Clinical Clues for Identifying Cracked/Fracture Roots

Accurate diagnosis of a cracked/fractured root is a difficult task. It is important to get it right, because the treatment for a cracked root is usually extraction. I explain to patients that there are some clinical signs that would indicate a cracked root, but they are not 100% conclusive all the time. These same clinical signs can occur in other situations as well.

The typical signs associated with a cracked/fracture root that we have previously reported:

1. J-shaped lesion or large lateral lesion

2. Deep, narrow periodontal pocket

A couple new clinical signs that I have not previously reported include:

3. Swelling in the in the marginal gingival, adjacent to the fracture

4. Failure of a swelling to resolve despite a course of antibiotics

The more of these clinical signs I see in one patient, the more confident I am that the root is cracked/fractured.

I explain to patients that the only way to know with certainty is to visualize the crack. This is most effectively done with magnification. This can either be done through an endodontic access, or through a small periodontal flap to examine the root surface. I expect that with time, CBCT will be better able to help us in the diagnosis of cracked/fractured roots. At this time, the CBCT does not appear pick up on a cracked/fractured root until the pieces of the root begin to separate.

Here is an example of a case in which several of the described clinical signs were present indicating a cracked/fractured root. Access and visualization confirmed the diagnosis of cracked root.

Pt presents with a swelling in the marginal gingiva adjacent to distal root of #19. The radiograph shows a large, lateral lesion on mesial of distal root. Patient had been taking Penicillin for several days, without resolution of the swelling. Antibiotic was changed to clindamycin to see if swelling would resolve.

Swelling did not resolve after taking clindamycin.

At this point, I am quite certain I will find a cracked root. If this were simply a perio issue or an endo issue, I would have expected it to clear up with the antibiotics.

Access into pulp chamber exposes a vertical crack/fracture on the MB root as well as the DB root.

The tooth is deemed non-restorable and extraction recommended.

If you are unsure if a tooth has a cracked/fractured root, contact your endodontist. Not all teeth can be saved, but endodontists are the specialists for saving teeth and can help you determine which ones to save.

Upgrading your Root Canal

This root canal was originally done in 1965. A periapical lesion has developed. While the root canal filling is weak and the apical seal obviously an issue, the tooth is and has been fully functional.

Removal of previous gutta percha show obvious corrosion and leakage.

It is likely that the tooth had an apicoectomy, due to the short length of the root and open apex.
The open apex is debrided and a new apical stop is created.

The canal is then obturated with MTA. MTA is chosen as the obturation material due to the open apex and the ease of future apical surgery if needed. I call this a "root canal upgrade". Preserving this tooth preserves the periapical tissues and helps to maintain the bone around the tooth. While there are lots of good replacements for missing teeth, nothing preserve the periapical architecture as well as a healthy tooth & periodontal ligament.

Pulpal Regeneration - More Case Reports

For more information on pulpal regeneration, click here.

Uses of Cone Beam in Endodontics

At a recent Inner Space Seminar, Dr. Dale A. Miles reviewed the principles of cone beam imaging and introduced a wide variety of applications for CBCT in dentistry. The following video clip describes how CBCT may be useful in the practice of endodontics.



More information about Dr. Miles and cone beam and digital imaging can be found at Dr. Miles' website: www.learndigital.net

Malpractice Claims in Endodontics

A recent study by Givol, Rosen, Taicher & Tsesis, published in the Journal of Endodontics, points out some interesting facts about malpractice claims in endodontics.

Endodontic claims are the most frequently filed malpractice claims in dentistry. It has been reported that there are twice as many endodontic malpractice claims than other specialty areas. Endodontic claims have been reported to be 14% - 17% of the total malpractice claims in dentistry.

The study by Givol et. al. was a review of malpractice claims made in Isreal between 1992 - 2008. Some interesting data comes from this review. Of the 720 complaints that were analyzed, 72% were considered "justified" and 27% were considered "unjustified" complaints.

Errrors found and analyzed were categorized as pre-operative, intra-operative or post-operative.

Most of the errors occurred in the intraoperative phase of treatment. These included access preparation, detection of canals, instrumentation or filling.

Swelling & pain as the only complaint were reported in 100 cases and none of them were considered "justified" complaints. Swelling and pain are considered a side effect of treatment and not a complication. Patients should be informed of this possible side effect during informed consent. It has been reported by Tsesis et. al. that pain and swelling can occur following endodontic treatment in 1.5% - 20% of cases. Helping patients understand this possible side effect can help prevent misunderstanding and hopefully prevent unnecessary malpractice claims.

The lack of adherence to strict treatment protocols resulting in poor quality treatment was a common cause of malpractice claims.

Endodontic treatment requires exceptional technical skill and strict adherence to accepted treatment protocols. Proper case selection and appropriate referral to a specialist can also prevent unnecessary complications.



SOURCES
Givol N, Rosen E, Taicher S, Tsesis I. Risk Management in Endodontics. J Endod 2010;36:982-984.

Tsesis I, Faivishevsky V, Fuss Z, Zukerman O. Flare-ups after endodontic treatment: A meta-analysis of literature. J Endod 2008;34:1177-81.

Why All the "Buzz"? Cone Beam Imaging

Dr. Dale A. Miles DDS, MS, a diplomate of the American Board of Oral and Maxillofacial Radiology will be presenting the upcoming Inner Space Seminar entitled, "Why All the "Buzz"? Cone Beam Imaging. At Superstition Springs Endodontics, we feel it is the role of specialists, not manufacturers, to educate the dental community. With all the new information regarding 3D imaging, and the barrage of marketing to go with it, we have invited a specialist in radiology to come and share his expertise and experience with cone beam imaging.

Regenerative Endodontics - Another Case Report

Regenerative endodontics is the application of tissue engineering concepts into the treatment of the pulp-dentin complex. We all know that the pulp has regenerative/healing properties. We routinely tell our patients that the restorative treatments that we do will cause inflammation/irritation to the pulp. Occasionally, we even encroach upon the pulpal space and then medicate the pulp in an effort promote pulpal healing and repair. The formation of reparative dentin is evidence of the pulp's ability to regenerate/repair dentinal tissues.


Regenerative endodontics is currently in its infancy. However, the possibilities are exciting and the research is ongoing. Regenerative dental therapies may one day lead to more effective vital pulp therapy, more effective treatment of immature teeth, traumatized teeth, and possibly the replace of missing teeth with bioengineered teeth.


Current clinical success in regenerative endodontics is seen in the treatment of necrotic, immature teeth with apical periodontitis.


The following case, treated at Superstition Spring Endodontics, has shown ideal pulpal regeneration allowing for the continued development of an immature root.

A necrotic tooth #29, with a large periapical lesion, and wide open apex is selected for regenerative endodontic therapy. The canal accessed and the pulp completely removed to the apex with minimal filing and copious NaOCl irrigation.

A coronal MTA plug is placed to prevent coronal leakage, while the apical portion of the tooth is left wide open for regeneration.

At 3 months, the large apical lesion has healed.

At 6 months, the apex is thickening and lengthening.

At 6 years, the canal has closed, root has lengthened, and the tooth is now responding to electric pulp testing.


This procedure has allowed this patient to retain a tooth that otherwise may have been lost.


The future of regenerative endodontics is bright and exciting.

Regenerative Endodontics - New Frontiers in Endodontics

Regenerative endodontics is an exciting new concept that seeks to apply the advances in tissue engineering to the regeneration of the pulp-dentin complex. Multiple case reports have shown the ability for previously necrotic, immature teeth to "regenerate" pulp-like tissue allowing for continued development of the tooth.

Traditionally, when an immature tooth became necrotic, root development was arrested and the endodontic goal was to create some kind of calcific barrier against which we could obturate. This is known as Ca(OH)2 apexification. The downside to this treatment was length of treatment time and weak, short, thin roots that remained.

More recently, MTA apexification has become more common. This consists of debridement of the immature root and immediate obturation with MTA. This shortened the treatment time, but the problem of short, thin roots still remained.

Multiple case reports, including cases at Superstition Springs Endodontics, have shown the ability to remove the necrotic tissue and stimulate regeneration of pulpal-like tissue into the canal. This allows for the continued growth of the immature root. The dentinal walls thicken, the length of root increases, periapical lesions heal and the open apex closes.

This is a completely new way of approaching apexification and provides a glimpse at exciting new horizons in endodontics and tissue engineering. I was recently asked by a colleague if I had interest in placing implants. I explained to him that while implants provide a valuable service to replace missing teeth, as an endodontist, I am dedicated to preserving the natural tooth. I am grateful to work with so many great implant surgeons, but I expect there will come a day when real teeth are replaced with real, bioengineered teeth.

Here is an example of pulpal regeneration performed at Superstition Springs Endodontics.

This young patient had tooth #8 avulsed. The tooth was stored in milk <1hr>

Tooth #8 was accessed, pulpal tissue removed with minimal filing and copious NaOCl irrigation.

Coronal MTA plug placed w/ cotton & resin access filling.

At 2 months, the periapical lesion is gone and tooth is asymptomatic.

At 4 year recall, the apex has closed, the dentinal walls of the root have thickened and the tooth is asymptomatic and functional.

The protocol for this procedure is still being developed. The American Association of Endodontists is building a database regenerative cases to aid in the development of this protocol.

The upcoming Inner Space Seminar entitled, "It's Alive! Pulpal Regeneration" will review concepts in stem cell therapy, current accepted treatment protocol for pulpal regeneration and additional case reports of pulpal regeneration.

Indications for Intentional Replantation

Intentional replantation is the intentional removal of a tooth and replantion into the socket following endodontic manipulation.

Success with this treatment is dependent upon atraumatic extraction, minimal manipulation of the periodontal ligament, rapid replacement into the socket, and minimizing occlusal forces following replantation.

While endodontic apical surgery (apicoecotomy) is the most common type of endodontic surgery performed, intentional replantation is an option when apical surgery is not indicated due to anatomical considerations. These may include: proximity to the mental foramen or mandibular canal, thickness of Md buccal bone along oblique line angle, and proximity to Mx sinuses.

I have found intention replantation useful in the following clinical situations:

Cases where endodontic surgery is not an option due to difficult anatomy...

1. Md 2nd Molars - access through buccal bone difficult
2. Md 1st & 2nd Bicuspids - closeness to the mental foramen
3. Mx 2nd Molars - access difficult & sinus complications likely

Cases where conventional retreatment has been unsuccessful or not likely to be successful

1. Cases with ledging and/or separated instruments
2. Retreatment has been attempted without success

Other factors to consider...

The root anatomy has to allow an atraumatic extraction to occur. Conical shaped roots are most ideal.

Intentional replantation provides a treatment option when tooth replacement with an implant or bridge is not feasible.

These patients have already had endodontic therapy, and crowns placed. Costs associated with this additional treatment are minimal compared to cost of tooth replacement.

The following cases demonstrate intentional replantation.

CASE #1

RCT was completed and patient continued to have apical pain. Extrusion of sealer was assumed to be the cause of the apical periodontitis. Close proximity to the mental foramen makes apical surgery contraindicated.

Following atraumatic extraction, the gross overextension of gutta percha is obvious. Apical resection and burnishing of gutta percha completed within minutes.

Tooth replanted and treatment completed.

CASE #2

Initial RCT completed.

Sinus tract persists.


Non-surgical retx completed and symptoms persist. Discussion with patient of options:
1. Extraction
2. Replantation
Pt understood options and selected intentional replantation.

Atraumatic extraction, immediate resection.

Replantation completed.

3 month recall. Tooth asymptomatic and completely functional.

Sources:
Pathways of Pulp, 9th edition - online version. p767-768.

Is That a Root Fracture?

Large J-shaped lesions are often associated with vertical root fractures. This tooth was asymptomatic to percussion, non responsive to thermal testing and surprisingly normal to probing. Diagnosis: necrotic pulp and asymptomatic apical periodontitis. It was was determined to be an endodontic problem.

The large radiolucency extends up the distal root into the furcation. Microscopic examination during endodontic therapy revealed no root fracture. In this case, the assumption of a root fracture, based on radiographs alone, would have been incorrect.

Without proper diagnosis, this tooth might easily be labeled a fractured root and extracted. A new crown is indicated to prevent coronal leakage.