Internal radicular resorption - Courtesy ROOTS
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From: Javier Pascual
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
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?
a) Long and narrow, deeper than the resorption deffect to have
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
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
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
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).
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
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
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
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
- 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 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, 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).
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:
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
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
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
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
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
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!
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