Internal radicular resorption - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: Javier Pascual
To: ROOTS
Sent: Friday, June 11, 2010 12:16 AM
Subject: [roots] after Marga´s lecture I want more and more and more...

79 years old lady referred to my practice for RCT on tooth 1.2 with 
an internal radicular resorption

Vital pulp tissue inside the root canal system. Working lenght 
determination with Root ZX to 19,5 mm and confirmation with 
radiographs. Instrumentation with Protaper/Profile. Apical 
gauge bigger than #60. Irrigation with 4% NaOCl and PUI with 
Satelec Irrisafe. Intracanal dressing with Calcium Hydroxide
Ultracal XS because uncontrolled bleeding

NEXT VISIT in 7 days. What do you think about this treatment 
option?

Apical plug with MTA. Do you think this is a good option here 
Grey angelus 15 minutes setting and then a fiber post in the 
same visit? Or should I wait with a wet cotton pellet and give 
the patient a third visit?

Fiber Post:

a) Long and narrow, deeper than the resorption deffect to have 
   better stability
b) Short and wider in order to fit it to the resorption deffect 
   as much as possible

Can you give me some clinical tips...??

use scope, use centrix system to deliver core material inside 
the canal...

which core material? which adhesive system? how to apply properly 
my adhesive system? what kind of matrix should i use here? 
single or multiple isolation? ... ..Javier

Dear Javier, I agree with your approach here, and would opt for B, a post that fit into the resorption process passively. I would not remove additional dentin to accomodate the post. That means that the resorption process will be mainly filled with composite. I usually reschedule a patient after placing an apical MTA plug. Looking at your case, my rational for this: 1. Apical foramen is not very wide, MTA needs moisture to set. I would insert a moist pellet to add some extra moisture 2. There are some papers that showed that acid-etching on fresh MTA may affect the compression strength and surface hardness of MTA. Therefore. it is recommended to postpone acid-etching of MTA for at least 96 hours after its application. I agree with centrix system. Luting a post is a topic in itself. Unfortunately I had no time to address this in my presentation. Here is some info that might be useful, these are some slides that I haven't showed in Barcelona. I am always very bad in estimating the time that I need to present the material....:-). To make a long story short: Self-adhesive cements offer a new, simpler approach, but the efficacy of many recently marketed products is not known, and there is little data in the literature regarding their in vitro or clinical performance. At this point in their development, the literature generally shows them to be inferior to the total-etch method. Hope this helps! - Marga

Javier.....MTA Angelus is fine Post system A Is patient doing a crown or just a restoration. If a crown then perhaps just build it up quickly with a core material. If not then you have to use composite. - Glenn Microroughening of FG posts with H2O2 is a simple, predictable and effective method which can be done by every dentist. More time consuming is sand blasting. - Valeri Stefanov Javier, Forgot to mention that Angelus Gray MTA only starts to get hardened 15 min after mixing and placing. It is definetly not fully hardened after just 15 minutes. Have this in mind. - Valeri Here are some SEM pictures showing what is the result after ten minutes treatment of FG posts with 24 % H2O2. - Valeri Valerie.....you mentioned Sandblasting is more "time consuming". You posted 24% H2O2 after TEN minutes. it takes me 10-15 seconds to sandblast a post. - Glenn Glenn, You are correct, but only when speaking about blasting a single post. What if you have to blast all 30 of them from a starting kit ? Second - one should have a mini blaster at her / his practice. With H2O2 you just put all 30 posts inside the solution of H2O2 for 10 min and then rinse them under running water. I would say it is quite obvious which one is more convenient for a busy practice :-). Both methods are useful, though to get posts' surface roughened. So, one can choose what suites her/him best. - Valeri JAVIER .:Conoces el Luxacore ?? ( empresa DMG ) es un material cementante y reconstructor ideal para poner pernos de fibra de vidrio en conductos muy amplios , viene con su propio sistema adhesivo Luxabond .y sirve para reconstruir conductos amplios o deformes como es el caso de una reabsorción interna - Gabriela Sánchez Hello Javier, Very nice documentation. MTA filling. My restorative choice would certainly not be what you depicted in option B (enlarge to accommodate for the resorption). This will force you to sacrifice sound dentin structure and further weaken the tooth. So option A would represent a better choice although again, I wouldn't necessarily extend the fiber post beneath the resorption especially if it requires a post preparation at that level. Resin cement (dual-cure or self-cure) and direct composite restoration with or without subsequent crown coverage. I am attaching a study we did on the subject at the university of Siena in 2008. - Hani Practically, nothing bonds chemically to fiber posts. If the fiber post's matrix is epoxy resin, methyl metacrylates are unable to chemically bond to it; and if its matrix is methyl metacrylate, it is completely polymerized and as such has little (if any) free radicals left on the surface for chemical bonding to occur (basically like trying to bond fresh composite to an old composite). Retention between the post resin cements/cores and fiber reinforced posts occurs mainly by micromechanical retention which is why silanization is required (to provide some chemical bonding to the glass surfaces of the fibers) and also why flowable composites present better push out strengths than conventional ones. Placing a bonding agent prior to using the flowable agent also helps as the bonding resin is even more fluid than flowable composites (I am attaching 2 paper on research we conducted on the subject). - Hani Hi Hani, NICE explanation ! I have been trying to explain / tell all this to Bulgarian dentists for quite sometime, but it seems few are getting it :-(. Some of those that were not getting it are on this list, too. So, I hope they will get it from you now after being unable to get it from me :-). These colleagues were telling everyone there is no need for silanization of FG posts at all ! Microroughening of FG posts with H2O2 is a simple, predictable and effective method which can be done by every dentist. More time consuming is sand blasting. - Valeri Stefanov So the best thing is to put FGP in h2o2 (for 1 minute?) and then use a silane? (I only used to use the silane) But the o2 doesnt inibits the polimerization? - Nuno Not exactly. After you buy the FG root posts you put them into a regular, stock available, 30 % solution of H2O2 for 10 minutes. Oxygen is different from H2O2. Then you rinse the root posts under running water for at least 3- 5 minutes and finally you put them into 70 % alkohol bath for 10 - 30 minutes. Afterwards leave them into suitable sterile container (Petry dish for example) to dry out and these are now roughened and ready for use :-). Before covering them with bond solution you need first to cover them with silane as you are already been doing it. You can also keep them constantly into 70 % alkohol solution and dry them with air just before usage. Hope that helps.- Valeri Stefanov Dear Valeri, Thank you :) A word of caution however regarding etching techniques. Attached is the article by Francesca Monticelli on hydrogen peroxide etching. As you can see, she tested FRC posts with epoxy resin matrix. Using this technique on fiber posts with methyl metacrylate based matrix will not work. Another issue is that the amount of etching required/ performed cannot be controlled properly: if you overetch, and we saw that in some of our testings, fibers could detach from the FRC post and you might actually lose retention instead of increasing it (you might also jeopardize the structural integrity of the post that can lead to loss of physical properties). - Hani Hani, Do you have any information about the use of Composite Resin conditioners that are sold to improve the bond to old composites that have been in function for a period of time? Do they actually work, or are they a waste of time and money? - Henry C. Levant Hello Henry, I can actually help a bit on this one. A friend of mine, Federica Pappachini did her PhD thesis on composite repair. Long story short, composite repair is favorably influenced by: - obtaining micromechanical retention on the repair site through sandblasting (best surface result) - Using silane coupling agent (will create some chemical bonds to the exposed glass particles) - Using a hydrophobic bonding agent (the bonding liquid of 3-step bonding systems). Other types of bonding are actually amphiphilic mixes and their hydrophilic components may hinder the bonding process and be the source of nanoleakage. - Warm air drying (as it will promote the evaporation of the solvent from the bonding liquid) - use of a flowable intermediate layer (lower viscosity improves spreading ability) I hope this helps, Hani Thanks very much. I suspected this was the case, but needed some informed confirmation! - Henry C. Levant When we take about direct resin bonding research conducted by Lambrechts and Vanherle in 1982 suggests that delayed resin resin bonding works best when bonding to a heavy filled material.Bonding to a microfilled resin is the most difficult procedure. This research concluded that delayed resin–resin bonding is a mechanical retention phenomenon in which a bonding agent interlocks with the surface irregularities of the underlying, previously cured composite. Other studies confirmed that the best results are achieved in delayed resin resin bonding by adding to macrofilled composites. These composites have more bond strength than microfilled composites "Miranda F, Duncanson M, Dilts W. Interfacial bonding strengths of paired composite systems. J ProsthetDent 1984;51:29 32.". Regardless of which types of composites are involved, for maximum bond strength, the old composite should be trimmed with a coarse disc (or diamond), etched, dried, and covered with a thin layer of unfilled resin bonding agent prior to the addition of a new composite. Bond strength values for delayed resin–resin bonding can achieve only 50% (for microfill repairs) to 70% (for macrofilled repairs) of the original cohesive strength. Other studies show that under the best circumstances, on average, delayed resin–resin bonding provides only 36% of cohesive strength to an untreated surface. This can be improved by 22%, to yield 40 to 50% cohesive strength, if an unfilled resin used. Some studies show even greater bond strengths if a phosphonated bonding agent is used as an intermediate layer. This increased strength may be related to improved wetting of the resin surface. When we take about Etching composites to remove fillers by using conditioners Strong etching solutions (eg, hydrofluoric acid) have been used as a conditioner to remove soluble macrofillers from the surfaces of pre-cured indirect resin veneers. The spaces left by the glass filler particles allow formation of resin tags, creating a micromechanical bond to the composite luting agent. This bonding results in greatly improved strength for these indirect resin veneers. This method of attachment is only effective with resin restorations in which the internal layer contains a macrofilled composite with a soluble glass filler. The etching solution used must be matched to the filler to dissolve it away effectively. This method of attachment is not advised for restorations made entirely on microfilled composite. Primers are usually reduce the surface tension of a cured resin surface; this makes it easier for the bonding agent to penetrate surface porosities. In addition, primers are thought to cause the resin matrix to swell and to open spaces among the polymer strands. The bonding agent may penetrate some of these spaces. One drawback to the use of primers is that, since they dilute the luting agent and make it more porous, they may affect the color stability of the restoration. - Mohammed Thanks for the hint.Most of FG posts sold in Bulgaria are with epoxy resin matrix, so technique is OK here at least. There is NO technique or kind of treatment which to have advantages only :-). Until now I have not observed any problems with posts I am using, but that of course does not automatically means these can not happen. Lower percentage solution for shorter time would give the dentist some more predictability, but I would mention it again that I did not have any problems up to now - Valeri Sand blasting remains as another option, too. Thanks for attaching the Monticelli article :-). - Valeri Valeri and Hani, The surface treatment with H2O2 can be used on epoxy resin posts, but does work equally well on fiber posts with a MMA based resin, see attached paper by Vano et al., published in 2006. I agree with Hani, overetching might be a problem, but this applies also to oversandblasting. Both procedures will work when used properly. . By removing a surface layer of epoxy resin or methacrylate, a larger area surface area of exposed fibers is available for silanization. In addition, the spaces between the fibers, created by etching or sandblasting, will provide a surface roughness, and enhance the micromechanical retention of the composite resin to the post. - Marga Marga, I do not see differences in my and your opinion about roughening of FG root posts. I agree that either etching with H2O2 or sand blasting when used properly will give predictable results. I have not done etching with hydrofluoric acid, but from publications available to me on the matter I made a conclusion it's the least desirable method for roughening of FG posts. - Valeri Valeri, We are used to soak the posts for 10 minutes in hydrogen peroxide 24%. This can be done in advance. Sandblasting is more difficult to standardize, because it is dependent of the time, distance and particle size of the al oxide. Therefore, I ususally recommend etching with H2O2 - Marga Hani, Do you have any information about the use of Composite Resin conditioners that are sold to improve the bond to old composites that have been in function for a period of time? Do they actually work, or are they a waste of time and money? - Henry C. Levant Usually such "conditioners" are in fact diluted UDMA. A hardened and "old" composite imho can not be properly chemically bonded to a new composite. It is strongly advisable to remove an old compsite retsoration in total and replace it by a new one. Henry , I can not send you the article about switching platform hype now. When my daughter fix my old PC ( J ) I will be able to give you a name of the colleague from Lithuania who has made this study and you could contact him and ask him to send you a copy of his study.. - Valeri Valeri, Thanks for following up on this. I’ll look forward to the information. - Henry C. Levant Thank you very much Glenn and Hani. Really nice paper Hani!!! So which adhesive system and core material would you recomend me? What about Permaflo DC from ultradent? - Javier I personally like to use Muticore Flow (Ivoclarvivadent) for post cementation and core reconstruction with either a 3-step adhesive or a 2 step (etch + prime and bond). - Hani Dear Hani, Why not thinking in some self-adhesive like RelyX Unicem for post cementation? - Gustavo Does it bond to the fiber posts? - Guy Hello Guy, I assume you are asking about Rely X Unicem although it does not really matter. Practically, nothing bonds chemically to fiber posts. If the fiber post's matrix is epoxy resin, methyl metacrylates are unable to chemically bond to it; and if its matrix is methyl metacrylate, it is completely polymerized and as such has little (if any) free radicals left on the surface for chemical bonding to occur (basically like trying to bond fresh composite to an old composite). Retention between the post resin cements/cores and fiber reinforced posts occurs mainly by micromechanical retention which is why silanization is required (to provide some chemical bonding to the glass surfaces of the fibers) and also why flowable composites present better push out strengths than conventional ones. Placing a bonding agent prior to using the flowable agent also helps as the bonding resin is even more fluid than flowable composites (I am attaching 2 paper on research we conducted on the subject). - Hani Hani, I was aware of some of this but thanks. Here’s my technique. I lightly sandblast the Unicore. Then I hit it fairly hard with the CoJet powder in a separate mini blaster silane bonding agent with self cure component and cement with a resin cement after prepping the canal with self etch bonding agent. Maybe it doesn’t work but I'’ve only had one Unicore come out in over six years. They fit the drill prep well and that could be a factor but they appear to bond better than the fiber posts did prior to me using the CoJet. I know that is meant for zirconia - Guy Dear Gustavo, Why not, of course. I also use Rely X Unicem. We performed testing on both materials and both materials perform well when used with sound clinical principles. As I do not really believe in bonding inside root canals, it doesn't really make a difference what I place inside the root canal. However, inside the access cavity, I can relatively control the bonding process and there, 3-step gives better results than self-etch (as far as the bonding technique is concerned). So in the cases I use RelyX, but I will use it inside the canal only. I have then to restore the core with Multicore that actually gave the best results in our studies. When I use Multicore flow alone, I can also use it as cement inside the root canal (that is one step closer to monoblock and one less clinical step for me). I can post the articles if you want. - Hani Hani, Your sentence sumarizes all issue and should be underlined in order to reach some stubborn ears: "As I do not really believe in bonding inside root canals..." I just would include: with the current avaliable dentin adhesive technology. - Gustavo Dear Gustavo :))))) Of course... anything we say is function of available technology. I am not against bonding inside the root canal, I'm just saying whatever we have now does not satisfy me (personal opinion) and I am careful when using it in patients - Hani For me I would agree with. Dr.Gustavo unicem rely x - Mzs Self-etching resin cements like Unicem are good choices, but work even better if you first use a bonding agent within the canal. I use SE Bond AND I first etch with phosphoric acid for 10 seconds to ensure a clean surface. This was first proposed by John Kanca for all self-etching resin cements to improve bonding strengths of these cements and has proven itself in my practice for several years! - Henry C Levant My humble opinion is that etch-prime-bond or etch + PB in one (Hani's way ) is better than self adhesive cements alone in the canal. We learned it a hard way in cases with canals been filled with Russian red paste where "gluing" to red dentin is in fact almost a mission impossible :-(. Beside, why use more expensive SAC which give inferior results in such circumstances ? I first treat/etch the canal walls with the liquid of phosphate cement for at least one minute - that is higher percentage solution of orthophosphoric acid compared to 10 % etching gel. Then prime and bond or these days etch + PB in one. Inside canal I use dual cure Luxacore and lately dual cure Luxacore Z ( Luxacore re- inforced with zikonium particles ) of DMG - Germany in which I swear for many years. (they have a branch in USA, too ) My 2 cents. - Valeri The best thing about prime and bond or XP-bond from Dentsply they also have a activator so it’s chemically also ! Very nice down in the canl. The luxacore Z is promoted to be used as the cement but also as the buildupcorecomposite, it saves another step. - Sparrgaren Here are a couple of references that echo that thought: 1) Publication: Quintessence International February 2008 Volume 39 , Issue 2 Biomechanical considerations for the restoration of endodontically treated teeth: A systematic review of the literature, Part II (Evaluation of fatigue behavior, interfaces, and in vivo studies) Didier Dietschi, DMD, PhD, PD/Olivier Duc, DMD/Ivo Krejci, DMD, PhD/Avishai Sadan, DMD 2) CARDP Journal (Canadian Journal of restorative Dentistry and Prosthodontics May 2009 , Santos et al "Shear Bond Strength of Dual Resin Cement Bonded to Dentin with Simplified and Conventional Adhesive systems." Both these articles suggest total etch with 2 or 3 step adhesives as producing much higher shear bond strengths to dentin. - Brian Henry I am sure you mean Self-adhesive resin cements - Mzs While this class of cements is advertized as Self-Adhesive, as with all cements I would assume it adheres to a substrate or why use it? Actually, it’s the property of the cement that results in etching the surface to which it is applied that makes it unique. For instance, refer to the link below that describes Pentron’s version called Breeze Self-Adhesive Cement wherein they describe how it works: This unique self-etch formulation incorporates new resin technology for enhanced bond strength with greater reliability Upon application, Breeze Cement quickly goes to work to condition dentin, enamel, and the restoration all in one quick and simple step. By eliminating the etching, priming and bonding steps, both postoperative sensitivity and procedure time are drastically reduced, improving peace of mind and freeing up precious chair time. The problem is if you use it as it’s dispensed, your values are far lower than if you supplement the bonding of the cement to dentine by first applying a separate bonding agent. As I said earlier, and I repeat this comes from John Kanca, though I haven’t seen him publish it as yet, the bonding values go way up! He promotes his own bonding agents Simplicity and Surpass in this technique, but most bonding agents would help over using the cement without any - Henry C. Levant Sorry, Here’s the link from which I just quoted: http://www.synca.com/english/breeze_e.html - Henry C. Levant Here’s the link to Kerr’s version Maxcem Elite Self-Etch, Self-Adhesive Resin Cement http://www.dentalcompare.com/review.asp?rid=295 This is why I referred to this classification of dental cements as Self-Etching - Henry C. Levant Thank you henry for reply. The point is the unicem rely x is self-adhesive and dose not need etching, yes there are sysytem which are self-etching In regard to bond strength yes these system yield more bond strength when you etch dentin even if its inside the root canal But the question remain unanswered regard if you really have any significance regarding that bond strength inside the canal if you have a strong bonding in the core portion and an enough ferrule effect to resist occ. Force to the crown So that bond strength inside the canal will have little effect on the final restoration If somebody what a literatures you can download restoration of endodntically treated teeth file from Rob page Also an excellent book recently released by marino ferdiani - Mzs THANKS ALL FOR YOUR MAILS, THEY ARE TRULY APPRECIATED. FINALLY REFERRING DENTIST DIDN´T ALLOWED ME TO RESTORE THE TOOTH. THIS IS TYPICAL IN SPAIN IF YOU HAVE A PRACTICE LIMITED TO ENDODONTICS. I HAVE JUST FINISHED ENDO RIGHT NOW. FINALLY A GUTTAPERCHA/AHPLUS OBTURATION FOR THE APICAL THIRD, I MANAGED TO FIT A GUTTA CONE (GAUGE #60) MODIFIED SECTIONAL OBTURATION WITH SYSTEM B IN ORDER TO AVOID GUTTAPERCHA OR CEMENT IN THE RESORPTION DEFECT AND THEN CAREFULL BACKFILL WITH EXTRUDER JUST APICAL TO THE RESORPTION DEFFECT. GP WANTS OPTION B FOR THE FIBER POST (POST JUST AS BIG AS -POSSIBLE- RESORBTION DEFECT) - Javier

Hi Javier Can You Describe modified sectional obturation.- imran So, resuming, the best product to restore with a fiber post would be luxacore with a 3 step bonding system like all bond2, rigth? I know tha marga uses luxacore with kuraray´s bonding system (don´t remember the name). I use paracore with all-bond 2 and parapost...Nuno Vasques Javier, Please, don't tell me that you accept this without any attempt to inform the RD that "it is in the best interest of the patient that the person who finishes the endo should take care of the post placement and build-up as well"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! In particular in a case with complicated anatomy as you have showed us!! This is from our chapter in Dental Clinics of North America that was published recently. I tried to attach the full article, but for some reasons it hasn't come through. If you are interested, please let me know, and I'll post it to your private email address. Advantages of immediate post placement The literature on the timing of the post-space preparation is inconclusive. Some studies showed less leakage after immediate post space preparation, whereas other papers showed no differenc. Some in vitro studies showed that delayed cementation of a fiber post resulted in higher retentive strengths. SEM examination revealed a more conspicuous presence of sealer remnants on the walls of immediately prepared post spaces. Remnants of sealer and gutta-percha may impair adhesive bonding and resin cementation of fiber posts. Therefore, it is important to clean the root canal walls before conditioning the dentin for post placement. Acid-etching of the prepared post space and EDTA irrigation combined with ultrasonics are reported to be an effective method. The use of magnification can highly facilitate inspection of the post space on cleanliness. Immediate preparation for post placement following obturation has a number of advantages. The operator has a great familiarity with the root canal morphology, working lengths and reference points of the root canal system. In addition, placement of a temporary post and restoration can be avoided, as maintaining the temporary seal can be difficult. In vitro studies by Fox & Gutteridge and Demarchi & Sato showed that teeth restored with temporary posts leaked extensively. YOU can make a difference. Inform, educate and spread the word, tell your RD's that is will make a difference if you are going to place the post. Let them know that you are knowledgeable, and most of all, that it is in the best interest of the patient! Good luck! - Marga and that the core is being placed under rubber dam - Cecil Bergman I couldn't agree more, for every adhesive procedure, the use of a rubber dam is essential - Marga

Protaper flaring

6 yr old Empress

Cvek pulpotomy

Middle mesial

Endo misdiagnosis

MTA retrofill

Resin core

BW importance

Bicuspid tooth

Necrotic #8 treatment

Finding MB2 / MB3

Deep in a canal

Broken file retrieval

Molar cases

Pushed over apex

MB2 and palatal canal

Long lower third

Veneer cases

CT Implant surgury

Weird Anatomy

Apical trifurcation

Canal and Ultrasonics

Cotton stuffed chamber

Pulp floor sandblasting

Silver point removal

Difficult acute curve

Marked swelling

5 canaled premolar

Sealer overextension

Complex anatomy

Secondary caries

Zygomatic arch

Confluent mesials

LL 1st molar (#19)

Shaping vs Cleaning

First bicuspid

In Vivo mesial view

Inaccesible canals

Premolar 45

Ortho and implant

Radioluscency

Lateral incisor

Obturation

Churning irrigant

Cold lateral

Tipped to lingual

Acute pulpitis images

Middle distal canal

Silver point

Crown preparation

Epiphany healing

Weird anatomy

Dual Xenon

Looking for MB2

Upper molar resorption

Acute apical abcess

Finding MB2

Gingival inflammation

Irreversible pulpitis

AG BU ortho band

TF Files

using TF files

Broken bur

Warm technique

Restorative prognosis

Tooth # 20 and #30

Apical third

3 canal premolar

Severe curvature

Interesting anatomy

Chamber floor

Zirconia crown

Dycal matrix

Cracked tooth

Tooth structure loss

Multiplanar curves