The Endo Fix

Category: Tips, Tricks, and Hacks

Decompression of a Dens in Dente Central Incisor

Large Lesion, Tips, Tricks, and Hacks

This was was an interesting tooth. It had a large talon on the palatal leading to a c shaped dens in dente or tooth within a tooth. There was a very large apical finding. Symptoms didn’t resolve after the first round of calcium hydroxide. So we added a decompression. The main goal of a decompression is to shrink the “lesion” and decrease the likelihood of collateral damage. In this case, surgery would have almost certainly devitalized the adjacent lateral incisor.

Decompression or true marsupialization works on the theory that creating a drain makes the epithelium creep inward along the bone pushing the cyst or granuloma outwardly. Otherwise it works by traumatically disrupting things allowing for subsequent healing. Marsupialization is a pretty slow process. We created a flange on a piece of surgical tubing, then sutured into place. The patient had instructions to irrigate a couple times a day with chlorhexidine. In this case we kept it in for over 3 months. This was a longer term calcium hydroxide case. We root-filled at about a year. Complete radiographic clearing was realized over time.

Decoronation of an Ankylosed Tooth

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Decisions…decisions. A very young looking 10 year old girl presented after an avulsion of tooth number 9 with a very short extra-oral dry time, immediately replanted and subsequently splinted. The decision of whether to initiate endo on the central is dictated by the time out of the mouth and the development of the tooth. I made the call that the apex looked wide open and the tooth hadn’t completely developed. So we decided to wait and see if the tooth would revascularize. My first follow-up time of trauma is typically 3 weeks. I saw her inside of 4 and resorption was already full on; progressive and aggressive. Classification wise this would be external axial resorption. We initiated endo immediately, but the damage was done. Additionally, the concussed lateral wasn’t responding to cold, so we started endo on that one as well.

We kept the tooth in medication for 5 months changing it out monthly. Over that period of time there was ankylotic tone and no mobility under the scope using 2 mirror handles to evaluate. Ugh. We placed Vitapex in the canal which lasts longer than many other CaOH preparations, and restored. Over time, washing out of the medication could be observed; a common finding in a resorbing root. We waited until we measured 3mm infra-occlusion and set her up for a flapless decoronation like my buddy Buck came up with circa 2008.

If you can, preserve the pulp. If you can’t; save the root and tooth. If you can’t do that, at least save the bone. That’s where decoronation comes in.

We clamped the other central and split dam to the distal of the lateral and used a rubber dam triangle to wedge the dam distally. Then we cut the crown off using a an 014 tapered diamond. Then a surgical length 556 on end, we cut the tooth flat to 1-2mm below the bone. It’s critical to remove all the enamel as it won’t resorb. We observed granulomatous soft tissue extending from the canal space. A good clot was evident before dismissing the patient.

Hindsight being 20/20 I woulda medicated the tooth at a week. Similar patient representing the same way? That’s tougher. I’m thinking if the tooth looks most of the way developed, regardless of the apex developement, I might jump in. It’s a tough call.

System S

Tips, Tricks, and Hacks

When your filling with rubber you got options. Carrier based, cones, and System S, otherwise knows as the Squirt.

I first learned of the Squirt from Joey Dovgan in 2008 whilst at Einstein and while I didn’t consistently squirt until a few years ago, there would be some cases that I would employ the method when I felt appropriate. That changed some when I introduced “enhanced irrigation” aka the laser in my case to our practice. Like Joey said back in the day, the most important part of filling is actually the instrumentation. However, I would submit that neither deep shape nor continuous taper are necessary to get consistent fills. But, the capture zone in the apical 1/3; that is pretty important.

Regardless of your system with system S, your going to have to live with some variability. That’s the rub. It’s easier, faster, displays some cool anatomy, but sometimes its a bit on the splashy side. And that’s not for everyone. And finally, you gotta be careful in the posterior mandible when the apices of lower teeth approximate the mandibular canal. The CBCT is your guide in such cases in it’s ability to determine anatomical positioning.

But the typical case is often amenable to System S. Instrumentation wise, system S works well with Rootform Appropriate Instrumentation. Typically the main difference with instrumentation is that I will typically take rotary instruments 1 full mm from the 00 on the EAL as opposed to .5mm when I cone-fill. During the course of treatment the laser is employed and final series of enhanced irrigation performed (3 min of sweeps with Hypo and EDTA). Patency is confirmed with a 15K file before the final series. A final rinse with alcohol makes for expedient drying of the tooth. Medium paper points are used and should not sail long. If they do, then consider an alternate filling technique. Generally speaking I would move to a cone. And if a 40.06 cone goes long, I’m considering MTA. When the cones are dry, AH+ sealer is applied to a medium paper point and used to coat 1-2 canals. More canals require another coated paper point. Then one or two dry paper points per canal to remove the excess. If your fills are two splashy, dry more.

The OG’s of squirt will tell you Schwed in an Obtura is the way to go. And that’s fine. I prefer the Calamus with the thinner gauge tip. They fit great into the instrumented canals. But like many things the old school Calamus are made with a better plastic and are more durable. Most times just placing the tip and allowing the machine to back you out of the canal results in a great fill. Not surprisingly, if you want to plunge the gp after application, Joey D’s niti pluggers are the best. Unfortunately, they are no longer made but perhaps you can find one on the after market.

In Type 2 canal systems, the gp can get hung up where the canals join and not proceed to the terminus. You got options though. Block one canal with one plugger, then plunge the other with another plugger (whilst moving the first to the mirror hand- yes your hand can hold two things). Or block one with a plugger and use the calamus to force-fill the other. Both work. I still take downpack films which are neither films nor the result of any downpacking, but usually I can’t wait to get my thrill of the fill, even after filling well over 10K teeth.

Custom Resin Matrix

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su
Suflolk Endodontist

Terminal teeth are tough to band and keep rubber dam isolation. So we came up with an alternative- the custom resin matrix. Using green opaldam we make a custom matrix to pack amalgam with or place a controlled field resin. Often we use the technique subgingivaly on bone. For first iterations we used white Opaldam but found it hard to discern on bone. The green is easier to see and thus remove. Waiting 5 minutes or so for the amalgam to harden makes the green matrix easier to remove

Dycal Help with Matrix

Daily Fix, Tips, Tricks, and Hacks

Suffolk Endodontist

The distal invagination of maxillary molars can create a bit of a challenge when adapting a matrix band. There are lots of matrix options, but if your normal armamentariam is a toffle-meyer and band, then an application of a little Dycal can help out. Just a dab applied with a perio probe to fill the space. Then smooth carbide to clean up the flash. This can be removed an interproximal carver at the time of amalgam carving or later with a scaler. Having this tip in the bag helps one practice Restoratively Driven Endodontics.

Root Tip Endo

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Consider these observations:

Chesapeake Endodontist
Suffolk Endodontist

These are but a few of the many documented cases of root tip endos that I’ve seen over the years in practice. The patients are all asymptomatic, albeit clearly not functional. We can see food, plaque, and caries sitting on the root filling. These roots have been infected for years. If we were to say that there was some sort of threshhold of bacteria that need to be removed to have a favorable endodontic outcome; these teeth would represent the maximum, most bacteria filled, most infected roots possible. And as such these teeth should have both clinical symptoms of pain and swelling as well as radiographic signs of endodontic pathosis. However, all of these patients are asymptomatic. And radiographic interpretation suggests they are typically free of apical findings. How could it be that the most infected roots have no radiographic findings? It must be something more than just the presence of bacteria or some degree of bacteria in the root of the tooth that defines endodontic pathosis.

Perhaps the lack of occlusion on these roots has something to do with it. If this is true, as the available evidence suggests, then occlusal function plays a role in “endodontic pathosis”. Such a supposition isn’t terribly surprising in that occlusal parafunction can lead to endodontic necrosis in the absence of caries. Furthermore, many of the signs and symptoms traditionally associated with infection related endodontic pathosis can be associated with occlusal parafunction even in the absence of infected roots or proximal caries. Thus, the myriad of endodontic conditions that present in clinical practice are not well explained by the apical periodontitis disease model and the relationship between radiographic findings and endodontic pathosis is not a direct one.

Considering Revascularization, Regendo

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Suffolk Endodontst

This was a regendo case, or at the time almost 10 years ago we revered to these cases as revascularization. This tooth belonged to a young Asian girl who had a dens invaginatus. We also had to do the contralateral tooth as both became necrotic. She presented very swollen as a result of this infected tooth. We placed a mix of antiobiotic paste in the tooth for two to three weeks. At the second appointment after rinsing out the antibiotic mix, we used a file long with a little EDTA. A collagen matrix was placed, so that it wicked blood above the CEJ. Grey MTA was placed as a barrier above the collagen, and then the tooth was restored with composite. Axial root development occurs although not much at the level of the CEJ. At the time there was hope that regenerative endodontics could continue root development leading to stronger teeth that could last longer.

Chesapeake Endodontist

The forces of anterior teeth are different than posterior teeth. As such, structural failures often result in “snap off” failures at or about the level of the CEJ. Axial dentin in this area or as Clark and Khademi define pericervical dentin (PCD), is the predominant structure that defends against this type of force and prevents snap off failures. My good friend and co-resident David Prusikowski won a prize for a revascularization poster where the management was applied to an anterior tooth. Unfortunately for the patient and the subject and poster, the tooth snapped off not long after the prize was awarded.  The mix of hard tissue is somewhat unpredictable, and while some root lengthening, or some apical development may occur, it is very rare to find cases where PCD was increased in any real way.

 

Hampton Roads Endodontist

This is an interesting case where I learned a few things. The patient presented with swelling and had a history of trauma. Given the development of the tooth we opted to try a regenerative approach to build some dentin strength and add for some longevity. At the time the patient requested her restorative dentist place the filling and we obliged. In this case we used calcium hydroxide instead of the bimix as the recommendations had changed. We still used collagen and MTA though. The tooth was restored by her dentist. After 4 years we can see some apexification. However, no PCD acquisition was evident.

Suffolk Endodontist

The patient returned with symptoms of acute percussive pain on the tooth. I thought it odd as there was boney infiltrate throughout the canal. Regardless it was prominent and repeatable. Additionally, staining of the MTA was observed. So we decided on a revision. A significant void was noted over the MTA on re-entry. After the MTA was removed, bone was observed just below the level of the MTA, at the level of the CEJ. Calcium hydroxide was expressed into the canal amongst the bone infiltrate. Over several appointments, the bone was removed by devitalizing it with calcium hydroxide, ultrasonics, and small burs. The tooth was also bleached to remove the MTA staining.

Eventually we were ready to obturate, and grey MTA was placed apically.

 

 

We inverted a fiber post which we bonded in with a dual cure buildup material and placed a few accessory posts. We trimmed back the posts and provided a “Clark cala lilly preparation” which creates long bevels in enamel before restoring with composite.

So, in considering the number of these types of cases that I’ve done over the years as well as how anterior teeth most often fail, I think taking the benefit of fiber post reinforcement is often preferable to revascularization as the regendo cases don’t predictably create PCD. There are a few cases types though, perhaps with really divergent apices where it may be the only choice. But by the time most of these teeth hit the mouth, they have enough development that tilt the decision in favor of fiber reinforcement.

 

 

Trauma, Resorption, and Decoronation

Resorption, Weekly Fix

Suffolk Endodontist

This little guy caught a fly ball… in the mouth. The lateral was laterally luxated. The central was avulsed and replanted with a dry time of 15 minutes. The lateral was repositioned and splinted. I saw them the day after the injury. We made sure he was on an antibiotic and anti-inflammatory and saw him back in a week to start endodontic therapy as the apex of these teeth were completely deveoloped and the risk of resorption high. After what we thought was a sufficient time in both CaOH and splint therapy, we completed the endodontic therapy and placed fiber posts.

Newport News Endodontist

Over the next few years we saw resorption develop. According to the Resorption Classification for Clinicians, this resorption would be considered External Crestal Resorption, moderate scooping. We removed the invasive tissue and restored the root using composite. A custom resin matrix was used for isolation.

Hampton Roads Endodontist

Over time, we could see that the central was subject to resorption as well; External Ankylotic Resorption. This was evident by the ankylotic tone when percussed. Radiographically, this was evident my the marked lack of periodontal ligament and lack of tooth root definition. Clinically, this was evident by the infraposition of the clinical crown relative to the other central.

Root Canal Expert

In treatment planning the case, the orthodontist thought some initial leveling and aligning using the ankylosed tooth would be helpful before decoronation. After this was accomplished, the fiber post and root filling was removed and the crown was decoronated using the flapless decoronation approach as outlined by Jared Buck in Best Practices: A Desk Reference

Chesapeake Endodontist

A pontic was added to the orthodontic therapy.

Harbor View Endodontist

We can see over time that bone developed over the tooth root and the the root is turned over in osseous regeneration. The alveolar ridge is preserved for future restorative replacement.

Hampton Roads Endodontist

Here’s the 5 year followup.

Crown Repair

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Chesapeake Endodontst

Hampton Roads Endodontist

Newport News Endodontist

Newport News Endodontst

Suffolk Endodontist

 

A quality crown repair is important for successful patient centered outcomes. What’s desired is a quality core and an esthetic closure. There are options in achieving these goals, and presented here is just one process. I’ll outline the steps, materials, and rationale. This case was a retreatment from a restorative failure; the core was poorly adapted and the tooth was symptomatic. The patient was highly motivated to prevent this mode of failure on the retreatment. Amalgam as a core has a long track record and because of it’s handling characteristics works will in very conservative accesses where pulp horns have been intentionally preserved.

  1. Chamber Cleanup: After obturation, I like to clean up the obturation interface with a peezo with that little bump cut off. Just zip it off with a football bur.  A #2 works well if your final file is around a Protaper F1 (22.07). If more conservative instrumentation is used, I find the #1 works well. Then alcohol to clean up any remaining sealer, followed by etch. That’s my chamber cleanup protocol.
  2. Bonded Amalgam: At this point you gotta decide if your going to bond your amalgam. The available evidence suggests there are likely benefits, so I do it. Clearfill primer, air dry, then Clearfill bonding agent which is light cured. A second unset bonding agent is placed and the amalgam is condensed into this second top layer of uncured bonding agent. The dual cure nature of this bonding agent creates the bonded amalgam.
  3. Carving the Amalgam: I like a spoon for this. If you want you can get some mechanical retention by undercutting the casting a little. Hard to say if it makes a difference. But I do it on Zirconium crowns.
  4. HF Etch: At this point make sure you have a good bevel using a course football bur. Then hydrofluoric acid is used to etch the porcelaine, this minute feels like forever. Then my assistant suctions the acid and she rinses while I scrub the precipitate off. If you don’t scrub it, the bond won’t be as good. I just use a piece of sponge. Then dry the water off.
  5. Silane: You can use an additive to the Clearfill Primer or just the silane. The silane has a long track record. Newer isn’t always better. The silane needs to be air thinned.
  6. Bonding: Then I place the Clearfill bonding agent over the porcelaine and amalgam.
  7. Opaquer: I like the permaflow flowable composite. It has an opaquer shade that hides the silver really well.
  8. Composite: We use Filtek body- it works well with Clearfill products. My assistant expresses part of a carpule on a mixing pad, then scoops up the composite on the back of a spoon. We use the orange filter so the composite doesn’t set, and apply the first bank of composite. After it’s manipulated in place and cured, we add a couple more increments using an endo explorer or a spoon to shape the composite.
  9. Finish and polish: Usually we don’t need much adjustment. But it’s important to get the occlusion right. A fine football and a zirc polishing point helps on any adjusted parts of the crown.

That’s it! Pretty and predictable.

 

 

Deep Margin Management

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hampton roads endodontist

Suffolk Endodontist

 

Deep caries and the resulting deep margins can be a restorative problem especially when the patient has a history of interproximal caries or a “high caries hostility index”. Generally speaking it’s better to have a crown that fits and fits on a meticulously placed deep restoration than a crown that doesn’t fit. And when the margin is very deep, then that is when a poorly prepared and poorly captured margin is most likely. An alternative is DME or deep margin elevation. Dentists have unintentionally placed margins on amalgam for decades with success. It’s likely that the outcomes will be even more favorable when done intentionally under controlled circumstances, under magnification and with no overhangs. Attached is a 7 year outcome with the crown placed on amalgam. Also attached are two very long term outcomes. When placing margins on restorative material, it is probably best to choose amalgam over composite as it does not rely on bonding which is poor under such conditions. It’s also advisable to evaluate the emergence profile of the tooth, it’s contact with adjacent teeth, and potential plunger cusps that led to the problem to begin with. Managing these variable can prevent food impaction and decrease the probability of failure to recurrent caries.