From: Sashi Nallapati
To: ROOTS
Sent: Sunday, August 27, 2006
Subject: Re: [roots] one more dens bites dust

Here is a interesting tooth I treated  yesterday.

Having been involved with the successful management of 3 cases of this nature, I am acutely aware of the complex anatomy of these teeth
and the difficulty in achieving predictable success with NSRCT alone (read: in my hands)
I decided to do a Non Surgical RCT and Surgical RCT at the same appointment.

1. Caries control. Buildup of the tooth

2. NSRCT : Access, Clean the dens tract that communicated from the incisal to the apical 'pouch' (in the cartoon i drew look at the black
   line.) If possible try to clean the remnants of the main canal (interrupted green line) but not waste too much an effort if it is not possible.

3. Raise a flap , curettage (Lesions of this nature can be through and through..as in this case, so be mindful of placing a finger on the
   palatal side to feel the curettage.root end  resection.

4. The most important aspect in this treatment is the thorough toiletry of the apical pouch. with a prebent 27G needle i irigated the pouch
   with copious amounts of chlorhexidine.Then i used a custombent ball ended US tip to further clean the irregularities of the walls and the
   floor of the pouch. Then i irrigated the dens tract through the incisal access to flush 'through and through' , you can see the black schmutz
   ( blue arrow) that came out through the canal into the crypt.

5. The most challenging aspect of this case is the dens retrofilling of the defect which can be very deep. I decided to use a syringable dual cure
   resin that i can place though a needle tip into the defect because of the depth and complex wall and foor anatomy.the problem  ofcourse is you
   need a dual cure resin that has enough setting time to allow teasing it into the complexities. I used Permaflo DC which has rapid setting and
   before i could manipulate it well, it set on me. hence that heart-breaking void in the buccal aspect of the apical pouch (WHERE THE GREEN LINE
   OPENS IN THE CARTOON). (I was seriously tempted to remove the resin and do it agian, but felt that was  inappropriate). it isnt a perfect
   retrofill despite me being prepared for this challenge.eats me away... oh well.... Since the lesion is thorugh and through i placed some caso4
   for the good measure..i dont know if it prevents a scar or not...

6. verify the apical fill, close the flap, place the dam back and dry the dens tract, sealer, and guttapercha- squirt. seal the access.

7: I am going to sit back and watch it heal :-)) . Dont worry you will get to see the recalls... Sashi Nallapati






That is truly inspiring sashi. what about the other 3 similiar cases you mentioned? Did you try to treat any of those cases non surgically?
I recall Alex Moule from Australia ( I don't know if he is on Roots) show a few similiar cases couple of years ago. He gained access through the dens,
used ultrasonics to clean, induced apexification by calcium hydroxide and then filled it once the barrier formed. Thanks for sharing Sashi, - Siju

Hi siju, there is more one way to manage these cases. The more favorable the apical form is (read conical, smaller pouch, and bigger access to the pouch
orthograde) the better chance we have in getting healing nonsurgically alone. A lot of time the pulp gets pushed laterally and contained within numerous
little dentin lined tracts its almost impossible to clean the system out. the best bet we have is either induce a apical closure with long term
apexification or immediate surgical closure. Remember, endodontics is a clincial speciality that deals with patients...not lab forms. depending on
where you live and where you practice, what type of patient pool you are working on, what dental IQ they have and finally the financial commitment
from both the patient's end and the doctor's end will eventually paly a significant part in taking the appropriate tx plan.
the first ever case that i treated like this (2002) after a couple of months caoh i obturated ( i was naive) and a surgery had to be done subsequently.
the second was treated exactly the way this case was treated.  that case was published in the JOE (oct2004)

the third was treated, and surgerised by colleagues and yet didnt respond. I did an intentional replant and that fixed the problem.
all cases have recalls that showed complete healing so far...
people also had succcess in removing the entire dens part nonsurgically with ultrasonics (Girsch,mcclammy JOE). But to me it was hollowing the root
significantly. At the end of the day, there is more than one way to skin a cat and this is my way ;-)) - Sashi Nallapati

Bravo....terrific handling of very difficult case. - Fred
Very cool case Sashi, beautifully handled, as usual. Looking at your approach,
I was wondering if it would have been possible to access the apical pouch by removing some additional tooth structure with NSRCT. I don't say you
could have avoided a surgery, but I was thinking of filling the apical pouch with MTA with NSRCT, and then take out the knife and proceed
the way you did.  - Marga



Marga, yes. it would be possible. it would ensure more predictable(esthetic) root end filling by eliminating the deeper defect.
but ofcourse it would mean removing more root structure, spending a lot more time in trying to pick at the different dentin tracts that may or may
not be feeding the pouch.  Remember the apical pouch is not a single hollowed area. it has different elevations and depressions with the enamel
tract projecting into it. there is septum in the floor that divided the buccal pouch to the lingual pouch where the dens emerged. Also to try and
fill this defect through orthograde will be to try and clean a room through a keyhole. The dens tract is lined with enamel so only a handpiece
with diamond will get rid of it quickly and effectively.by removing the dens tract you can gain more access through orthograde,
at the expense of weakening the root, acually its possible now! i can reenter orthograde right now, use some diamonds or munce burs and drill to the
pouch and pack againt the void ... I am tempted , but i dont think its appropriate..thanks for the dialogue.. - Sashi

Sashi, Thanks for your comments. I understand your approach here, and removing the dens with burs has a down side, namely sacrifying additional tooth
structure. I asked this question for a specific reason, because I have also treated some of these anomalies. I recently retreated a case, on which
I did the initial treatment myself, followed by a surgery, also done by myself. I didn't use composite, but MTA as a retrofil.  It failed. Nowadays,
I would probably use composite. I decided to do a third attempt, and removed the whole dens with burs, packed Ca(OH)2 for a period of 3 months,
and filled the tooth again after having seen radiographic signs of healing. I keep my fingers crossed. These cases are very challenging. - Marga
clap. clap, clap.
I add to other accolades about your case that your photography of the surgical crypt is outstanding.
Sashi:
Why didn't you use CaSO4 from the beginning to line the crypt?
No one seems to using it for crypt control much these days...why? is it too hard to manipulate or carve back? takes too much time?

Also did you use any NaOCL in this case or just CHX?
I was just wondering once you have the apex plugged, to go back in and do a Lussi experiment.
or am I just going crazy with this summer heat?...))  - Ahmad

Ahmad, you know the photography was less than perfect with the halogen light source , but thanks for making me feel good anyway ;-)
good questions..
you know, a lot of what we do clinically depends on how you are trained.i learnt the caso4 trick for hemostasis from gary carr back in 2001 and did
most of the cases back then that way. I didnt have racelets and thought ferric sulfate (cuttrol) made a huge mess. so naturally i used caso4 on
every case. At school i used a lot of racelets and had good results with it. So i used them in this case. its just 'fresh in the mind' thing...
Once the curettage was over, i realised the lesion is through and through, but i had excelllent crypt control with epi soaked pellets. CaSo4 in
guided bone regeneration  to prevent epithelial migration and subsequent long junctional epithelial attachment has been talked  (ricci and sottosanti)
but not convincingly proven. so, i placed caso4 as a matter of fact in the crypt at the very end, thinking i got nothing to lose...
Only chlorhexidine was used to irrigate because hypo could be very caustic to apical tissues if spilled and also dangerous to the patient if swallowed
(it was open coronally, remember) the lussi experiment needs ofcourse the pulp sucker machine for one. and a canalspace that leads to the apical third,
....Sashi Nallapati

Ahmad, epi pellets work usually fine. Nothing specific with through and through lesions except have to be careful not to be aggressive in curetting the
palatal flap and tearing it. Its a school of thought to do  GTR with a membrane in these cases.. i normally give Lido with 1:50000 epi for anesthesia and
hemostasis. 2-3 carps.. - Sashi Nallapati


Sashi, The photos are still good...they are focused, your mirror is clean and angled just right to show the apex, etc....
I can understand why you would be partial to Racelet since it is easy and not messy, yet it takes less time too. But I am worried about those bleeders
that can start in the middle of surgery...Is that a concern or is easily controlled with the epi pellets? also if the lesion was thru and thru...
what would you do differently?
what is the routine % and cartridges of anesthesia protocol for the surgical cases?

The lussi remark was not so much to suck the pulp out , but to forcefully flush out the remaining canal space with hypo once the apex was closed.
- Ahmad

Thanks gary, I have had the previlege of learning from some of the best in endodontics.the result though,could have been improved.. Its all a
learning process and the better we get at understanding the anatomy of these teeth, which can be very diverse, the more efficacious and efficient
(in that order) our treatment would be. - Sashi Nallapati 

Hi sahi, perfect diagnosis, perfect decision ,  perfect flap design, perfect crypt management, but why the hell you are doing a resin retrofill???
There must be a huge problem do fill it with MTA, so I will use in these cases of super eba cement. its in my eyes the second best. another material
if you would like to use resin is retroplast, but I have not a good feeling to bring it down .  I will sit and watch with you..  Holger Dennhardt

Holger, whats wrong with resin as retrofill? i have had fair amount of success with resin retrofills..Sashi Nallapati

Hi sashi,  the only man in the world who can show periodontic healing with resin products is nick dragoo.  and nobody could repeat it. J there are
so beautiful materials for retrofilling, I guess resin sealer is the worse to use it. but I must say your handling is perfect as usual.
- Holger Dennhardt

Holger, every case is different and sometimes the anatomical complexity of the retroprep/retrocavity warrants using suitable materials that would
fill the defect. periodontal reattachment from a periodontics standpoint is a defferent outcome from endodontic healing. my job is to create an
environment to promote healing of the periradicualr tissues.thorough debridement of the retrocavity and good obturation is what promotes it. there
are papers showing  cemental apposition against resins like retroplast. i have shown  case of mine with perfect healing and pdl
regeneration ( rad outline of pdl space) around the root in the dens type3B condition. I don't think the choice of retrofill material is as critical
as the proper execution of the surgical therapy in the outcome of cases like these. - Sashi Nallapati