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Failed treatment on a dens in dente- Courtesy ROOTS
From: Marga Ree
To: ROOTS
Sent: Tuesday, January 10, 2006 7:01 PM
Subject: [roots] Failed treatment on a dens in dente

This 14 your old patient was referred because the endodontic treatment performed by his dentist was not successful, with a persistent apical periodontitis as a consequence. After a look at the rad I thought, hmmmm, I probably can do this better.................,and I retreated this tooth about 2,5 years ago, apical closure with MTA, gutta-percha and PCS, adhesive composite restoration. But, I was wrong :-(, I didn't do a better job, after 1 year there was still a persistent apical periodontitis, and even after 2 years the radiolucency remained the same, these cases make you very humble........................ I decided to do surgery, and found a bizar anatomy in the apical part after the apicoectomy, with quite some untreated canal space, I did a retrofill with MTA, and there was also a perforation at the buccal side which I closed with MTA.

The patient didn't want to come for a follow-up because of the travelling distance, but today I received a rad from the referring doc (last rad) No signs of healing whatsoever 1,5 year post surgery, and the patient complained about a recent, painful swelling. Would anyone try to do something else? Intentional replantation? He is 18 years old now, and I think an implant is the way to go. What went wrong? - Marga

-------------------------------------------------------------------------------------------
Marga,

Is there the possibility of a communication between the area of apectomy and the oral cavity?( See your fig 3) Is there any probing depth on the labial side? ( Maybe the referring collegue knows) - Jörg

Hi Jörg, No probing depths of any significance. In retrospect, I should have used an adhesive retrofill, and should have tried to obtain a better seal on this complicated root canal system.- Marga

Why do you say that? Yes, you may have gotten a better seal, certainly mta leaks, but even so I haven’t seen anything in the literature perform better clinically. I’m curious as to why you would want an adhesive retrofill, knowing as we do that a dentin bond, and afterall that is what you are establishing in a retrograde, is, in the words of Dave Garber at amed, “temporary at best.” - Gary

Gary, I an very familiar with MTA, and used it many, many cases, but after retreating some of my own surgeries performed with MTA retrofills, I have experienced that these retrofills can also leak, in 2 cases it even had not set, I could very easily penetrate the MTA with a file.

In this dens in dente, there was a large root opening, so the amount of cavosurface that had to be sealed was BIG. Of course I am not sure if another retrofill material would have given a better treatment outcome, but next time I would probably do a dome shaped adhesive retrofill on this type of tooth, to seal the whole cavosurface after root resection - Marga

Gary, I wonder if "temporary at best" refers to coronal bonding where thermocycling has a significant impact? Did he make any attempt to qualify the comment or was it just a blanket statement? - Randy Hedrick

He wasn’t referring specifically to endo bonding, but there is a good deal in the literature regarding the relative weakness of bond strength to dentin as compared to enamel and ceramic, and the continued weakening of that bond over time. And a year or two ago we had quite a discussion, which I don’t have on this laptop but which I will try to repost for the benefit of newer members, after one of our guest lecturers presentations, about the duration of the bond with our resin based fillers. (ask terry, he’ll tell you J). No question in my mind the jury is still out here. I teach in restorative that the best dentin retention is called a ¼ round bur!- Gary

What comes to mind is a presence of a groove i thin on the mesio palatalside that provides champange to the bugs to grow- Gurpreet Singh

In the realm of adhesive retrofills........do most ROOTERS still use Optibond or are they using UPI materials the names of which escape me or other materials...........if you would kind enough to list and elaborate in regard to the technique used for finishing et ..........whomever responds...........kendo
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