Ikatan Konservasi Gigi Indonesia
TEMU ILMIAH NASIONAL IKORGI III (TINI III) Surabaya, 27 – 29 Nopember 2014
EDITOR: Prof.Dr.Latief Mooduto,drg.,SpKG(K).,MS Prof.Dr.Adioro Soetojo,drg.,SpKG(K).,MS M.Rulianto,drg.,SpKG(K).,MS Ari Subiyanto,drg.,SpKG(K)., M.Kes Karlina Samadi,drg.,SpKG(K).,MS Ketut Suardita,drg., SpKG.,Ph.D Dr. Ira Widjiastuti,drg.,SpKG(K).,M.Kes Cecilia G.J.Lunardhi,drg.,Sp.KG(K).,MS Febriastuti Cahyani,drg.,SpKG Eric Priyo Prasetyo,drg.,SpKG
Diterbitkan oleh:
IKATAN KONSERVASI GIGI INDONESIA
Kata Pengantar Perkembangan IPTEK bidang kesehatan gigi dalam beberapa dasawarsa terakhir ini sangat cepat akibat tuntutan masyarakat yang berkembang. Selain itu, masyarakat selalu menuntut untuk mendapatkan pelayanan kesehatan gigi yang sempurna. Seorang dokter gigi saat ini tidak bisa menghindar dari persaingan yang semakin ketat, oleh karena itu harus terus menerus meningkatkan profesionalismenya, salah satunya dengan terus menerus menambah informasi ilmiah terbaru. Informasi ini selalu diperlukan demi tercapainya profesionalisme dokter gigi yang handal yang siap bersaing di pasar bebas. Pada era globalisasi saat ini, akan membuat persaingan dunia usaha yang sangat ketat dengan kompetisi yang terbuka. Hal tersebut akan membuat pelanggan (pasien) dengan mudah membanding-bandingkan kualitas pelayanan antara dokter gigi satu dengan yang lain. Oleh karena itu, secara tidak langsung akan memaksa dokter gigi untuk mengembangkan model dan strategi pelayanan yang tepat dan bermutu. Untuk mengantisipasi hal tersebut, Ikatan Konservasi Gigi Indonesia terus berusaha untuk meningkatkan kualitas dokter gigi Indonesia khusus dalam bidang konservasi gigi dengan cara mengadakan seminar ilmiah secara berkala. Temu Ilmiah Nasional IKORGI (TINI III) ini diharapkan dapat digunakan sebagai sarana untuk alih teknologi ilmu kedokteran gigi mutakhir dalam upaya meningkatkan profesionalisme dokter gigi di era persaingan global. TINI III ini diharapkan dapat menambah pengetahuan dokter gigi sehingga dapat melahirkan dokter gigi dan dokter gigi spesialis konservasi gigi yang sukses dan mampu melayani masyarakat secara optimal serta diharapkan dapat digunakan untuk alih pengetahuan dan teknologi baik di bidang ilmu manajemen kesehatan maupun ilmu kedokteran gigi mutakhir. Selamat mengikuti seminar, sampai jumpa di Temu Ilmiah Nasional Ikatan Konservasi Gigi Indonesia III yang akan datang.
Surabaya, 27-29 Nopember 2014
Ari Subiyanto,drg.,SpKG(K).,MKes Ketua Panitia TINI III
CONTENTS Page 1.
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Evaluation of the Effect of Extruded Calcium Hydroxide-based Endodontic Sealer on Periapical Tissue: A Case Report Chenny Diana, Bernard O. Iskandar, and Wiena Widyastuti .................... Root canal treatment of c-shaped canal on second mandibular molar case report Sarah Kurniawan, Herry Sofiandi Halim and Elline ................................... Composite resin restoration in class iv cavity using crown former Sannia Pratiwi, Herry Sofiady Halim and Anastasia Elsa Prahasti ........... Endodontic treatment using reciprocating file (case report) Esther Esti Pangesti, Juanita A. Gunawan and Meini F. Amin .................. Esthetic rehabilitation of a post-traumatic tooth through a comprehensive approach : a clinical case Maria Yovita Lisanti, Juanita A. Gunawan and Anastasia Elsa Prahasti . Esthetic rehabilitation in endodontic failure case of maxillary left lateral tooth (case report) Ingrid Natasha, Yanti L. Siswadi and Eko Fibryanto .................................. Root canal treatment of right mandibular first premolar with anomaly type iv weine Hendriyanto Wijaya, Sri Subekti Winanto and Meiny Foda Amin Djamal .............................................................................................................. Clinical Management of Broken Files in 1/3 Apical Root Canal with Dental Operating Microscope: 3 Case Reports Arif Abdul Gani, Sri Subekti Winanto, Ade Prijanti, and Bernard O. Iskandar ........................................................................................................... Nonsurgical endodontic retreatment of a maxillary first molar with metal onlay restoration : a case report Lisa Pramitha Setiawan, Tien Suwartini, and Eko Fibryanto..................... Mineral trioxide aggregate effect to periapical lesion healing as an apical closure material at immature tooth: Case report Meryna, Bernard O.Iskandar, and Elline Richmond crown on four anterior teeth with 1/3 cervical fractures Nurhayaty Natsir, and Vero H Sanusi ........................................................... Endodontic treatment of internal root resorption using mta in incisor mandibular: a case report Juni Jekti Nugroho , and Nurul Wadudah AS .............................................. Obturation of an internal resorption root canal maxillary left central incisor Haslinda , and Nurhayaty Natsir .................................................................... Esthetic Rehabilitation of Post-Traumatic Anterior Maxillary Teeth With Fiber Reinforced Posts: A Case Report Erny Djuhais, and Juni Jekti Nugroho .......................................................... Treatment of internal resorption with mta : a case report Wahyuniwati, and Aries Chandra Trilaksana ............................................. Indirect veneer of first premolar mandibular with enamel hypoplasia : a case report Kurniawaty, and Juni Jekti Nugroho ............................................................ Direct veneer in maxillary incisor with enamel hypoplasia : a case report Hermiati Daharuddin, and Aries Chandra Trilaksana ..................................
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7-12 13-17 18-23
24-30
31-37
38-41
42-52
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59-64 65-68
69-73 74-78
79-83 84-88
89-92
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18. Root-end filing Technique with BioAggregate Yusri, and Christine A. Rovani ...................................................................... 19. Single Visit Endodontic in the Management of Symptomatic Irreversible Pulpitis and Pulp Necrosis with Apical Periodontitis: Report of Two Cases Cut Nurliza and Trimurni Abidin .................................................................. 20. The selection of final restoration for endodontically treated right mandibular first molar with mesial drifting of the second molar: a case report Teddy, and Trimurni Abidin .......................................................................... 21. Pathogenesis of periapical lesion and discoloration caused by Traumatic injury : case report Member Reni Purba, and Trimurni Abidin .................................................. 22. Management Of Mandibular Insicors With External Inflammatory Resorption And 2nd Degree Of Mobility Due To Traumatic Occlusion Used As Overdenture Abutments: A Case Report Martha Hasianna Purba and Trimurni Abidin ............................................ 23. Root Canal Treatment with Limitation of Radiographic Procedure: Two Case Reports Widi Prasetia and Trimurni Abidin .............................................................. 24. Endodontic treatment on mandibular first molar with radix entomolaris: a case report Kurniawan, and Endang Suprastiwi .............................................................. 25. Management Of Vertical Crack On Mandibular Molar (Case Report) Hirania Soraya and Nilakesuma Djauharie .................................................. 26. Crown lengthening for dowel crown restoration on maxillary premolar tooth with subgingival fracture Jennifer Fortiana and Dini Asrianti .............................................................. 27. Management Of Flare-Up On The Mandibular Right Second Premolars (Case Report) Nova Elvira and Kamizar ............................................................................... 28. Direct composite laminate veneer on maxilary anterior teeth due to discoloration post endodontic treatment and secondary caries: a case report Inez Hanida and Nilakesuma Djauharie Setyopurnomo .............................. 29. Type Iii Weine Configuration On Endodontically Treated Maxillary Second Premolar Putie Ambun Suri and Kamizar .................................................................... 30. Treatment Of Palatal Cusp Fracture On Maxillary Second Premolar (Case Report) Sylva Dinie Alinda and Gatot Sutrisno .......................................................... 31. The endodontic management of maxillary first molar with curved root canal (case report) Medwin Setia and Munyati Usman ................................................................ 32. Diastema closure by proximal build-up technique (case report) Dimas Mahardika Generosa and Gatot Sutrisno .......................................... 33. Root Canal Treatment of Mandibular Right First Molar with Endo-Perio Lesion (Case Report) Mazhar alamsyah and Endang Suprastiwi ................................................... 34. Management Of Root Canal Treatment And Restoration Of Anomaly Left Maxillary Central Incisor By Using Cold Flowable Filling System And Fiber Reinforced Direct Composite Desy Maulia and Taofik Hidayat ................................................................... 35. Indirect composite onlay using fiber reinforcement technique on second
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molar mandibula Fadli Azhari and Grace Virginia Gumuruh ** ............................................ Crown Fracture Management Of Maxillary Right Central Incisor With Prefabricated Direct Composite Veneer (Componeer): A Case Report Danica Anastasia and Irmaleny ...................................................................... Make Over The Teeth, Make Over The Performance By Componeer Irmaleny ............................................................................................................ The Treatment Perforation Bifurcation Using Mineral Trioxide Aggregate (MTA) In The Lower Left Molar Tooth Case Report Sulistianingsih and Milly Armillia .................................................................. Treatment Of Crown Fracture Of Maxillary Right Central Incisor With One Visit Endodontik And Direct Composite Restoration: A Case Report Triana Agustanti and Milly Armilia .............................................................. Management Of Curved Canal With Reciprocal Technique In Lower Right Third Molar Christy Maria Hermawan and Rahmi Alma Farah Adang ......................... Periapical curettage of overfilling of the root canal: A case report Margareta Rinastiti, Wignyo Hadriyanto and Diatri Nari Ratih ............... Hemisection for treatment of endo-perio lesion: a case report Mutiara Anindita, Adioro Soetojo and Ketut Suardita ............................... Complex Aesthetic Treatment for Fracture and Dental Trauma Anterior with Open Apex central incisor on Maxillary : a case report Nurul Puspita Sari, Karlina Samadi and Devi Eka Yuniarti ...................... Endodontic SurgicalTreatment of Posterior Teeth with Bifurcation Perforated : a case report Buyung Maglenda, Karlina Samadi and Devi Eka Yuniarti ....................... Non surgical endodontic treatment and internal bleaching on maxillary right central incisor with periapical lesion Irfan Dwiandhono, Agus Subiwahyudi and Mandojo Rukmo ..................... Management of Maxillary Left Incisor with Large Periapical Lesion and Tooth Discoloration : a case report Shintya D Halim, Moh.Rulianto and Febriastuti Cahyani .............................. Indirect porcelain veneer restoration for central diastema closure Hendra Christian Rusady, Tamara Yuanita and M. Mudjiono ................. Clinical Treatment of Hemisection Tooth with Mesioversion Position : a case report Sophian Abdurahman, Moh.Rulianto and Tamara Yuanita ...................... Aesthetic improvement of discolored anterior maxillary teeth: A case report Mochamad Farid Diantara, Ruslan Effendy and Laksmiari Setyowati .... Complex aesthetic treatment as a correction for maxillary protrussion and central diastema closure Putri Galuh Prawitasari, Ari Subiyanto and Setyabudi ..................................... Apexification in maxillary left incisor with mineral trioxide aggregate (MTA) Ahmad Riza Faruqi, Nanik Zubaidah and Febriastuti Cahyani ................ Single Visit Endodontic Treatment Using Reciprocal System with Thermoplastic Obturation Technic : a case report Srimelvina Riesky Murnidewi, Nirawati Pribadi and Achmad Sudirman Management of Peg Shaped Maxillary Lateral Incisor during orthodontic treatment by esthetical approach: a case report
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Camelia Ariesdyanata, Adioro Soetojo and Dian Agustin Wahjuningrum Splint-crown for post hemisection tooth Bagoes W. Pribadi, Cecilia G.J Lunardhi and Setyabudi ............................ Modulasi endogenous stem cells, STRO-1, CD44, CD105, CD146 pada jaringan ligamen periodontalgigi tikus wistar pasca trauma avulsi dengan paparan aloevera Yuli Nugraeni, Edi Widjajanto and Wibi Riawan ....................................... Root Apex Resection In Patient With periapical lesion and traumatic history (Case Report) Joshua Sutedjo, Sri Kunarti and Febriastuti Cahyani ................................. Internal bleaching of discolored tooth with calcific metamorphosis abnormality Rendhy Popyandra, Latief Mooduto and Eric Priyo Prasetyo .................... Management of traumatic immature teeth in maxillary incisor by aesthetic approach Yusuf Bagus Pamungkas, Dian Agustin Wahjuningrum and Laksmiari Setyowati........................................................................................................... Internal Bleaching Treatment For the Patient With Traumatic History a Case Report Irwan Lazuardi, Ira Widjiastuti and Eric Priyo Prasetyo ........................... Root canal retreatment challenge of abscess periapical in maxillary central incisors by aesthetic approach Aditya Syahputra, Dian Agustin Wahjuningrum and Ira Widjiastuti ...... Endodontic re-treatment on right maxillary incisive central tooth using reciproc system Oktari Paramita, Mandojo Rukmo and Edhie Arief Prasetyo .................. Aesthetic Odontoplasty With A Nanohybrid Composite Laksmiari Setyowati ....................................................................................... Componeer as a direct veneer restoration on maxillary anterior teeth Hanny Ilanda, Tien Suwartini and Wiena Widyastuti ................................. Treatment Of Toothwear Nevi Yanti and Trimurni Abidin .................................................................... The Difference In Root Canal Surface Smoothness At The Apical Third Between Instruments With Continuous Rotation And Reciprocating Movement Wahyuni Suci Dwiandhany, Munyati Usman and Endang Suprastiwi ...... MTA application in internal resorption case managementcase report Diana Soesilo and Fani Pangabdian ............................................................... Retreatment on inadequate root canal filling of lower left premolar using NiTi file rotary instrument Fairuza Afada, Ketut Suardita and Cecilia Gerda Juliani Lunardhi ......... Internal bleaching treatment in geriatric patient: review and case report Fani Pangabdian and Diana Soesilo ............................................................... Cytoxicity Test of Diadema Setosum Shell Extract Againts Fibroblast Culture Cell Novi Virina Irawati, Aprilia and Meinar Nur Ashrin .................................. The Inhibition of Rhizophora mucronata Bark Extract Against The Growth of Enterococcus faecalis Bacteria Muhammad Baraja, Twi Agnita Cevanti and Kristanti Parisihni ............. Repair Of Furcation Perforation With Mineral Trioxide Aggregate (MTA) Rista Eka Aprilianti Sugiono and Ratna Meidyawati ..................................
271-275 276-279
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72. Root canal retreatment of maxillary first molar (case report) Sonny and Ratna Meidyawati ......................................................................... 73. Consideration In Choosing Provisional Restoration In Endodontically Treated Maxillary Incisor With Periapical Lesion: A Case Report Susi and Trimurni Abidin .............................................................................. 74. Endodontic Retreatment Of Left Mandibular First Molar Using Retreatment Files: A Case Report Novelin Y. Ompusunggu and TrimurniAbidin ............................................. 75. Proper Selection of Local Anesthetic in Case of “Hot” Tooth Tri Widiarni and Trimurni Abidin ................................................................ 76. Resin bonding agents as inductor DAMP response in dentin pulp complex Widya Saraswati .............................................................................................
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Evaluation of the Effect of Extruded Calcium Hydroxide-based Endodontic Sealer on Periapical Tissue: A Case Report Chenny Diana1, Bernard O. Iskandar2, Wiena Widyastuti2 1 Resident of Conservative 2 Department of Conservative Faculty of Dentistry, Trisakti University Jakarta – Indonesia
Abstract Background: The most important objective of successful root canal treatment is thorough biomechanical preparation of root canal. Elimination of infected pulp and dentine, adequate root canal preparation and three dimensional obturation constitute the basic principle of root canal treatment. Ideally, the filling material along with sealer should be confined to the root canal without extending to periapical tissue or other neighboring structures. Endodontic filling material and sealer, beyond the apical foramen may give rise to clinical manifestations as a result of the toxicity of the product. Purpose: To evaluate few cases of apical extrusion of sealer during obturation and its effects on periapical tissue and the success of treatment.Cases: Case 1: A 43 year-old female had a symptomatic necrotic pulp on the left mandibular second premolar and 2nddegree of mobility. Case 2: A 28 year-old female reported with uncomfortable in left maxillary central incisor. Retreatment was than planned. Case 3: A 34 year-old female patient did report pain in the anterior mandibular region. Case management:All of the cases were instrumented with rotary ProTaper file to apical, confirmed with electronic apex locator and radiograph. Apical patency was maintained throughout instrumentation using a # 8 K-file. Sealapex (calcium hydroxide-based) was used as a sealer. Conclusion:After regular follow up these cases appeared clinically normal and radiographic improvement, indicating that the sealer was well tolerated the periapical tissue. Key Words: sealer, calcium hydroxide, obturation, extruded
INTRODUCTION An important aim of endodontic therapy is the elimination of microorganisms from the root canal. Instrumentation, irrigation, and intracanal medication significantly reduce the population of microorganisms inside the infected root canal1. It is impossible, however, to completely eliminate the microbes from the root canal system in all cases. Consequently, the use of root canal filling materials with antibacterial activity is considered beneficial in the effort to further reduce the number of remaining microorganisms and to eradicate the infection2. The use of a root canal sealer in conjunction with a core material remains the most widely accepted obturation technique in endodontics. An adequate seal cannot be obtained without the use of a sealer because gutta-percha does not spontaneously bond to dentin walls. Therefore, ideal endodontic cement should show good sealing ability. In addition, it should have adhesive strength and also have
cohesive strength to hold the obturation together3. A sealer is a good lubricant. Sealer helps to fill in irregularities and minor discrepancies between the filling and canal walls, accessory canals and multiple foramina. Sealer discloses the presence of resorptive areas, root fractures, shape of the apical foramen and other structures due to its radio-opacity. The sealer acts as a binding agent to the dentin and to the core material, which usually is gutta percha4. Grossman delineated 10 requirements for an ideal root canal filling material that apply equally to metals, plastics, and cements4: (1) It should be easily introduced into a root canal. (2) It should seal the canal laterally as well as apically. (3) It should not shrink after being inserted. (4) It should be impervious to moisture. (5) It should be bacteriostatic or at least not encourage bacterial growth. (6) It should be radiopaque. (7) It should not stain tooth structure. (8) It should not irritate periradicular tissue. (9) It should be sterile or easily and 1
quickly sterilized immediately before insertion.(10) It should be removed easily from the root canal if necessary. The anatomic limits of the pulp space are the dentinocemental junction apically and the ideal apical limit of the root canal filling. Beyond this point, the periodontal structures begin. The dentinocemental junction is an average of about 0.5 to 0.7 mm from the external surface of the apical foramen. Purposely overfilling to produce a periradicular “puff” is advocated primarily by the proponents of the diffusion technique or the softened gutta-percha technique. Ostensibly, the “puff” or “button” is designed to compensate for shrinkage of the filling by pulling down tightly against the apex. The advocates of softened gutta-percha fillings interpret the apical “puff” as an indicator that the gutta-percha has been densely packed into the apical preparation and that all of the aberrations, as well as the lateral and accessory canals of the root canal system, have been cleansed and filled4. Sealapex (Sybron Endo, Glendora, CA) is a calcium hydroxide–containing sealer clinically accepted mainly because of the healing process obtained from its use. The diffusion of calcium and hydroxyl ions from the sealer raises the pH at the surface of the root adjacent to periodontal tissues. It also favors the repair, the antimicrobial action, the degradation of bacterial lipopolysaccharides, the induction of hard tissue formation, and also the control of inflammatory root resorption6.
examination mandibular 2nd premolar was tender on percussion, electronic pulpal testing was negative, mobility was grade 2 with metal onlay fixed on it (Fig. 2). The patient‟s medical history was non-contributory. The probing depths of this tooth was in normal limits. A clinical diagnosis of pulpal necrosis with periapical periodontitis left mandibular 2nd premolar was made. After complete explanation of the treatment procedure, risk, benefits, informed consent was obtained from the patient.
Fig. 1. Pre operative radiograph.
Fig. 2. Photograph of tooth no 35.
Removed plaque, calculus, onlay restoration (Fig. 3a) and all of the caries lesions from tooth 35. Access opening of the pulp chamber (Fig. 3b), installation of a matrix and strengthens tooth structure using canal projection technique to the teeth 35. Canal projection technique using gutta percha covered with vaseline, then put it in the root canal and build-up with dual cure materials (Build-IT FR, Pentron) around gutta percha (Fig. 3c).
PURPOSE The purpose of the article is to present a series of case reports in which the sealer had extruded beyond the apical foramen causing the periapical healing.
Fig. 3a. Removed onlay. Fig. 3b. Access opening. Fig. 3c. Canal
CASE REPORT
projection.
CASE I. A 43 year female patient reported with mobility in left mandibular back region to the Department of Conservative Dentistry at Trisakti University. Radiographic examination (Fig. 1) showed root canal treatment undone and an 0.5 cm x 0.7 cm periapical lesion at the apex of tooth. In clinical
Following rubber dam isolation (Fig 4) dan irrigation with 2ml of 2.5% sodium hypochlorite to remove the debris. The #8, #10 and #15 K-files are utilized to make a glide path. Tooth 35 was treated with crown down technique by Protaper rotary (Denstply). After the exploration with K-files, check the working 2
length with electric apex locator (RootZX Mini, Morita, Japan) and radiograph (Fig. 5), WL= 19 mm.
Fig. 4. Isolation tooth 35 with rubber dam; Fig. 5. Confirmation WL with radiograph
Biomechanical preparation was done until the file F3. Each turn of the needle is done, check the apical patency using K-files # 8 to avoid the accumulation of debris in the apical part. Root canals were dried using sterile paper points, apply medicaments calcium hydroxide (Ultracal, Ultradent) and the cavity closed using temporary restoration (Cavit-G). On the second visit, 10 days later, was asymtomatic. Temporary restoration of tooth 35 is opened and irrigated with 2.5% sodium hypochlorite to dissolve calcium hydroxide, used as a root canal medicament. Try in the gutta percha point F3 on the root canal of tooth 35 and confirmed by radiograph (Fig. 6). Root canals irrigated with 2.5% sodium hypochlorite , which is activated by Passive Ultrasonic Irrigation (PUI) (P5, Satelec Acteon) for 1 min, followed by 17% EDTA solution (Smear Clear, Sybron Endo), clorhexidine 0.2% (Minosep), and aquadest. Root canal was dried with sterile paper points and obturated with single gutta percha cone and sealer (Sealapex, SybronEndo). Gutta percha cut at the orifice and performed vertical condensation using a plugger (Fig. 7).
Fig. 6. Try in gutta percha F3.; Fig. 7. Radiograph showed extruded sealer.
On the third visit, was asymtomatic and no mobility on tooth 35. The post-hole preparation begins with the removal of the root filling material using a Peeso or Gates Glidden reamer. Try-in the post into the root canal (Fig. 8). The root canal walls were etched with 37% phosphoric acid (Ultraetch, Ultradent) for 15 s, rinsed using a water syringe and then gently dried with paper points. The bonding agent (Prime and Bond, Denstply) was applied into the root canals with a microbrush. The excessive bonding agent solution was removed with a paper point and then gently air-dried, and then light cured for 20s. Finally, the post (Fibre Kleer, Pentron) was covered with resin cement (Build-IT FR, Pentron) and seated in the root canal (Fig. 9) the excess resin was subsequently removed. The resin cement material was lightcured simultaneously through the post for 60 s. The tooth was then prepared with an adequate ferrule design to receive a porcelain-metal crown.
Fig. 8. Try in the fiber post.; Fig. 9. After cementation.
On the fourth visit, cementation porcelain-metal crown on tooth 35 used GIC (Fuji I, GC). Patient was recalled after 3 month and 6 month. Post operative radiograph showed healing process of the periapical tissue. (Fig. 10).
Fig. 10. Recall after 3 and 6 month
3
CASE II. A 28 year female patient reported with pain and discoloration in left anterior maxillary region to the Department of Conservative Dentistry at Trisakti University. Radiographic examination (Fig. 11a) showed root canal treatment with metal post was done 16 month ago. In clinical examination tooth 21 was tender on percussion. The patient‟s medical history was non-contributory. The probing depths of this tooth was in normal limits. Retreatment was then planned for tooth 21. After complete explanation of the treatment procedure, risk, benefits, informed consent was obtained from the patient. Root canal retreatment was performed and obturation utilizing vertical compaction technique with gutta percha and sealer (Sealapex, SybronEndo). Periapical radiograph showed extrusion of the sealer at the apical region (Fig. 11b) which was then restored with fiber post (Fibre Kleer, Pentron). Patient did report an uncomfortable for a few days after the obturation. After 4 month, follow up radiograph showed healing process of the periapical tissue and clinical examination showed negative to percussion (Fig. 11c).
examination tooth 32 was tender on percussion. The patient‟s medical history was noncontributory. The probing depths of this tooth was in normal limits. After complete explanation of the treatment procedure, risk, benefits, informed consent was obtained from the patient. Root canal treatment was performed, used calcium hydroxide for medicament and obturation utilizing vertical compaction technique with gutta percha and sealer (Sealapex, SybronEndo). Periapical radiograph showed extrusion of the sealer at the apical region (Fig. 12b). Patient was advised antiinflammatory drugs only if required. After two months, resorption of the sealer was seen in periapical region and no pain was observed in examination (Fig. 12c).
Fig 12a. Pre operative; Fig 12b. After obturation. Fig 12c. 2 month recall.
DISCUSSION
Fig 11a. Pre operative.; Fig 11b. After obturation.; Fig 11c. 4 month recall.
CASE III. A 34 year female patient reported with pain and swelling in left anterior mandibular region to the Department of Conservative Dentistry at Trisakti University. Radiographic examination (Fig. 12a) showed root canal undone, an 0.8 cm x 0.4 cm periapical lesion at the apex of tooth and composite restoration on tooth 32. In clinical
Microbes and microbial products are the main etiologic factors of pulpitis and apical periodontitis. Therefore, an important aim of endodontic therapy is the elimination of microorganisms from the root canal. Instrumentation, irrigation, and intracanal medication significantly reduce the population of microorganisms inside the infected root canal. It is impossible, however, to completely eliminate the microbes from the root canal system in all cases. Consequently, the use of root canal filling materials with antibacterial activity is considered beneficial in the effort to further reduce the number of remaining microorganisms and to eradicate the infection7. Calcium hydroxide, because of its biological effects, is now accepted along with 4
endodontic sealers and gutta-percha points. It acts at the tissue level by favoring alkaline pH (approximately 12.5–12.8) and calcium release, producing biochemical effects culminating in speedy repair process. Furthermore, the calcium ion exerts essential paper in the mineralization, stimulating the fibronectin gene expression. The high pH values of calcium hydroxide promote antibacterial activity through an irreversible enzymatic reaction, and calcium release clears up the carbon dioxide that bacteria use for anaerobic respiration. Calcium hydroxide also inhibits irritant lipopolysaccharides present in the external membrane of gram-negative bacteria8. The antimicrobial activity of calcium hydroxide is related to the release of hydroxyl ions in an aqueous environment. Hydroxyl ions are highly oxidant free radicals that show extreme reactivity with several biomolecules. This reactivity is high and indiscriminate, so this free radical rarely diffuses away from sites of generation. The lethal effects of hydroxyl ions on bacterial cells are probably due to the following mechanisms: damage to the bacterial cytoplasmic membrane; protein denaturation; and damage to the DNA9. When root canal sealers are extruded, they contact periodontal ligament (PDL) cells directly. The root filling materials may potentially damage the periapical tissue, lead to tissue inflammation or destruction, and impair apical healing. Sealapex was associated with the least inflammatory reaction compared to the other sealers used, because it caused moderate inflammation at 48 h that became mild. Zinc oxide-eugenol, Tubliseal and Endoflas F.S. were highly toxic at 48 h and 7 days. This toxicity decreased gradually with time. No inflammatory reaction was seen at 3 months with any of the sealers9,10. Antibacterial activity and biocompatibility of calcium hydroxide based sealer is lower than resin and zinc oxide eugenol based sealer, but the calcium and hydroxyl ions released in a longer time presented a mild inflammation reaction is an advantage for periradicular tissue. Furthermore, calcium hydroxide sealer had no genotoxicity10,11. The extrusion of sealer through the apical foramen is an issue of concern. Some authors have stated that this may interfere with the repair
process. The short-term clinical and radiographical follow-up revealed that only few of the cases were interpreted as endodontic failures12. There is less agreement about what constitutes true healing when the majority of the literature is considered. Nonetheless, there are key shared characteristics that are universally accepted in all considerations of successful healing, even when overfill is an outcome of treatment: an absence of pain and swelling; no evidence of on-going tissue destruction; a repair of any sinus tracts; the tooth is in function; and there is radiographic evidence of repair or lessening of the rarefaction between 6 months and 24 months13. CONCLUSION The remaining cases did not show postoperative complications, and no radiographic evidence of sealer was observed in the periapical tissues resulting in a return to a normal radiographic appearance. After regular follow up these cases appeared radiographically normal, indicating that the sealer was well tolerated by the periapical tissues. The few cases that showed a slight resorption of filling material within the lumen of the root canal had a root fill that was located approximately 2 mm from the radiographic apex. It was therefore believed that the sealer had disappeared, not the fill. REFERENCES 1. 2.
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4.
5.
Hargreaves KM, Cohen S. Pathway of The pulp. 10th ed. St. Louis: Mosby Inc; 2011. Ørstavik D. Materials used for root canal obturation: technical, biological and clinical testing. Endod Topics 2005:12:25-38. Ersahan S, Aydin C. Dislocation resistance of iRoot SP, a calcium silicate–based sealer, from radicular dentine. J Endod 2010;36:2000-2002. Ingle Jl, Newton CW, West JD., et al. Obturation of the radicular space. In: Ingle JL, editor. Enodontics.5th ed. Canada: B. C Decker Inc. 2002:573-590. Duarte MAH, Demarchi AC, Henrique M, et al. Evaluation of pH and calcium ion release of three root canal sealers. J Endod 2000;26:389-390. 5
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Gomes JE, Watanabe S, Gomes AC., et al. Evaluation of the effects of endodontic materials on fibroblast viability and cytokine production. J Endod 2009;35:1577-1579. Zhang H, Shen Y, Ruse D, et al. Antibacterial activity of endodontic sealers by modified direct contact test against Enterococcus faecalis. J Endod 2009;35:1051-1055. Duarte MAH, Ordinola R, Bernardes RA, et al. Influence of calcium hydroxide association on the physical properties of AH Plus. J Endod 2010;36:1048-1051. Mohammadi Z, Dummer PMH. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J 2011;44:697-730. Chang MC, Lin LD, Chen YJ., et al. Comparative cytotoxicity of five root canal sealers on cultured human periodontal ligament fibroblasts. Int Endod J 2010;43:251-257. Huang TH, Lee H, Kao CT. Evaluation of the genotoxicity of zinc oxide eugenolbased, calcium hydroxide-based and epoxy resin-based root canal sealers by comet assay. J Endod 2001;27:744-748. Chhabra A, Teja TS, Jindal V., et al. Fate of extruded sealer: a matter of concern. J Oral Health Comm Dent 2011;5:168-172. Gluskin AH. Anatomy of an overfill: a reflection on the process. Endod Topics 2007:16:64-81.
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Root canal treatment of c-shaped canal on second mandibular molar case report Sarah Kurniawan1, Herry Sofiandi Halim2 , Elline2 1 Resident Post Graduate of Conservative Dentistry, Faculty of Dentistry, Trisakti, University 2 Conservative Dentistry, Faculty of Dentistry, Trisakti, University
Abstrak : Introduction : C-shaped canal is usually found on second molar mandibular, mostly in Asian population. The failure of Hertwig‟s epithelial root sheath to fuse onto the buccal or lingual root surface may be the main cause of C-shaped root formation. In this root there are irregularity which debris and infected pulp tissue remain unclean. The success of root canal therapy depends on cleaning and shaping and also three dimensional obturation of root canal space. Cone Beam Computed Tomography (CBCT) can be used to identify C-shaped canal and evaluate the treatment of root canal. Purpose: The purpose of case report is to explain management of root canal treatment on C-shaped canal to achieve a good result. Case: On this case report, 25 years old woman diagnosed with irrerversible pulpitis on tooth #37 and on opening revealed ribbon like orifice and classified as Menton C2. Case management: Vital pulpectomy was performed on tooth #37 and prepared with rotary Protater (Dentsply) and obturated with themoplastized guttap percha. Evaluation of obturation was done with CBCT. Conclusion: Root canal treatment on C-shaped canals need a modification and carefull management on cleaning, shaping and obturating to achieved maximal result. Keyword : C-shaped, root canal treatment, CBCT
INTRODUCTION The C-shaped canal, which was first documented in endodontic literature by Cooke and Cox in 1979, is so named for the crosssectional morphology of the root and root canal.(1) This C-shaped canal is an anatomical variation of a root fusion and a type of taurodontism. This results from the failure of Hertwig‟s epithelial sheath to develop of fuse in the furcation area in the developing stage of the teeth. Failure on the buccal side results in a lingual groove, and the opposite cases is possible. Failure on both sides results in the formation of a conical or prism-shaped tooth.(2) The main anatomic feature of C-shaped canals is the presence of a finor web connecting the individual canals. The coronal orifice of these canals is usually located apically to the cementoenamel junction level and may appear and may appear as a single, ribbon-shaped opening with a 1800 are linking all the main canals or a ribbon-shaped canal that includes the mesiobuccal and distal canals.(3) Central to successful endodontics is knowledge, respect and appreciation for root
canal anatomy and careful, thoughtful, meticulously performed cleaning and shaping procedures. It is understood that well-shaped canals will enhance a three-dimensional seal of the canal system that is the aim of root canal obturation. However some canal configurations like the C-shaped canals are known to present a complex canal anatomy with numerous fins connecting individual canals, thus requiring supplementary effort to accomplish a successful root canal treatment.(4) Root canal treatment on C-shaped canals provides a challenge with respect to debridement and obturation, especially because because it is unclear whether the C-shaped orifice found on the floor of the pulp chamber actually continues to the apical third of the root.(1,3) Irregular areas in a C-shaped canal that may house soft-tissue remnants or infected debris may escape through cleaning or filling and may be a source of bleeding and severe pain.(3) CASE REPORT A 25-years-old woman reported to Department of Conservative Dentistry, Faculty of
Dentistry, Trisakti University with the chief complain of severe pain in lower left posterior region. Clinical examination revealed a broken amalgam filling and secondary caries lesion on the occlusal surface of tooth #37. Thermal test gave a long lasting pain sensation even though the stimuli had already been removed. Periapical radiograph examination showed a decay exposing the pulp chamber in tooth #37.
Figure 1. Clinical examintation revealed a broken amalgam filling and secondary caries lesion on the occlusal surface of tooth #37.
Figure 2. Periapical radiograph examination showed a decay exposing the pulp chamber in tooth #37.
Diagnosis for tooth #37 was irreversible pulpitis thus vital pulpectomy followed with composite onlay was proposed. Inferior alveolar nerve block was performed and isolation with rubber dam, followed with removal of carious lesion, construction of an artificial wall and then access opening was made on tooth #37 which revealed C-shaped orifice. Extirpation was performed with a extirpation file. Exploration of these canals with a K- file #8, #10 and #15 revealed diversion of distal and mesiolingual canal with separated foramen apical. Working length was determined using apex locator (Root ZX Mini, Morita) and confirmed with radiograph.
Figure 3. C-shaped orifice.
Figure 4. Determination and confirmation of working length with radiograph.
The mesiolingual canal was cleaned and prepared by crown down technique with Protaper Rotary (Dentsply) and was irrigated with 2,5% sodium hypochlorite after each file. C-shaped canal was prepared with circumferential filling and irrigated with copious 2,5% sodium hypochlorite and activated with ultrasonic to enhance the removal of debris and infected tissue from the inaccessible areas of the root canal system. Canals were dried with sterile paper points, filled with calcium hydroxide paste as intracanal medicament and temporized with temporary filling.
Figure 5. After instrumentation of tooth #37
At the next visit, one week later, calcium hydroxide was removed with sodium hypochlorite and guttap percha for mesiolingual canal was fitted and confirmed with radiograph. Root canal system irrigated with 2,5% sodium hypochlorite¸ 17% EDTA and 2% chlorhexidine and then dried with steril paper point. Obturation
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for mesiolingual canal was carried out using warm vertical condensation and for c-shaped canal was done with themoplastized guttap percha along with AH plus endodontic sealer (Dentsply). Barrier with glass ionomer cement was placed and temporized with temporary filling and then confirmed with radiograph. The quality of vital pulpectomy was observed with Cone Beam Computed Tomography (CBCT).
A
B
In the next appointment, glass ionomer cement barrier was removed and 3mm guttap percha on mesiolingual canal was removed with heat carrier for intraradicular retention.The space was etched, bonding agent was applied and then filled with resin composite as intraradicular retention. (Fig 9)
Figure 9. 3mm guttap percha on mesiolingual canal was removed for intraradicular retention
Figure 6A. Fitting of guttap percha cone Figure 6B. Confirmed with radiograph
A
B
Figure 10. The cavity was etched with 37% phosphoric acid
Figure 7A. Obturation of root canal system Figure 7B. Confirmed with radiograph
Figure 11. Aplication of bonding agent
Figure 8. Evaluation the quality of obturation with CBCT (sagittal view), and shows that the root canal system is fully condensed.
Figure 12. Intraradicular retention with composite
Coronal structure was prepared for composite onlay (Figure 13) and then impression
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was made with double impression. In the next visit, composite onlay was cemented with resin cement and confirmed with radiograph. (Figure 14)
Figure 13A. Onlay preparation on tooth #37 Figure 13B. Impression was made
Melton et all in 1991 proposed the following classification of C-shaped canals based on their cross-sectional shape.(1,2) Category I : continuous C-shaped canal running from the pulp chamber to the apex defines a C-shaped outline without any separation (C1) Category II : the semicolon-shaped(;) orifice in which detine separates a main C-shaped canal from one mesial distinct canal (C2) Category III : simply have two or more distinct canals (C3)
Figure 14. Cmposite onlay (buccal view, occlusal view, lingual view Figure 16. Classification of a C-shaped canal configuration
Figure 15. Confirmation with radiograph
DISCUSSION The C-shaped canal is most frequently found in the mandibular second molar. The prevalence of C-shaped canal systems has been reported to range from 2,7%-44,5% in mandibular second malar, depending on the population. It is a significant ethnic variation that has a high prevalence in Asians. The prevalence of C-shaped canals is estimated to be between 2,7% and 9,0% in Whites, but is as high as 31,5% among Asians populations such as the Chinese and Japanese. In the Korean population 32,7% of second mandibular molars have been reported to have a C-shaped canal.(3)
Fan et al in 2004 modified Melton‟s method into following categories Category I : the shapes is an uninterrupted “C” with no separation (C1) Category II : the canal shapes resembles a semicolon resulting from a discontinuation of the “C” outline, but either angle or β should be no less than 600. (C2) Category III : two or three separated canals are present and both angles and β are less than 600 (C3) Category IV : only one round or oval canal is found (C4) Category V : no canal lumen can be observed, usually seen near the apex. (C5)
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Figure 17. Meansurement of angles for the C2 canal.
Figure 18. Meansurement of angles for the C3 canal
As irregular areas in C-shaped root canal system may house soft tissue remnant or infected debris which may escape thorough cleaning and filling procedurs, many modified techniques have been provoked to manage such cases. The canals prepared conventionally, however, the isthmus should not be prepared with larger than ISO no 25 files; otherwise strip perforation is likely.(1) Copious irrigation is a key to thorough debridement of narrow canal isthmuses. Alternative canal cleaning techniques is using ultrasonic to enhance debridement. Sealing C-shaped canal is a difficult thing to do, using themoplasticized guttap percha is more likely. Guttap percha can be thermoplasticized with heated or electric spreader or with injectable systems. Liewehr et al.(5) develop a “zap and tap” technique to obturated root canal system. This technique use a spreader of the Endotec which preheated (zap) for 4-5 s and then the hot instrument is moved in short continuous in-and-out motion (tap) 10-15 times with very little apical preasure. Zap and tap provide homogenous obturation.(5) Radiography has an essential place in dentistry, some radiographic methods used in analyzing root canal morphology, such as the cone beam computed tomography (CBCT). CBCT is reported to be adequately precise for morphology analysis. Compared with
conventional medical computed tomography CBCT have adequately lower effective dose and shorter working time.(6) On traditional periapical radiographic films, the recognition of C-shaped canals is challenging because of the two dimensional nature of the images produced, geometric distortion and anatomical noise.(3) Practically it is very difficult but not impossible to diagnose a Cshaped canal from pre-operative radiograph which usually shows single fused or images of two distinct roots. Micro computed tomography also helps in diagnosing it in a non-destructive manner. Intraoral periapical radiograph taken while negotiating the canals may reveal any of the following characteristic: (1) instrument tending to converge at the apeks, (2) instruments appearing both clinically and radiographically to be centered and appearing to be exiting at the furcation.(1) Clinical recognition of C-shaped canals is unlikely until access to the pulp chamber has been achieved.(1,2) CONCLUSION The C-shaped canal need modification on its management which provides a better and promising result of root canal treatment, such as modification and a careful of instrumentation, copious irrigation companied with ultrasonic and a meticulous obturation to give good sealing of irregular areas on C-shape canals. CBCT can be used to help diagnosis of C-shaped and to evaluate obturation of C-shaped canals. REFERENCES 1. Patel P, Shah S, Parmar N. C-shaped root canal system in mandibular second molar: a case report and discussion. J Dent Scien. 2010; 2 (2): 34-7. 2. Kadam NS, Ataide IN. Managemen of Cshaped canals: two case reports. J Orofac Scien. 2013; 5(1):37-41. 3. Vikram M. C-shaped canal, an endodontic challenge. Health renaissance. 2013; 11(1): 89-91
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4. Walid N. The use of two pluggers for obturation of an uncommon c-shaped canal. JOE. 2002; 26(7). 422-4. 5. Liewehr F, Kulild JC, Primack PD. Obturation of a c-shaped canal using an improved method of warm lateral condensation. JOE. 1993; 19(9): 474-7.
6. Miloglu O, Yildirim E, Ersovy I, Demirtas O, Akgul HM. Root morphology and c-shaped canal system in mandibular second molars on cone beam computed tomography images. J Dent Fac Ataturk Uni 2012; 22(3): 225-9.
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Composite resin restoration in class iv cavity using crown former Sannia Pratiwi1, Herry Sofiady Halim2 , Anastasia Elsa Prahasti2 1 PPDGS, Conservation Department , Faculty of Dentistry, Trisakti University 2 Lecturer on Conservation Department, Faculty of Dentistry, Trisakti University
ABSTRACT Background: Creating an aesthetic form of the teeth is a challenge in a large cavity on anterior teeth. Crown former facilitates the formation of restorative material that resembles the shape of a natural tooth. Crown former is ideally used with composite resin and can be removed easily without leaving residue. Available for anterior and posterior teeth with various sizes so applicable to every individual. Case 1: 24 year old female patient complained on her upper left front teeth cavities that often tucked food. Patient wants her teeth to be filled to get a better appearance. Case 2: The 33 year old male came with upper right front teeth broken. Patient wants a good and economical restoration. Case management: Composite resin restorations in class IV cavities using crown former. Conclusion: The use of crown former was able to create an aesthetic shape of the teeth in a very good, easy, and economical way. . Keywords: class IV cavities, composite resin restorations, crown former
Introduction In today‟s world, looking good is a prime concern. Appearance is closely linked to social acceptance and professional success. Beauty in health is the new mantra. Neer technologies are being harnessed for this purpose and advanced research is being undertaken1. The focus of dentistry in the present time is not only on prevention and treatment of disease but on meeting the demands for better esthetics. Thus, dentistry has evolved from a curative to a creative science in a very short span. Esthetic dentistry is emerging as one of the most progressive and challenging branches of this field. The practice of esthetic dentistry must be based on ethical principles with a holistic approach towards total dental health rather than mere cosmetic consideration2. The conservative treatment approach is best collaborated with the use of composite due to their ability of bonding to many surfaces including natural teeth. This has opened up many avenues for the use of these materials for esthetic benefits in cases that probably could not be treated effectively, or at all in their absence. The results with this material are quick, esthetic, and economical, repairs are easy and the material per se does not call for unnecessary tooth reduction for its effective placement. In most instances, the
final results are all in the control of the dentist without the involvement of laboratory technicians thus providing the dentist an opportunity to exhibit his skills and finesse2-4. Several treatment techniques have been developed to overcome the problem of dental aesthetics with composite resin restorations. Here are delivered using a composite resin restoration techniques “crown former”. CASE 1 Female patient, 24 years old, came to RSGM-(P) Trisakti University complained on the left front tooth cavities. Patient wants her teeth to be filled to get a better appearance. On visual inspection there appears dental caries in the distal part of 21 and in the mesial of 22 (Figure 1). The overjet and aoverbite are normal.
a
b
Figure 1. Caries on 21 and 22 from labial (a) and palatal (b) view
On radiograph, caries has not reached the pulp in 21 and 22 (Figure 2). 13
a .
Figure 2. The radiograph of 21 and 22
The diagnosis of 21 and 22 are reversible pulpitis. Treatment of 21 and 22 is composite resin restoration using crown formers as follows: Determination of the color using Vita Lumin Vacuum shade guide obtained color A3 (figure 3).
b .
c .
Figure 5. Aplication of Etsa phospat acid 35% in cavity for 15 seconds (a) The cavity after the etsa was cleaned from labial (b) and palatal (c) view
Aplication of bonding agent (Optibond S, KERR) using microbrush on the cavity then activated it using light cure for 20 seconds (Figure 6).
Figure 3. Color determination using vita lumin vacuum obtained color A3
Caries removal and cavity preparation using a round bur and then made a hollow ground bevel on all cavo surface margin towards the outer surface of the tooth using a flamed shape diamond bur (Figure 4).
a
b
Figure 6. Aplication of bonding agent on 21 and 22
The crown formers (Anger G&A) were prepared. The width of teeth were measured mesio-distally (Figure 7a). The width of 21 and 22 were 85mm and 75mm. Choose the crown formers which were fit to the width of 21 and 22 (Figure 7c). Crown formers were cut and formed leaving the palatal, and mesio distal of the teeth (Figure 7d).
Figure 4. Cavity preparation on 21 and 22 from labial (a) and palatal (b) view.
Aplication of Etsa phospat acid 35% (Ultradent) on cavity for 15 seconds, then clean it with aquadest. Cavity was dried using light air spray. Rubber dam was placed for isolating the teeth (Figure 5).
a . b c . 7. Crown formers preparation (a) Measurement . Figure width of teeth. The width of 21 and 22 were 85 and 75 mm. (b) Choose the crown formers which were fit to the width of
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teeth. (c) Crown formers were cut and formed so be ready to be used.
Crown former was put on 22, filled with resin composite on palatal and mesial first to form the wall, activated with light cure for 20 seconds. After the form of wall was ready, the crown former was put off, then filled the rest part of 22 (Figure 8b and c). Put the separating tape (plumber tape) on 22 as separation with 21. Crown former was then put on 21 (Figure 8d), then filled with resin composite on palatal and distal first to form the wall (Figure 8e), activated with light cure for 20 seconds. After the form of wall was ready, the crown forme was put off, then filled the rest part of 21 (Figure 8f). Restoration of 21 and 22 were done in incremental layering step using plastis filling and burnisher by teflon. Each layer was activated with light cure for 20 seconds. The separating tape was then put off.
a
Figure 9. Results of the polishing on 21 and 22
After filling and polishing, checked with articulating paper to see whether or not overfilling; also checked the contact by using dental floss (Figure 10).
Figure 10. Contact checking by using dental floss
b Figure 11. Result of fillings on 21 and 22 from labial and palatal view
CASE 2 c
d f
e Figure 8. Composite resin fillings in palatal wall and the mesial wall section of 22 using crown formers (b)&(c) Composite resin fillings on whole section of 22 (d) Installation of plumbing tape separation and repositioning of crown former on tooth 21 (e) the composite resin fillings on palatal wall and distal wall section of 21 (f) overall filling on 21
After the resin composite fillings done, do polishing using a superfine bur and optidisk (KERR) (Figure 9).
Male patient, 33 years old, came to RSGM- (P) Trisakti University complaining his right upper front tooth which is broken. Patient want his tooth to get a better appearance. On visual inspection there is a tooth fractures appear in the mesio-incisal of 11 (Figure 12).
Figure 12. Tooth fracture appear on mesio-incisal of 11
Determination the color of teeth by using Vita lumin vacuum shade guide and got A3 color. Preparation of cavity edge bevel by hollow ground bevel on around the cavo surface 15
margin towards the outer surface of the tooth using a flamed shape diamond bur. The application of 35% phosphoric acid etching (Ultradent) in the cavity for 15 seconds, then rinse with distilled water. Cavity is dried using an air spray lightly. Application bonding (Optibond S, KERR) using microbrush on the entire tooth cavity and activated by light cure for 20 seconds. Preparation of crown former (Anger G & A) to be used. Mesio-distal width is measured. Selection of the appropriate crown former mesiodistal width of the tooth. Crown Former was cut and formed (Figure 13). Composite resin material is inserted into the crown former (Figure 14). Then the crown former containing composite was placed on 11 (Figure 15). Activation with light for 40 seconds.
Figure 13. Crown former preparation. Selection of the appropriate mesio-distal size of crown former. Crown former was cut and shaped so ready to use
Figure 14 composite resin material (Premisa, KERR) inserted into the crown former
Figure 15. Crown former containing composite that had been placed into 11
DISCUSSION In both cases the composite resin restorations have been directly applied because caries and crown fracture become a barrier for patients to communicate with others, besides that, there are economic and time constraints. Composite resin restorations were selected because of esthetic factors and good retention, as well as economic considerations and patient time. Composite resin restoration aims to restore the fuction esthetically, but otherwise it should be also considered how this restoration long last, because one of the downsides of this restoration is not last long. Retention of composite resin determines the length of the composite resin restorations survive, the better the retention, the longer this last restoration. Retention of composite resin obtained from preparation form , most also rely on the attachment of composite tissue restoration. Therefore, to obtain optimal retention of this attachment, the operators should know the physical properties of a composite filling materials, the physical properties of the network that will be the restoration of the enamel and dentin, composite types that are used, and works following the instructions described in the product. The advantages of composite resin restorations using crowns former is minimal preparation so as not to interfere the integrity of the healthy tooth tissue, reducing the time of the visit, as they are made directly, the patient regains its aesthetic function on the same day when the restoration done, can be repaired immediately when there is a shortage, more economical because it does not require additional lab fees, materials are more economical when compared with ceramic materials, it is easier to get a form that resembles the shape of a natural tooth. Disadvantage of composite resin restorations using crowns former is, former crown preparation requires operators‟ skill and precision in designing and shaping the crown formers to obtain the appropriate forms, composite resin restorations generally lasting less than the jacket crown restoration.
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In the former case 1, crown formers were cut and shaped to leave the palatal and mesio-distal (Figure 7d). This resembles the composite resin restoration technique using a silicon index. However, the use of crown former is superior because the operator does not need to make study models and diagnostic wax-up that often require additional visits and restoration can not be done directly. Through the use of crown former, the operator is able to produce a good tooth shape with one visit, with a shorter duration.
cut in a half in vertical direction, so we can just use the mesial alone, or distal, depending on the area of the fracture. BIBLIOGRAPHY 1.
2.
3. In the case of tooth fractures as case 2, crown former was cut and shaped to leave the incisal (Figure 13). It is very easy in the rebuilding of the fracture. It can be done if we have the former in various sizes crown mesio distal teeth. But if we do not have the right size crown former, the crown former approximately equal size, can be
4.
Robertson TM. Art and science opeative dentistry. 5th edition. St Louis: Mosby Elsevier; 2006. p.648-62 Patil R. Esthetic dentistry an artist‟s science 1st edition. PR publication. Mumbay 2002. p.96-105 Freedman G. Comtemporary Esthetic Dentistry. 2nd edition. St Louis: Mosby Elsevier; 2007. p214-226 Summit JB. Robbins JW and Schwaetz RS. Fundamentals of operative dentistry. 2nd edition. Illinois: Quintessence PublishingInc; 2001. p236-243
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Endodontic treatment using reciprocating file (case report) Esther Esti Pangesti1, Juanita A. Gunawan2, Meini F. Amin2 1 Resident of Conservation and Endodontic Program of Dentistry of Trisakti University 2 Lecturer of Conservation and Endodontic Program of Dentistry of Trisakti University
ABSTRACT Endodontic treatment aims to clean almost all of the root canal system mechanically and chemically, disinfect the root canal and do obturation in three dimension. One of the important step to clean the main root canal is done mechanically using root canal files. The cleaning and shaping stages using the Nickel-Titanium files using endodontic motor is getting more popular and gives some advantages. Ni-Ti files are more flexible than Stainless Steel files, it can follow the shape of root canal. One of the movements that use in the preparation of the root canal using endodontic motor is reciprocating movement. Three reciprocating cycles could for one full circle. Reciprocating file that available in the market is a single use sterile Nickel-Titanium root canal file so it can avoid the cross contamination and the manufacturer claims this kind of file have minimal fracture potential. This file has two sides : the clock wise non cutting side and the counter clock wise cutting side, and it has relatively big taper with small apical size so the shaped form facilitate irrigation and adequate obturation without the loss of the apical constriction. Case I: Maxillary right second premolar (tooth 15) with caries D5, Black‟s Class II cavity at the mesial. The patient complained spontaneous pain with long duration. Diagnosis: Irreversible pulpitis. Treatment: endodontic treatment, root canal preparation using file Reciproc R25 and R40. Case II: mandibular right first molar (tooth 46) with large resin composite restoration that extended to the orifice. Spontaneous pain, thermal test negative, percussion test positive. Diagnosis: symptomatic periodontitis apicalis. Keywords : endodontic, root canal preparation, reciprocating file.
INTRODUCTION The success of the endodontic treatment is gained from three-stages-chain that could not be separated. Those stages are: cleaning, disinfection and three obturation. The cleaning the main part of the root canal is done mechanically by doing the cleaning and shaping the root canal using the root canal files. The main purpose of cleaning and shaping of the root canal is to remove the infected soft tissue and hard tissue, make space for the insertion of the root canal medicament and obturation material, maintain the integrity of the root structure.1 The root canal preparation procedure using Ni-Ti files with larger taper than stainless steel file with 0.02 taper is an effort to increase the result of the root canal shaping and cleaning. The use of this instrument result better root canal shape, less instruments and the shorter working time. Ni-Ti instruments have additional benefits if it is used with endodontic motor.2 Cleaning the root canal with endodontic motor is more popular technology now a days and gives some additional
benefits: consistent file movement and smooth root canal wall with a smooth root canal shape. One of the root canal preparation movements using endodontic motor is the reciprocating motion. The instrument was designed to work with a reverse cutting action, it has ability to cut the dentine when it moves counter clock wise. The instrument has modified convex triangular cross-section at the tip end and a convex triangular cross-section at the coronal end. This design was claimed improve the instrument flexibility. The tip of the root canal file was modified so could follow the curved shape of the root canal accurately. The variable pitch flutes along the length of the instrument was claimed has ability to improve safety.4 Three reciprocating cycles complete one full reverse rotation and the instrument move gradually to the apical. Ni-Ti rotary instrument caused more transportation and zipping than instrument with reciprocating motion. Reciprocating instrument could shape the root canal faster than the rotary system.4 Tinoco et. al. were doing the research about the bacterial extrusion to the apical and got the result that 18
rotary system with multiple files and the reciprocating file cause the bacterial extrusion to the apical but two reciprocating system files cause less bacterial extrusion than the rotary system.5
with thermal test (+), percussion (-) and palpation (-). Radiographic examination showed the cavity has reached the pulp chamber. Diagnosis: irreversible pulpitis.
A. A.
B.
Picture 1. A. Reciprocating file apical cross-section, modified convex triangular. B. Reciprocating file crosssection, convex triangular.
Picture 2. Three complete reciprocation motion make one complete reverse circle motion
Glide path is needed in the rotary Ni-Ti system to minimize the instrument fracture in the root canal. The tip of the rotary instrument could be stuck in the canal. Therefore, initial glide path of minimal root canal enlargement is needed before using the rotary instrument. Reciprocating system could be used after make the glide path using root canal files size no. 10 or no. 15 according to ISO.6 The manufacturer of two kind of reciprocating file, Reciproc (VDW) and WavveOne (Dentply) stated that these reciprocating file could be use without making the glide path.6,7 CASE I Patient, female, 42 years old came to the Dentistry of Trisakti Univesity‟s Tooth and Mouth Hospital to treat the upper right tooth that has cavity and the patient sometimes feel pain spontaneously. Clinical examination: tooth 15 caries D5, Black‟s class II cavity in the mesial. There‟s porcelain crown at tooth 14. Vitality test
B.
Picture 3. A. Clinical tooth 15, Black‟s class II cavity in the mesial. B. Radiograph shows the cavity has reached the pulp chamber.
TREATMENT OF CASE I First visit, anamnesis, clinical examination, radiographic examination, diagnosis and making treatment planning. The patient was explained about the treatment planning and was asked to sign the informed consent. Local anesthetic with infiltration technique using mepivacain, caries removing and making access cavity to the pulp chamber. The artificial wall was made with resin composite using universal matrix band. Initial exploration using K-file size no. 10 and no. 15 then the working length was measured with electronic apex locator and do the radiographic examination for the confirmation (the working length of tooth 15 is 17 mm). Isolate the tooth 15 using the rubber dam. Glide path was made with hand use K-file according to the working length the do the shaping and cleaning using file Reciproc 25 that has apical size no. 25 with 0,08 taper and continue with file Reciproc R40 that has apical size no. 40 with 0,06 taper. EDTA 15% gel was used. Irrigation with NaOCl 2,5 % every two or three vertical movement of the file. Apical gauging using K-file size no. 40. Final irrigation using NaOCl 2,5 %, EDTA 17 %, sterile aquadest and Chlorhexidine 2 %, 2,5 ml each. Trying the R40 gutta percha cone in the root canal and doing the confirmation with radiograph. The root canal obturation using R40 gutta percha cone and resin based root canal sealer. The gutta percha cone was cut at the orifise and doing the warm vertical condensation. Put the glass ionomer cement as lining on the
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orifice. The temporary filling was put in the cavity of tooth 15.
Picture 4. Universal matrix band was used to make the artificial wall.
CASE II Patient, female, 32 years old came to the Dentistry of Trisakti Univesity‟s Tooth and Mouth Hospital to treat the lower right tooth. The tooth had been being treated and restored in the Community Health Centre few years ago but the patient complained that sometimes she felt the spontaneous pain. Clinical examination: tooth 46 with large resin composite restoration. The buccal wall fractured partially. Vitality test with thermal test (-), percussion (+) and palpation (-). Radiographic examination showed the restoration extended to orifice of tooth 46. The tooth had received the mummification treatment from the pervious treatment. Diagnosis: symptomatic periodontitis apicalis et causa necrotic pulp.
Picture 5. The result of the root canal obturation before put lining on the orifice.
A.
B.
Picture 8. A. Clinical tooth 46 seen from buccal, there‟s large resin composite restoration and the buccal wall fracture. B. Tooth 46 seen from occusal.
Picture 6. Radiograph of maxillary right second premolar after obturation. The ramification of root canal was seen at the apical.
Second visit, 10 days after the first visit. Subjective examination: no complain. Objective examination: percussion (-), palpation (-). Radiograph showed there‟s no radiolucency in the periradicular area of tooth 15. The restoration that will be made for tooth 15 is porcelain fused to metal crown with fiber post.
Picture 7. Radiograph of tooth 15 was taken as control at the second visit 10 days after the first visit.
Picture 9. Radiograph of tooth 46. The restoration‟s extended to the orifice and there‟s lamina dura enlargement at the apical of mesial root.
MANAGEMENT OF CASE II First visit, anamnesis, clinical examination, radiographic examination, diagnosis and making treatment planning. The patient was explained about the treatment planning and was asked to sign the informed consent. Removing the resin composite restoration, removing seconder caries and cleaning the pulp chamber and orifice from the restoration material. The artificial wall was made with glass ionomer cement using universal matrix band. Isolation the tooth 46 using rubber dam. 20
Initial exploration using K-file size no. 10 but the file could not enter 1/3 apical of the tooth 46‟s root canals. This condition was known by using the electronic apex locator. Root canal exploration was continued using C Pilot file size no. 6, no. 8, no. 10 and K-file size no. 15. The working length was measured using electronic apex locator and made radiograph of tooth 46 as confirmation. The working length of the distal root canal: 22 mm. The mesial root canals had form that suitable with type II Vertucci‟s classification. When each root canal was measured separately, the working length of mesiobuccal is 21,5 mm and the mesiolingual‟s 21.5 mm. But when a file was put in the mesiobuccal root canal until the apical foramen – was confirmed with electronic apex locator and another file put in the mesiolingual, after the file entered the mesiolingual as long as 18 mm, the file could not enter further to the apical but when checked using the electronic apex locator the indicator showed that the file had reached the apical foramen. The working length was confirmed using the radiograph without rubber dam. After take the radiograph, the tooth 46 was isolated again using rubber dam. The glide path was made using K-file hand use size no. 15 according to the working length. Then shaping and cleaning the rooth canals using file Reciproc R25. Both mesial canals was prepared until the apical foramen, the working length confirm using the electronic apex locator that attached to the endodontic motor handpiece. Irrigation with NaOCl 2,5 % every two or three vertical movement of the file. Apical gauging using Kfile size no. 25. Final irrigation using NaOCl 2,5 %, EDTA 17 %, sterile aquadest and Chlorhexidine 2 %, 2,5 ml each. Fitting the R25 gutta percha cone in the three root canals and the radiograph was taken as confirmation. The calcium hydroxide was packed into the root canals and the temporary filling was put to close the cavity.
A.
B.
Picture 10. A. Clinical of tooth 46 after removing the resin composite restoration. B. Artificial wall from glass ionomer cement
Picture 11. Working length measurement. At the mesial seen that only one file could enter the 1/3 apical
Picture 12. Tooth 46 was seen from occlusal after shaping and cleaning the root canals using reciprocating file R25.
Picture 13. Fitting the gutta percha cone in the root canals of tooth 46. Only one gutta percha cone that could enter the 1/3 apical mesial root.
Second visit, 14 days after first visit. Isolating the tooth 46 using rubber dam, removing the temporary filling and cleaning the root canals from the medicament then the root canals was dried using paper point. Obturation of the root canals with R25 gutta percha cone and resin based root canal sealer. The gutta percha cone was cut at the orifices and doing the warm vertical condensation. Put glass ionomer cement as lining on the orifices. The cavity of tooth 46 was closed using temporary filling.
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Picture 14. The radiograph of tooth 46 after obturation of the root canals. Only one gutta percha cone could enter the 1/3 apical of the mesial root because two mesial canals become one canal in the apical.
Third visit, 7 days after second visit. Clinical examination, the temporary filling was good. Subjective examination, patient had no complain. Objective examination of tooth 46: percussion (-) and palpation (-). Tooth 46 was going to restore with porcelain fused to metal crown with fiber post but for temporary an acrylic provisional crown was put on the tooth 46 to avoid fracture of the crown.
Picture 15. Radiograph of tooth 46 at the follow up visit 7 days after the obturations visit.
DISCUSSION The root canal preparation mechanically was expected could give major contribution to reach the purpose of the root canal shaping and cleaning. The use of root canal files those designed for reciprocating motion could reduce the numbers of the root canal files that‟s needed to clean and shape the root canals. At case I, after making glide part using K-file size no. 15 with 0,02 taper the reciprocating file R25 was directly used then followed with the use of reciprocating file R40. This condition was able because R25 file has 0,08 taper so the root canal was not to narrow for the R40 file with 0,06 taper. Besides that, because the R25 file has quite big taper so the 2/3 coronal could be shaped without remove to much dentine int the apical. The result will facilitate the adequate irrigation into the root
canal and the debris will not be pushed to the apical by the irrigant. It also cut the time that‟s needed for the root canal preparation. The root canals shaping and cleaning of tooth 46 in the case II only using reciprocating file R25 after making the glide path. It could be done because the flexibility of R25 file that made from the Nickel Titanium and the design of the variable pitch flutes along the length of the instrument. Young et. al. said the technical purpose of the root canal preparation is to shape the root canal so the biological purpose could be achieved and could facilitate the obturation of root canal by put high quality material in the root canal.8 Schilder stated some mechanical purpose that suppose to get from instrumentation of the root canal: continuous tapering from the access cavity to the apical foramen, the preparation of the root canal should be able to maintain the original path of the root canal as before the intervention, the position of the apical foramen should be maintain originally, the opening of the apical part of the root canal should be as small as possible.9 The manufacturers of reciprocating files, Reciproc (VDW) and WaveOne (Dentply) stated that the reciprocating file could be use with or without making glide path. The glide path is still necessary to keep the original anatomy of the root canal.10 The reciprocating file was designed for single use and cannot be sterilized. The single use of endodontic files was further supported to reduce instrument fatigue and possible crosscontamination associated with the use of Ni-Ti rotary instruments for the root canal instrumentation.10 The reciprocating file system could be one of the root canal files that use to do shaping and cleaning the root canal with the gold standard result. REFERENCES 1.
Peters, O. A. dan Peters, C. I. Cleaning and Shaping of the Root Canal System. In : Hargraves, K. M., Cohen, S. dan Berman L. H. Pathway of the Pulp. St. Louis: Mosby Elsevier;2011.Page 283-341.
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2.
3.
4.
5.
6.
Saunders, E. M. Hand Instrumentation in Root Canal Preparation. Endod Topic. 2005; 10: 163-167. Webber, J., Machtou, P., Pertot, W., Kuttler, S., Ruddle, C. dan West, J. The WaveOne Single-file Reciprocating System. Clinical Technique_WaveOne. Downloaded from : http://www.endoexperience.com/documents/ WaveOne.pdf (at 15th June 2013). Haimed, A. S. A., Dummer, P. M. H. dan Bryant, S. T. Comparative Study of The Canal Shaping Ability of Reciprocating Versus Rotary NiTi Instruments In Curved Simulated Canals. IEJ. 2012. 45(11): 105562. Doi: 10.1111/j.1365-2591.2012.02066.x Tinoco, J. M., De-Deus, G., Tinoco, E. M. B., Savedra, F., Fidel, R. A. S. dan Sassone, M. Apical Extrusion of Bacteria When Using Reciprocating Single-file and Rotary Multifile Instrumentation Systems. IEJ. 2013. Doi: 10.1111/iej.12187. Brosur Produk VDW. There Are Two Ways of Using RECIPROC : With and Without Initial Hand Filing To Create A Glide Path. Downloaded from : http://www.vdw-
dental.com/en/products/reciprocatingpreparation/reciproc/clinical-use/glide-pathmanagement.html (at 25th June 2014). 7. Brosur Produk WaveOne. WaveOne Single File Technique With Reciprocation. Downloaded from : http://www.tulsadentalspecialties.com/defau lt/endodontics_brands/WaveOne_systems.as px (at 25th June 2014). 8. Young, G. R., Parashos, P. dan Messer, H. H. The Principles of Techniques for Cleaning Root Canals. Aust. Dent. J. 2007. 52(1 Suppl):S52-3. 9. Schilder, H. Cleaning and Shaping The Root Canal. Dent. Clin. North. Am. 1974. 18:3540. 10. Berutti, E., Paolino, D. S., Chiandussi, G., et. al. Root Canal Anatomy Preservation of WaveOne Reciprocating Files with or without Glide Path. JOE. 2012. 38: 101-104. Downloaded from : http://www.zahnheilkunde.de/beitragpdf/pdf _7398.pdf (at 22nd July 2014).
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Esthetic rehabilitation of a post-traumatic tooth through a comprehensive approach : a clinical case Maria Yovita Lisanti1, Juanita A. Gunawan2, Anastasia Elsa Prahasti2 1 Resident of Conservative Dentistry Specialist Program, Department of Conservative Dentistry Study Program, Trisakti University, Jakarta 2 Department of Conservative Dentistry Study Program, Trisakti University, Jakarta
ABSTRACT Background: Trauma to the anterior teeth may result in various problems in terms of esthetic and physical appearance. Trauma to the incisor may result in tooth fracture, malposition, and discoloration due to the necrotic pulp. A combination of endodontic and esthetic treatment is needed to restore tooth‟s functionality. Purpose of the study: To present an overview about a comprehensive treatment to a post-traumatic tooth with fracture and malposition. Clinical case: A 30 year old woman presented with a darkened anterior left tooth, and a history of trauma to the corresponding tooth about 20 years ago. Examination revealed a fractured crown on left central incisor with evident discoloration and malposition. Vitality test showed negative response. Radiography showed radiolucency at the apex of the corresponding tooth. Treatment: Endodontic treatment on the left central incisor, followed by intracoronal bleaching (walking bleach technique) and composite resin build-up restoration. Conclusion: A comprehensive treatment comprises of endodontic treatment, bleaching and composite resin restoration can repair tooth‟s esthetic and functionality after a trauma. Keywords: tooth fracture, necrotic pulp, bleaching, composite resin.
INTRODUCTION Crown fracture is a type of dental trauma that often occurs among children or adults.1 Trauma to the permanent tooth usually relates to collisions, traffic accidents, act of violence or sport accidents. Crown fracture occurs on almost 25% of the total patients.2 The majority of dental trauma occur on anterior teeth, in particular on the maxilla incisive. Maxilla incisive is the most susceptible tooth to a fracture due to its size and position in the dental arch. Compared to maxilla central incisors, mandibula central incisors and maxilla lateral incisors are rarely involved in a trauma.3 Trauma may cause a change in tooth‟s position, rotation, and intrusion of the anterior permanent teeth.3 Various factors determine the selection of treatment for each crown fracture case, such as: severity of fracture, pattern of fracture, secondary trauma to the soft tissue, tooth fragment and its relation to the remaining tooth structure, occlusion, esthetic and financial consideration, and the overall prognosis of the situation.1
Trauma may cause obstruction in the blood vessel, which leads to the damage of blood vessel, dilatation of the capillary vessel and degeneration of the capiller. Such degeneration of the capiller leads to pulpal edema. The pulpdentin complex is a closed system with a little collateral system. Pulpal edema with limited collateral sirculation leads to tissue infarction due to the ischemic condition and, on the advance stage, may result in pulpal necrose.4 A necrotic pulp, if left untreated, may trigger the formation of periapical lesion in the periodontal tissue. The body defense system and antibiotic therapy can not reach the bacteria biofilm which exist inside the necrotic pulp due to the reduction of the blood supply to the pulp. In such condition, the ability of the periradicular tissue to regenerate decreases due to the rampant bacteria toxin and its product in the pulpal system. Such decline in the regeneration ability may cause disorders in the periapical area. Bacteria biofilm in the root canal complex may be eliminated through a series of root canal procedures, such as mechanical instrumentation, antiseptic irrigation, and
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intracanal medication. When bacteria is effectively removed from the root canal, or when the root canal is obturated and the root canal system is adequately protected with no microleakage, then healing response and tissue regeneration may occur. Activation of healing response/tissue regeneration causes inflammatory area around the periapical to heal.4 Tooth discoloration post trauma occurs due to the penetration of bacteria products from the necrotic pulp towards the surrounding dentin tubules. The degree of discoloration is parallel to the duration of the necrotizing pulp. Tooth discoloration may also originate from the rupture of the capillary vessel caused by trauma. Blood, or blood‟s component, in the pulp chamber will diffuse into the dentin tubules. Then, haemoglobin is released through the haemolytic process of the blood cells, continued by degradation process that releases iron component. The iron component will form a bond with hydrogen sulfate of the bacteria product, resulting in a black iron sulfate component which will penetrate into the dentine tubules, hence, causing the discoloration. Generally, a tooth will manifest discoloration a few weeks, months, or years post trauma.5 In recent years, physical apperance has become widely recognised. Tooth discoloration directly affect a person‟s esthetic appearance. Various esthetic treatments have been developed over the years in an attempt to create beautiful smiles, including the alteration of tooth shape, texture, position and color.6 Technology advancement in dentistry enables esthetic treatments, such as dental bleaching and toothcolored restorations. Dental bleaching has become one of the most developed treatments due to the high demand. Dental bleaching is believed to be a conservative and effective treatment for tooth discoloration with satisfying esthetic result, compared to another invasive treatments such as dental veneers and crowns.8 Intracoronal bleaching is used for teeth that have undergone root canal treatment, and it is done by putting strong oxydator agent in the pulp chamber. Intracoronal bleaching can be performed through walking bleach technique, thermocatalytic technique, or combination of both. Procedure for walking bleach technique
starts with choosing the tooth color, using a shade guide, and preoperative photography is taken as a comparison of result. Working area is isolated using a rubber dam and the pulp chamber is cleansed from residual debris in the pulp horn and along the incisal edge of the cavity. Barrier material, such as glassionomer cement, IRM, polycarboxylate cement, or resin composite, is applicated in wing shaped design, laid on the endodontic obturation. Proximal area of the cementoenamel junction (CEJ) is approximately 2,4 mm coronal of the facial area of the CEJ. Bleaching gel is applicated in the pulp chamber towards the labial wall and pressed with a cotton pellet. Temporary restoration is then placed in 3 mm thickness.5 Patient is instructed to return in 5 days following placement of the Opalescence Endo. Post traumatic tooth needs adequate restoration for conserving the remaining teeth structure and fix the position and function of the teeth. Esthetic and function rehabilitation on anterior teeth is important for the patient. Fracture involving enamel and dentine can be restored with composite resin. A non-vital treated anterior teeth with losing one side of the proximal part, it can be restored by composite resin build-up restoration.3 Minimal lost of tooth structure after root canal treatment is indication of direct composite restoration. Composite resin is material consists of polymerized resin and strengthen by unorganic filler. Composite resin has compressive strength 280 MPa and modulus of elasticity 10-16 GPa, which are similar to natural dentine. A complete polymerized composite has a high esthetic value and strength enough due to the mechanism of bonding that lies within the restoration structure.8 CASE REPORT A 30-year-old woman came to Department of Conservative Dentistry and Endodontics, Trisakti University, Jakarta, reported complaint of discolored tooth in the upper anterior region. Patient reported that her teeth was fractured because of collision 20 years ago. Intraoral clinical examination revealed uncomplicated crown fracture (enamel-dentin fracture without pulpal exposure) in the
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maxilarry central incisor (tooth 21). The tooth fractured from the distal side. Tooth was grayish discolored and in malposition into mesio-labiotorso version due to the accident (Figure 1). A
B
Figure 1. A. Clinical view of tooth 21 at the first visit showing email dentine fracture on one-third incisal at the mesial side with severe discoloration due to pulp necrotic caused by trauma. B. Palatal view of tooth 21 showing malposition of the tooth caused by trauma.
Diagnostic testing was inconclusive on cold and electric pulp testing, but the patient reported sensitivity to percussion and there was no abnormal mobility. Overbite and overjet is about 2 mm. An intraoral periapical radiograph was taken, which revealed periapical radiolucency in relation to tooth 21 (Figure 2).
CASE MANAGEMENT The patient was given detailed information regarding the treatment procedure and written consent was obtained. A rubber dam was placed in position. Correct opening access preparation was performed and necrotic tissue was removed from the pulp chamber with hedstorm file and rinsed with 2,5% of NaOCl irrigation. Initial exploration of the canal was done using K-file #15. Electronic apex locator was used to measure the working length and it was confirmed through radiographic examination (Figure 3).
A
B Figure 3. Working length measurement of tooth 21 with Kfile #15: A. Clinical view; B. Radiographic confirmation of the working length.
Figure 2. Periapical radiograph showing periapical radiolucency in relation to 21.
Based on these findings, tooth 21 was diagnosed as asymptomatic apical periodontitis et causa pulp necrosis with discoloration and uncomplicated crown fracture (fracture code 873.61 WHO Classification of Dental Trauma and modified by Andreasen). The treatment plan were divided to noninvasive and invasive treatment. The noninvasive treatment was dental health education about daily preventive care, including proper brushing and flossing. A treatment plan of endodontic therapy, intracoronal bleaching, and composite restoration with mock-up technique was planned as invasive treatment for teeth 21.
Root canal were prepared with step back technique. Copious irrigation with 2,5% sodium hypochlorite was done throughout cleaning and shaping procedures. During canal preparation procedures, the canal was lubricated with 17% of ethylenediaminetetraacetic acid gel (EDTA) to chemically soften the root canal dentine and dissolve the smear layer, as well as to increase dentine permeability. Final preparation was held using K-file #60 (Master Apical File) with circumferential filing and the canal were irrigated with 2 mL of 2,5% sodium hypochlorite and 2mL of 2% chlorhexidine gluconate. After the biomechanical preparation the root canal was dried with paper points and a paste of calcium hydroxide (Ultracal, Ultradent, USA) were used as intracanal medication. Cavit (Cavit G, 3M ESPE, Germany) was used as a provisional restorative filling between visits. At the second appointment, there was neither subjective nor objective symptom reported by the patient. Calcium hydroxide were removed from the canal with NaOCl irrigation.
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Master cone gutta percha was fitted into the prepared canal. With the gutta percha cone fitted in the canal, a radiograph was taken to confirm fit of master cone. Prior to obturation, the canal was final irrigated with 2,5% sodium hypochlorite, followed by 17% EDTA solution (SmearClear, Kerr Endo, CA, USA), then rinsed with aquadest, and final irrigation with 2% of chlorhexidine (Consepsis, Ultradent, USA). The canal then dried with paper points. Calcium hydroxide based sealer (Sealapex, SybronEndo, CA, USA) was used as sealer. The obturation technique chosen was the cold lateral condensation. Gutta percha was cut 3 mm apically to the orifice and the pulp chamber was cleansed with cotton pellet. The pulp chamber was prepared for walking bleach intracoronal bleaching. An impermeable base of glass ionomer cement (Fuji II, GC, Japan) with wing shaped design was laid on the rootcanal filling material. The aim of this barrier was to provide an adequate cervical seal that will prevent the hydrogen peroxide from penetrating the root at the cementoenamel junction (CEJ). The access cavity was temporarily sealed with provisional restorative filling (Cavit G, 3M ESPE, Germany).
were placed in the pulp chamber and condensed with a cotton pellet. A piece of dry cotton was placed over the gel and the access cavity was double sealed with zinc phosphate cement (Elite Cement, GC, Japan) and Cavit (Cavit G, 3M ESPE, Germany). The patient was recalled after 5 days for a review. At the next visit, the tooth showed a definitive improvement in the shade. The color became same with the adjacent tooth. The patient was satisfy with the result of bleaching procedure. So, internal bleaching procedure was stopped. Bleaching agents were removed from pulp chamber and the cavity was rinsed with warm aquadest to remove all the residual of oxidation-reduction reaction from the bleaching agents. The cavity was dried and temporary restorative filling was placed. The patient was scheduled after 2 weeks for final restoration. An alginate material was used to take a full arch impression. Preoperative wax up and silicon index from polyvinylsiloxane impression were made as reference for making the composite build-up restoration.
A
B Figure 5. Bleaching result in tooth 21. A. Preoperative photograph of tooth 21 before intracoronal bleaching. B. Five days after intracoronal bleaching, there was obvious tooth color change.
Figure 4. Radiograph showing obturation of tooth 21.
At the third visit, one week after the second visit, the patient did not have any complaint. Clinical and radiographic examinations were carried out. Radiographic examination showed that the periapical lesion was healed. The color of tooth 21 was evaluated using shade guide (VITA shade guide) and a photographic baseline notation was taken before the bleaching procedure. A rubber dam was applied to ensure the complete isolation of the tooth. Bleaching gel consist of 35% hydrogen peroxide (Opalescence Endo, Ultradent, USA)
Figure 6. Wax mock up and silicon index of tooth 21.
Two weeks after the last visit, temporary filling was removed from the cavity. Reduction of 1,5 mm facial enamel was done using diamond tapered bur. The reduction was more on the mesial side to eliminate the overlapping enamel and fix the malposition of tooth 21. A long bevel was made at the facial marginal line angle. The 27
color of tooth was evaluated using shade guide (VITA Shade Guide), and due to the evaluation the color of tooth 21 was A2 at the dentin, and A1 at the enamel part. The silicon index was seated on the tooth from the palatal side as the reference to rebuild the contour of the tooth. Tooth 21 was restored with direct composite restoration using the incremental layering technique. Dentine shade was used to build-up the internal tooth structure and areas of enamel and incisal was built with translucent shade. The last steps were finishing and polishing the restoration. Finishing and polishing were completed with enhance polishing system and rubber polishing point with aluminosilicate/composite polishing paste. Interproximal area was stripping with diamond strip. Occlusion and articulation were checked with articulating paper. After 1 month, the patient came for follow up. There was no complaint reported and the patient is satisfy with final result of the treatment. B A
Figure 8. Complete restoration of tooth 21 at the follow-up appointment. B. Final periapical radiograph of the endodontic treatment on tooth 21.
DISCUSSION Dental trauma can cause damage in hard tissue or periodontium tissue. Anterior tooth is instrumental in one‟s esthetic appearance. Trauma to anterior tooth can cause fracture of the crown, tooth detachment from the socket, tooth discoloration, or change the position of the tooth. This condition will interfere with the function and esthetic of the anterior tooth. Proper treatment of the traumatic anterior tooth can fully restore one‟s tooth function and esthetic. 2.9 The first treatment in post-traumatic teeth with necrotic pulp is root canal treatment.
In this case, root canal treatment was done to eliminate the bacteri that were present in the root canal so that the periapical healing could occur. Calcium hydroxide was used as intracanal medicament for it acts as an anti-inflammatory, neutralizing the acid product, eliminating bacteria, and accelerating healing. Obturation was completed with gutta percha combined with calcium hydroxide based sealer with lateral condensation technique. Esthetic problems relating to posttraumatic tooth discoloration can be tackled with intracoronal bleaching treatment. Besides invasive and expensive conventional restorative options, such as full crowns or veneers, whitening of teeth is an alternative therapeutic method. Internal bleaching procedures such as the “walking bleach” technique can be used for whitening of discolored root-filled teeth, which is simple and time-saving method with superior esthetic results and safety. Non-vital bleaching treatment is especially indicated for discolored teeth due to dentral trauma where tooth is in the esthetic zone, with minimal loss of tooth structure.10 This case used 35% of hydrogen peroxide (H2O2) as bleaching agent. The teeth whitening mechanism is based on oxidation reaction and decomposition of the double chain stain molecules. Effects of whitening tooth occurs because the molecular weight of the large stain is broken down into smaller moleculus, that can diffuse through the semi-permeable membrane on the tooth surface.11 Tooth discoloration caused by organic compounds, such as FeS, will oxidize. The chemical reaction that will occur is as follows : 2H2O2 → 2H2O + O2 FeS + O2 + H2O → Fe2O3 + H2S FeO (white) + O2 The end result of the oxidation reaction is FeO which is brighter in color, resulting in the disappearance of the dark coloring.12 In this case the tooth whitening technique performed was walking bleach. This technique is performed by application of gel consisting of 35% hydrogen
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peroxide (H2O2) in the pulp chamber. The walking bleach technique can lead to successful whitening of non-vital root filled teeth without the risks of side-effects. This technique is easy to perform, consumes the least time, relatively inexpensive and requires no special equipment.10 Resin based restoration material is the most often used to restore tooth fracture. Composite resin has color and translucence similar to the dentin and enamel, and thus resulting in better esthetic in anterior tooth restoration. In this case, restoration was done through several steps, such as tooth preparation providing extra retention by making long bevel on marginal line angle, isolation of the tooth area with a retraction cord, and the provision of acid etching and adhesive bonding to the tooth structure. Acid etchant of 37% phosphoric acid was applied to remove the smear layer, to form micropores on enamel surface, and to expand the area for the adhesive material/bonding provision. Adhesive bonding application aims for mechanical interlocking with the formation of resin tags. Malposition tooth repair was done first on a working model and mock up made from red wax according to the ideal shape. Restoration placement in tooth was done using mock up technique with the silicon mold or silicon index to facilitate the formation of dental anatomy, especially in the palatal section. The silicon index provided a boundary for the outer contours of the restoration in the incisal and palatal direction, so that the contour of the tooth could easily be recreated when fabricating the definitive restoration. The choice of color and good anatomy formation is a key esthetic improvement on the anterior teeth. CONCLUSION Trauma on the anterior tooth can result in many problems which influence one‟s esthetic appearance. In this case reported before, a trauma caused uncomplicated fracture on the anterior teeth which was followed by pulp necrotic, changing position of the tooth, periapical lesion formation, and tooth discoloration. Treatment of dental trauma is complex and requires a comprehensive treatment plan, including
endodontic treatment and esthetic approach. In this case, the treatment included root canal treatment, followed by intracoronal bleaching and a composite resin build-up restoration. An accurate diagnose and a comprehensive treatment plan can restore the function and esthetic of a post traumatic tooth. REFERENCES 1. Macedo, GV, Diaz, PI, Fernandes, CA, dkk. Reattachment of Anterior Teeth Fragments: A Conservative Approach. J Esthet Restor Dent.2008;20:5-20. 2. Krishna, A, Malur, MH, Swapna, DV, dkk. Traumatic Dental Injury – An Enigma for Adolescents: A Series of Case Report. Case Report in Dentistry.2012;756526.doi 10.1155/2012/756526. 3. Turkasian, S dan Turna, C. The Esthetic Rehabilitation of Misplaced Dental Arch After Fracture of Anterior Maxillae: A Case Report. Cases J.2009;2: 8723. 4. Hagreaves, KM, Cohen, S, editors. Cohen‟s Pathway of the Pulp. 10th ed. St. Louis:Mosby; 2011. 5. Halim, HS. Perawatan Diskolorasi Gigi Dengan Teknik Bleaching. Jakarta: Universitas Trisakti; 2006. 6. AlQahtani, MQ. The Effect of a 10% Carbamide Peroxide Bleaching Agent on The Microhardness of Four Types of Direct Resin-based Materials. Oper Dent.2013;38:316-23 7. Tezel, H. dan Kemaloglu, H. Susceptibility of Enamel Treated With Bleaching Agent to Mineral Loss After Cariogenic Challenge. JAFMC Bangladesh 2010;6:75-92. 8. Powers, JM, Sakaguchi, RL. Craig‟s Restorative Dental Materials. Ed. 12. St.Louis:Mosby;2006. 9. Anchieta, RB, Rocha, EP, Watanabe, MU, dkk. Recovering The Function and Esthetics of Fractured Teeth Using Several Restorative Cosmetic Approach. Dent Traumotol.2012;28:166-72. 10. Nagaveni, N.B., Umashankara, K.V., Radhika, N.B., Satisha, T.S. Management of Tooth Discoloration in Non-vital Endodontically Treated Tooth-A Report of 6
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Year Follow-Up. J Clin Exp Dent. 2011; 3(2):180-3. 11. Freedman, G. Contemporary Esthetic Dentistry. St. Louis: Missouri; 2012. Hlm.341-403.
12. Sony, PL. Textbook of Organic Chemistry. Ed Ke-10. New Delhi: Sultan Chand & Sons; 1976.
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Esthetic rehabilitation in endodontic failure case of maxillary left lateral tooth (case report) Ingrid Natasha1, Yanti L. Siswadi2, Eko Fibryanto2 1 PPDGS, Bagian Konservasi Gigi, Fakultas Kedokteran Gigi, Universitas Trisakti 2 Staf Pengajar Bagian Konservasi, Fakultas kedokteran Gigi, Universitas Trisakti
ABSTRACT Background: Tooth discoloration, inadequate restoration, and irregular tooth position have great effect on esthetic. As the post-endodontic restoration technique develops , estethic correction of anterior teeth can be easily achieved by preserving healthy tissue as much as possible. Purpose: To correct esthetic and endodontic re-treatment of maxillary left lateral incisor due to inadequate previous endodontic. Case Report: 26-years old female patient presented a symptom on her left anterior tooth when biting and was endodontically treated. On clincal examination, tooth discoloration and Class IV composite restoration was found on mesial portion of the tooth. Radiographic view showed a radiolucency on periapical of tooth with inadequate root canal oburation and widened lamina dura. Management: Restoration was removed and root canal re-treatment was done. Followed by intracoronal bleaching and restoration replacement. Palatal portion was restored with direct composite. Direct veneer of resin composite was used as final restoration to correct the tooth esthetic view. Conclusion: Rehabilitation of anterior teeth esthetic view is able to achieved with combination of intracoronal bleaching and resin composite direct veneer. Keywords: non-surgical root canal re-treatment, esthetic, intracoronal bleaching, restoration, resin composite direct veneer
INTRODUCTION Color, shape, structure, and position aberration of anterior teeth can cause esthetic matter to the patient (1). To restore natural esthetic of teeth is important to dentist. Esthetic function is important, especially for anterior teeth, besides phonetic and other function. One of the most common problem found in anterior teeth is discoloration. This can due to extrinsic and intrinsic factors. Discoloration caused by extrinsic factor only affect the outer surface of tooth, including colored food and beverages, smoking, and chlorhexidine mouthwash. While intrinsic factor consisted of endogenous factors originated from both local and systemic sources (2) . Discoloration caused by intrinsic factor includes trauma haemorrage, pulp tissue decomposition, medication effect, root obturation and restoration material. (2). Root obturation material can caused discoloration if left in pulp chamber and located superior to gingival margin. Gutta percha is the commonly used material for obturation, but has been reported to cause pinkish discoloration. Root obturation material has the
potential for discoloration due to un-reacted component or component corrosion as the consequence of humidity and / or chemical interaction with dentin. Root canal obturation material has different color before mixed, therefore it is possible to experience chemical interaction with dentin after color mixture and physical alteration during setting (3). Treatment options for tooth discoloration include: bleaching, veneer, extraction followed with denture or implant placement. Treatment option depends on tooth structure, operator's skill, and periodontal tissue health condition. Defective tooth shape and position, extensive caries, and poor restoration must be noticed by dentist. Treatment for tooth with defective shape and position can be divided into two categories, direct and indirect restorations. Direct restoration includes resin composite veneer restoration, while indirect restoration includes crown and veneer (4). Resin composite direct veneer can be done with or without preparation, depends on the tooth requirement. For intact tooth crown with abnormal color or shape alteration, resin composite direct veneer can become the
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treatment option. Indication of resin composite direct veneer includes enamel hypoplasia, agenesia of lateral insicor, diastema, irregular tooth position, and discoloration due to necrotic pulp or inadequate root canal treatment (5). This case report will discuss the esthetic correction of tooth with failed endodontic treatment and discoloration, along with defective shape and position. CASE 26-years old female patient presented to tooth conservation specialist clinic of RSGM FKG Trisakti to check her upper left anterior tooth (tooth 22) which had discoloration and tenderness when used to bite. The tooth had been endodontically treated by a dentist. Clinical examination on tooth 22 showed discoloration and Class IV resin composite restoration on mesial part of the tooth (Figure 2). Objective examination: palpation negative, percussion positive (uncomfortable), and thermal test negative. Radiographic evaluation showed radiolucency on periapical part with inadequate rooth canal obturation and widened lamina dura (Figure 3). Diagnosis for tooth 22 was chronic apical periodontitis post endodontic treatment. The treatment plan was non-surgical root canal re-treatment with intracoronal bleaching to correct tooth color and followed by resin composite direct veneer.
a B Figure 2. tooth 22, discooration and Class IV resin composite restoration was found on mesial part of tooth. Labial view (a) and palatal view (b)
Figure 3. Radiographic showed inadequate rooth canal obturation, radiolucency on apical part of tooth 22, and widened lamina dura.
CASE MANAGEMENT Treatment was initiated by cavity access opening of tooth 22 with endo access bur (Dentsply) and rubber dam placement (Figure 4). Gutta percha was removed with Hedstroem file marked with rubber stop to the length defined through radiographic and aided with xylol solution. After the entire gutta percha was removed from root canal, tooth 22 was radiographed to confirm that no gutta-percha was left in root canal. Tooth 22 was then prepared with crown down technique using Rotary Pro Taper. First, exploration was done with K-file #8, #10, and #15 according to 2/3 temporary working length obtained from pre-operative radiograph. After each file, irrigation was done with 5 mL NaOCl 2,5%. S1 file was used with 2/3 estimated working length, followed by working length measurement with apex locator (VDW Gold, Germany). Working length was confirmed with radiograph using file #15 (Figure 5). Working length obtained for tooth 22 is 20 mm. Preparation was then proceeded with file S1, S2, F1, F2, and F3 according to the working length and each file was coated with EDTA. After that, apical gauging was done with K-file #30, irrigated with 5 mL NaOCl 2,5% and dried with paper point. The next step was medicament placement into the canal, namely Ca(OH)2 (Ultracal,Ultradent), followed by temporary restoration (cavit-G, 3M Espe). Patient was instructed to return next week.
b
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Figure 4. Access opening and rubber dam placement Figure 6. Confirmation of gutta percha obturation result
Figure 5. Radiograph confirmation of tooth 22 working legth
On second visit, examination was done on tooth 22. Percussion test showed negative respond and no subjective complaint. Temporary restoration was removed, irigation of tooth 22 was done with 5 mL NaOCl 2,5% to clean the Ca(OH)2, followed by EDTA 17% and chlorhexidine gluconate 2% (Consepsis, Ultradent) irrigation. Root canal of toth 22 was dried with sterile paper point. Root canal obturation was done by single cone technique with ProTaper F3 gutta percha and root canal sealer (Sealapex, Sybronendo). Obturation was then confirmed by radiograph (Figure 6). Gutta percha was cut 2 mm below orifice, apically to root canal and vertical condensation was done using heat carrier (System B) and plugger, then glass ionomer cement (Fuji I, GC) barrier was placed until cementoenamel junction border. Cavity of tooth 22 was closed with temporary restoration (Cavit-G) and patient was instructed to return next month to follow-up the periapical lession and initiate intracoronal bleaching procedure.
On third visit, tooth 22 was evaluated and no complaint was found. Treatment was then continued with intracoronal bleaching procedure, started with initial shade determination using shade guide and A3,5 shade was chosen (Figure 7). Tooth 22 was isolated with rubber dam and temporary restoration was removed, followed with 2 mm of wing-shaped barrier placement (thicker on the proximal) using glass ionomer cement (Fuji II, GC). Bleaching material contained 35% hydrogen peroxide (Opalescence Endo, Ultradent) was placed superior to barrier on labial, cotton pellet was placed and double seal technique with zinc phosphat cement (Elite Cement, GC) and cavit-G was done to prevent leakage. Patient was instructed to return 3-5 days later.
Figure 7. Tooth 22 before intracoronal leaching treatment
On fourth visit, tooth 22 was found brighter and shade determination with Vitapan shade guide (Vita Zahnfabrik) obtained the desired color, namely A1 (Figure 8). Bleaching material was removed from pulp chamber, irrigated with aquadest solution for total cleaning, cavity of tooth 22 was dried with cotton pellet, and temporarily restored with Cavit-G. Patient was instructed to return 2 weeks later to receive resin composite restoration.
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Figure 8. Tooth 22 after intracoronal bleaching treatment.
Fifth visit, shade of tooth 22 is similar to the adjacent teeth, therefore resin composite restoration of tooth 22 was continued and the old resin composite restoration on the mesial part was replaced to mimic the tooth color after intracoronal bleaching (Figure 9). First, cavity was etched (phosphat acid 35%) (3M ESPE) for 15 seconds, rinsed, and dried. Dentin bonding (Prime Bond, Dentsply) application on the entire tooth cavity was done with microbrush, and activated by light (Light cure) for 20 seconds. The procedure was continued with resin composite restoration on the palatal part of tooth 22 and Class IV resin composite replacement on the mesial part. Patient was reminded to return one month later to evaluate periapical lesion and resin composite direct veneer placement.
Figure 9. Tooth 22 after replacing the restoration
After one month, periapical lesion was evaluated with radiograph, and was found to be reduced in size (Figure 10). Resin composite direct veneer procedure was done to correct the tooth esthetic view. Initial step was done by taking impression of upper and lower arch using alginate for study model, and then mock up was made on study model by shaping the labial and incisal part of tooth 22 using red eax (Figure 11). Silicone index was made with putty type polyvinylsiloxane impression material as the labial and incisal guideline when fabricating direct veneer (Figure 12).
Figure 10. Periapical lesion control
Figure 11. Mock up on tooth model
Figure 12. Silicone index as guideline in resin composite direct veneer fabrication
On the next visit, minimum preparation was made on labial part of tooth 22, followed with retraction cord placement (Figure 13). Adjacent teeth of tooth 22 were covered with plumber tape for protection during resin composite direct veneer process (Figure 13). Tooth 22 was etched (phosphat acid 35%) (3M ESPE) on the labial surface for 15 seconds, rinsed with water, and dried. Dentin bonding (Prime Bond, Dentsply) was applicated to the labial surface with microbrush, and activated with light (Light cure) for 20 seconds. The next step was direct fabrication of resin composite veneer.
Figure 13. Retraction cord placement and plumber tape placement on tooth 21 and 23
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Direct veneer fabrication using resin composite (Premisa, Kerr) with silicone index guideline was started with A1 email shade placed on the silicone index with 2 mm thickness, and polimerized with light cure for 20 seconds. After labial and incisal wall guidelines were obtained, fabrication was continued with application and condensation of B1 dentin shade, carved to adapt the dentin anatomy, and activated with light cure for 20 seconds. It was recommended to not apply dentin shade in thick portion in order to adapt adjacent teeth anatomy. Completed veneer were removed from silicone index and polished with polishing bur to made up the veneer edge. B1 dentin shade resin composite was then placed without light cure polimerization and veneer was inserted to tooth 22 by condensating veneer so that the unpolimerized resin composite could adapt the tooth shape (Figure 15). Composite deficiency on the proximal could be filled with flow resin composite material and seluloid strip to obtain proximal contour and polimerized with light cure. The following steps were polishing and contouring.
Figure 15. Inserting resin composite direct veneer of silicone index to tooth 22
Figure 16. Radiograph confirmation after resin composite direct veneer fabrication and periapical lesion was no more observed
FIgure 17. Before (a) and after (b) resin composite direct veneer fabrication
a b
DISCUSSION In this case, patient expected esthethic correction for her anterior tooth which had received failed endodontic treatment. Tooth discoloration, inadequate restoration, irregular shape and position were found. Tooth discoloration found in this case was caused by several factors, namely pulp tissue decomposition after tooth necrosis or root canal treatment and uncleaned necrotic tissue left in pulp chamber. Beside that, discoloration could be due to medication and root canal obturation material. Root obturation material can cause discoloration if left in pulp chamber or superior to gingival margin. Root obturation material or medication that have the potential to cause discoloration usually contain zinc oxide eugenol cement, nitrate silver which can cause dark grey discoloration, iodine and iodoform compound which can cause greyish to brownish discoloration, while metal salts and several essential oil like cassia oil can cause brownish discoloration. (2). Gutta percha is one of the most commonly used obturation material yet can cause pinkish discoloration. Root canal obturation material has different color before mixed, therefore it is possible to experience chemical interaction with dentin after color mixture and physical alteration during setting (3). Several techniques are available to overcome discoloration on endodontically treated teeth, namely walking bleach technique, thermocatalytic technique, or combination of walking bleach and thermocatalytic (2). Walking bleach technique is the most common tooth bleaching technique. In this case, walking bleach technique was chosen because of it's safety and ease of use. Materials used in walking bleach technique are hydrogen peroxide and natrium perborate. Bleaching material used in this case was hydrogen peroxide 35% (Opalescence Endo, Ultradent). In intracoronal bleaching technique,
35
the usage of bleaching material must be thorough, therefore barrier or endodontic seal placement must be noted. Barrier is placed between root canal obturation and bleaching material. Barrier placement must be noted carefully due to high and fast penetration of peroxide through dentin tubuli. Beside that, bleaching material can cause external and internal resorption (6). Barrier was made wingshaped on proximal part (Figure 18) using glass ionomer cement, IRM (Intermediate Restorative Materials), polycarboxylate cement, and resin composite or cavit with 2 mm thickness over the endodontic obturation (2).
This case also needed special consideration due to abnormal position, namely rotation. Part of tooth that came out towards labial and located out of desired arch must be removed before preparation based on ideal arch, while the other part that was located behind the desired arch just needed to be roughened or slight enamel removal (Figure 19) (4).
Figure 19. Preparation plan diagram for rotated tooth (4)
Figure 18. Three-dimension configuration of endodontic seal (6)
In this case, bleaching was done in the beginning because at first the patient didn't expect tooth shape correction, therefore veneer was done after bleaching. Tooth with irregular position and shape can be corrected with veneer. There are two types of veneer, namely composite veneer and ceramic indirect veneer (4). Resin composite direct veneer was chosen in this case due to minimal tooth preparation, didn't require dental technician, able to be made directly in one visit, more affordable compared to ceramic indirect veneer, and set aside the long laboratorium procedure (1, 7, 8). However, resin composite direct veneer has disadvantages in durability and fracture if compared to ceramic indirect veneer. In this case, resin composite direct veneer was chosen because the patient demanded one visit and affordable treatment. There were several considerations in resin composite direct veneer procedure. Including: (1) tooth in normal position with slight discoloration or teeth with extreme or dark shade; (2) tooth with abnormal position like rotation, palatoversion, protrusive, and diastema closure; (3) on lower teeth; (4) on teeth with old restoration.
Restoration choice is crucial for successful treatment, therefore function, esthetic, and restoration strength must be taken into consideration, and also the amount of tooth structure removal (1). DAFTAR PUSTAKA 1.
2.
3.
4. 5.
6.
7.
Korkut B,Yanikoglu F, Gunday M. Direct composite laminate veneers: three case reports. JODDD. 2013;7(2):105-11. Halim HS. Perawatan diskolorasi gigi dengan teknik bleaching. Jakarta: Penerbit Universitas Trisakti; 2006. Ahmed HMA dan Abbott PV. Discolouration potential of endodontic procedures and materials: a review. Int Endod J. 2012;45:883-97. Dharma RH. Veneer. Jakarta: PT. Dental Lintas Mediatama; 2001. Mangani F, Cerrutti A, Putignano A, Bollero R, Madini L. Clinical approach to anterior adhesive restorations using resin composite veneers. The European Journal of Esthetic Dentistry. 2007;2(2):28-51. Rismanto DY, Dewayanti IM, Dharma RH. Dental whitening. Jakarta: PT. Dental Lintas Mediatama; 2005. Medeiros de Araujo E, Baratieri LN, Monteiro S, Vieira LCC, Cakleira de Andrada MA. Direct adhesive restoration of
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anterior teeth: part 2. clinical protocol. Pract proced Aesthet Dent. 2003;15(5):351-7.
8.
Filho EG. An innovative direct technique for resin composite veneers for teeth with color alterations. Quintessence Int. 1998;29:731-5.
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ROOT CANAL TREATMENT OF RIGHT MANDIBULAR PREMOLAR WITH ANOMALY TYPE IV WEINE
FIRST
Hendriyanto Wijaya1, Sri Subekti Winanto2, Meiny Foda Amin Djamal2 1 PPDGS, Conservation Section, Faculty of Dentistry, University of Trisakti 2 Conservation Section, Faculty of Dentistry, University of Trisakti
ABSTRACT Background: Anatomy and morphology of root canal determine parameters endodontic treatment that will be achieved and affect the success of treatment directly. Internal morphology of mandibular premolars have a highly variable. This is because of the possibility that the root canal is more than one. Therefore, it is important for dentists to understand the root canal anomalies. Case: 49 years old female patient came with a reference to root canal treatment complications. Case management: root canal treatment at right mandibular first premolars with root canal anomaly type IV Weine. Conclusion: Knowledge of root canal anomaly is needed to determine successful root canal treatment. Keywords: Anomaly in root canal, root canal treatment, mandibular premolar
INTRODUCTION
OBJECTIVE
Knowledge the morphology and anatomy of the root canal variations are very important in achieving successful root canal treatment. And then followed by negotiations, cleaning, shaping, and obturation of the root canal system in three dimensi.1,2 Ingle1 reported that the most significant cause of the failure of root canal treatment is root canal instrumentation which not perfect, followed by wrong root canal obturation. Slowey3 said that maybe because of variations in the anatomy of root canal, mandibular premolar is the hardest to do root canal treatment. Variations in root canal morphology is regarded as the highest frequency possible reason for the occurrence of flare-up and failures in root canal treatment.3-5 Mandibular premolar usually has single root with single root canal system.4 There are also some case report and anatomic studies have reported the number of roots and root canals which is very varied. Morphology of root and root canal of the mandibular premolar can be very complex and variation.6 There are several factors that may contribute the differences in anatomy of root canal such as ethnic, age, and gender.
The purpose of this case report is to perform root canal treatment in mandibular premolar with root canal anomalies. CASE REPORT Female patients, 49 years came to the RSGM(P) Trisakti University by referral from colleagues for root canal treatment, on the lower right region. Clinical examination of the teeth 44 with class II cavities on the disto occlusal and reach the pulp chamber. Teeth 44 is not sensitive to the vitality of dental examinations using chlor ethyl and EPT (electric pulp tester), sensitive to percussion and there is no tooth mobility. At radiographic examination is seen the lamina dura thickening. Root canal branches in third apical which is anomaly type IV Weine. Diagnosis of 44 is pulp necrosis.
A
Figure 1. A. From the occlusal, teeth 44 with class II cavities in the distal. B. Overview radiography. Seen root canal branches in third apical (class IV Weine)
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Treatment plan consists of a noninvasive and invasive. Non-invasive treatments include administration of Dental Health Education about the correct way of brushing teeth, brush your teeth twice a day (in the morning and evening), flossing daily, reducing of sweet and sour food between meal times, and increase water intake. Invasive treatment of the teeth 44 is root canal treatment. On the first visit, doing subjective and objective examination, taking intra oral photos, radiographs, diagnosis, scaling, followed sign Informed Consent to approve the plan and the cost of treatment. After that, remove of caries and make access of cavity in 44, followed by the manufacture of artificial wall using a glass ionomer cement. Matrix was mounted on 44. To prevent the materials entry into the pulp chamber, the access cavity was closed with a cotton pellet moistened with water. Then do the mounts of a rubber dam for isolation of the work area.
A
lubricated with 15% EDTA gel (RC-Prep). Each turn of the files, the root canals were irrigated with 2 mL of 2,5% NaOCl to prevent debris to the apical. Finishing of preparation followed by apical gauging to determine that preparation is enough with the last file is K-file # 30 along the working length of each root canal. Furthermore, root canals were irrigated with 2 mL of 2,5% NaOCl and dried with sterile paper points. Do intracanal medicament administration by using a paste that contain Ca (OH)2 (Ultradent), then the cavity was filled with temporary filling. Patients were instructed to return one week after the first visit.
B
Figure 2. (A). Clinical features after removal of dental caries 44 and matrix was mounted for the manufacture artificial wall. (B). Clinical features after rubber dam was mounted.
Pulp chamber was irrigated using 2,5% NaOCl to clean up all the debris. Biomechanical preparation was done with ProTaper Rotary Instruments. Initial exploration of the root canal using a K-file #8, #10 and #15 along the estimates of working length that obtained from preoperative radiographs minus 3mm. Then followed by the measurement of working length using electric apex locator and confirmed by using radiograph. The result of working length is 19 mm on the buccal root canal and 19 mm at the lingual root canal (Figure 3). And then, root canal preparation using rotary files S1, S2, F1, F2, and F3 along the working length of both root canal. During biomechanical preparation, file was
Figure 3. Working length radiograph measurements on 44 teeth with two root canals. Buccal root canal: 19 mm (red arrows) and Lingual: 19 mm (yellow arrows)
One week after first visit, no subjective and objective complaints. Rubber dam was mounted to isolation work area. Temporary filling was removed and root canals were cleaned of calcium hydroxide with irrigation by 2.5% NaOCl. Gutta percha F3 was sterilized by soaking in a solution of 2.5% NaOCl for 1 min and rinsed with alcohol. Then, do the fitting of Master Point with gutta percha F3 on both the root canal. 19 mm for buccal root canal and 19 mm for lingual root canal and then confirmed by radiograph.
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Controls carried out one week after the second visit, patients were satisfied and no subjective and objective complaints.
Figure 4. Buccal root canal 19 mm with gutta percha F3 (red arrow) and lingual root canal with 19 mm with gutta percha F3 (yellow arrows)
Befor doing obturation, root canal was irrigated with a 2 mL of 2.5% NaOCl to eliminate organic tissue within the root canal, followed by 2 mL of 17% EDTA to remove the smear layer, then rinsed with 2 mL aquabidest, and the last irrigation is 2mL of 2% chlorhexidine gluconate as an anti-bacterial. Obturation the root canal with single cone technique using sealer (Sealapex) on the wall of buccal and lingual root canal. First, obturation was performed in lingual root canal that is not a straight line, while the straight buccal root canal was inserted by spreader with the same size as the master points to prevent the entry of gutta-percha. After lingual root canal obturation done, spreader was pulled out and then do the obturation in buccal root canal. After that gutta percha was cut at the orifice by using the System B heat carrier and performed vertical condensation to 2 mm apical direction and then confirmed by radiograph (Figure 5). Then continued with giving the barrier using glass ionomer cement (Fuji IX, GC) and the cavity was filled by glass ionomer cement (Fuji II, GC) as a temporary filling.
Figure 5. Obturation root canals and giving barrier using glass ionomer cement.
DISCUSSION Mandibular premolar is one of the most difficult teeth for the endodontic treatment.7 This can be attributed to variations in the internal morphology of their pulp cavity, considering the number of root canals, apical deltas and lateral canals.8 In addition, the access cavities in these teeth are relatively small, hence reducing the visualization of the area. A wider endodontic access is necessary to locate extra root canals.9 Preoperative radiographs are used to identify anatomical alterations of the root canal system. The analysis of the anatomical aspects of pulp chamber roof can also help identifying these internal variations thus, facilitating the properly location of all root canals.8 During radiographic examination, a careful interpretation of the periodontal ligament space could suggest the presence of an extra root canal. Indeed, in the present case, it can be noticed a sudden change of the radiopacity of the canal space. in order to better visualize the pulp chamber, the access cavity should have divergent walls to the oclusal face.10 In this case, some resistance was felt during the initial negotiation of canals with #08 and #10 instruments, indicating the presence of more root canals. it is important to use tactile sensibility and also observe the direction of the endodontic instrument during its introduction into the canal. After localization of the canals, preflaring of cervical root section allows the correct determination of the initial instrument, and for better cleaning and obturating of the apical third of the root canal.
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REFERENCES 1.
2.
3.
4. 5.
6.
Ingle JI. A Standardized Endodontic Technique Utilizing Newly Designed Instruments and filling materials. Oral Surg Oral Med Oral Pathol 1961; 14: 83–91. Walton R, Torabinejad M. Principles and practice of endodontics. 2nd ed. Philadelphia: WB Saunders Co, 1996. Slowey RR. Root canal anatomy: road map to successful endodontics. Dent Clin North Am 1979; 23: 555–573. Ingle J,Bakland L. Endodontics. Ed-5. Hamilton: BCDecker, 2002. England MC, Hartwell GR, Lance JR. Detection and Treatment of Multiple Canals in Mandibular Premolars. JOE 1991; 17: 174-178. Sert S, Aslanalp V, Tanalp J. Investigation
of the Root Canal Configurations of Mandibular Permanent Teeth in the Turkish Population. Int Endod J 2004; 37: 494-499. 7. Awawdeh LA, Al-Qudah AA. Root Form and Canal Morphology of Mandibular Premolars in a Jordanian Population. Int Endod J 2008; 41: 240-248. 8. De Moor RJG, Calberson FLG. Root Canal Treatment in a Mandibular Second Premolar With Three Root Canals. JOE 2005; 31: 310- 313. 9. Tzanetakis GN, Lagoudakos TA, Kontakiotis EG. Endodontic Treatment of a Mandibular Second Premolar with Four Canals Using Operating Microscope. JOE. 2007; 33: 318-321. 10. Soares LR, Arruda M, Arruda MP, dkk. Diagnosis and Root Canal Treatment in a Mandibular Premolar with Three Canals. Braz Dent J 2009; 20(5): 424-427.
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Clinical Management of Broken Files in 1/3 Apical Root Canal with Dental Operating Microscope: 3 Case Reports Arif Abdul Gani1, Sri Subekti Winanto2, Ade Prijanti3, Bernard O. Iskandar3 1. Postgraduate student, Department of Conservative Dentistry, Trisakti University 2. Head of Postgraduate Program of Conservative Dentistry, Trisakti University 3. Lecturer of Postgraduate Program of Conservative Dentistry, Trisakti University
Abstract Background: Breakage of endodontic files during root canal preparation can result in serious complications and reduce the success rate of endodontic treatment. Prevention of file breakage is complicated by the fact that clinician has limited visibility inside the root canal, lack in knowledge of root canal anatomy, cyclic fatique and torsional stress of endodontic files which sometimes do not show wear before breakage. Objectives: To discuss the causes, show prevention and removal of separated endodontic files in 1/3 apical root canal. Case: 3 patients came with different chief complaints, first patient with continuous pain, second patient with uncomfortable feelings after RCT, third patient with pain at night. These 3 cases have complexities of narrow canals, missing canals and separated instruments. All of those complexities make root canal treatment procedure different from the general root canal treatment. Case Management: All broken files was then retrieved with combination of bypass technique, ultrasonic tips, irrigation solution of NaOCl 2,5 % and all the procedure were performed under the microscope. Root canal obturation was done by using warm vertical condensation technique to create good apical sealing. Conclusion: Advances in technology such using ultrasonic and dental operating microscope surely help dentists in particular situation, like these cases are possible to remove instrument fragments from root canal that in the past have been impossible to retrieve. Key words: cyclic fatique, torsional stress, ultrasonic tip, dental operating microscope
Introduction Intracanal instruments fracture is one of procedural problems that can happened during root canal preparation. including barbed broaches, stainless steel hand files, rotary nickeltitanium instruments, lentulo spiral fillers and thermomechanical compaction devices. The existence of broken file during root canal preparation will reduce the success rate of endodontic treatment. The clinician should attempt to retrieve the fragment using the techniques and equipments available, but determined efforts to do so may result in a weekened root or a perforation. Advances in technology (eg, ultrasonics, IRS) and the introduction of dental operating microscope in particular now make it possible to remove instrument fragments that would in the past have been impossible to retrieve1. Cyclic fatigue occurs when the file is freely rotating in a canal and flexes until fracture occurs. Usually the file fractures at the point of
maximum flexure (clinically, this corresponds to the most curved portion of the root). Cyclic fatigue is similar to taking a piece of wire and bending it up and down until it breaks. Rotational speed of the instrument has also been shown to contribute to cyclic fatigue. With higher rotational speed, the time to file failure decreases significantly2. Torsional stress occurs when the tip or any other part of the file is locked or bound within a canal while the shaft continues to rotate. A study by Sattapan and colleagues noted that torsional stress occurred in 55.7% and cyclic fatigue occurred in 44.3% of the fractured files that were evaluated2. Several studies have reported the ability of rotary Niti to produce well-centered, smooth, minimally transported canals while minimizing procedural errors. One disadvantage of its usage is file breakage which often occurs without prior warning to the operator. Ruddle recently reported a technique using combination of the microscope and ultrasonic instrumentation which have driven
42
“microsonic” techniques and dramatically improved the potential and safety when removing broken instruments6. The present report describes the use of an ultrasonic technique aided by dental operating microscope (DOM) magnification of the surgical site, combined with bypass technique and using Niti files to remove a fractured rotary nickeltitanium file at 1/3 apical from the narrow distolingual canal from tooth #46, distobuccal canal from tooth #37, mesiobuccal canal from tooth #46. The goal of obturation of root canal is to prevent the reinfection of root canals that have been biomechanically cleaned, shaped and disinfected by instrumentation, irrigation and medication procedures7. The classic Washington study observing that 58.66% of endodontic failures were caused by incomplete obturation. Other well-established undergraduate textbooks have emphasized that lack of adequate seal is the principal cause of endodontic failure. Technique for 3-dimensional filling was perfected and promoted by Herbert Schilder. His approach to filling all ramifications of the pulp space and create good apical sealing, made his method one of the best method in root canal obturation. Warm vertical condensation begins with down-packing of core material and sealer to the apical third of the root canal using commercially available heating devices such as System B (Kerr). The next step is to fill the coronal part of the canal by doing the backfilling thermoplasticized core material using the Elements Obturation Unit™ (Kerr) from the apical to the coronal third8.
canal was found from the radiograph(Fig. 1b). Based on these findings, tooth #46 was then diagnosed as irreversible pulpitis.
b
a
Figure 1(a) Clinical examination mandibular left second molar (b) Radiography revealed a broken file in distolingual canal.
Local anesthesia was performed to anesthetize nervus alveolaris inferior, nervus buccalis and nervus lingualis. Artificial wall was made to create good control of saliva during root canal treatment and isolated with rubber dam (Fig. 2a). Temporary restoration removal using scaler, then access opening was smoothed with endo-access bur and ultrasonics. (Fig. 2b-2d)
a
c
b
d
Case 1 : Report & Case Management Female patient, 42-years old visited my dental clinic, Jakarta, with a chief complaint of mandibular right posterior tooth felt pain at night after her last root canal treatment 7 days ago. Intraoral clinical examination revealed temporary restoration at the occlusal, proximal and buccal of mandibular right first molar (tooth #46) (Fig. 1a). Tooth was slightly tender on percussion. Radiography revealed access cavity of tooth #46 was already opened, the tooth hasn‟t obturated yet, but a broken file in 1/3 apical distolingual
Figure 2 (a) Artificial wall was made and and the tooth was isolated with rubber dam (b) Access opening was done using endo-access bur, continued with ultrasonic tips (c) Distolingual canal showed small orifice (d) Distolingual canal found a broken file under the microscope.
The first step, irrespective of what type of instrument has fractured, the goal is to modify the access cavity to create straight-line access to the fragment. Re-access cavity preparation was performed, and straight-line access to the canals was tried to be made (Fig. 3b) using a P5 Newtron Ultrasonic Device (Satelec, Acteon
43
Group, France) equipped with ultrasonic tips ET18D and ETBD with rubber stop at working length where the file brokes (Fig. 3a). a
a b
c
b
Figure 3(a) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET18D and ETBD tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (b) Modifying the access cavity to create straight-line access to the fragment.
The second step is to retrieve the broken file. Once straight access has been achieved and the fragment is visible, a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET20D and ET25 are used to create gutter around the fragment (Fig. 4a). Before using the ultrasonic instruments in multi-rooted teeth, it is advisable to place cotton pledgets in other canal orifices to ensure that if the fractured instrument is retrieved and prevented from dropping into another canals. Once a gutter has been created in the dentin, the ultrasonic tips is vibrated while in contact with the fragment and rotated in a counterclockwise direction in a lower-power setting followed with copious irrigation until the broken file dislodged (Fig. 4b-f). During the straight-line access and canal preparation procedures, the canal were rinsed with 2.5% sodium hypochlorite and RCPrep (Premier EC Representative: MDSS GmbH, Schiffraben, Hannover, Germany) alternatively.
d
e
f
Figure 4(a) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET20, ET25 and ET25S tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (b-e) The process of broken file retrieval (f) Broken file in distolingual canal has been dislodged.
The root canal confirmed with radiograph to ensure if there is no broken file left in distolingual canal. (Fig. 5).
Figure 5. The broken file was successfully retrieved from distolingual canal of the tooth.
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Initial exploration of the canal was done using K file #8, #10, #15 and #20. Mesiobuccal, mesiolingual, and distobuccal canal were prepared using Protaper Rotary instrument (Dentsply Endodontics, Tulsa). Distolingual canal was prepared using Protaper Manual Instrument to prevent another file broken inside this canal. The apical third of each of three canals was shaped and completed with Protaper F2 file (0.25mm in diameter, 0.08 taper) (Fig. 6a). Before obturation procedure, the tooth was irrigated with 2,5% sodium hypochlorite 2,5 mL, rinsed with aquadest, followed by 17% EDTA solution 1mL(SmearClear, KerrEndo, Orange, CA, USA), rinse again with aquadest and 2% chlorhexidine 1 mL(Consepsis, Ultradent) used as last irrigant. All canals were dried using paper points and obturated with Protaper G-P cones (Dentsply, Ballaigues, Switzerland) combined with TopSeal resin sealer (Dentsply) using warm vertical compaction method. Fiber post placed in mesiobuccal canal and followed with self adhesive resin core (Breeze), the patient scheduled for final crown restoration.
tooth 37 already treated with mummification and found big periapical radiolucency (Fig. 1b). Based on these findings, tooth #37 was then diagnosed as symptomatic apical periodontitis.
a
b
Figure 1(a) Clinical examination mandibular left second molar showed tooth 37 has restored with composite resin (b) Radiography revealed, the tooth already treated with mummification and found big periapical radiolucency.
The tooth was isolated with rubber dam (Fig. 2a). Access opening was done using endoaccess bur. Preparation of the tooth then smoothed using ultrasonic tips and was performed under the microscope (Fig. 2b).
a
b
Figure 2(a) The tooth was isolated with rubber dam (b) Access opening was done using endo-access bur, continued with ultrasonic tips. a
b
Figure 6(a) Master cone radiograph using Protaper G-P Cones F2 (b) Radiograph showed good root canal obturation.
Case 2 : Report & Case Management Female patient, 35-years old visited my dental clinic, Jakarta, with a chief complaint of mandibular left posterior tooth with uncomfortable feelings after root canal treatment about 2 years ago. Intraoral clinical examination revealed a big resin composite restoration at occlusal area of mandibular left second molar (tooth #37) (Fig. 1a). Tooth was slightly tender on percussion. The pulp did not respond to thermal test (chloretyl). Radiography revealed
Initial exploration of the canal was done using K file #8, #10, #15 and #20. Canals were prepared using Protaper rotary instrument (Dentsply Endodontics, Tulsa). During shaping in the distobuccal canal with the NiTi rotary F2 file (No.25, 0.08 taper; Dentsply. Maillefer, Ballaigues, Switzerland), instrument fracture occured. A radiograph was taken to confirm the instrument separation. From the radiograph, the instrument was seen at the 1/3 apical portion in distobuccal canal.
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fragment. The preparation begins with smalldiameter files, using K-File #6,#8,#10,#15 with 2% taper using watchwinding motion, the files should be precurved and used with copious amounts of chelating agent. Working length was then established using K-file #15 (Fig. 5)
Figure 3. Broken NiTi Protaper File F2 is shown in the1/3 apical of the distobuccal root canal.
The first step, irrespective of what type of instrument has fractured, is to modify the access cavity to create straight-line access to the fragment. Re-access cavity preparation was performed, and straight-line access to the canals was tried to be made (Fig. 4b) using a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET18D and ETBD with rubber stop at working length the file brokes (Fig. 4a). The broken file is visible by the dental operating microscope.
a
b
Figure 5. Working length confirmation by radiograph
The third step is to retrieve the broken file. Once straight access has been achieved and the fragment is visible, a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET20D and ET25 are used to create gutter around the fragment (Fig. 5A). Before using the ultrasonic instruments in multi-rooted teeth, it is advisable to place cotton pledgets in other canal orifices to ensure that if the fractured instrument is retrieved and prevented from dropping into another canals. Once a gutter has been created in the dentin, the ultrasonic tips is vibrated while in contact with the fragment and rotated in a counterclockwise direction in a lower-power setting followed with copious irrigation until the broken file dislodged (Fig. 6b). During the straight-line access and canal preparation procedures, the canal were rinsed with 2.5% sodium hypochlorite and RCPrep (Premier EC Representative: MDSS GmbH, Schiffraben, Hannover, Germany) alternatively.
Figure 4(a) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET18D and ETBD tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (b) Modifying the access cavity to create straight-line access to the fragment.
The second step is to do the bypass technique. The goal of the second step is to pass a stainless steel hand file laterally alongside the
46
a
rinsed again with aquadest, and 1 mL chlorhexidine 2% (Consepsis, Ultradent) used as last irrigant. All canals were then dried using paper points and were obturated with Protaper GP cones (Dentsply, Ballaigues, Switzerland) combined with TopSeal resin sealer (Dentsply) using a warm vertical compaction method. Fiber post placed in distolingual canal and followed with self adhesive resin core (Breeze), the patient scheduled for final crown restoration.
b
Figure 6(A) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET20, ET25 and ET25S tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (B) The broken file has been dislodged from the root canal.
a b
The root canal confirmed with radiograph to ensure if there is no broken file left inside the tooth. (Fig. 7).
Figure 8 (a) Master Cone radiograph using Protaper G-P Cones F2 (b) Obturation showed good root canal obturation.
Case 3 : Report & Case Management
Figure 7. The broken file was successfully retrieved from the distobuccal canal of the tooth.
The three canals were shaped with NiTi Protaper Rotary (Dentsply, Maillefer, Ballaigues, Switzerland), the apical third of each of three canals was shaped and completed with a Protaper F2 file (0.25mm in diameter, 0.08 taper) (Fig. 8A). After performing the biomechanical preparation, the main root canal was totally sterilized with the calcium hydroxide paste (Ultracal XS, Ultradent). At the following appointment, 10 days later, prior to obturation, the tooth was irrigated with 2,5 mL sodium hypochlorite 2,5%, rinsed with aquadest, followed by 1 mL 17% EDTA solution (SmearClear, KerrEndo, Orange, CA, USA),
Male patient, 33-years old visited Department of Conservative Dentistry and Endodontics, University of Trisakti, Jakarta, with a chief complaint of mandibular right posterior tooth felt pain after his last root canal treatment about 1 month ago. Intraoral clinical examination revealed tooth has restored with zinc phosphate, but showed secondary caries around zinc phosphate filling (tooth #46) (Fig. 1a). Tooth was slightly tender on percussion. Radiography revealed access cavity of tooth #46 was already opened, the tooth has endodontically treated, but the obturation was not adequate and found a broken file in mesiobuccal canal. (Fig. 1b). Based on these findings, tooth #46 was then diagnosed as endodontically treated tooth with apical periodontitis.
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b
a
Figure 1(a) Clinical examination mandibular right first molar (b) Radiography revealed deep carious lesion involving the pulp without any visible periapical radiolucency.
The old zinc phosphate was removed and all caries lesion were removed by using longshank diamond bur. Artificial wall was made to create good control of saliva during root canal treatment (Fig. 2a). The tooth was then isolated with rubber dam (Fig. 2b). Gutta-percha was removed with the use of ultrasonics tips and performed under the microscope (Fig. 2c) and found distolingual canal as missed canal. (Fig. 2d).
a
Radiograph photo is taken to confirm all gutta-percha had been removed (Fig. 3). The first step, irrespective of what type of instrument has fractured, the goal is to modify the access cavity to create straight-line access to the fragment. Reaccess cavity preparation was performed, and straight-line access to the canals was tried to be made using a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET18D and ETBD with rubber stop at working length where the file brokes (Fig. 4a). The broken file was then visible by the dental operating microscope (Fig. 4b).
a
b b
c
d
Figure 2(a) Tooth 46 after zinc phosphate and caries removal (b) Artificial wall build using composite resin (c) Gutta-percha was removed with ultrasonics under the microscope (d) Found missed canal(distolingual canal).
Figure 3. Radiograph confirmation of gutta-percha removal from tooth 46
Figure 4(a) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET18D and ETBD tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (b) Modifying the access cavity to create straight-line access to the fragment.
The second step is to retrieve the broken file. Once straight access has been achieved and the fragment is visible, a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET20D and ET25 are used to create gutter around the fragment (Fig. 5a). Before using the ultrasonic instruments in multi-rooted teeth, it is advisable to place cotton pledgets in other canal orifices to ensure that if the fractured instrument is retrieved and prevented from dropping into another canals. Once a gutter has been created in the dentin, the ultrasonic tips is vibrated while in contact with the fragment and rotated in a counterclockwise
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direction in a lower-power setting followed with copious irrigation until the broken file dislodged (Fig. 5b-d). During the straight-line access and canal preparation procedures, the canal were rinsed with 2.5% sodium hypochlorite and RCPrep (Premier EC Representative: MDSS GmbH, Schiffraben, Hannover, Germany) alternatively.
a
b
c
d
Figure 5(a) The EndoSuccess™ kit of ultrasonic tips features a novel type of titanium-Niobium instruments, the ET20, ET25 and ET25S tips and piezoelectric ultrasonic generator : Suprasson® P5 Newtron (b-d) Broken file retrieval using ultrasonics with counter-clockwise direction, broken file in distolingual canal has been dislodged.
inside this canal. The apical third of mesiolingual and distobuccal canal were shaped and completed with a Protaper F3 file (0.3mm in diameter, 0.09 taper). The apical third of mesiobuccal and distolingual canal were shaped and completed with a Protaper F2 file (0.25mm in diameter, 0.08 taper) (Fig. 7a). Before obturation procedure, the tooth was irrigated with 2,5% sodium hypochlorite 2,5 mL, rinsed with aquadest, followed by 17% EDTA solution 1 mL(SmearClear, KerrEndo, Orange, CA, USA), rinse again with aquadest and 2% chlorhexidine 1 mL (Consepsis, Ultradent) used as last irrigant. The canals were then dried using paper points and were obturated with Protaper G-P cones (Dentsply, Ballaigues, Switzerland) combined with TopSeal resin sealer (Sealapex, SybronEndo, Orange, CA, USA) using warm vertical compaction method. Fiber post placed in distobuccal canal and followed with self adhesive resin core (breeze), the patient scheduled for final crown restoration.
The root canal confirmed with radiograph to ensure if there is no broken file left inside the tooth (Fig. 6). a
b
Figure 7(a) Master Cone radiograph using Protaper G-P Cones F2 (b) Radiograph showed good root canal obturation.
Discussion
Figure 6. Broken file in mesiobuccal canal was successfully retrieved.
Initial exploration of the canal was done using K file #8, #10, #15 and #20. Mesiolingual and distobuccal canal were prepared using Protaper Rotary instrument (Dentsply Endodontics, Tulsa). Mesiobuccal and distolingual canal were prepared using Protaper Manual Instrument to prevent another file broken
The success of endodontic treatment is affected negatively by inappropriate shaping, disinfection and obturation of the root canal system. It may take several months, or even years, for objective evidence of failure to appear radiographically as patients rarely experience pain. This can lead to patient confusion in regard to the relationship between failure and treatment carried out several years earlier9. Fractured root canal instruments might include endodontic files, lateral or finger spreaders, spiral fillers, or Gates-Glidden burs, wether manufactured from nickel titanium
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(NiTi), stainless steel (SS), or carbon steel. With the advent of rotary NiTi files, there has also been a perceived increase in the occurrence of broken instruments. In most circumstances fracture results from incorrect ise or overuse of an endodontic instrument. Although there is a perception that rotary NiTi instruments might fracture without warning, recent work indicates that fracture involves many factors, the most important of which seems to be the clinian‟s conscious decision to use instruments a specified number of times or until defects (unwinding, torsional fracture, or flexural fracture) were evident10. When the file is freely rotating in a canal and flexes until fracture occurs it is called cyclic fatique. Usually the file fractures at the point of maximum flexure (clinically, this corresponds to the most curved portion of the root). Cyclic fatigue is similar to taking a piece of wire and bending it up and down until it breaks2. Torsional stress occurs when the tip or any other part of the file is locked or bound within a canal while the shaft continues to rotate. Pruett and coworkers3 stated that the radius of curvature, angle of curvature, and instrument size play a role in cyclic fatigue. Rotational speed of the instrument has also been shown to contribute to cyclic fatigue. With higher rotational speed, the time to file failure decreases significantly4,5. Careful analysis of conventional and angled radiographs will allow the clinician to see canal in which the fragment is located, size of the fragment, nature of the instrument, position of the fragment within the canal, root anatomy, defects in the initial access preparation. The length of time needed to remove a fractured instrument is highly variable and depends on the type of instrument, the size of the fragment, and whether the instrument has threaded into the dentin1. The highest proportion of instrument fragments occurs in the middle and apical third of the mesial canals of mandibular molars, and at the same location in the mesio-buccal roots of maxillary molars. It is caused by root canal curvatures, these roots are not only characteristically curve distally, but often the mesiobuccal canal curves lingually, and the mesiolingual canal curves slightly to the buccal.
These lingual and buccal curves are not visible on the film11. Many factors are involved when deciding how to deal with fractured instruments lodged within the root canal. If removal is attempted, the chance of success should be balanced against potential complications. Highly successfully in removing files lodged in the coronal and middle thirds of curved canals, but considerably less successful with files in the apical third. The removal procedure significantly reduced root strength when the file was located in the middle or apical third of the root12. In the last 15 years, for nonsurgical and surgical endodontics, there has been an explosion in the development of new technologies, instruments, and materials. These developments have improved the precision of endodontists is performance. These advances have enabled clinicians to complete procedures that were once considered impossible or that could be performed only by talented or lucky clinicians13. Specifically, the dental operating microscope allows clinicians to visualize most broken instruments and fulfills the age old adage, “If you can see it, you can probably do it”. In combination, the microscope and ultrasonic instrumentation have driven “microsonic” techniques which have dramatically improved the potential and safety when removing broken instruments14. Irrespective of what type of instrument has fractured, the first step is to modify the access cavity to create straight-line access to the fragment, followed second step by doing bypass technique. The goal of bypass technique is to pass a stainless steel hand file laterally alongside the fragment1. The third step is to retrieve the broken file. Once straight access has been achieved and the fragment is visible, a P5 Newtron Ultrasonic Device (Satelec, Acteon Group, France) equipped with ultrasonic tips ET20D and ET25 are used to create gutter around the fragment. Before using the ultrasonic instruments in multi-rooted teeth, it is advisable to place cotton pledgets in other canal orifices to ensure that if the fractured instrument is retrieved and prevented from dropping into another canals1.
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The preferred armamentarium for broken instrument removal is: Satelec Endo Success Retreatment Kit (Acteon, France) contains of ETBD, ET18D, ET20, ET 25, ETPR, etc. These ultrasonic tips were equipped to the Satelec P5 Newtron (Acteon, France), which is the piezoelectric ultrasonic unit of choice for performing endodontic treatment and retreatment procedures. This unit affords precise working accuracy and has a broad power range, and its unique “feedback” system measures tip resistance, regulates tip movement and reduces the potential for tip breakage14. Root canal obturation involves the threedimensional filling of the entire root canal system and is a critical step in endodontic therapy. Two purposes of obturation are to eliminate all of avenues of leakage from the oral cavity or the periradicular tissues into the root canal system and the sealing within the root canal system of any irritants that remain after appropriate shaping and cleaning of the canals, thereby isolating these irritants. It is good to use warm vertical condensation to fill all ramification around the apical third15. Warm vertical condensation technique was perfected and promoted by Herbert Schilder. His approach to filling was a described as 3dimensional, indicating an intention to fill all irregularities and ramifications of the pulp space and create good apical sealing. Warm vertical condensation begins with down-packing of core material and sealer to the apical third of the root canal using commercially available heating devices such as System B (SybronEndo, Orange, Calif.). The next step is to fill the coronal part of the canal by doing the backfilling thermoplasticized core material using the Elements Obturation Unit™ (SybronEndo, Orange, Calif.) from the apical to the coronal third. Conclusion Breakage of endodontic files during root canal preparation can result in serious complications and reduce the success rate of endodontic treatment Broken file is a common accident that we found in daily practice. The clinician should attempt to retrieve the fragment
using the techniques and equipments available, but determined efforts to do so may result in a weekened root or a perforation. The retrieval or bypass of broken files is more successful in the coronal and middle thirds compared with the apical third of the canal. Advances in technology such as ultrasonic and microscope surely help dentists in particular now make it possible to remove instrument fragments that would in the past have been impossible to retrieve. REFERENCES 1. Simon S, Pertot WJ. Paris. Clinical Success in Endodontic Retreatment. 2009;3:43-88. 2. Sattapan B, Nervo GJ, Palamara JE, et al. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000;26:161-165. 3. 7. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23:77-85. 4. Li UM, Lee BS, Shih CT, et al. Cyclic fatigue of endodontic nickel-titanium rotary instruments: static and dynamic tests. J Endod. 2002;28:448-451. 5. Martin B, Zelada G, Varela P, et al. Factors influencing the fracture of nickel-titanium rotary instruments. Int Endod J. 2003;36:262-266. 6. Ruddle CJ. Micro-endodontic nonsurgical retreatment. Dent Clin N Am. 1997;41(3):429-54. 7. Himel VT, DiFiore PM. Obturation of Root Canal Systems. Colleagues for Excellence. AAE. 2009; 1-8. 8. Whitworth J. Methods of filling root canals: principles and practices. Endod Topics. 2005;12:2-24. 9. Simon, S. Influence of fractured instruments on the success rate of endodontic treatment. Dent Update.2008;35:172-179. 10. Panitvisai P PP, Sathorn C, Meser HH. Impact of a retained Instrument on Treatment Outcome: A Systematic Review and Metaanalysis. JOE. 2010;36(5):775-80. 11. Cohen SJ GG, Mounce R. Rips, Strips and Broken Tips : Handling the Endodontic Mishap Part 1: The Separated Instrument. Oralhealth. 2005:10-20.
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12. Souter JN MH. Complications Associated with Fractured File Removal Using an Ultrasonic Technique. JOE. 2005;31(6):4502. 13. Carr GB, Murgel CAF. The Use of the Operating Microscope in Endodontics. Dent Clin N Am. 2010;54:191–214.
14. Ruddle CJ. Broken instrument removal. The Endodontic Challenge. Dentistry today. 2002;21(7):70-2,4,6. 15. Gutmann JL, Kuttler S, Niemczyk SP. Root Canal Obturation: An Update. AGD 2010:111.
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Nonsurgical endodontic retreatment of a maxillary first molar with metal onlay restoration : a case report Lisa Pramitha Setiawan1, Tien Suwartini2, Eko Fibryanto2 1 PPDGS Bagian Konservasi Gigi, FKG Universitas Trisakti 2 Staf Pengajar Bagian Konservasi Gigi, FKG Universitas Trisakti
ABSTRACT Endodontic treatment may fail if the treatment is improperly performed. When this failure has happened root canal treatment need to be conducted again and this retreatment requires special technique. One of the techniques to take out the gutta percha which still remain in the root canal due to the previous treatment is to use Xylol, headstrom file, and spreader which is heated. This technique is easy and very effective to remove the gutta percha during the root canal treatment without any surgery. The size of the spreader depend on the diameter of the root canal. A twenty three year old female patient was recommended to undergo a root canal treatment on her left maxillary first molar, because sometimes she felt a throbbing pain. During the clinical examination, a filling was found and the tooth tender to percussion. A radiograph examination has shown that a root canal treatment was already conducted on the tooth and a widening of the lamina dura at the apical of the dental root. This findings indicate that the tooth needs a nonsurgical root canal retreatment then an metal onlay restoration is required to improve the coronal seal. Key words: non-surgical root canal retreatment, gutta percha removal, coronal seal Correspondence: Lisa Pramitha Setiawan, PPDGS Konservasi Gigi, Fakultas Kedokteran Gigi Universitas Trisakti. Jl. Kyai Tapa No. 1 Grogol Jakarta Barat , Indonesia.
INTRODUCTION Root canal treatment is a biological, chemical, and mechanical procedure to eliminate pulp and periradicular diseases and also to stimulate the healing and repairment of periradicular tissues.1 The success of endodontic treatment depends on the cleaning, shaping and obturation of the entire root canal system. If the cleaning, shaping and obturation of the root canal and also the coronal seal are inadequate, then the root canal treatment can fail.2 Etiology of the endodontic treatment failure that often occurs is the micro leakage at the apical area caused by the inadequate apical seal. This micro leakage cause periapical liquid, protein and bacteria to enter into the root canal and generate the inflammation reaction. Apical seal is affected by adequate obturation of the entire system of root canal and the coronal seal is as important as the apical seal because the apical seal can fail if the coronal seal dissapears or is damaged. The three dimensions of the root canal obturation can prevent the penetrating of microorganisms and toxin from oral cavity into
periradicular tissues. Coronal seal and a good root canal obturation can stimulate the healing of the inflammation or periapical lesion.3,4 The optional treatment of the teeth with failure of root canal treatment, is either by extraction or surgical or nonsurgical endodontic retreatment. The optional treatment depends on the operator (instruments, knowledges and capabilities), patient condition and pre-operative diagnosis.5 Nonsurgical endodontic retreatment is the first option which can be considered because it‟s non-invasive. Endodontic retreatment includes the removal of the obturation material from previous treatment and continuation with the conventional root canal treatment (the debridement and root canal obturation). The level of healing of nonsurgical retreatment ranges between 74% - 98%. Also the risk of nonsurgical endodontic retreatment is low because the post treatment trauma is minimum. The teeth after endodontic treatment should be restored immediately to protect and to return the function of the teeth.5,6
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CASE REPORT
MANAGEMENT
Female patient, 23 years old, was referred to conservation specialist clinic RSGM Trisakti University for treatment of her left maxillary first molar with intermittent throbbing pain since 4 months ago. Seven months ago, patient had been treated but hadn‟t finished with her treatment because she had no time to come back to the first dentist. Clinical examination on tooth 26, there was temporary filling (Fig. 1), objective examination : negative vitality, positive percussion, negative palpation, negative tooth mobility, and no abnormality of gingiva around tooth 26. Radiographic examination showed widening lamina dura around tooth apex and non-hermetic root canal obturation (Fig. 2). Diagnose for tooth 26 is cronic apical periodontitits et causa inadequate root canal treatment. Good prognosis because patient‟s oral hygiene was good, patient is still young, no systemic disorders, treatment can be accessed through coronal and tooth can be well restored. Treatment that will be performed for this tooth is nonsurgical endodontic retreatment followed by metal onlay restoration, because of only one cusp loss, no aesthetic needed and antagonist tooth is also metal crown.
At first visit, the old filling was removed using a round diamond bur then to gain access into the opening of the root canal system with endo access bur. Artificial wall was built with glass ionomer cement (Fuji II, GC) at palatal wall and rubber dam was used to prevent saliva contamination (Fig. 3).
Figure 1. Clinical examination of left maxillary obturation and widening lamina dura around tooth apex (arrow).
Figure 3. Cavity access opening of left maxillary first molar.
Gutta percha was removed from the palatal root canal by heating the tip of spreader number 20 which was inserted 5 mm to apical from orifice and then pulled out to make a canal into the middle of the gutta percha, then headstrom file number 30 was inserted into that canal and rotated clockwise while pressed to the apical and then headstrom file was pulled out. Gutta percha in mesio buccal and disto buccal root canal were removed by application of cotton pellet which has been wetted with xylol and wait for few seconds. Headstrom file number 15 was inserted around gutta percha until gutta percha was soft. Then headstrom file number 25 was inserted into root canal and rotated clockwise until gutta percha sticks and coiled by file and then pull out the file. The pulled out gutta percha from three root canals looks intact (Fig. 4). Each root canal was irrigated by 5 mL NaOCl 2,5%. Then confirm with radiographic photo to ensure all gutta percha was all out. Radiographic photo showed clean root canal from gutta percha (Fig. 5).
Figure 2. Radiography revealed inadequate first molar.
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4 .
5.
Figure 4. Gutta percha after removed from root canal. Figure 5. Radiography revealed all gutta percha in root canal was removed.
Root canal treatment was performed by crown down technique using Protaper Rotary Instrument (Dentsply). Started with initial exploration using K-File #08, #10 and #15 along the 2/3 of the temporary working length which we get from the pre-operative radiographic photo, continued with file S1 along 2/3 of the temporary working length. Measure working length with K-File #15 with electric apex locator (Raypex 5, VDW) also confirmed by radiograph, root canal working length of mesio buccal and disto buccal was 15 mm and palatal was 17 mm (Fig. 6). Root canal preparation was continued with file S1, S2, F1, F2, F3, F4 for mesio buccal and disto buccal root canal and until F5 for palatal root canal along the working length. During root canal preparation, every turning instrument, root canal was irrigated with 2 mL NaOCl 2,5%. Root canal was dried with sterile paper point and given calcium hydroxide as intracanal medicament (Ultracal, Ultradent) and then filled with temporary filling.
canal and F5 at palatal root canal according to working length and confirmed by radiograph (Fig. 7). Obturation was done with single cone technique, using gutta percha ProTaper and sealer (Sealapex, SybronEndo). The 2 mm cut of gutta percha to apical from orifice and perform vertical condensation using plugger. Glass ionomer cement was used as barrier above gutta percha (Fuji I, GC) and filled with temporary filling (Fig. 8).
Figure 7. Master point gutta percha. Figure 8. Obturation of root canal.
The third visit, patient had no subjective and objective symptoms. Preliminary impression of tooth 26 was made with irreversible hydrocolloid to make provisoris. Temporary filling and artificial wall were removed, and then made a glass ionomer cement basis (Fuji IX, GC), and then prepared tooth 26 to make metal onlay with divergent wall to occlusal and all margins are at tooth structure (Fig. 9). Impression of metal onlay preparation of tooth 26 was made with double impression technique, using polyvinyl siloxane and impression of antagonist jaw was made using irreversible hydrocolloid, followed by taking bite registration. Preliminary impression was used to make temporary onlay with bis-acrylic composite material (Tempofit, Detax) (Fig. 10). Then temporary onlay was inserted on tooth 26 with temporary cement (Freegenol, GC).
Figure 6. Working length of left maxillary first molar.
At second visit, patient had no subjective and objective symptoms. Rubber dam was placed and temporary filling was removed. Root canal was irrigated with NaOCl 2,5% to dissolve calcium hydroxide then dried with sterile paper point. Gutta percha fitting ProTaper F4 was performed at mesio buccal and disto buccal root
Figure 9. Tooth preparation for metal onlay restoration.
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A
C
B
D
Figure 10. Temporary onlay with tempofit. A. Tempofit. B. Tempofit application into impression of the tooth. C. Temporary onlay after remove from patient‟s mouth. D. Temporary onlay after it was trimmed with taperred fissure superfine bur.
After 1 week, patient came back and temporary metal onlay was removed. Metal onlay was tried in, and then was confirmed by radiograph (Fig. 11). Metal onlay was cemented with glass ionomer cement material (Fuji I, GC) (Fig. 12 and 13).
Figure 11. Metal onlay tried in.
Figure 12. Metal onlay after cementation. A
B
Figure 13. A. Tooth 26 after metal onlay cementation. A. Occlusal view. B. Buccal view.
DISCUSSION Root canal treatment can fail because of many factors, such as bad cavity design, the root
canal is not entirely treated, inadequate root canal cleaning, shaping, and obturation, failure during instrumentation (ledge, perforation, and broken instruments). The main cause of endodontic treatment failure is microorganisms, which in the first diagnosis cannot be known for sure, usually the etiology can be known only after the treatment has been finished and is successful. Treatment planning and deciding prognosis of each case, based on etiology of root canal treatment failure as mentioned before.5 Persistence microorganisms in root canal come from contamination of root canal system and dentin tubules by bacteria and its products and if bacteria spread to periradicular tissues will cause apical periodontitis. Inadequate cleaning, shaping, obturation and teeth restoration after root canal treatment can cause failure of treatment with pain symptom or periradicular and periodontal disorders. Iatrogenic incident such as ledge and broken file can cause bacteria trap in root canal because root canal cannot be cleaned at ledge area and at area that is obstructed by broken file.5 Etiology of endodontic treatment failure in this case is probably caused by inadequate cleaning, shaping, obturation and restoration which isn‟t done immediately and caused coronal leakage. Treatment for this case is nonsurgical endodontic retreatment because the teeth can be restored and treatment access can be done from coronal. Widening lamina dura shows inflammation reaction caused by bacteria from inside and outside of the root canal Nonsurgical endodontic retreatment is done by getting coronal access, removing all root canal filler until we get optimum working length so cleaning, shaping and obturation of root canal can be well done. In this case coronal access was easy to get because only the temporary filling needs to be remove. Gutta percha can be removed from root canal with many ways, such as ; heat combination, gutta percha solvent and mechanical instrumentation.5 In this case we removed gutta percha in palatal root canal with spreader which was heated until we made a canal for headstrom file entrance. Gutta percha in mesio buccal and disto buccal root canal was removed with gutta percha solvent (xylol) and headstrom file. The heated spreader and gutta
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percha solvent is useful to facilitate headstrom file instrument to enter until gutta percha can be removed. In this case we used a different method and both of them can be used easily and effectively. After gutta percha was removed, root canal was irrigated and checked to see if there was MB2 root canal with Dental Operatory Microscope (DOM). In this case the tooth 26 only has 3 root canals. Endodontic treatment procedure was done with crown down technique using ProTaper Rotary System. Crown down technique was chosen because preparation is started from coronal to enable irigation solution to penetrate into and prevents debris from being push to apical.7 Irigation solution used is NaOCl 2,5 %, it can dissolve organic material and its disinfection material; EDTA 17% (Ethylenediaminetetraacetic acid), EDTA can dissolve smear layer; and chlorhexidin is an effective antimicrobes. These are used to remove persistent microorganisms in root canal.8 Calcium hydroxide has been successfully used as intracanal medicament because its antimicrobes, lessen inflammation, able to solve organic tissues and inactive bacteria toxin.9,10,11 The endodontic treated teeth is better to be restored with cuspal coverage to prevent fracture. In this case tooth 26 was restored with metal onlay. The metal onlay restoration was selected because a lot of the tooth 26 structure still left, only one palatal cusp was loss so with onlay the cusp can be protected without removing more of the tooth structure, moreover restoration margin border is above gingiva so hygiene can be controlled. Restoration material was metal because its strength and antagonist tooth was also metal, also tooth 26 doesn‟t need aesthetic.12 Cases of failed endodontic treatment is quite a lot to be found in dental practice. The first treatment selection is nonsurgical endodontic retreatment. This treatment is non-invasive and easy for the patient. Treatment option for failed endodontic treatment depends on the level of damage of periodontal tissues and operator capabilities in accessing root canal.
DAFTAR PUSTAKA 1. Chng HK, Chen NN, Koh ET. Guidelines for Root Canal Treatment. Singapore Dent J 2004; 26(1) : 60-2. 2. Eskandarinezhad M, Ghasemi N. Nonsurgical Endodontic Retreatment of Maxillary Second Molar with Two palatal Root Canals : A Case Report. J Dent Res Dent Clin Dent Prospect 2012; 6(2): 75-8. 3. Deepali S, Hegde MN. Coronal Microleakage of Four Restorative Materials Used in Endodontically Treated Teeth as A Coronal Barrier-An In Vitro Study. Diunduh dari : http://medind.nic.in/eaa/t08/i2/eaat08i2p27.p df . 4. Aae.org [Internet]. Chicago: Coronal Leakage Clinical and Biological Implications in Endodontic Success ; 2002 [cited 20 Mei 2014]. Diunduh dari : http://www.aae.org/uploadedfiles/publication s_and_research/endodontics_colleagues_for_ excellence_newsletter/fw02ecfe.pdf . 5. Roda RS, Gettleman BH. Nonsurgical Retreatment. In: Hargreaves, K.M. dan Cohen, S. Ed. Ke-10. Cohen‟s Pathways of the Pulp. St. Louis : Elsevier Mosby; 2011: 890-952. 6. Caendo.ca [Internet]. St. Mary Avenue : Standards of Practice; 2006 [Cited 20 Mei 2014]. Diunduh dari : https://www.caendo.ca/about_cae/standards/s tandards_english.pdf . 7. Huang X, Ling J, Wei X, dkk. Endodontic Retreatment. J Endod 2007; 33 : 1102-5. 8. Bergenholtz G, Bindslev PH, Reit C. Textbook of Endodontology. Ed. Ke-2. Singapore: Wiley-Blackwell; 2010: 147-9. 9. Andofatto C, Silva GF, Cornelio ALG, dkk. Biocompatibility of Intracanal Medications Based on Calcium Hydroxide. Diunduh dari : http://www.hindawi.com/journals/isrn.dentist ry/2012/904963/ 10. Walton RE, Holton IF, Michelich R. Calcium Hydroxide as an Intracanal Medication : Effect on Post Treatment Pain. J Endod 2003; 29(10) : 627-9. 11. Vilela DD, Neto MM, Villela AM, dkk. Evaluation of Interference of Calcium
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Hydroxide-based Intracanal Medication in Filling Root Canal Systems. Thejcdp 2011; 12(5) : 368-71. 12. Dietschi D, Bouillaguet S, Sadan A. Restoration of the Endodontically Treated.
In: Hargreaves, K.M. dan Cohen, S. Ed. Ke10. Cohen‟s Pathways of the Pulp. St. Louis : Elsevier Mosby; 2011: 777-807.
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Mineral trioxide aggregate effect to periapical lesion healing as an apical closure material at immature tooth: Case report Meryna*, Bernard O.Iskandar**, Elline** *Student of PPDGS Conservation Departement **Lecturers of Conservation Departement Faculty of Dentistry,Trisakti University Jakarta-Indonesia
Background: An immature permanent teeth have open apices. Trauma of young permanent teeth can cause pulp necrosis. Consequently, apical closure proccess is interrupted and dentinal tubules remains wide, which allow the penetration of bacteria and their irritants. The penetration of bacteria and their irritants at necrosis teeth will develop periapical lesion if untretated. According to literatues, Mineral Trioxide Aggregate (MTA) can be considered as an effective material for endodontic treatment in permanent teeth with open apices. MTA was chose due to promoting periapical healing. Aim: The aim of this case report is to demonstrate the use of MTA as the apical closure, which can promote periapical healing at immature permanent teeth. Case report: A 27 year old woman report complaining of fracture tooth due to trauma at 7 years of age. Clinical examination revealed crown fracture with discoloration at tooth 21. Vitality test was negative and sensitive to percussion. Radiographic examination demonstrated that the left central incisor had an open apex and periradicular radiolucency around the apex. Case management: root canal treatment and open apex closure use MTA, followed by intracoronal bleaching (walking bleach technique) and resin composite restoration. Conclusion: Root canal treatment at open apex tooth using MTA can be done immediately and promote periapical lesions healing. Key Words: immature permanent teeth, periapical lesion, apical closure, MTA.
INTRODUCTION Traumatic injuries to young permanent teeth are said to affect 30% of children.1 Complete formation of the root and closure of the apical foramen continues for up to 3 years following eruption of the tooth. If the pulp of young permanent teeth is damaged before the closure of the apical foramen, pulp necrosis may occur. 1,2. Consequently, the canal remains large, with thin and fragile walls, and the apex remains open. In immature teeth, dentinal tubules are wide and allow the penetration of bacteria and their irritants. 3 These features make instrumentation of the canal difficult and hinder the formation of an adequate apical stop. In such cases, in order to allow the condensation of the root filling material and to promote an apical seal, it is imperative to create an artificial apical barrier.3 Many materials have been suggested as apical sealing material. Mineral trioxide aggregate (MTA) is the most popular material as an artificial apical closure. This material can
form a plug at the apical end of the root and helps prevent extrusion filling material. MTA contains fine hydrophilic particles of tricalcium silicate , tricalcium oxide and silicate oxide.4 In the vast majority of cases, nonvital teeth are infected, so the first phase of treatment is to disinfect the root canal system to ensure periapical healing. The canal length is estimated with a parallel preoperative radiograph, and after access to the canals is prepared, a file is placed to this estimated length. When the length has been confirmed radiographically, very light filing (because of the thin dentinal walls) is performed with copious irrigation with 0.5% NaOCl. A lower strength of NaOCl is used because of the increased danger of placing the agent through the apex in immature teeth. The increased volume of irrigant used compensates for this lower concentration of NaOCl. An irrigation needle that can passively reach close to the apical length is useful in disinfecting the canals of these immature teeth. The canal is dried with paper points and a creamy mix of calcium hydroxide (toothpaste thickness) spun into the canal with a
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Lentulo spiral instrument. Additional disinfecting action of calcium hydroxide is effective after its application for at least 1 week, so the continuation of treatment can take.5 The MTA is mixed and placed into the apical 3 to 4 mm of the canal in a manner similar to the placement of calcium hydroxide. A wet cotton pellet should be placed against the MTA and left for at least 6 hours. After the MTA is fully set, the entire canal is then filled with a root filling material.5
Figure 2. Preoperative diagnostic radiograph showing tooth 21 with open apex and periradicular radiolucency around the apice.
CASE MANAGEMENT CASE REPORT A 27-year-old woman was reffered to RSGM(P) Universitas Trisakti for evaluation and treatment of the maxillary left central incisor. Patient‟s dental history revealed that he had suffered a trauma of tooth 21 at 7 years of age. Clinical examination revealed uncomplicated tooth fracture at tooth 21 (Class III WHO‟s classification) and tooth discoloration. Vitality testing was negative to chlor ethyl and EPT (electric pulp tester) , sensitive to percussion and no mobility (Figure1a, 1b).
a
b
Figure 1. Pretreatment photograph of tooth 21 showing discoloration and uncomplicated tooth fracture, a. Labial view, b. Palatal view.
Radiographic examination demonstrated that the left central incisor had an open apex and periradicular radiolucency around the apice of 21 (Figure 2). The diagnosis of asymptomatic apical periodontitis with crown discoloration and 873.61 WHO‟s classification ( enamel and dentine fracture without pulp exposure) was made for left central incisor.
Treatment plans are consists of noninvasive and invasive treatments. Non invasive treatments include dental health education. Invasive treatment of tooth 21 include root canal treatment with apical closure use MTA, followed by intracoronal bleaching, and composite resin restoration. At first appoinment, the appropriate peroperative preparatory step include inform consent, intraoral photograph, radiographic evaluation, subjective and objective examination, and diagnosis. Initial step was dental scalling. Endodontic therapy was carried out with rubber dam isolation. Access cavity was prepeared and pulp chamber was irrigation by NaOCl 0,5% to clean necrotic tissue. Working length measurement used (electric apex locator) and confirmed radiographically (Figure 3). The working length was 19 mm. Biomechanical preparation was carried out by circumferential filing using K-file #90. Root canal was irrigated by NaOCl 0,5% solution. Intracanal dressing using Ca(OH)2 paste (Ultradent) was placed in the canal. Access cavity was sealed with temporary filling.
Figure 3. Working length was verified radiographically at tooth 21.
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At second appointment, seven days after intracanal medicament, objective and subjective examination revealed asymptomatic. Temporary filling was removed and root canal was irrigated by NaOCl 0,5% to clean calcium hydroxide, followed by aquadest, EDTA 17%, aquadest, and 2% chlorhexidine gluoconate. Root canal was dried with paper point. MTA mixture (MTAAngelus white) was made and placed in the apical portion of the canal using hand plugger and paper point (Gambar 4). The thickness of the apical plug was 4 mm. A cotton pellet soaked with aquadest was then placed in the pulp chamber and access cavity was sealed with temporary filling.
Figure 4. The apical plug radiographically at tooth 21.
MTA
was
verified
At third appointment, 7 days after second appointment, objective and subjective examination revealed asymptomatic. The temporary filling and cotton pellet were removed, the canal was irrigated with NaOCl 2,5%. Root canal was dried with paper point. The rest of the canal was obturated with thermoplastic guttapercha (backfill technique) applied in association with a canal sealer (Sealapex,SybroEndo). Obturation was verified radiographically. After obturation, the tooth was prepared for intracoronal bleaching. A barrier was made with composite resin (Premisa, Kerr). The barrier was „wing‟ form with 3 mm in thickness (Figure 5). 35% hydrogen peroxide paste (Opalesence Endo, Ultradent) was placed into the cavity and contact to labial surface. Cotton pellet was the placed in the cavity and access cavity was sealed with double seal filling. The double seal filling were zinc phosphate and temporary filling.
Figure 5. Obturation and wing barrier was verified radiographically at tooth 21.
At fourth appointment, 5 days after third appointment, there was a change in the tooth color with satisfactory results. Bleaching materials was removed from cavity with warm water to cleaned remain oxidants. Cotton pellet was the placed in the cavity and access cavity was sealed with temporary filling. Composite resin restoration was done after 1 week. This procedure is intended to render neutral the pH and colour stabilization (Figure 6).
Figure 6. There was a change in the tooth color at tooth 21.
Maxilla and mandibule impression was done to obtain study model. The tooth 21 was formed with wax at study model. Silicone index was made with polyvinylsiloxane impression material putty type. The silicone index provided a boundary for the outer counturs of the restorations in the incisal and palatal direction (Figure 7).
a
b
Figure 7. The tooth 21 was formed with wax. a. Labial view, b.Palatal view
At fifth appointment, 7 days after fourth appointment, temporary filling was removed. The tooth was to be restored with composite resin using silicone index. Composite resin color determination using shade guide (Vita lumiin vaccum). The composite resin material was hybrid type (Premisa,Kerr), using generation V ecthing bonding technique. Subsequent step were 61
occlusal checking with articulating paper, followed by counturing and polishing (Figure 8).
a
b
Figure 8. Photograph of tooth 21. a. before treatment, b. After treatment
DISCUSSION A serious consequence of traumatic injuries of teeth with immature root formation is the contusion of the apical part of the pulp and severance of pulpal blood supply,which can result in pulp necrosis, especially if the possibility of pulp revascularization is unlikely. Anachoresis through the apical foramen and bacterial contamination of the periodontal ligament (PDL) appear to be the source of infection of the compromised pulp. In cases of asymptomatic untreated pulp infection, occurrence of apical periodontitis is inevitable which is frequently symptom‑ free and discovered primarily by the radiographic appearance.6 Treatment options to manage large periapical lesion with open apex ranges from non surgical root canal treatment and/or apical surgery to extraction. Mechanical instrumentation not always completely removes debris from root canal and periapical tissue, therefore dressing with chemical medicaments has been considered as one of the most important steps to obtain and maintain sterile root canal after mechanical instrumentation and before root canal obturation. Current philosophy includes the use of non-surgical root canal treatment. Many materials have been used successfully for apical closure and periapical repair but the exact mechanism of action is unknown. However calcium hydroxide remains a popular material to accomplish apical closure and periapical repair. The most common difficulty in the classic apexification technique with calcium hydroxide is the duration of the therapy, which is from 3 to 21 months, it depends on factors such as size of the apical opening, the traumatic displacement of the tooth and the repositioning methods used.
Calcium hydroxide creates an environment conducive to the formation of an apical barrier formed by osteo-cementum tissue at the end of the root canal in teeth with open apices. During apexification procedure the root canal is susceptible to reinfection because it is covered by a temporary seal. In addition, the canal is susceptible to fracture during treatment. A permanent treatment is preferable to minimize the chances reinfection which can result in apical periodontitis and inhibit canal closure.7 In recent times, creating MTA apical plug in one visit is suggested for the treatment of the nonvital immature permanent teeth as an alternative to long-term apexification treatment. Lee and colleagues first described this material to dental literature in 1993. MTA is a material which has less leakage, better antibacterial properties, high marginal adaptation, short setting time (~ 4 hours), a pH of 12.5 and is more biocompatible. The clinician may restore the tooth after setting of MTA. Thus, the fracture resistant of the teeth with thin dentinal walls increases. MTA can be used in teeth with pulp necrosis and inflamed periapical lesions because it may set in moist environment.2 Rich in calcium oxide after setting, MTA generates calcium hydroxide upon contact with tissue fluid or water. The resultant Ca(OH)2 produces the high pH of this material and might contribute to the early action of the material. Cellular and metabolic activity has the potential to induce periodontal ligament (PDL) cell attachment, and might stimulate PDL fibroblasts to display the osteogenic phenotype and promote the production of osteonectin, osteopontin, and osteonidogen and increase alkaline phosphatase levels.4 MTA is a bioactive silicate cement, alkaline in nature by itself, and is able to induce premature and enhanced expression of alkaline phosphatase activity for fibroblast populations, which may help in the process of the mineralized areas observed. This osteoinductive and cementogenic agent stimulates immune cells to release lymphokines and stimulates bone coupling factors necessary for the bioremineralization and healing of osseous periapical defects, inducing the regeneration of cementum and the PDL.4
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In this case, the closure of the apex using MTA (MTA-Angelus white). MTA was chose because it produces a good apical closure, reduction in the frequency of visits, number of visits and radiographic. The advantages of this material as artificial apical plug formation are obturation can be done immadiately after setting. Other advantages are cementoconductor and osteoconductor.3,8 MTA White was used in this case because it has a better aesthetic than gray MTA. This is because the content of iron, aluminum and magnesium oxide on the white MTA less than gray MTA. White MTA has antibacterial and antifungal activity.18 Before placing the MTA apical barrier, the manufacturer recommends the use of calcium hydroxide [Ca(OH)2] for one week as intracanal dressing and its subsequent removal. The use of calcium hydroxide has been considered an important step in the reduction of the intracanal microbial flora. Because of the detrimental effects of an acidic pH, caused by the inflammation of periapical tissues, on various physical properties of MTA, it could be advisable to delay the placement of the MTA plug to a second session, using Ca(OH)2 as interappointment intracanal medication in order to achieve additional disinfection and neutralization of an acidic environment.10 Circumferential filling techniques using K-file # 90 was chose in this case. Light filling techniques recommended in teeth that have large apical diameters. Excessive lateral pressure should be avoided during filling because the tooth has thin root wall.2 Irrigation solution used in this case were NaOCl, EDTA and chlorhexidine. Before the application of MTA material for apical closure, root canals were irrigated with 0.5% NaOCl solution. NaOCl known to be toxic, especially if highly concentrated. Young permanent teeth with open apex has a high risk of pushed irrigation solution to the apical foramen, so it is advisable to use a low concentration of NaOCl.11 EDTA is normally used at a concentration of 17% and can eliminate the smear layer when in direct contact with the canal walls for less than 1 minute.12 Final irrigation protocols using EDTA and NaOCl is considered to enhance the bond strength of the sealer because it affects
penetration into dentinal tubules that produce microretention13. Irrigation of high pH Chlorhexidine gluconate 2% was used to inhibit the remain of bacteria growth such as Enterococcus faecalis 13 Intracoronal bleaching was done by walking bleach technique using 38% hydrogen peroxide. Hydrogen peroxide is a strong oxidizing agent will diffuse into the email and releases oxygen. Discoloration on the teeth whitening process is due to the oxidationreduction (redox) reaction. The mechanism of tooth whitening is unknown exactly,but suspected that the oxidizer of hydrogen peroxide can dissolve organic materials which are not firmly attached to the tooth and without dissolving the matrix enamel so the color of the tooth is brighter. There is also an opinion that the peroxide-free group will solve a large pigment molecules via oxidation and reduction reactions.14 Composite resin as intracoronal bleaching barrier was chose for this case due to offers the clinical advantage of an on-demand set, which enables subsequent application of the bleaching agent at the same appointment.15 After bleaching results achieved as desired, then followed by restore fracture part with composite resin using a silicon index. This technique was chose because give guidance in filling palatal and incisal part. Dental treatments for tooth with open apices, periapical lesions and discoloration could be complete comprehensively using current material such as MTA, bleaching material, and it needs precise management . The reduction of treatment duration was done by MTA apical plug technique (a one-step obturation) which can minimize the chance root fracture and give comprehensive esthetic benefits for the patient. REFERENCES 1.
2.
Anantharaj A, Praveen P, Venkataraghavan K, Prathibha RS, Sudhir R, Murali Krishnan B. Challenges in pulpal treatment of young permanent teeth a review. J Dent Scien Res. 2011;2:142. Güneş B, Aydinbelge HA. Mineral trioxide aggregate apical plug method for the
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treatment of nonvital immature permanent maxillary incisors: Three case reports. J Conserv Dent. 2012;15(1): 73–76. Felippe WT., Felippe MCS., Rocha MJC. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J. 2006;39:2–9. Torabinejad M, Ibrahim AT. Management of teeth with necrotic pulps and open apices. Endodontic Topic. 2012;23:105–130. Sigurdsson A, Trope M, Chivian N. The Role of Endodontics After Dental Traumatic Injuries. Dalam Pathway of the Pulp. Cohen S, Hargreaves KM. (editor). Ed ke-10. Mosby, St.Louis. Hlm.620-654. Asgary S, Fazlyab M. Nonsurgical management of an extensive endodontic lesion in an orthodontic patient by calcium‑enriched mixture apical plug. Contemporary Clinical Dentistry. 2014;5(2):278-281. Govila, S dan Govila, V. Mineral trioxide aggregate as an apical plug for apical closure and periapical healing - A case report. Indian Endodontic Society. 2010;22(2): 65-9. Broon, NJ. dkk. Healing Of Root Perforations Treated With Mineral Trioxide Aggregate (MTA) And Portland Cement. Journal of Applied Oral Science. 2006;5(14): 305-11. Robertsa HW, Toth JM, Berzinsc DW, Charltond DG. Mineral trioxide aggregate
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material use in endodontic treatment: A review of the literature. Dental Material. 2008;24:149-164. Afonso T, Pega ML, Michelotto AL, Abrantes AM, Oliveiros B, Carrilho EV. Effect of calcium hydroxide as intracanal medication on the apical sealing ability of mineral trioxide aggregate (MTA): an in vitro apexification model. J Health Sci Inst. 2012;30(4):318-22. Mozayeni MA, Zadeh YM, Paymanpour P, Ashraf H, Mozayani M. Evaluation of pushout bond strength of AH 26 sealer using MTAD and combination of NaOCl and EDTA as final irrigation. Dent Res J. 2013;10(3): 359-63. Metzger Z, Basrani B, Goodis H. Instrumens, Materials and Devices. Dalam Pathway of the Pulp. Cohen S, Hargreaves KM. (editor). Ed ke-10. Mosby, St.Louis. 2011. Hlm.223-82. Cohen S dan Hangreaves KM. Pathways of the Pulp. Ed. Ke-10. St Louis:Mosby 2011:521-522. Halim HS. Perawatan Diskolorasi Gigi dengan Teknik Bleaching. Universitas Trisakti. Jakarta. 2006:73. Canoglu E, Gulsahi K, Sahin C, Altundasar E, Cehreli ZC. Effect of bleaching agents on sealing properties of different intraorifice barriers and root filling materials. Med Oral Patol Oral Cir Bucal. 2012;17(4):e710–5.
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Richmond crown on four anterior teeth with 1/3 cervical fractures Nurhayaty Natsir*, Vero H Sanusi* *Staff of Department conservative dentistry, Faculty of dentistry, Hasanuddin University
Abstract Introduction: Loss of the tooth structure of four anterior teeth simultaneously is rare, remains less of structure. Restoration with intracanal retention is an appropriate to support these condition in restoring the function and esthetic appearance. Case: A Male patient, 24- year old, came to department of endodontic , Faculty of Dentistry Hasanuddin Universty hospital with fractures of four anterior teeth 12,21,11,12 which remain 1/3 cervical with diagnosis of chronic apical periodontitis. Treatment: Conventional endodontic treatment using Crown Down Preparation technique is performed then obturate with single cone technique and restore with Richmond crown. Conclusion: Fractures teeth with less remained teeth structures can be restored with Richmond crown to provide maximal retention where the post, core and crown in one block system. Key word: Richmond crown, teeth fractures, post crown Kontak person: Nurhayaty Natsir,bagian konservasi FKG Unhas, jalan Perintis kemerdekaan km 10, E-mail:
[email protected], Hp: 08124293906
INTRODUCTION Dental trauma is most common in the 7 to 12 year-old age group and the cause is mainly due to falls and accidents near home or school. Most dental trauma occurs in the anterior region of the oral cavity, affecting the maxillary more than the mandibular jaw. Can occur to one or more teeth, but the incidence on multiple teeth is very rare 1. One of the most common dental trauma types is crown fracture 1,2. When half or almost all of the structure of the crown is lost, of course, it is not possible to obtain sufficient retention of the remaining dentine structure. In these conditions, the root canal retention needed to support the final restoration and fracture resistance. In the posterior teeth do not always need post-retained core due to sufficient dentin bulk and receive load axially. Because of anterior teeth which receive load nonaxially, more stress develops when chewing forces exerted. Thus,post and core procedure has been advocated to get retention for the final restoration 3,4,5,6,7. There are two types of posts that used, prefabricated posts and custom posts, which the posts selection depends on the remaining structure of the tooth crown2,3. Custom posts is
better used if less of the crown structure remain or there is no clinical crown, so it needs protection against fracture with a ferrule or metal collar effect covering around the root surface8,9. Richmond crown is a restoration with custom posts, which brings post and core together become a unit. Providing a better geometric adaptation to the flare or elliptical shaped root canal. Indicated to teeth that have less crown structure remains and lack occlusal clearance 10,11. CASE REPORT A male patient aged 21 years old came to the Unhas Dental Hospital, with chief complaint one third cervical fracture of 4 anterior teeth. Fractures occurred one year ago as a result of trauma. Objective examination obtained fracture with less remaining crown structures, deep-bite occlution, and short size teeth (Fig 1 ). Thermal test does not give respond, tenderness to percussion test. On radiograph image showed normal root with apical radiolucency (Fig 2). The diagnosis is chronic apical periodontitis.
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Fig 7: Richmond crown was cemented Fig 8: Lateral view of Richmond crown Fig 1 : Pretreatment condition Fig 2 : Radiography imagine of the tooth
CASE MANAGEMENT Root canal preparation performed on #11,#12,#21,#22 with crown-down preparation technique using ProTaper files to file F5 (Denstply Maillefer, Switzerland). Dressing of Ca (OH)2 and temporary restoration given. A week later the root canal filling performed with single cone technique with Guttappercha sizes F5 (Denstply Maillefer, Switzerland) with the root canal resin cement AH 26 (De Trey Denstply Germany), temporary restoration given. In next appointment, post space prepared was prepared using peeso reamer no. 1-4 (Mani, Japan), preparation of crown structure, shade selection, rubber base impression made (inc GC, Japan), then given a temporary crown . On the next visit try-in and Richmond crown was cemented with glassionomer (GC Corporation Tokyo, Japan).
Fig 3 : Try- in the gutta-percha Fig 4 : Single root canal obturated
Fig 5 : After tooth preparation Fig 6: Try-in Richmond crown
DISCUSSION Teeth are in a challenging environment, facing heavy and repeated occlusal loads more than 1 million rounds per year, throughout its life 2 . Anterior teeth with structural damage or loss of extensive dental crown (trauma, extensive proximal caries), need a core that uses posts in the root canal to hold the core and the final restoration 2,3,12. The main changes in the biomechanical properties associated with dental tissue loss due to caries, fractures, restorative procedures, occlusal wear increasing the risk on teeth during normal functioning. Teeth that had endodontic treatment performed are at greater risk than vital teeth, so the selection of restoration must meet the criteria of: 1) protecting the remaining tooth structure, 2) minimizing cuspal plexure, 3) providing crown seal to achieve satisfying function and esthetics 2,3. The need of posts core and posts are vary depending on the size and load that tooth received. If the tooth crown much still remains, the core material choice is not important, but it becomes very important when only a less of the crown structure remains. Core that made of composite resin, glassionomer, and cermet would be a risky option 12. There are some types of posts that could be an option. This indicates that there are no posts that can meet all the criteria of ideal posts, so that the selection depends on the condition of the tooth crown structure 8,9,12. When sufficient amount of tissue is present at periphery of the toot prepared tooth,a direct pondation restoration is indicated,which is a prefabricated post is cemented inside of the root canal and the core is built directly on the prepared tooth 2. But when less of tooth crown structure is remains, it is an indication to use the custom post 8,9. The risk of root fracture based on tensile stress of the tooth
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structures was higher with the post and core composite than with custom post and core, these stresses doubled when the restoration were not bonded the tooth structures 13. The advantages of custom post and core system is that the post and core is united, and that the core does not depend on mechanical factor for retention on the post. This construction prevents the separation of the core from the post and root canal when less tooth structure remains2,3. Post and core form is in accordance with the shape of the root canal and the remaining tissue structures so that would minimize dentin tissue loss, both on the root canal and the crown. While the prefabricated post must remove the tissue to follow the available posts shape 2. If there is a ferrule, custom posts can provide more high resistance to fracture than the prefabricated posts that made of metal or carbon and core made of composite. Presence of ferrule is determining factor on the strain,stress distribution, fracture resistance and failure mode. A uniform 2 mm ferrule were more fracture resistance than those with a uniform 1 mm ferrule in endodontically treated maxillary central incisor 14. In the absence of ferrule the use of fiber glass post refresents conservative choise because of the non catastrophic fracture pattern was observed. When a custom post and core are used, the post should be as long as possible,whereas the biomechanical performance of fiber glass post was less sensitive to post length 15. Custom Post and cores fabricated using a standardised fabrication technique have a good long-term prognosis. Clinically longevity of the post and core resotoration can be influenced by many factors including magnitude and direction of the occlusal load, design of dowel, thickness of the remaining dentin, quality of cement layer and creation of ferrule effect to enhanced structural durabilityof final restoration 14 . Most common cause of failure is the loss of retention 5. Although there are also studies that claim there is no data supporting that custom post and core custom is better than prefabricated post or otherwise. Disadvantages of custom post and cores are more time consuming and frequently involves greater laboratory and material costs. So if the quality of treatment comparabale, direct
core restoration can reduced both time and financial burdens on the patient 4,9. Various kinds of cement has been used for post cementation, such as the traditional cement, glassionomer cement, and resin cement. Traditional cement is zinc phosphate cement or polykarboxylate cement. This cement provides mechanical retention and does not have a mechanical bond to the posts and dentin. Clinically provides sufficient retention to the posts if the tooth structure is adequate. Some authors recommend glasssionomer cement for custom post insertion as it can be manipulate easily, settings chemically, and is able to bind to both tooth structure and post 3. In this case report, Richmond crown was decided to restore fractures involving 4 anterior teeth with less remaining crown structure, with deep bite occlusion and short tooth size. Richmond crown is a restoration that brings together the post and core in a unit. It is very appropriate in this case so that limited space problem for final restoration placement can be overcome by it. The crown that unite with the post has several advantages compared to the crown with several parts. When a separate post and core, posts can be bent due to functional load, causing pressure between the post and the core, resulting separation of the post and core. Caries or loss of the crown can cause core damage also damage to the core material after a while. Therefore, it needs a restoration that brings together post, core and crown in one unit for long term stability 10,11. CONCLUSION Tooth fracture with little remaining tooth structure and deep bite occlusion condition does not have sufficient space for the placement of restoration. Richmond crown may be an option in order to obtain maximum retention through a union between a post and core in one system. However, it has to be used judiciously according to tooth condition. REFERENCES 1.
Sigurdsson A, Trope M, Chivian N; The role of endodontic after dental traumatic injuries
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In Hargreaves KM , et al,editors: Cohen‟s pathways of the pulp,10 th ed,St Louis,2011,Mosby. Messer HH, Goodacre CJ; Preparation for restoration In Torabinejad M, et al editors: Endodontics principles and practice,4 th ed,St Louis,2009,Saunders. Dietschi D, Bouillaguet S, Sadan A; Restoration of the endodontically treated tooth In Hargreaves KM , et al,editors: Cohen‟s pathways of the pulp,10 th ed,St Louis,2011,Mosby.s Heydecke G, Peters MC; The restoration of endodontically treated,single rooted teeth with cast or direct post and core: A systematic review, The Journal of Prosthetic Dentistry,2002;87;380-6. Balkenhol M,Wostmann B,Rein C,Ferger P; Survival time of cast postand cores: A 10 – year retrospective study,Journal of Dentistry 35 (2007) 50-58. Sabbak SA; Prefabricated post and core material versus custom-cast post and core in maxillary first premolar tooth: Review of literature and management of clinical case, Cairo Dental Journal 14 (1):23-26,1998. Da Silva NR, Raposo LHA,Versluis A et al; The effect of post,core,crown type,and ferrule presence on biomechanical behavior of endodontically treated bovine anterior teeth, Journal of Prosthetic Dentistry, Journal of Prosthetic Dentistry,2010;104:306-307. Rubina, Kumar M, Garg R et al; Prosthodontic management of endodontically treated teeth- A review,
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International Dental journal of student‟s research, Feb 2013-May 2013,Vol 1,Issue 4. Cheung W; A review of the management og endodontically treated teeth post ,core and final restoration,JAD vol 136, May 2005. Kini SK, Muliya VS; Restoration of an endodontically treated premolar with limited interocclusal clearance. Indian J Dent-Res (serial online) 2013 (cited 2014 Jul 10);24:518-20). Garwal AA, Chanda K et al; Richmond crown- A conventional approach for restorationof badly broken posterior teeth, Journal of Dental Peers,Vol 1, Issue 1, April 2013. Ibbetson RJ; Restoration of endodontically treated teeth In Pitt Ford TR editor: Harty‟s Endondontics in clinical practice, 5 th ed, Edinburgh,2004,Wright. Sing S, Thareja P; Fracture resistance of endodontically treated maxillary central incisors with varying ferrule height and configuration: In vitro study, Journal of Conservative Dentistry 2014, Mar-Apr; 17 (2) : 115-18. Ona M, Wakabayashi N, Yamazaki T et al; The influenceof elastic modulus mismatch between tooth and post and core restoration on root farcture, International Endodontic Journal, 46,47-52,2013. Santos-Filbo PCF, Verisssimo C, Vinicius S et al; Influence of ferrule, post system, and length on biomechanical behavior of endodontically treated anterior teeth, J Endod 2014;40:119-23.
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Endodontic treatment of internal root resorption using mta in incisor mandibular: a case report Juni Jekti Nugroho1 , Nurul Wadudah AS2 Departement of Conservative Dentistry, Dentistry Hasanuddin University, Makassar 2 Resident of Dental Conservation, Specialist Dentistry Educational Program, Dentistry Hasanuddin University, Makassar1
Abstract Introduction : Internal root resorption is a progressive destruction of intra-radicular dentin and dentinal tubules along the middle third and apical third of the root canal wall due to chronic inflammation and bacterial invasion of the pulp. Case: A 32-year-old female patient complained a decay in her linguo-cervical of #31 and wanted to restore her tooth. It was also mobile 3. Case management: root canal treatment is done to maintain #31 teeth with a hybrid technique, using sectional gutta-percha obturation and Mineral Trioxide Aggregate (MTA) application. Discussion: Mineral Trioxide Aggregate has chosen to treat internal root resorption because it is an excellent repaired material with good sealing ability and mechanical strength . Keywords : internal root resorption, Mineral Trioxide Aggregate Corresponden: Juni Jekti Nugroho, Departement of Conservative Dentistry, Dentistry Hasanuddin University, Jl. Perintis Kemerdekaan Km.10, Makassar - Indonesia, Mobile. 081355229964; e-Mail:
[email protected]
INTRODUCTION Internal root resorption has been described as a resorptive defect of the internal aspect of the root following necrosis of odontoblasts as a result of chronic inflammation and bacterial invasion of the pulp tissue.(1) Internal root resorption is a pathological phenomenon that is characterized by loss of dentin due to the action of clastic cells.(2,3,4) Root resorption may occur as a physiologic remodeling throughout life, root resorption of permanent teeth does not occur naturally and and is invariably inflammatory in nature. Thus, root resorption in the permanent dentition is a pathologic event; if untreated, this might result in the premature loss of the affected teeth(2,5,6,) Root resorption might be broadly classified into external, internal and periapical resorption. Internal root resorption divides into intracoronal and intracanal type . Internal root resorption might occur along coronal, the middle and apical thirds of the canal walls.(2,5,6) Incorrect diagnosis might result in inappropriate treatment in certain cases. Intraradicular internal resorption is an inflammatory condition that results in
progressive destruction of intraradicular dentin and dentinal tubules along the middle and apical thirds of the canal walls. The resorptive spaces might be filled by granulation tissue only or in combination with bone-like or cementum-like mineralized tissues.(2,6) Compared with intraradicular internal resorption, apical internal resorption is a fairly common occurrence in teeth with periapical lesions.(2) The authors examined the extent of internal resorption in 75 roots (69 roots with radiolucent lesions and 6 vital control roots) and graded the severity of resorption on a 4 point scale. They concluded that 75% of teeth associated with periapical lesions had internal apical resorption and that vital teeth had statistically less apical internal resorption than teeth with periapical lesions. Severe internal resorption could be identified in 48% of those cases with periapical lesions. Conversely, only 1 root in the control group displayed mild internal resorption, which was speculated to be transient in nature as a result of trauma.(2,3) Etiology of internal root resorption is quite unclear. In a study of 27 teeth with internal resorption, trauma was found to be the most common predisposing factor that was responsible
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for (45%) of the cases examined followed by carious lesions (25%).(3,4,5,6) Other predispose factors including trauma, pulpitis, pulpotomy, cracked tooth, tooth transplants, restoration procedures, invagination, orthodontic treatments, and even herpes zoster infection.(6,7) It was concluded that trauma and pulp inflammation/infection are the major contributory factors in the initiation of internal resorption.(1,3-7) This paper presented a case of internal root resorption on mandibular central incisor which was treated with endodontic treatment and MTA repair. CASE A 32-year-old female patient complained a decay in her linguo-cervical of #31 (Figure 1a & 1b). The patient‟s medical history was noncontributory. The tooth never caused a spontaneous pain. Currently, she is wearing orthodontic appliances for about 3 years. Thermal sensitivity test was negative and tooth mobility was o3. Periapical radiograph and computed tomography scan showed a welldefined radioluscent area on middle third of root canal, which indicated internal resorption and periapical radioluscency. Alveolar bone only supported apical third of root aspect (Figure 2a & 2b). The possibility of conserving tooth #31 was considered through a hybrid technique by combining cold gutta- percha obturation and internal MTA repair.
a.
b.
Figure 1. Preoperative photograph: (a). labial view, (b). lingual view
a.
b.
Figure 2. (a). Preoperative periapical radiograph labial view (b). Preoperative computed tomography scan
CASE MANAGEMENT The tooth was isolated with a rubber dam without a clamp, to avoid the possibility of horizontal fracture. After coronal access, the pulp tissue was removed. After working length determination which is 18 mm, the canal was shaped with # F1-F3 proTaper rotary files and lubricant. This was accompanied by copious irrigation with 1% sodium hypochlorite. Calcium hydroxide paste was placed for 1 week as root canal dressing (Figure 3a & 3b).
a.
b.
Figure 3. (a). Working length determination. (b). Calcium hydroxide application
On the next appointment, the root canal dressing was removed with 1% sodium hypochlorite, then irrigated using saline solution and dried with sterile paper points. The apical third of root canal was filled with F3 sized guttapercha and resin sealer, we called this sectional obturation (Figure 4a). Next, white MTA was applied on internal resorption area, using amalgam carrier and condensed with finger plugger until the canal filled completely (Figure 4b). A moist cotton pellet was applied above the white MTA, then cavity access was filled with temporary restoration.
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DISCUSSION
a.
b.
Figure 4. (a). Application of sealer and sectioned F3 sized gutta-percha in 1/3 apical,(b). Application of white MTA in resorption lacuna and the rest of root canal
On the third appointment, the setting of white MTA was verified using gutta-percha. The patient never complained pain and tenderness on percussion. Coronal and linguo-cervical cavity was filled with composite (Figure 5).
Figure 5. The coronal chamber and decay in linguo-cervical were restored with composite
Clinical and radiographic follow-up was conducted one month after treatment, demonstrating a functional tooth with no endodontic pathosis. The periapical radioluscency area was decreased (Figure 6). Patient was referred to a periodontist for alveolar bone treatment using guided tissue regeneration (GTR) and bone graft.
Figure 6. Follow up extra oral photograph and radiograph after 1 month
Resorption is a condition associated with either a physiologic or a pathologic process resulting in a loss of dentine, cementum, and/or bone. Root resorption may occure after various injuries, including mechanical, chemical, or thermal. Internal resorption is an inflammatory process initiated within the pulp space with loss of dentine and possible invasion of the cementum.(3,4) Internal root resorption is usually asymptomatic.(1,3,5,6,8) and often recognized on clinically through routine radiography. Pain may occur depending on the pulpal condition or perforation of the root resulting in a periodontal lesion. However, clinical signs may vary according to the location and its wideness. If internal resorption is located in the coronal part of the canal, a clinical aspect of “pink spot” can be observed. The pink color turns grey/dark grey when the pulp becomes necrotic.(1,3,6,8,9) For internal resorption to take place, vital apical pulp adjacent to resorption areas is required. If left untreated, internal resorption will grow significantly until the inflamed connective tissue filling the resorption defects degenerate, hence the lesion will grows toward apical direction. Finally, if left untreated, apical pulp tissues of the resorption lesion undergoes necrosis, bacterial will infect all of the root canal system, and triggers an apical periodontitis. The development of complete pulp necrosis stops the growth of the resorption because the resorptive cells are cut off from the blood supply and nutrients if the pulp chamber is sealed.(2,3,4,6,8) Internal root resorption may be located everywhere within the root canal system. Intraoral radiography showed an oval enlargement within the pulp chamber or root canal.(1,2,3,6) This condition is undetected until the lesion undergoes significant development that perforated or causing acute/chronic apical periodontitis as consequences of total pulp necrosis and infected pulp chamber.(2,6) Internal root radiolucencies are not detectable on radiographs at their early stages, when they are small, or because of limitations of this 2-dimensional method. Cone beam computerized tomography (CBCT) provides a 3-
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dimensional view of the resorption with axial, coronal, parasagittal views of the anatomy. Cone beam computerized tomography is a more powerful tool which allows an earlier and more accurate diagnosis of these lesions.(1,2,3,6) Root canal treatment remains the treatment of choice of internal root resorption as it removes the granulation tissue and blood supply of the clastic cells.(1,3,5,6,8,9) Internal root resorption presents specific difficulties in instrumentation and filling. The access cavity preparation must be as conservative as possible to preserve tooth structure and avoid further root fractures.(3,5,6,8) Because of the limited access by instruments to all areas of the resorption cavity, chemical means are needed to completely clean the canal. Irrigation with sodium hypochlorite (NaOCl) is an important part -of the treatment of teeth with internal resorption. In small perforations, hypochlorite will help to control bleeding from perforation and disinfect and clean the area with perforation complications. However, with large perforations, lowconcentration hypochlorite solutions should be used and other irrigants, such as chlorhexidine should be considered.(5,8) The use of calcium hydroxide as an interappointment dressing maximizes the effect of disinfection procedures, helps to control bleeding, and necrotizes residual pulp tissues, maintains the alkalinity, prevents recurrent resorption.(3,5,8) Studies on the effectiveness of sodium hypochlorite and calcium hydroxide to remove the resorption and other tissues from the root canal indicate that they have an additive or even synergistic effect. In cases where the resorption has not perforated, it is usually enough to use calcium hydroxide paste in the canal once from 1 to 2 weeks. This allows removal of the residual tissue at the next appointment by irrigation and instrumentation.(8) In this case, hybrid technique with sectional gutta-percha and white MTA were used in the obturation. Apical third of the root canal was filled with F3 sized sectional gutta-percha. After that MTA was done on middle third of root canal (resorption lacuna) to the rest of root canal, because it was difficult to apply and condense MTA in a narrow root canal diameter. MTA
repair was used because it was a bioactive, biocompatible material with favorable sealing ability and well-tolerated by the periradicular tissue.(6,7,9-13) CONCLUSION Internal root resorption is relatively rare root resorption on permanent teeth. This pathologic lesion caused by pulp inflammation and bacterial invasion. MTA is an excellent alternative to repair internal root resorption. In this case, the patient‟s tooth was symptom-free and functional after 1 month follow up. SUGGESTION Further follow up was needed to confirm that the resorptive process has stopped and to control the tooth mobility after referred for treatment by a periodontist. The obturation technique chosen to treat internal root resorption depends on the condition of tooth and equipments available, which one is most easily done with the maximum result. REFERENCES 1. 2.
3.
4.
5.
6.
7.
Maria R et al. Internal resorption: A review and case report. Endodontology:100-8 Patel S, et al. Internal root resorption: A review. Journal of Endodontic 2010 Jul;36(7):1107-21 Elisabeth Nilsson et al. Management of internal root resorption on permanent teeth: Review article. International Journal of Dentistry 2013 Kanas RJ and Kanas SC. Dental root resorption: A review of literature and a proposed new classification. AEGIS Communic 2011;32(3):185-201 Martos J, et al. Internal root resorption in the maxillary central incisor: Case report article. South Brazilian Dent J 2010 Jun;7(2):23943 Greta Sckaljac-Staudt et al. Internal resorption, therapy and filling. Acta Stomatol Croat 2000; 34(4):431-33 Fernandes M, de Ataide I, Wagle R. Tooth resorption part I- pathogenesis and case
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series of internal resorption. J Conserv Dent 2013;16 (1): 4-8 8. Ozer YS. Diagnosis and treatment modalities of internal and external cervical root resorption: review of the literature with case report.IDR 2011;1(1):32-6 9. Haapasalo M and Endal U. Internal inflammatory root resorption: the unknown resorption of the tooth. Endodontic Topics 2008;14:60-79 10. Mohammadi Z, et al. Non-surgical repair of internal resorption with MTA: A case report. Iranian Endodontic Journal 2012 Mar;7(4):211-14
11. Hebert CA. Internal vs external resorption. Endodontic Center: A professional dent corp. 12. Jacobovitz M. and de Lima RKP. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. International Endod Journal 2008;41: 905-12 13. Fuss Z, Tsesis I, Lin S. Root resorptiondiagnosis, classification and treatment choices based on stimulation factor. Dent Traumatol 2003;19:175-82 14. Andreasen, JO and Andreasen, FM. Essentials of traumatic injuries to the teeth, pp.116-9
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Obturation of an internal resorption root canal maxillary left central incisor Haslinda* , Nurhayaty Natsir** * Resident of conservation department of Hasanuddin university ** Staff of conservation department of Hasanuddin university
Abstract Introduction : One of the critical success factors of endodontic treatment is the hermetic obturation technique that aims to prevent re - infection and healing in peri - radicular tissues . Clinicians frequently find endodontic treatment case with root canal irregular shape due to internal resorption , which required obturation techniques to fill the irreguler shape of root canal in order to obtain good results of endodontic treatment . This case report present a case of root canal treatment on a maxillary left central incisor with internal resorption in the middle third of the root area . Case : A 29 years old male came to the Halima Dg . Sikati Hospital Tamalanrea Unhas with diagnosis incisor pulp necrosis in the left centralis maxillary incisor. Patient had a history of dental trauma about 12 years ago . Radiographic showed an irregular root canal form where the one-third middle wider than the coronal and apical regions of the root canal because of internal resorption due to trauma . Case management : In the 21 dental root canal treatment performed with conventional techniques . Obturation was done with warm gutta-percha vertical compaction with downpack and backfill system . Conclusion and suggestion: In the case with root canal internal resorption, warm gutta-percha vertical compaction technique is preferred. These technique is effective because filling material can penetrate properly, filling the entire surface of root canal. Keywords : obturation , warm gutta-percha vertical compaction, internal resorption Koresponden: Haslinda, Resident of conservation department of Hasanuddin university. Address : Jl. Perintis Kemerdekaan Km.10, Makassar, Indonesia. Phone: 0853 1211 9191. E-mail:
[email protected].
INTRODUCTION Endodontic treatment can be divided into three main phases (triad endodontic), which are; biomechanical preparation of root canal, disinfection, and obturation. Biomechanical preparation intended to cleanse and disinfect root canals assisted with irrigation agent and form the root canal wall so that the obturation with a filler material can be done accurately. However, there are some pathological conditions in the root canal causing preparation and obturation step become quite difficult so it does not allow fillingto be doneconventionally. One of these conditions is internal resorption in root canals with the formation of irregular defects which can not be accessed either by conventional preparation and obturation.1,2,3 Internal resorption is a condition in which the damage occurs due to the inflammatory process of vital pulp that triggers the activity of dentinoclastic causing resorption of the root canal, where the radiographic imageshows irregularity of the root canal walls.
This will cause difficulties in performing endodontic treatment, where the preparations areunable to take all of the infected tissue and the walls of the root canal can not be formed well and conventionalobturation will not be able to cover the entire root canal accurately. Therefore, the main treatment in this case after the removal of infected tissue from root canal is to sterilizied it with the help of an dressing agent. One of the obturation technique suggested by Tanikonda et al, is vertical compaction of warm gutta-percha as filler material that can penetrate well, filling lateral and accessories canals, as well as saving the time.3,4,5 The purpose of writing this case report is to present root canal treatment of permanent maxillary incisors thatwere experiencing internal resorption in the middle third area, which the treatment includes conventional endodontic treatment and ends with thermoplastic obturation using vertical compaction techniques of warm gutta-percha.
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CASE REPORT A man aged 24 years old came to the Halima Dg. Sikati Dental HospitalinTamalanrea Unhas with complaints offront teeththat acheswhen chewing. The patient had a history of dental trauma about 16 years ago. From the objective examination, the patient does not respond to the thermal test and cavity test, as well as tenderness on percussion test. Radiographic image shows radiolucency of the periapical areaand internal resorption in root canals where irregular damage seen in the middle-third wider than the coronal and apical area. Diagnosis of the left maxillary permanent teeth incisivus is chronic apical periodontitis.
Figure 2. Working length #21 is 20mm
CASE MANAGEMENT Access cavity preparation was performed on #21 using endo access bur. Initial file obtained #35 then measured working length is determined with the aid of radiographs. Working length obtained is 20mm (fig 2). Root canals were prepared with a circumferential techniques to the K-file # 80 and every turn of the files root canal irrigated with 2.5% sodium hypochlorite and rinsed with sterile saline and then dried with paper points. Calcium hydroxide (Ultracal ® XS, Ultradent product.inc) is placed in the root canal as a dressing agent, then #21 filled with temporary fillings. Patient was asked to control 3 weeks later.
Figure 1. Clinical features and radiographs before treatment
Figure 3. Radiographic image after filling calcium hydroxide (ultracal)
On the second visit, calcium hydroxide removed and the root canals were irrigated again with 2.5% sodium hypochlorite and rinsed with sterile saline, then dried with paper points. Then a vertical compaction obturation warm guttapercha was done using Beefill 2in1 (VDW company, Germany) as shown in figure 5. Appliance is equipped with 2 systems, packs down and back fill. As for the filling step, tryin?the master gutta-percha #80 in appropriate working length (fig 4), then the master guttapercha filling done in the root canal with sealer resin (AH plus, denstply). After that, a tip that serves as a heat carrier activated and used to cut gutta-percha to the limits of the CEJ. After that, vertical condensation performed on the entire root canal wall with a plugger to obtain maximum density. Then, tip hot carrierswitched back and put in the root canal about 3-4mm from the corona, the tool switched off, waited a few moments, then tools removed. Vertical condensation re-done using plugger with a smaller diameter in the same way as the first vertical condensation. The second vertical condensation would leave the master guttapercha about 4-5mm in apical area (fig 6a and 6b).
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internal bleaching restorations.
with
composite
resin
Figure 4. Try-in the master gutta-percha # 80 Figure 7 (a). Filling warm gutta-percha, (b), Vertical condensation with a hand plugger
Figure 5. Beefill 2in1 Figure 8. Radiograph after obturation
DISCUSSION
Figure 6 (a). Cutting the master Gutta-percha on the CEJ area, (b). Vertical condensation with a hand plugger
The next step was filling with heated gutta-percha, by means the tip of the cannula containing gutta-percha inserted into the root canal until itreachedthe master gutta-percha that has been compacted previously, then pressed the button of heat then the gutta-percha would come out of the cannula and filling the remaining of root canal system and at the same time pushing the tool out of the canal. Fillingstopped by removing the button of heat, then vertical condensation with plugger done until the entire root canal system is fully up to the limit of the orifice (fig 7). Filling evaluation done with radiographic image as in figure 8. Control done 2 weeks later, on subjective and objective examination of the patient there is no complaint on #21, then radiographs image taken to re-evaluate the results of the filling. Patients scheduled to return with the plan of
Internal resorption is the destruction of tooth substance that begins in an area adjacent to the pulp of internal dentin walls that eventually penetrate the external surface of the crown and root.7 Destruction pathogenesis begins with alteration of normal pulp tissue into granulation tissue with giant nucleus cells in which play a role in dentin resorption. Changes in pulp tissue originates from chronic inflammation of the coronal pulp by long-term continous stimulation of bacteria.8 Chronic inflammation of the pulp is a common thing in the pulp, but internal resorption will occur if the odontoblast layer and predentin lost or the structure of dentin changed. The cause of the predentin layer loss can not be ascertained clearlyuntil now. In some cases, the cause is internal root resorption.6,8 Internal resorption is generally asymptomatic and develop slowly. If not detected quickly, destruction will occur progressively lead to perforation of the pulp wall and necrosis of the pulp. The clinical appearance of internal resorption varies depending on the occurrence of internal resorption. If an internal resorption is located on the coronal part of the root canal, it
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will look like a pinkspot due to high vascularity of granulation tissue cells that play a role in the resorption. This color will change to a gray/black in the necrotic pulp.7 Radiographically, widening of the root canal looks irregular because of the canal walls confining line that disappear as seen in Figure 1.4,9 The main management in internal resorption case is root canal treatment, but the treatment phase will be quite complex due to two main factors, resorption area can not be accessed properly using conventional methods both on root canal preparation phase and obturation phase because of the irregular root canal shape and the magnitude of the damage can not be estimated accurately using two dimension X-ray photograph.6,7 Few things that need to be considered in performing root canal treatment with internal resorption, such as access preparation is recommended as conservative as possible to prevent the weakening of remaining tooth structure.7 Therefore the preparation instrument can not take and removeall granulation tissue and infected tissue, so it requires disinfection materials that capable to dissolve necrotic tissue, in this case is sodium hypochlorite.7,10 In addition to the use of irrigation, the use of calcium hydroxide as a medicament dressings will maximize the disinfection procedure because it has excellent antimicrobial feature,that isable to eliminate bacteria, and neutralize the toxin that remains there.4,7,10,11 Obturation materialsthatused must be flowable,which capable to fill the resorption of root canal system. Resin-based sealer (AH plus, Denstply, Germany) is used because it has a low solubility and good adhesive character, then apply warm vertical compaction obturation technique with thermoplasticized guttapercha.6,7,10,12 In this case, obturation performed with BeeFill 2in1 (VDW Company, Germany), which consists of two devices with down-pack and back-fill mechanism. Warm vertical compaction technique was first discovered in the early 1960s by Dr. Herbert Schilder, a combination of simple root canal filling system with maximum filling effectiveness on a normal root canal and complex root canals, and as a base for the development of other obturation
techniques such as master-cone sectional, warm gutta-percha and thermoplasticized technique.3,13,14 This is consistent with the case, which in the root canal with irregular shape, the warm vertical compaction technique with thermoplasticized gutta-percha can fill the root canal system because it can increase the density and homogeneity of the gutta-percha and guttapercha will flow to fill the irregular root canal system, lateral canals and accessories canals properly, compared with lateral condensation technique that has several shortcomings including gutta-percha mass is not homogeneous, not able to fill the root canal space and lateral canals properly, leaving a space for bacteria to grow.5,12,15 Systematically how these tools work, outlined in the figure below: 3,6,7,12,13,14
Figure 9 Down pack, which gutta-percha is taken with a tip that delivers heat to the CEJ (a). vertical condensation with a larger size plugger (b) (Reference : Ruddle C J. Threedimensional obturation of the root canal system. Dentistry today. July, 2006 ; 1-11)
Figure 10 (a). Heater tip re-inserted into the root canal around 3-4mm. (b). Heater was turned off momentarily and then removed from the root canal, as well as bringing guttapercha out about 3-4mm. (c). Vertical condensation with smaller plugger, leaving a master gutta-percha in the apical around 4-5mm. (Reference : Ruddle C J. Three-dimensional obturation of the root canal system. Dentistry today. July, 2006 ; 1-11)
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6.
Figure 11 Backfill, cannula containing gutta-percha inserted into the root canal until it touches the master apical guttapercha, heater then activated so gutta-percha flowed and filled empty root canal (a). vertical condensation with smaller plugger (b). cannula containing gutta-percha flowed back, and condensed vertically to fill the entire root canal system (c). (Reference : Ruddle C J. Three-dimensional obturation of the root canal system. Dentistry today. July, 2006 ; 1-11)
7.
8.
CONCLUSION AND SUGGESTION 9. Application of resin-based sealer with warm gutta-percha vertical compaction and thermoplasticized gutta-percha will increased quality of sealing because the resin has a low solubility and good adhesive character,also this obturation technique can penetrate and fill the entire surface of both root canals, lateral canals, and accessories canals.
10.
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Elzubair A, Elias CN., et. Al. The physical characterization of a thermoplastic polymer for endodontic obturation. Journal of Dentistry. Elsevier. 2006; 784-9. Ugur Inan, Hikmet A, Tamer T. Leakage evaluation of three different root canal obturation techniques using electrochemical evaluation and dye penetration evaluation methods. Aust Endod J. 2007; 33 : 18-22. Ruddle C J. Three-dimensional obturation of the root canal system. Dentistry today. July, 2006 ; 1-11. Martos Josue, Silveira L F,et. Al. Internal root resorption in the maxillary central incisor. South Brazilian Dent J. 2009; 359464. Tanikonda R, Sekhar S K, Anupreeta A. Flowable gutta-percha in endodontics-
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15.
reviem and few case reports. J res Adv Dent 2013; 2 : 3 : 86-90. Agarwal M, Rajkumar K, Lakshminarayan L. Obturation of internal resorption cavities with 4 different techniques : an in-vitro comparative study. Endodontology J 2002 ; 14 ; 1-6. Nilson E, Bonte E, et. Al. Review article : Management of internal root resorption on permanent teeth. International Journal of Dentistry; October 2013 : 1-7. Maria R, Mantri V, Koolwal S. Internal resorption : a review & case report. Department of conservative dentistry and endodontics, modern dental college, indore. 1-9. Ozer SY. Diagnosis and treatment modalities of internal and external cervical root resorptions : review of the literature with case report. Int Dent Res. 2011; 1; 327. Fernandes M, de Ataide I, Wagle R. Tooth resorption part I- pathogenesis and case series of internal resorption. J Conserv Dent [serial online] 2013 [cited 2014 Jun 25];16:4-8. Available from: http://www.jcd.org.in/text.asp?2013/1 6/1/4/105290. 2013; 16; 1: 4-8. Mustafa M, Saujanya Kp, et.al role of Calcium hydroxide in endodontics : a review. GJMEDPH. 2012; 1 ; 1; 66-71. Nunes V.H, Silva R.G, et. Al. adhesion of Epiphany and AH Plus sealers to human root dentin treated with different solutions. Calcedo R, Odon, Clark M.S. Modern perspective in root anal obturation. www.ineedce.com. The Academy of Dental Therapeoutic and Stomatology : 1-14. Schilder H. Vertical compaction of warm gutta-percha.76-99. Kandaswamy D, Venkateshbabu N, et. Al. Comparison of laterally condensed, vertically compacted thermoplasticized, cold free-flow GP obturations- a volumetric analysis using spiral CT. J. conserve Dent ; 2009 oct-dec; 12 (4); 145-149.
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Esthetic Rehabilitation of Post-Traumatic Anterior Maxillary Teeth With Fiber Reinforced Posts: A Case Report Erny Djuhais1, Juni Jekti Nugroho 2 Resident of Dental Conservation, Specialist Dentistry Educational Program, Dentistry Hasanuddin University, Makassar1 Department of Conservative Dentistry, Dentistry Hasanuddin University, Makassar 2
Abstract Introduction: Maxillary incisors are most commonly involved in dental trauma and dental crowns are frequently damaged because of their exposed position in the dental arch. When, there is an extensive loss of coronal tooth structure, a tooth colored metal-free post may be required for retention of crown to restore the dental morphology. The advantages of using reinforced fiber to construct intracanal post include crown reinforcement, translucency, and relative ease of manipulation.Case: A 34 years old female involved in a motorcycle accident that causing crown fracture to her four maxillary incisors [tooth 11, 12, 21, and 22]. Four days after the accident, she presented to Conservative Department RSGM Halimah Dg. Sikati with chief complaint of crown fractures and unpleasant esthetic on four maxillary incisors. Case Management: Endodontic treatment was performed on the four maxillary incisors, and restored with porcelain crowns using fiber post as retention. Conclusion: Multiple crown fractures present a challenge. During follow up appointments, clinical and radiograph examination revealed the efficacy of the treatment in retaining the fractured teeth.Patients was happy and feeling confident. Keywords: Crown fractures, fiber-post, esthetic rehabilitation. Koresponden: Erny Djuhais, Resident of Dental Conservation, Specialist Dentistry Educational Program, Dentistry Hasanuddin University, Jl. Perintis Kemerdekaan km. 10, Makassar, Indonesia, Mobile. 085395609191; e-Mail:
[email protected]
INTRODUCTION Maxillary incisors are most commonly involved in dental trauma and dental crowns are frequently damaged because of their exposed position in the dental arch. Esthetics take a front seat and are of utmost importance when anterior teeth are involved. Excessive losses of dental hard tissues pose difficulties for the esthetic outcome of subsequent prosthetic restorations. In such instances, an interdisciplinary approach is necessary to evaluate, diagnose, and resolve esthetic problems using a combination of endodontic, periodontics, and prosthodontic treatments.1,2 The restoration of endodontically treated teeth with root canal post is usually indicated when crown retention is required. In recent years, various types of fiber reinforcement have come into widespread use as an alternative to cast or prefabricated metal post. The advantages of using reinforced fiber to construction intracanal post
include translucency, and relative ease of manipulation. The lower flexural modulus of fiber-reinforced post measures closer to that of dentin and can decrease the incidence of root fracture.1 This paper presents post-traumatic rehabilitationof a 34 years old female who involved in a motorcycle accident that causing crown fracture to her four maxillary incisors that were restored with fibre-reinforced post and ceramic crown. CASE A 34 years old female involved in a motorcycle accident that causing crown fracture to her four maxillary incisors [tooth 11, 12, 21, and 22]. Four days after the accident, she presented to Conservative Department RSGM Halimah Dg. Sikati with chief complaint of crown fractures and unpleasant esthetic on four maxillary incisors.
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Clinical examination revealed a fracture line at the cervical third of the upper left central incisor that extended subgingivally in the palatal aspect [Fig. 1].The tooth 21and 12was tender on percussion with a mobile coronal fragment. The other anterior teeth was fractured on the middle third.
root canal obturation[using ProTaper files] with crown down pressure technique [Fig 4]. Post space was prepared.
Figure 3. Fracture fragments of tooth 12 and 21 [left]. Clinical photograph after the mobile fragment removed [right].
Figure 1. Pre-treatment photograph. Fractures on fourth upper incisors.
Radiographic observation revealed a fracture line at the cervical third of the tooth 21 and 12. A diagnosis of complicated crown fracture was made [Fig 2]. Single visit root canal treatment and esthetic rehabilitation with fiber post and a ceramic crown was planned to all four teeth.
Figure 4. One-visit endodontic treatment to all of the anterior fractured teeth.
CASE MANAGEMENT
With a suitable sized drill, a post space was prepared by carefully removing an obturating material from the two third of the canal, leaving 5 mm apical gutta percha [Fig 5]. A minimum 1 mm collar on sound tooth structure is required. A prefabricated fiber post [Kleer Pentron, Orange, CA, USA] of proper diameter was selected, tried into the canal and cut at the required length with a diamond disc. The working field was isolated. The canal was rinsed thoroughly and dried with paper point. The canal walls and remaining tooth were coated with Primer for 1 min, which combines single step disinfecting, etching, priming and bonding with the help of micro brush.
One-visit endodontic treatment was done a week before the post placement to all of the fractured anterior maxillary incisors [11, 12, 21 and 22].Under local anesthesia, the fracture segment of tooth 12 and 21 was removed without damage [Fig 3]. Pulp chamber was cleaned by removing pulp tissues. Pulp tissues from the root canal was extirpated. Working length was determined radiographically. Cleaning and shaping of the root canal was done followed by
Figure 5. The remaining gutta percha on apical third.
Figure 2. radiograph.
Pre-treatment
panoramic
and
periapical
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The canal was carefully dried with paper point followed by gentle stream of air to evaporate the volatiles. Primer also applied to clean surface of the post for 30 sec and lightly dried.A self-etched cement [Breeze, Pentron, Orange, CA, USA] was applied over the surface of the post in a thin layer. The post was carefully seated into the canal using light pressure [Fig 6]. The cement was light cured for 20 sec. Excess cement expressed out of the canal was used as a base for core buildup. Built-it FR [Pentron, Orange, CA, USA] was used as a core material. After setting, minimal preparation was carried out to finish the margins and impression was taken to fabricate the all ceramic crown using putty and light body exaflex with double impression technique.Color 1E 230 fromChromascope shades guide [Ivoclar Vivadent, US] was chosen. A temporary restoration was given [Fig. 7]. The patient was recalled after 5 days and the crowns were cemented. Maintenance instructions were given to the patient.
Figure 6. Radiograph of posts insertion to the root canals of upper right and left incisives.
Figure 7. Shade selection [left]. Temporary crown try-in [right].
DISCUSSION Modern dentistry aims at conservation of remaining tooth structure and restoring it back to its normal function and esthetics. This procedure become more complex when the involved teeth
have previously undergone trauma, extensive fractures, endodontic-access preparation, canal instrumentation and other idiopathic causes. The problems result in loss of tooth structure and consequent reduction in tooth resistance to masticatory forces.1,3,10,15 Undoubtedly, fractures is one undesirable incident to both patients and dentists alike. Fracture of anterior tooth demands immediate treatment and esthetic rehabilitation to overcome the psychological trauma. Various treatment approaches have been indicated for fractured teeth such as fragment removal followed by restoration, fragment re-attachement, crown lengthening, forced surgical extrusion, vital root submergence, extraction followed by surgical implants or fixed partial denture. The treatment option chosen depends on site of fracture, size of fracture, periodontal status, pulpal involvement, maturity of root formation, occlusion and invasion of biological width.4,5,15 For this case, the use of a fiber post was a good choice with the patient‟s past history of trauma to the anterior teeth. To avoid disastrous consequences of root fracture and tooth loss, the fiber-reinforced post offer an excellent alternative to metal or ceramic posts that can cause root fracture.3,8 Anterior teeth with extensive loss of coronal tooth structure usually need a post because the pulp chamber and single canal are generally not adequate to retain a core. In addition, anterior teeth are subject to lateral forces during function.3,7 Most fiber posts contain either carbon fiber or quartz fiber. They have a modulus of elasticity similar to dentin which allow them to flex with the root when under stres. This is believed to distribute the stresses more evenly throughout the tooth than metal posts, making the root less susceptible to fracture. Some studies have shown that fiber posts strengthen the root when used with a resin luting cement, and several short-term clinical studies have reported high success rates. Because of the post‟s high degree of light translucency, the esthetic were similar to enamel, allowing to blend in with both composite resin core and the ceramic crown. Also, the true root taper design of the post ensured the conservation of sound radicular and coronal
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structure. When considering restoring endodontically treated teeth, fiber post should be part of a clinician‟s armamentarium.4,6,7 The primary concern about fiber posts is wheter they allow movement of the core during function or parafunction. If a post has the same modulus elasticity as the root, but is much thinner in diameter, it will flex more under a load. This may cause leakage under the crown and buildup. Studies are currently underway to address this question and may lead to some reenginerering the current fiber posts. Any initial strengthening of the root by fiber posts is probably lost with time and function.7, 9,10 In recent years, single-appointment endodontics has gained increased acceptance. Recent studies have shown little or no difference in the quality of treatment or success rates between single- and multiple-visit root canal treatment. The correlation of postoperative pain with different variables, including the number of visits needed to complete root canal treatment, operative procedures, pulp vitality, and dental anatomy, has been the objective of numerous studies. Several studies have investigated the frequency of radiographic healing in teeth with preoperative periapical pathology and have compared single- and multiple-visit approaches, employing interappointment medications. Other studies recommended that endodontic treatment of non-vital teeth with infected root canals should be completed in one session, without any intracanal microbicidal dressing.11,12,13,14,15 CONCLUSION The treatment described in the case report is simple and effective, also represents a promising alternative for rehabilitation of grossly destructed or fractured teeth. Therefore, restoration of teeth after endodontic treatment is becoming an integral part of restorative dentistry. Patient co-operation and understanding of the limitations of the treatment is of utmost importance for good prognosis. During follow up appointments, clinical and radiograph examination revealed the efficacy of the treatment in retaining the fractured teeth. Patients was happy and feeling confident.
REFERENCES 1. Das U, Mukherjee S, Mazumder D. Rehabilitation of a complicated restorative case: a case report. IJRID, 2014 Mar-Apr; 4(2): 69-74. Available from: URL:http://www.ordoneardentistrylibrary.or g. Accessed June 21, 2014; 2. Kansal G, Goyal S. Restoring crown fractures with glass-fibre-reinforced composite and PFM crown (an interdisciplinary approach): a case report.IJMMS, 2013; 3(10): 83-88. Available from: URL:http://www.ijmms.sophiapublisher.com . Accessed June 21, 2014; 3. Strassler HE, Ganjavian B, Zitofsky J. Reinforcing a traumatized maxillary incisors using an esthetic post. Inside Dentistry 2009 Oct; 5(9). Available from: URL:https://www.dentalaegis.com/id/2009/1 0/reinforcing-a-traumatized-maxillaryincisor-using-an-esthetic-post. Accessed June 21, 2014; 4. Sujatha, Nadig P, Mangala MG. Instant esthetic for complicated crown fracture of maxillary anterior teeth: case report. IJMD 2011 May-June; 1(4); 5. Gaikwad AA. Reinforcing esthetic with fiber post. IJDC 2011; 3(2): 89-90; 6. Anil P, Aparna A. Esthetic rehabilitation of a crown fracture with glass-fibre-reinforced post: a case report. Int J Sci Res Pub 2012 Nov; 2(11). Available from: URL://http:www.isrp.org. accessed June 21, 2014; 7. Anonim. Restoration for endodontically treated teeth: the endodontist perspectives, part I. endodontics: colleagues of excellent. Spring/summer 2004. Available from: http://www.aae.org/uploadedfiles/publication s_and_research/endodontics_colleagues_for_ excellence_newsletter/ss04ecfeforweb.pdf. Accessed July 26 2014; 8. Sharma A, Bhanot R, Mittal R, Bansal P. Restoration of traumatically fractured anterior teeth: a case report. IJDS 2009; 9(1). Available from: http://ispub.com/IJDS/9/1/6090. Accessed at July 26 2014;
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9. Aydin U, Kulacaoglu N, Ozsevik S, Inan U. Endodontic and restorative considerations of traumatically injured teeth. J Res Dent 2014; 2(2): 101-105. Available from: http://www.jresdent.org/article.asp?issn=232 14619;year=2014;volume=2;issue=2;spage=1 01;epage=105;aulast=Aydin Accessed at July 26 2014; 10. Sharma N, Yadav A, Shetty N, Agrawall S. Esthetic management of a rare combination of dental trauma with a multidisciplinary approach: a case report. Journal of interdisciplinary dentistry Sep-Dec 2013; 3(3). Available from: http://www.jidonline.com. Accessed at July 26 2014; 11. Gomes AF, Sousa BC, Leite MCF, et al. effectiveness of single- versus multiple-visit endodontic treatment of two mandibular central incisors from the same patient. Aus Endo J 2007: 1-3;
12. Weiger R, Rosendhal R, Lost C. Influence of calcium hydroxided intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000; 33: 209-26; 13. Figini L, Lodi G. Gorni F. Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth [Review]. Cochrane database of systematic reviews 2007; 4: 1-37. Available from: http://www.thecochranelibrary.com. Accessed at July 26 2014; 14. Field JW, Gutmann JL, Solomon ES, et al. A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment. Int Endod J 2004; 37: 70-82;
15. Cohen S, Burns RC. Pathways of the pulp, 8th ed. St. Louis, MO: Mosby. 2002.
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Treatment of internal resorption with MTA : a case report Wahyuniwati*, Aries Chandra Trilaksana** Resident of Conservation, Faculty of Dentistry, Hasanuddin University * Departement of Conservative Dentistry, Hasanuddin University **
ABSTRACT Background. The clinical appearance of internal resorption is vary considerably and detection of lesion is often made incidentally. Resorption of root surfaces whether internal or external, occurs by the action of odontoclastic or osteoclastic cells. Treatment may involve the tooth and pulp and management can be complex. Case. A 32 years old male with the chief complaint of discoloration in relation to upper front fractured tooth with a history of trauma in that region at the age of 10 years. Tooth have been treated endodontic but not finished about 3 years ago. Treatment. Treatment based on reconstructing the tooth which involved root canal treatment and sealing of the resorbing area of the affected tooth as well as filling the resorbed area with MTA. Conclusion. The root resorption pose considerably challenges in management due to the complexity and aggresive nature of the resorptive process. Early diagnosis and appropriate treatment are the keys to a succesfull outcome. Keywords : Internal resorption, root canal treatment, MTA Koresponden: Wahyuniwati, Peserta Program Pendidikan Dokter Gigi Spesialis Konservasi Gigi, Fakultas Kedokteran Gigi, Universitas Hasanuddin, Jl. Perintis kemerdekaan km.10, Makassar, Indonesia, Telepon 085 255 284 234, e mail ;
[email protected].
INTRODUCTION According to the Glossary of the American Association of Endodontists, resorption is defined as a condition associated with either a physiologic or a pathologic process resulting in loss of dentin, cementum or bone. Pathologic resorption can occur following traumatic injuries, orthodontic tooth movement, or chronic infections of the pulp or periodontal structures. Pathologic resorption if untreated will result in the premature loss of the affected tooth. There are two types of tooth resorption in permanent tooth, internal and external resorption. Internal resorption has its origins in the dental pulp whereas external resorption begins in the periodontal ligament (PDL). Internal resorption is relatively rare and occurs as a result of trauma or caries-related inflammation of the pulp. 1,2,3,4 The normal root canal anatomy may be altered in various pathological processes and making it very difficult and at times impossible to achieve ideal obturation by normal methods. One such condition is internal resorption which presents as an irregular defect in the root canal making that area inaccessible to normal method
of cleaning and shaping as well as obturation. Internal root resorption originating from pulp inflamation is always pathological. Threedimensional imaging has shown such defects to be circumscribed anda oval shape. 4,5,6 Internal root resorption has been reported as early as 1830. Compared with external root resorption, internal root resorption is a relatively rare occurrence, and its etiology and pathogenesis have not been completely understood. Once internal root resorption has been diagnosed, the clinician must make a decision on the prognosis of the tooth. If radiograph signs of inflamatory root resorption become evident and the tooth is deemed restorable and has a reasonable prognosis, immediate endodontic intervention is required as the treatment of choice. The aim of root canal treatment is to complete remove any remaining vital, apical tissue and the necrotic coronal portion of the pulp in attempt to prevent further loss of hard tissues and to disinfect and obturate the root canal system.6,7,8,9 Internal root resorption lesions present the endodontist with unique difficulties in the preparation and obturation of the affected tooth.
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Access cavity preparation should be conservative, preserving as much tooth structure as possible, and should avoid further weakening of the already compromised tooth. The shape of the resorption defect usually renders it inaccessible to direct mechanical instrumentation. However, selecting suitable restorative materials for these cases remain a challenge, especially if tooth loss is extensive; extraction is the only realistic option in some cases. 6,7 The obturation of internal resorption defects can be difficult due to their shape and lack of adequate access. The warm vertical compaction and thermoplasticized gutta-percha techniques have proved beneficial in this regard as they seal the defects satisfactorily.1 The area of resorption should be restored with the proper material, depending on the indications and aesthetic needs. Mineral trioxide aggregate ( MTA) has been recommended in several case reports as the restorative material of choice because it is “biocompatible”.6,7,9,10 MTA has many favorable properties including a good sealing characteristic, biocompatibility, bactericidal effect, radiopacity, and ability to set up in the presence of blood. Root-end fillings, pulp capping, apical filling of tooth with open apices, apexification therapy, repair of root, and furcal perforations are the indications for the use of MTA. In addition, newly formed cementum coverage occurred with MTA is unique and had not been demonstrated with any other material. 6,11,12 This case reports the treatment of internal resorption managed by root canal treatment and mineral trioxide aggregate to filling resorption defect of anterior fractured tooth with discoloration and fiber post and all porcelain crown as the restoration. CASE A 32-year-old man came to the Hospital Clinic of Conservative Dentistry Dental Education Faculty of Dentistry, University of Hasanuddin with chief complaint of discoloration on the upper front tooth. On clinical examination, tooth 11 was discolored and fractured. The tooth have experienced trauma when the patient was
10 years old and had been treated root canal about 3 years ago but did not completed (figure 1).
Figure 1: The state of the tooth prior to clinical treatment
In the radiographic appearance a radiolucent on periapical area of tooth 11 and the condition of internal root resorption. Diagnosis of the tooth was necrosis. (Figure 2).
Figure 2. Radiograph tooth 11 before treatment
Treatment planning of tooth 11 is root canal treatment, filling defect resorption with MTA, thermoplastic obturation and restoration using fiber post and all porcelain crowns. CASE MANAGEMENT On the first appointment a clinical examination, a periapical radiograph, diagnosis and discussed treatment plans with patient was done. Patient agree to a treatment plan that is offered, patient were asked to sign an informed consent. The second appointment, dental care starts with a root canal treatment on tooth 11 with the first stage of the work is working length determination done with the help of measurement periapical radiographic. Debridement root canal with konvensional techniques wear hand K-files in accordance with the working length was accompanied by copious irrigation with 2.5% NaOCl and saline solution. Then dried root canal
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dressing with calcium hydroxide paste done for ± one month (figure 3).
Subsequent appointments made preparation for esthetic crown, then the tooth was mould with double impression material and then a temporary crown was inserted (figure 6).
Figure 3 . Dressing calsium hydroxide
Figure 6. Inserted of temporary crown
On subsequent appointments, the internal portion of resorbed area was filled with white MTA inserted by amalgam carrier and finger plugger (Figure 4).
The next visit, do try-in the all porcelain crown and checking with contacts antagonist and aesthetic, after permanent installation in accordance performed (Figure 7).
Figure 7. Insersion all porcelain crown on tooth 11 Figure 4. Filling resorption defect with white MTA
After two days later succesfull hardening of the MTA was verified and a thermoplastic obturation with continous wave techniques (downpack and backfill) was carry out (Figure 5).
After controlling one month later, the patient reports that the tooth is asymptomatic and from intra-oral examinations were also no complaints and normal gingival mucosa (Figure 8).
figure 8. One month after
DISCUSSION Figure 5. After thermoplastic obturation
The following week, a fibre-glass post bonded to length of 16 mm with a resin cement was inserted and core build-up is done.
In this case, after radiographic examination, there was radiolucent in periapical area of tooth 11 with internal resorption conditions, therefore, this case managed by root canal treatment, filling defect resorption with
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MTA and obturation with continous wave techniques.6 Internal root resorption is an insidious pathological process, initiated within the pulp space and associated with loss of dentine. It is often described as an oval shaped enlargement of the root canal space and is usually asymptomatic and detectable by radiographs. When diagnosed, immediate removal of the causative agent must be considered, aiming to arrest the cellular activity responsible for the resorptive activity. 6,7,9
Conventional root therapy should be instituted as soon as the diagnosis of internal resorption has been established. The use of a root canal dressing with a material based on calcium hydroxide between sessions was aimed at dissolving remaining pulpal debris and alkalinizing the environment. In the following session, the defect in the canal was filled with white MTA to seal the perforation and fill the resorbed area. For this case, MTA was selected because of its known abilities as a repair material, along with its sealing ability and mechanical strength (Torabinejad et al. 1995).4,6,11 By their very nature, internal root resorption defect can be difficult to obturate adequately. To completely seal the resorptive defect, the obturation material should be flowable. Gutta percha is the most commonly used filling material in endodontics. Gencoglu et all, examined the quality of root fillings in teeth with artificially created internal resorptive cavities. They found that the thermoplastic gutta percha techniques were significantly better in filling artificial resorptive cavities than cold lateral condensation.7 After obturation tooth 11, fiber glass post inserted in the root canal. This post fiber is intended to provide additional retention on tooth that have root canal treatment done. The selection of shapes and sizes depending on the kinds of clinical dental crowns, root canal diameter, and position of the tooth to be repaired so that the health of the periodontal tissues remain well preserved. In this case fibre-glass posts were used to enhance the fracture resistance of the tooth. Maccari et al. (2003) concluded that compromised tooth could be strengthened with
distribution of functional forces through the tooth‟s long axis. Clinical use of MTA in humans has demonstrated their applicability in wet environments, preventing bacterial microleakage and alkalinizing the medium. White MTA was introduced as a low-iron, nonstaining formula. 6 Principle of restoration on the tooth that has been treated root canal is to restore function and aesthetics, as well as equitable distribution of mastication pressure so good teeth and crowns last a long utilizing in the oral cavity.12 As restoration after root canal treatment, a crown made of all porcelain material was chosen because it has a nice aesthetic in terms of color and shape to obtain anatomical color more natural and able to restore function of the tooth. 13,14
Conclusion and Suggestion Patients were satisfied with the care that has been given because the patient complained earlier discoloration on the tooth, which changes the color of the main complaints can be resolved by restoring esthetics and function of the tooth and prevent tooth loss due to internal root resorption process. Mineral trioxide aggregate and a fibre-glass post were employed can restore a severely weakened, internally resorbed tooth. REFERENCES 1.
2.
3.
4.
5.
Fernandez M, et all. Tooth resorption part 1: pathogenesis & case series of internal resorption. Conserv.Dent J 2013;16:4-8 Ahmed N, et all. External cervical resorption case report and a brief review of literature. People‟s Journal of Natural Science 2014;5(1):210-213 Discacciati Cesar JA, et all. Invasive cervical resorption: etiology, diagnosis, classification and treatment. J of Contemp. Dent. Practice 2012;13(5):723-728 Kanas RJ & Kanas SC. Dental root resorption: A review of literature and a proposed new classification. AEGIS Communic 2011;32(3):185 – 201 Hariharan VS, Nandlal B, Srilatha KT. Management of recurrent fracture of central incisor with internal resorption using lignht
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transmitting (luminex) post. J of Indian Soc of Pedo & Prevent Dent,2010; 28(3):288– 292 6. Jacobovitz & De Lima RKP. Treatment of inflamatori internal resorption with MTA : a case report. Int Endo J 2008;41:905-911 7. Ozer YS. Diagnosis and treatment modalities of internal and external cervical root resorption: review of the literature with case report.IDR 2011;1(1):32-6 8. Segura-Egea JJ, et all. Green doscoloration of the crown after internal resorption treatmen with grey MTA.J Clin Exp Dent 2011;3(Suppl1):404-7 9. Heithersay GS. Management of tooth resorption. Aust Dent J Endo Suppl 2007;52(1):105-113 10. Subramanyappa SK. Management of perforating invasive cervical resorption. J of
11.
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Indian Acad of OM and Radio 2012;24(4):346-49 Yilmaz HG. Use of MTA in the treatment of invasive cervical resorption: a case report. JOE 2010;36(1):160-62 Schwartz RS. Management of invasive cervical resorption: observations from three practices and report of three cases. JOE 2010;36(10):1721-726 Ascheim KW and Dale BG. Esthetic Dentistry. A Clinical Approach to Techniques and Materials. 2nd ed. Mosby Inc. 2001; p.137-47(12) Ismiatin K. Restorasi kerusakan mahkota klinis gigi yang luas dengan penguat pasak jadi. Majalah Kedokteran Gigi (Dental Journal)2001;34(4):767 – 9(14)
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Indirect veneer of first premolar mandibular with enamel hypoplasia : a case report Kurniawaty*, Juni Jekti Nugroho** Resident of Conservative , Dentistry Faculty of Hasanuddin University * Department of Conservative , Dentistry Faculty of Hasanuddin University **
Abstract Background: Discoloration of the tooth is one of the most frequent reasons for a patient to seek dental care. Tooth discoloration is esthetically displeasing and psychologically traumatizing. The cause of tooth discoloration can be classified according to the location of stains, either extrinsic or intrinsic. One of the intrinsic stain is enamel hypoplasia, which is a defect of enamel quality that leads to decrease the thickness of enamel. Case: A 36-year old male experienced discoloration on his tooth where identified as enamel hypoplasia. Patient want the colour of his tooth has the same color as the other teeth. Case Management: Veneer is chosen for correcting the patient‟s tooth. Conclusion: Indirect veneer is effective to mask the discoloration due to enamel hypoplasia. Key Words : discoloration, hypoplasia, indirect veneer Koresponden: Kurniawaty, Resident of Conservative, Dentistry Faculty of Hasanuddin University Address: Perintis kemerdekaan km.10, Makassar, Indonesia, Mobile: 081 342 418 015, email:
[email protected].
INTRODUCTION Esthetics of the teeth is one of great importance to patients, including tooth color.1 Discolored teeth reduce their self-confidence and they are more hesitant to smile.2 Tooth discoloration is a frequent dental finding associated with clinical and esthetic problems.3 The causes of for tooth discoloration can be classified according to the location of the stains, as extrinsic or intrinsic.4,5 One of intrinsic stains is enamel hypoplasia which is a quantitative enamel defect that reducing enamel thickness. 6 This can be vary from white, yellow to dark brown.7 Art of dentistry has long been part of quest to achieve a beautiful smile. Discolored teeth are considered as major impairment in esthetics. 2 Many techniques are available to restore esthetics appearance, such as : bleaching, veneer, crown and orthodontic treatment.8-11 Recently, the demands for esthetics correction of anterior teeth are increasing and the most predictable and durable treatment has been achieved with full crown. 12 However, this approach is undoubtedly most invasive with substantial removal of large amounts of sound tooth substance and possible adverse effects on
adjacent pulp and periodontal tissue. 8-10 Beside, orthodontic appliance takes longer follow up. 10 The preparation concept that must be remember for cavity restoration is minimal sound tooth removal. Indirect restoration technique that fulfill this requirement is veneer.8,10,13 Veneer is a thin restoration that mask labial or buccal surface of teeth. It can be made directly or indirectly using composite or ceramic 13,14 The purpose of this case report is to explain indirect veneer restoration on first premolar mandible with hyploplasia enamel. CASE A 36 year old male patient reported to conservative department of Dentistry Faculty Hasanuddin University to have a tooth filling in his right mandibular tooth. The tooth is yellowish-brown, the surface is shallower then others and can be seen when smiling. He wanted his tooth have the same color with others.
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Figure 1. pre operative photograph
CASE MANAGEMENT At the first visit, operator checked the tooth, mucosa and oral hygiene condition of the patient. Diagnosis of pulpitis reversible in #44 was concluded according to objective and subjective examination. Choice of treatment was indirect veneer restoration. Pre-operative color determination was taken using crhomascop shade guide and it was 3E/340 for the color. (Figure 2)
Figere 4. Temporary veneer using Revotec LC
The mould was sent to dental laborarory. At second visit, temporary veneer was taken off, and all porcelain veneer was tried in at the patient. (Figure 5 & 6)
Figure 5. Veneer on stone mould
Figure 2. Tooth color determination
Full veneer conducted with window design (Figure 3), Gingival management was done before mould impression. Double impression technique was done in mandible and irreversibe hidrocoloid material was used for the antagonist. Temporary veneer was made with Revotek LC. (Figure 4)
Figure 6. Try in
Veneer surface was cleaned and dried, after that celluloid strips were put in interdental #44. Silane was applied before self adhesive resin cement (breeze) on veneer.The veneer was spot cured for 10 seconds initially. Excess cement was removed with explorer and then complete curing was done for 20 seconds. (Figure 7).
Figure 3. Veneer Preparation Figure 7. Veneer insertion
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One week later patient was asked to come again to control his veneer. There is no complaint from objective and subjective examination. (Figure 8)
Figure 8. Follow up photograph
DISCUSSION Enamel hypoplasia is defined as a deficiency in enamel thickness resulted from interference in the organic matrix of enamel which is susceptible to caries and will form a lesion.15,16 Irregular areas of hypoplasia allow the retention of plaque and lead to the development of caries lesions that may extend into the deeper part. 16 The clinical signs of enamel hypoplasia are : more opaque enamel color, erosion at tooth surface and shallow cavity accompanied with irregular tooth wear caused by the loss of microanatomy. It will affect the color, morphology, and texture of teeth. 16 In this case report, we can see the loss of tooth structure and severe discoloration which already involves enamel to dentin. Therefore, appropriate treatment option is indirect porcelain veneer restoration because it can provide better mechanical properties of the tooth structure and can cover the discoloration.7 Full veneer type is indicated to cover general or intrinsic defects involving facial surfaces of teeth. Incisal / occlusal veneer lapping preparation techniques in this case is based on a localized defect in the buccal surface of tooth 44, which almost reached the incisal edge, so it need to extend the preparation to the incisal of the tooth. Porcelain veneer has many advantages compared to composite resin veneer. It has good aesthetic, stable color and resistance to high
abrasion, also resistant to biological, chemical and mechanical destruction. The porselen veneer color is more easily adapted to tooth color, biocompatible and non-porous so can reduce the plaque adhesion and bad effects on gingiva health. 12,18-20 This can happen if the manufacture of veneers done carefully so that the porcelain surface becomes smooth and impermeable after glazing procedure. According Touti (1999) porcelain veneers is not easily adhered by plaque, and also protect tooth structure due to limited preparation on tooth enamel, 12 In indirect veneer restoration, healthy tooth preparation is minimum, (± 0.5-0.7 mm) .9,12,19,21,22 Maintaining as much as possible the healthy tooth is an important thing to be considered in conducting restoration. Local anesthesia is not required during tooth preparation, so it is beneficial for patients who are less cooperative to anesthetic procedure. 12 Enamel hypoplasia cases corrected with indirect veneer has a high success rate according to some research, . Veneers can last as long as 10 years (93.5%), 15 years (85.8%) and 20 years (78.5% ). 22 CONCLUSION Enamel hypoplasia is important known clinically because it may lead to increased caries susceptibility, increased tooth wear, tooth sensitivity and lack of dental aesthetics. As a result, it will influence big psychological impact on patients. Indirect veneer restoration can overcome enamel hypoplasia defect with good and long lasting result. REFERENCES 1. Joiner A, The bleaching of teeth: A review of the literature. Journal of Dentistry. 2006;34:412–9. 2. Shenoi P, Kandhari A, Gunwal M, Esthetic enchancement of discolored teeth by macroabrasion and its psychological impact on patients- a case series, Indian Journal of multidisciplinary dentistry. 2012; 2(1): 388392. 3. Khozeimeh G, Khademi H, Ghalayani P, The prevalence of etiologic factors for tooth discoloration in female students in isfahan
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high schools. Dental Research Journal. 2008; 5(1):13-16. 4. Manual ST, Abhisek P, Kundabala M, Etiology of discoloration-a review. Nig Dent J. 2010; 18(2): 56-63. 5. Watts A, Addy M, Tooth discoloration and staining: a review of the literature. BDJ. 2001;190(6): 309-316. 6. Musale PK, Yadav T, Ahmed BMN, Clinical management of an epigenetic enamel hypoplasia-a case report, Int. Journal of Clinical Dental Science. 2010; 1(1), 77-80. 7. Fonseca RB, et al. Enamel hypoplasia or amelogenesis imperfecta - a restorative approach. Braz. J Oral Sci. 2006; 5(16):9413. 8. Peumans M, et al. Porcelain veneers; a reiview of the literature. Journal of Dentistry.2000; 28:163-177. 9. Mathew CA, Sabeena M, Karthik KS, A review on ceramic laminate veneers. JIACDS. 2010; 1(4): 33-6. 10. Turkaslan S, Ulosoy KU. Esthetic rehabilitation of crowded maxillary anterior teeth utilizing ceramic veneers: a case report. Cases J. 2009: 2:8239. 11. Bhoyar AG, Esthetic closure of diastema by porcelain laminate veneers; A case report. People‟s Journal of Scientific Research. 2011; 4(1): 45-50. 12. Inayati E. Restorasi vinir keramik secara indirek. M.I. Kedokteran Gigi.2008; 23(1): 32-7.
13.
Gresnigt M, Clinical and laboratory evaluation of laminate veneer. 14. Joiner A, et al. A review of tooth colour and whiteness. Journal of Dentistry. 2008: s2-s7. 15. Shah P, et al. Enamel hypoplasia : the multidisiplinary approach-3 case reports. Journal of Dental Sciences. 2012; 2(1): 4850. 16. Martos J, Gewehr A, Paim E, Aesthetic approach for anterior teeth with enamel hypoplasia.Contempelindent. 2012; 3910. S82-5 17. Staylon RL, et al. Prevalence of enamel hypoplasia and isolated opacities in the primary dentition. American Academy of Pediatric Dentistry. 2001; 23(1):32-36. 18. Rosenstiel SF, Contemporary fixed prosthodontics. 3th ed. St. Louis. Mosby. 2001. P.609- 612. 19. Lim CC, Case selection for porcelain laminate veneers. Quintessence International. 1995; 26(5): 311-5. 20. Christopher CK, Porcelain veneers: Treatment guidelines for optimal aesthetics. Australian Dental Practice.2011: 154-164. 21. Belcheva A, Reconstruction of fractured permanent incisors in schoolchildren using laminate veneers (review). JIMAB. 2008; 14(2): 101-4. 22. Joseph B, Abhilash A,Kusum CK, Porcelain laminate veneers-the current concepts. KDJ.2013; 36(3): 175-9.
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Direct veneer in maxillary incisor with enamel hypoplasia : a case report Hermiati Daharuddin*, Aries Chandra Trilaksana** Resident of Conservative Dentistry, Faculty of Dentistry, Hasanuddin University* Department of Conservative Dentistry, Faculty of Dentistry, Hasanuddin University**
Abstract Background: Enamel hypoplasia is a defect in tooth enamel that results in less quantity of enamel. This condition, either can make tooth sensitivity, also can make aesthetic interference because of its yellow to brown defect and its rough tooth surface, especially if it’s happened in maxillary incisor. Tooth with enamel hypoplasia can be corrected with a variety of treatment options, one of them is direct veneer. Purpose: This case report will presents the procedures of direct veneer in tooth with enamel hypoplasia. Case: A 13 years old girl, feeling uncomfortable with her maxillary anterior incisor which is look rough on its labial surface and has brown defect. She wants her tooth to be repaired. Management: Direct veneer in one visited treatment has applied to the maxillary incisor with enamel hypoplasia. After the treatment, a satisfactory result has been achieved. Conclusion: Direct veneer is one kind of treatment choice for maxillary incisor with enamel hypoplasia to correct the aesthetic problem of its tooth. Key words: enamel hypoplasia, aesthetic, direct veneer Contact Person: Hermiati Daharuddin, Resident of Conservative Dentistry, Faculty of Dentistry, Hasanuddin University, Jl. Perintis Kemerdekaan Km.10, Makassar, Indonesia, Mobile: 081 241 444 37, Email:
[email protected]
INTRODUCTION Enamel Hypoplasia Enamel hypoplasia is a defect in the enamel surface that result in a decrease of the quantity of enamel. Defects in enamel hypoplasia may be a small hole or cavity in the tooth or may be amorphous defects widespread on the tooth surface. The defect can result the tooth become more sensitivity, not aesthetic, and even can cause the formation of cavities on the tooth. Some genetic diseases can lead the tooth to have an enamel hypoplasia.1,2 Enamel hypoplasia can occur multiple in any tooth. Tooth with enamel hypoplasia has presented clinical experience of white, yellow, to brown patches, with a rough surface or a cavity. In some cases, the quality of enamel influenced by the quantity of those enamel, so if there is interference on the quantity of enamel, it will affect the quality of those enamel.1,2 Tooth with enamel hypoplasia can be corrected with a variety of treatment options. Tooth bleaching treatment and microabrasion are very minimally invasive treatment options. Then, restorative treatment by layering the labial
surface of the tooth using a resin composite or known as direct veneer, become a treatment options that can provide the best aesthetic results in tooth with enamel hypoplasia, but in cases with severe enamel hypoplasia, indirect veneer treatment with the porcelain material is the most preferred treatment.2,3 This case report will be presented the procedure of direct veneer on the tooth with enamel hypoplasia. Direct Veneer Veneer is a layer of material that has the same color with tooth, which is layering on the labial surface. to restored tooth with defect or cavity. Based on the type of the material, veneer can be made by composite materials or ceramic porcelain.4,5 Generally, the indications for the veneer on the tooth surface are malformation, discoloration, abration, erotion, or a failed restoration. In addition, several other factors are important to consider before deciding on veneer treatment, include the patient's age, occlusion factors, the health of the tissues around the tooth,
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the position of the tooth and oral hygiene of the patient.4,5 1. Based on the aesthetic factor, veneers is divided into two type4: a. Partial Veneer, which is indicated on the teeth with a defect in some of the side; b. Full Veneer, which is indicated on the teeth with larger defects. 2. Based on the material used, veneers can be divided4: a. Direct Veneer, using a composite material which is applied directly in a single visit; b. Indirect Veneer, using porcelain or composite materials that are processed in the laboratory, so it takes more than one visit. According to Heymann, et al., design of veneer praparation can be divided into5: 1. "Window" preparation; 2. "Butt-joint incisal" preparation; 3. "Incisal-lapping" preparation.
From the results of anamnesis, patient reported that the condition has been experienced for a long time, but she did not feel disturbed yet. She starts not confident when she enters adolescence age. She did not feel pain. The patient, who was accompanied by her sister, came to tell that she has a history of taking antibiotics since childhood. She wants her tooth to be repaired, so that she can get her confidence again. On clinical examination, looks a rough defect with brown patches on the labial surface of her lateral incisor #22 (Figure 2). Gingival tissue around the teeth is normal and showed no signs of inflammation. Her lateral incisor #22 then are summed has enamel hypoplasia condition and will be treated with direct composite veneer.
Figure 2. Clinical feature of the lateral incisor before treatment. (Source: Private collection operator)
CASE MANAGEMENT Figure 1. Design of veneer preparation. A) Facial view of partial veneer that does not extend to the subgingival or involve incisal angle. B) Full veneer with "window" preparation design that extends to gingival crest and terminates at the facio-incisal angle. C) Full veneer with “butt-joint” or “incisal-lapping” preparation design that extends to involve subgingivally surfaces and incisal. D) Partial veneer. E) Full veneer with "window” design. F) Full veneer with “butt-joint incisal” design. G) Full veneer with “incisal-lapping” design.5
CASE REPORT In July 2013, a 13-year-old teenage came to the Department of Conservative Dentistry in Hasanuddin University with chief complaints feel not confident with her maxillary incisor which looks rough with brown patches on its labial surface.
Before the treatment on #22, the first is we clean the tooth‟s surface using a brush and pumis, then captured it before the treatment, and determined the colour of #22 with a shade guide from the composite materials which we used (Figure 3), which is adapted to the natural tooth colour. Having obtained the appropriate colour, then we made preparations to clean up the defect formation on the labial surface of #22. Gingiva in the cervical area of #22 was rectraction by using rectraction cord to open the gingival sulcus to facilitate the formation of a mixture endings in the cervical area. Furthermore, the preparation is done with "window" preparation design (Figure 4) using a diamond-bur.
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performed to remove the sharp contours of the tooth and form appropriate its anatomy, while polishing restoration aims to smooth and polish the surface of the restoration (Figure 7).
3a 3b nn. of the tooth colour nn. Figure 3. Determination with shade guide. a) shade guide m,.A2 match with its natural tooth m,. colour; b) shade guide A3 looks darker than its natural tooth colour. . . (Source: Private collection operator)
4a 4b nn.4. Clinical condition of the nn.tooth after preparation. a) Figure #22m,. after preparation looks from m,. the front; b) #22 after preparation looks from the proximal side. (Source: Private . . collection operator) After the tooth 4a prepared, it is cleaned with water and dried, then nn.isolated for subsequent etching and bonding material applied. Etching m,. material is 35 % phosphoric acid, which is . applied to the entire surface of the enamel and dentin of the teeth that have been prepared. Etching applied using microbrush. Etching allowed to stand for 15 seconds, then rinsed with water and dried. After that, the bonding material as the adhesive material agent, also applied on the labial surface of the tooth using microbrush, then irradiated with light cured for 10 seconds (Figure 5). And then, the composite is applied layer by layer on the labial surface of #22 and its carved anatomically. Previously, on the mesial and distal sides of #22, we placed celluloid strip to prevent overcontour proximal restoration (Figure 6). After the composite is applied and sculpted according to its anatomy, and then we giving way to the end of the procedure, called finishing and polishing. Finishing procedure
5b nn .m ,..
3b 5a nn. nn m,. .m . ,..
5b nn .m ,..
5b nn .m ,..
5c 5c nn nn 5. Etching and bonding procedures. a) the application Figure .m of etching .m to the #22; b) etching was applied for 15 seconds; c) application of bonding agent,.. on #22; d) aplication light ,.. 5d cured at #22 who has dental bonding agent for 10 seconds. (Source: Private Collection operator) nn 4b .m ,..
6a 6b nn nn on Figure 6. a) composite application on #22; b) light cured the .m composites that have been carved for 20 seconds. .m 6b (Source: Private collection operator) ,.. ,.. nn .m ,.. 7a 7b 7c .m .m procedures. .m Figure 7. Finishing and polishing a) using a needle-shaped finishing bur; b) using an aluminum-oxide ,.. ,.. ,.. 7a. 7b m, .m .. ,..
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7 m ..
disc; c) using an aluminum-silicon-oxide point. (Source: Private collection operator)
After all the procedures completed, we recaptured clinical images of #22 after direct composite veneer treatment (Figure 8) and matched its colour to shade guide A2 that have been adjusted before.
8a 8b nn nn Figure 8. Clinical .m feature of.m lateral incisor #22. A) before direct composite veneer; b) after direct composite veneer 8b ,.. ,.. (Source: Private collection operator) nn .m DISCUSSION ,.. Disruption due to the aesthetic condition of incisor with enamel hypoplasia may result in a decrease in confidence for patients, especially in women and adolescent patients. Enamel hypoplasia resulting yellow to brown spots with defects on the surface of the tooth, so the tooth feels rough and looks not aesthetic.1,2,4 Generally, there are several types of dental treatment options for tooth with enamel hypoplasia.1,2,3 One of them is direct veneer. Some of the advantages and disadvantages of the treatment options with direct veneer is 5,6,7,8: Advantages of direct composite veneer: 1. Conservative with minimally invasive; 2. Provide maximum aesthetic results; 3. Provide a good adaptation of the supporting tissues of the tooth; 4. Easy to applied, but it takes skill to adjust the colour; 5. Need short visit time with a cheap price relatively. Disadvantage of direct composite veneer: 1. Preparation technique is quite difficult; 2. Requires a lots clinical experience; 3. Tooth can become more sensitive; 4. Unable applied to tooth with severe discoloration or severe defects. Returns aesthetic from tooth with enamel hypoplasia by direct veneer treatment, either to improving the aesthetic condition of the
tooth, also improve the quality of the enamel, due to the clean up and closure of the defect by restoration materials that help tooth become more strength. The tooth will become stronger and aesthetic, and patient‟s confidence will increase.1,2,3 In addition to the direct veneer, tooth with enamel hypoplasia can also be corrected with tooth bleaching treatment or with indirect veneer.1,2,3 However, in this case, tooth bleaching is not recommended due to defects that occur already formed a shallow cavity that even been done tooth bleaching, still require additional treatment in the form of restoration of the cavity to cover the defect. In fact, the patient in this case want to get her tooth repaired immediately with a minimum visits. Meanwhile, treatment with tooth bleaching or indirect veneer is a treatment option that requires more than one visit. Each steps in the procedure of direct veneer treatment in this case is done by a variety of considerations. Selection procedure of shade guide tooth colour, for example, this procedure is done by involving the patient to assess the suitability of the colour of her tooth. The colour selection is done together with the patient and performed when tooth are not in the dry condition. Some of the colours chosen approach is compared with each other for the closest colour of natural teeth. As a result, we choose shade guide colour A2 which is thought to correspond to the naturall colour of the patient‟s tooth.9,10 Furthermore, the selection of "window" preparation design in the direct veneer in this case based on the defect is localized in the central region of the labial surface of the #22, which has not reached the incisal edge, so it is considered do not need to prepared the incisal edge of the area. Tooth then prepared carefully with minimum tooth prepared. Preparation of the tooth structure needs only limited enamel retrieval and does not exceed 0.5 mm, so that no difficulty in adjusting the colour, because the structure of enamel retrieval will cause the tooth structure becomes darker due to the structure of dentin increasingly imagined. Preparation of the tooth structure for incisors is maximum of 0.5 mm and for canines is maximum 0.75 mm. To controling the preparation of tooth structure can be used depth-cutting diamond bur 0.5 mm as the initial
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or guiding bur, followed by fissure diamond bur or diamond needle to smooth the tooth surface preparation and finishing tooth with a defect.8,9,10 As in the composite restoration procedure, in the direct composite veneer is also worth the things that can affect the adhesion strength of the composite to tooth structure, including cleaning the enamel before applying appropriate etching and bonding agent as manufacturer's instructions. Cleaning enamel can be done using alcohol or water from the threeway syringe, to improve adhesion bonding, because saliva, debris, and oil derived from the handpiece can hinder the process of etching and bonding. When the tooth surface is clean, then acid etching by phosphoric acid 35% - 37% be applied to the entire surface using microbrush on labial #22 for 15 seconds, then rinsed and dried. And then, the adhesive material applied as a bonding agent also to the entire labial surface of #22 evenly using microbrush and then irradiated with light cured for 10 seconds.11,12,14 Composite was applied to the labial surface of the teeth layer by layer until the tooth are formed in accordance with its anatomy. Good contact between the composite with the gingival tissue around the tooth are maximized, especially in embrassure area because of the the overcontour restoration and the presence of a thin composite layer in the composite margin will lead to easy fracture and gingival irritation. So that, to prevent that problems, we placed celuloid strips on the mesial and distal sides of the #22. Checking existence of the overcontour restoration can also be done by passing dental floss without wax on the proximal area.11,12,13,15 The end of treatment procedures in this case of direct veneer is finishing and polishing. This procedure is important to get the maximum direct veneer treatment. Finishing and polishing procedure performed with a variety of tools and materials such as finishing burs, an aluminum oxide discs, and an aluminum-silicon-oxide point to maximize the anatomical contours of the tooth, so that it looks more natural, throwing and smooth restoration which is sharp and rough to prevent retention of food and debris, as well to get shiny restoration results.12,13,15
CONCLUSION In the case of tooth with enamel hypoplasia, treatment with direct composite veneer may be appropriate treatment options to restore and improve the aesthetic condition of the tooth damaged by the existing defects. Besides easy to apply, relatively low cost, and short in visits, treatment with direct composite veneer are also promising a very satisfying aesthetic results for patients. SUGGESTION In this case, direct composite veneers in tooth with enamel hypoplasia gives satisfactory results for the patient. However, along with the development of knowledge and dental materials, the direct treatment of the veneer may be getting attention for continuously modified to obtain a new technique or other material better. REFERENCES 1.
2.
3.
4.
5.
6.
Slayton R.L., Warren J.J., Kanellis M.J., Levy S.M. and Islam,M. Prevalence of enamel hypoplasia and isolated opacities in the primary dentition. Pediatric Dentistry 23:32-36. Fonseca R.B., Sobrinho L.C., dkk. Enamel hypoplasia or amelogenesis imperfecta - a restorative approach. Braz J Oral Sci. 5 (16): 941-943. Turkun LS. Conservative restoration with resin composites of a case of amelogenesis imperfecta. Int Dent J. 2005; 55: 38-41. Zorba Y. O., Bayindir Y. Z., Barutcugil C. Direct laminate veneers with resin composites: twocase reports with five years follow-up. J of Contemporary Dent Practice. 2010; 4 (11): 1-6. Additional Conservative Esthetic Prosedures. In: Heymann HO, Swift EJ, Ritter AV, editors. Sturdevant’s Art and Science of Operative Dentistry. 6th ed. St. Louis:Mosby;2013.p.661-9. Belcheva A. Reconstruction of fractured permanent-incisor in schoolchildren using laminate veneers (review). J of IMAB. 2008. 14 (2).
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7.
Gresnigt M. Minimally invasive treatment method is the deciding factor – Composite Veneers. Netherland. 2011. 8. Mackenzie L, Shortall AC, Burke FJT. Direct posterior composites: a practical guide. Dent Update 2009; 36(2): 71–94. 9. Albers H.F. Tooth-Colored RestorativesPrinciples and technique. BC Decker Inc, Hamilton. London. 2002: 237-73. 10. Tay F.R., Pashley D.H. Resin bonding to cervical sclerotic dentin: a review. J Dent. 2004; 32: 173-96. 11. Paravina R.D., Westland S., Kimura M., Powers J.M., Imai F.H. Color interaction of dental materials: blending effect of layered composites. Dent Mater. 2006; 22 (10): 903.
12. Baratieri L.N., Araujo E., Monteiro S.Jr. Color in natural teeth and direct resin composite restorations: essential aspects. Eur J Esthet Dent. 2007; 2 (2): 172-86. 13. Fahl N.Jr. Step by step approaches for anterior direct restorative challanges. J of Cosm Dent. 2011. 4 (26): 42-55. 14. Boksman L., Carson B. Aesthetic veneer restoration of an anterior dentition postorthodontics complicated by ankylosis. Dentistry Today. 2005: 108-10. 15. Felippe LA, Monteiro S, Jr, De Andrada CA et al. Clinical strategies for success in proximoincisal composite restorations. Part II: Composite application technique. J Esthet Restor Dent 2005; 17: 11−21.
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Root-end filing Technique with BioAggregate Yusri*, Christine A. Rovani** * Resident of Conservative Dentistry Faculty of Hasanuddin University ** Department of Conservative Dentistry Faculty of Hasanuddin University
Abstract Background: One of the key of endodontic successfulness is reaching the hermetic seal from periodontium to apical foramina. If orthograde technique is impossible to be done, retrograde filling technique will be used. Many materials have been developed as root-end filling materials. Mineral Triokside Aggregate have been developed as standardized material. However, this substance has weakness such us: containing toxic substance, a long setting time and difficult of clinical application, hence BioAggregate was developed to minimize its disadvantages. Purpose: To identify clinical application of BioAggregate as root-end filling material. Review: In 2007 BioAggregate which is modified from Mineral Trioxide Aggregate was developed to cover the weakness of Mineral Trioxide Aggregate Conclusion: BioAggregate is possible to be an alternative treatment for root-end filling because of its advantages. Keyword: Mineral Trioxide Aggregate, root-end filling, BioAggregate Corespondence:
[email protected]
FOREWORD Microorganism plays important role in pathogenesis lesi apical on root canal system. Intraradicular microorganism induces inflammatory and immune response in periradicular cell that cause bone destruction.1,2,3 The purpose of endodontic treatment is to maintain teeth as long as possible in the jaw so that it functions back again.3.4 The most important factor to succeed endodontic treatment is by triad endodontic in which it comprises of pulpa access, cleaning and shaping and obsturasi hermetic. 5.6.7 Some researches reveal that obturasi which is not hermetic is one of fatal failures in endodontic treatment.3.6 If a failure endodontic case happens the alternative treatment is by bone conventional treatment and surgical endodontic therapy.3.7.8 Periradicular Surgical is the most often endodontic surgical procedures used when nonsurgical treatment is failed or impossible to undergo.3.7,8.9 The purpose of periradicular is to create optimum condition for recovery through tissue regeneration , includes new stick structure creation.6.7.8.10.11 Periradicular surgical comprising debridement periradicular pathologic tissue surgical, root end resection, root end preparation and the placement of root-end filling. 7.9.10.12
The material placement of root-end filling is a key of root end management. 7.8.12 The main aim of root-end filling is to give apical seal to prevent bacteria movement and bacteria product diffusion from root canal system to the cell.7.13 Some materials have been improved by various manufacturer to be used as root-end filling material.14 The ideal materials of root-end filling must be able to close the communicational line between root and the surrounding tissue, biocompatible, anti-bacteria, stable dimension and radiopaque and not dissolve in mouth environment. 6.7.8.15.16.19.20.21 Mineral Trioxide Aggregate has proved when it placed in tooth pulp or periradicular cell it is able to prevent microleakage, biocompatible, and stimulating tissue regeneration.6 Even though Mineral Trioxide Aggregate deemed having ideal characteristic the use is still limited due to its high cost, difficult process, long time adjustment and possibly change the color. This shortfall results in effort of material root-end filling development. Bio Aggregate is a modification or synthetic version of Mineral Trioxide Aggregate.9 When it has a contact with liquid tissue, this material will shape hidroksiapatit that marked by calcium hydroxide releasing.10 It has been reported that BioAggregate induces the
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formation of tissue mineralization and fibroblast ligament periodontium differentiation. LITERATURE REVIEW Most of endodontic treatments are done with intracanal endodontic measure. This happens because of pulp sickness and the periapical that has strong relationship between one to each other. Most of periapical sickness can be hidden with conventional endodontic measure by totally releasing vital pulp and forming root canal for obturasi preparation. Obturasi is a key measure in triad endodontic treatment principal. With hermetic obturasi bacteria will not be able to live in root canal because of the link connecting root canal and periapical tissue has been cut down.6.15 Generally, non-surgical bone treatment in failed cases of endodontic treatment gives good result. However, the success is difficult to reach due to the complicated root canal system, inadequate instrumental and the presence of physical barrier. Therefore endodontic surgical could be an option.16 In this case, surgical endodontic describes procedures combining root tip resection, apical curettage and root-end filling. The indications of periradicular surgical: 3,15,20 1. Obstruction of root canal that displayed on radiology description with or without clinical symptom. 2. Material obstruction on radiology description with or without clinical symptom. 3. The failure of root canal treatment when the subsequent treatment is impossible to undergo (ismust tissue, chronic symptom that stay longer or risk of root fracture). 4. Perforation on radiology description with or without clinic symptom where it is impossible to undergo treatment in pulp cavity. Besides that, we must consider objective indication of patient on psycologhy matter, treatment time and cost as well. Contradiction of periradicular surgical: 3,16,21 1. Anatomy factor around it such as root tip access is not able to reach.
2. Teeth with inadequate periodontal tissue support. 3. Uncooperative patient 4. Unsupported Health track record Root-end filling application is one of important steps in periradicular surgical. This material functions to give hermetic seal to root canal, hold up the pathogen coronal leakage and its product into periradicular tissue so that it accelerates recovery process and forms sementum on dentin surface.7,17 To get a satisfied endodontic therapy, the ideal root-end filling must fulfill requirements as follow: biocompatibility with normal cell, high sealing ability, ability on periapical tissue regeneration, effectively hold pathogenic microorganism, stable, get enough radiopaque to distinguish material from the surrounding issue, easy to apply and adapted as close as possible cavity wall.7,10,17,18,19,20,22 Research have been done to numbers of materials and developed by various manufacturer to be used as material of root-end filling in endodontic surgical such as gutta percha, amalgam, cavit, intermediate resitorative material, super EBA, glass ionomer, resin composite, carboxylate cement, zinc oxide eugenol and Mineral trioxide Aggregate. Yet, not one of filling materials fulfilled the requirements of root-end filling ideal material.4,6,7,10,11,16,18 Recently, Bioceramic has been introduced as alternative material of root-end filling that is BioAggregate (innovative Bioceramic, Vancouver, BC, Kanada), introduced in 2007 it is a derivative of bioceramic material as non-particle powder that consist of tricalcium silicate, calcium phosphate monobasic, amorphous silicon dioxide, tantalum pentoxide, and its liquid from water deionization (picture 1) 10,15,20,23,24,25,26,27,28 Through several research found that BioAggregate can be utilized as root channel reparation, pulp capping, root resorption, apeksificasi and root-end filling.22,23 Characteristics of BioAggregate are : (1) Biocompatible, (2) hermetic seal, (3) periapical cell regeneration, (4) effectively hold the pathogenesis microorganism, (5) radiopaque enough to distinguish Bio Aggregate with surrounding cells, (6) easy application. The
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Processing time of Bio Aggregate is 5 minutes. After the mixture is formed into pasta mix, if additional time is needed, the mixture should only be protected by damp guaze.4 The material of root-end filling used is BioAggregate. Surgical process is done for access to root end and root resection by recommended 3 mm depth using ultrasonic tip along tooth axis (Picture 3). Utilization of ultrasonic tip to minimize bone taking and ease the process, tip shall be low power with soft touch to minimize root crack risk (picture 4).13 Cavity is cleaned then dried and isolated from all liquid to get the hemostasis, the material of rootend filling BioAggregate is mixed according to manufacturer instruction, afterward BioAggregate is placed into cavity by retrofilling plugger, repeat the procedure till the root tip is rightly sealed, to make sure that BioAggregate is placed well radiography should be done, if the placement is not enough repeat the placement procedure. BioAggregate material will stay as permanent part at the root end. 3,8,10,22
Picture 3. Root-end preparation uses ultrasonic tip.(sumber: CLINICAL USE OF ULTRASONIC TIPS IN SURGICAL ENDODONTIC TREATMENT. Available from:http://www.dentalcetoday.com/courses/48/HTML/dt_s ection_4.htm Accessed Juli 21,2014)
(a)
(b)
(c)
Picture 4. (a) soft tissue is opened then the infected cell is taken. (b) root end resection is undergone and then fill with root-end filling material. (c) bone recovery displays (resource: Dovgan JS. Root canal surgery, Endodontic Sugery, Apicoectomy (Apico) or Surgical endodontic Therapy.2000-2004;(6 screens). Available from: http://www.endodovgan.com/Endoinfo_SET.htm. Accessed June 13, 2014) picture 1. BioAggregate Pouch (sumber: Vario Dental co Ltd-FAQ-BioAggregate. Available BioAggregate.com/product Accessed Juni 9,2014)
Picture 2. Diamond-coated stainless steel ultrasonic surgical retrotips.(Platino G, Pameijer CH, Grande NM, Somma F. Ultrasonic in Endodontic: A Review of the Literature. JOE 2007;33(2):81-95)
DISCUSSION One important trait should be possessed by material of root-end filling is good biocompatible and sealing ability. 9,13 Based on several researches, Mineral Trioxide Aggregate is material root-end filling perceived close upon ideal.6,8 Mineral Trioxide Aggregate developed by Dr. Mahmoud Torabinejad and Dean J.White in 1993, firstly developed as material of root-end filling in University of Loma Linda, California, USA.12,25,26 This material can also be utilized as therapeutic material of vital pulp, pulpotomy, reparation of tooth root perforation, apical plug, tooth root channel.4,7,9,17,22,23,27 Mineral Trioxide Aggregate is proven to be material with very good quality in sealing ability, bio-compatibility,
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as well as possess an ideal trait such as antimicro-bacteria, dimension stability, radiopaque and tolerance toward mixture with pH 12.5.6,7,9,12,16,17,25,28 Sarkar et al, state that Mineral Trioxide Aggregate is able to induct hydroxyl apatite, and when contacted with periradicular tissue, it can stimulate tissue reparation and stimulate new bone and cementum deposition.6,23,25,29 Kim and Kratchman stated that Mineral Trioxide Aggregate is material of root-end filling which is bio-compatible and can be used as prediction of successful endodontic surgery. However, Mineral Trioxide Aggregate is perceived close upon ideal trait, several researches affirm that this material has main flaws include potency of discoloration, difficult application, short solidifying period, existence of toxic within material composition and difficult to be broken off after setting.10,30 Therefore, to reduce several flaws Mineral Trioxide Aggregate, introduced a material i.e. modification of Mineral Trioxide Aggregate which is perceived able to repair physical trait of Mineral Trioxide Aggregate. BioAggregate is mostly like white Mineral Trioxide Aggregate, but its chemical composition is different, which mainly is free-aluminum known as toxic aluminum toward human body, it also contain calcium phosphate monobasic and tantalum pentoxide.15,20,23,24,26,27,29 Tantalum pentoxide is used on BioAggregate as radiopaque agent to be more bio-compatible in comparison with MTA which contain Bismuth Oxide.10,15,21,25,26,27,28,29 Grech et al observe, after mixing powder of BioAggregate with BioA Liquid (deionization water), there was a complex reaction leading to formation of nano-composite gel similar to hydration of silicate calcium mixed with Bioceramic hydroxyapatite, and clinically forming hermetic seal (cementogenesis) which is effective to block bacterial infection, its technical manipulation can easily make most innovative and unique BioAggregate. This material stimulates formation of hydrate silicate calcium and hydroxide calcium. Hydrated material consists of cementitious phase which is enriched with calcium and silicon and radiopaque material.4,24,27
Apical seal from material of root-end filling is an important factor of the success of periraducular surgery.13Stabloz et al, state that marginal adaptation is a direct method to determine sealing ability of root-end filling material.7 Leal et al, evaluate the ability of BioAggregate and Mineral Trioxide Aggregate as root-end filling material to prevent glucose leak. They report that sealing ability of BioAggregate is pretty good.27 Several researches have been conducted to find the cytotoxicity effect of BioAggregate on human cells. Yuan et al, observe cytotoxicity effect and proven anti-toxic on osteoblast cells. This material also increases expression of collagen type 1 which areosteopontin and osteocalcin i.e. gens related to mineralization within osteoblast.20,25,26,27 This material contains hydroxyapatite and amorf silicon oxide.23 This hydroxyapatite is proven increasing level of expression of MC3T3 coll cells. Lin et al, find hydroxyapatite regulate expression of coll in the osteoblast cells and also increasing expression level of MC3T3 ocn cells and these components exist only in Bio-Aggregate and not in Mineral Trioxide Aggregate.20,24Amorf silicon oxide is also added to reduce the content of hydroxide calcium produced in the hydration, which is weak phase. Hydration of BioAggregate causes the formation of hydroxide calcium.10 Yan et al, observe cytotoxicity of BioAggregate and compare to Mineral Trioxide Aggregate. They report that BioAggregate is anti-toxic for periodontal fibroblast ligament on human.25,26,29 CONCLUSION AND SUGGESTION Material application of root-end filling is an important step in periradicular surgery. This material is able to prevent blood periradicular contamination. BioAggregate is an alternative material of root-end filling because it is more biocompatible, better sealing ability¸ induces tissue regeneration and easy application. But, further research is needed on long term response of BioAggregate toward periradicular cells.
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BIBLIOGRAPHY 1.
Siqueira JS, Rocas IN. Clinical implication and microbiology of bacterial persistence after treatment procedures. JOE 2008; 34(11): 1291-1301 2. Kazem M, Eghbal MJ, Asgary S. Comparison of bacterial and dye microleakage of different root-end filling materials. IEJ 2010;5(1): 17-22. 3. Pedroche LO, Barbieri N, Tomazinho FSF, Ulbrich LM, Leonardi DP, Sicuro SM. Apicoectomy after conventional endodonti.c treatment failure: case report. RSBO 2013 10(2): 82-7. 4. Grotra D, Subbrav CV. Bioactive material used in endodontics. Recent research in science and Technology 2012;4(6): 25-7. 5. Endodontis opening and colleagues for excellence. Acces opening and canal location. American Association of Endodontics 2010: 2-8. 6. HL Shadara, Briget B. A comparative evaluation of the sealing ability of mineral trioxide aggregate, high copper silver amalgam, conventional glass ionomer, cement, and glass cermet as root end filling materials by dye penetration method. JIOH 2011;3(2): 31-5. 7. Saini D, Nadig G. A comparative analysis of microleakage of three root end filling material-an in vitro study. Archives of Orofacial Science 2008;3(2): 43-7. 8. Chong BS, Ford TRP. Root-end filling materials: rationale and tissue response. Endodontic Topics 2005;11: 114-30. 9. Saxena P, Gupta SK, Newaskar V. biocompatibility af a root-end filling materials: recent update. RDE 2013:119-27. 10. Arx TV, Gerber C,Hardt N. Periradicular surgery of molar: a prospective clinical study with a one-year follow-up. IEJ 2001;34: 520-5. 11. Khan SIR. Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new root-end filling material. Journal of Dentistry 2012;2(2):166-9. 12. Gondim E, Zaia AA, Gomes BPFA, Ferraz CCR, Teixeira, Souza-Filho FJ. Investagation of the marginal adaptation of
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root-end filling materials in root-end cavities prepared with ultrasonic tips. IEJ 2003;36: 491-9. Mohammadi Z, Shalavi S. Effect of hydroxyapatite and bovini serum albumin on the antibacterial activity of MTA. IEJ 2011;6(4): 136-9. Grech L, Mallia B, Camilleri J. Characterization of set intermediate restorative material, biodentine, bioaggregate and a prototype calcium silicate cement for use as root-end filling materials. IEJ 2013;46:632-41. Asgary S, Shahabi S, Jafarzadeh T, Amini S, Kheirieh S. The properties of a new endodontic material. J Endod 2008;34:990-3 Erkut S, Tanyel, Keklikoglu N, Yildirim S, Katiboglu AB. A comparative microleakage study of retrograde filling materials. TurkJ med Sci 2006;36:113-20. Dammaschke T. Root-end filling with a new bioactive cement. Inside dentistry.2012;8(3) Tanalp J, Kazandag MK, Dolekoglu S, Kayahan MB. Comparison of the radiopacities of different root-end filling material and repair materials. SWJ 2013: 1-4 Yuan Z, Peng B, Jiang H, Bian Z, Yan P. Effect of bioaggregate on mineral-associated gene expression in osteoblast cells. JOE 2010;36(7):1145-48. Arx TV. Failed root canals: the case for apicoectomy (periradicular surgery. J.Oral Maxillofac.Surg.2005;63: 832-7. Parirokh M, Torabinejad M. Mineral trioxide aggregate: A Comprehensive literature review-part I: chemical, physical, and antibacterial properties. JOE 2010;36(1):16-7. Guven Y, Tuna EB, Dincol ME, Aktoren O. X-ray diffraction analysis of MTA-plus, MTA-sngelus and DiaRoot BioAggregate. EJD 2014;8(2):211-15. Hashem AAR, Marzouk AM, Far HME. The push-out bond strength of different furcation perforation repair material: A comparative study. ENDO (Long Engl) 2012;6(4):22782. R Priyinka S, Veronica. A literature revieuw of root-end filling materials. IOSR JDMS 2013;9(4):21-5.
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25. Shoukouhinejad N, Nekoofar MH, Razmi H, Sajadi S, Davies TE, Saghiri MA, Gorjestani H, Dummer PMH. Bioctivity of endosequence root repair material and bioaggregate. IEJ 2011;45:1127-34. 26. Madfa AA, Al sanabani F, Al Qudami NH. Endodontic repair filling:a review article. BJM&MR 2014;4(6): 3059-79. 27. Bosio CC, Felippe GS, Bortoluzzi EA, Felippe MCS, Felippe WT, Rivero ERC. Subcutaneous connective tissue reaction to iRoot SP, mineral trioxide aggregate (MTA) Fillapex, DiaRoot BioAggregate and MTA. IEJ 2013:1-8.
28. Camelleri J, Ford TRP. Mineral trioxide aggregate: a review of the constituents and biological properties of the material. IEJ 2006;39:747-54. 29. Chang SW, Lee SY, Kum KY, Kim EC. Effect of proroot MTA, bioaggregate, and micromega MTA on odontoblastic differentiation in human dental pulp cells. JOE 2014;40(1): 113-8. 30. Chung CR, Kim E, Shin SJ. Biocompatibility of bioaggregate cement on human pulp and periodontal ligament (PDL) derived cells. JKACD;35(6):473-7.
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Single visit endodontic in the management of symptomatic irreversible pulpitis and pulp necrosis with apical periodontitis: report of two cases Cut Nurliza, Trimurni Abidin Department of Conservative Dentistry Faculty of Dentistry University of Sumatera Utara
Single visit endodontic (SVE) therapy may be defined as the conservative non surgical treatment of an endodontically involved tooth, consisting of complete chemicomechanical instrumentation and obturation of the root canal system accomplished in one visit. This case report aims to describe two cases namely mandibular first molar with symptomatic irreversible pulpitis and maxillary first molar with pulp necrosis with apical periodontitis referred to the Clinic of Department of Conservative Dentistry, Faculty of Dentistry University of Sumatera Utara treated with single visit endodontic treatment. All cases were successfully completed in one visit with direct composite onlay as final restoration. Following one-year evaluation, there was no clinical symptoms and healing of periapical tissue was observed. Under controlled circumstances including accurate diagnosis, proper case selection, and skilled treatment technique, with single visit treatment, postoperative sequelae and healing will produce a high success rate. Keywords: Single visit endodontics. Irreversible pulpitis, pulp necrosis, apical periodontitis, healing
Introduction Since its introduction, single visit endodontics has been a form of focus of controversy.1,2 Some advocate that all root canal treatments to be done in one visit while others do not consider it even in cases of vital pulp extripation.1-3 Some studies have reported statistically insignificant difference between single and multiple visit endodontics in terms of survival, post-operative pain or flare-ups.4 So, it depends only on the preference of the operator to adopt single or multiple visit endodontics.5 Single-visit endodontic therapy is defined as „the conservative non-surgical treatment of an endodontically involved tooth consisting of complete biomechanical cleansing, shaping and obturation of the root canal system during one visit‟.6 With the advent of new instrumentation techniques, material science and technology, it is no more an orthodox empirical procedure for obturation of root canals.7 However, with the introduction of magnifying loupes surgical microscopes, NiTi rotary instrument systems, ultrasonic devices, newer obturation systems (injectable obturation system), it is now considered as an acceptable alternative treatment procedure for endodontic problems.8 Although a number of clinical
research studies have shown favourable results with single visit protocols, evidence-based studies do report that there is a lack of clinical evidence to support these results.9 Thus, it is still a dilemma for the contemporary general practitioner as well as the specialist as to when and how to proceed with single visit endodontics.10-12 This article describes two cases of irreversible pulpitis and pulp necrosis with apical periodontitis treated in one visit. Case Series Case 1: A 25-year-old female patient presented to the Dental Clinic at Department of Conservative Dentistry, University of Sumatera Utara, with the chief complaint of a toothache in her right mandible. She had spontaneous throbbing pain during her sleep and she felt discomfort on eating. Clinical examination revealed that the tooth #46 had deep caries that had reached the pulp from distal part. The tooth gave positive response to electric pulp test and was not tender to percussion and palpation. A diagnosis of symptomatic irreversible pulpitis with a normal periapical tissue and pre operative
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radiography was was made (Fig. 1).
Chlorhexidine. Fitting master cone was done and the radiography was taken (Fig. 4).
Figure 1. Pre operative
The patient‟s medical history was noncontributory and an emergency pulpectomy was performed at the first visit. During examination with an operating microscope (JedMed/Kaps, St Louis, MO, USA) the anatomy of the first right mandibular molar was determined as follows: two canals in the mesial root and distal root (Fig. 2). Under the microscope it was possible to insert a size #10 and #15 K-file for glidepath and working length was determined with electronic apex locator (Root ZX, J. Morita MFG. Corporation, Kyoto, Japan) (Fig. 3).
Figure 4. Fitting of master cone
Obturation was done using combination of lateral condensation and warm gutta percha technique using System B tip (Sybron) and hot injection (Discuss Dental) (Fig. 5).
Figure 5. Obturation
Figure 2. Clinical view of access preparation
Composite resin with fiber reinforced onlay restoration was made as final restoration. Twelve months later the patient was recalled for a follow-up. At the clinical examination the tooth was asymptomatic and the radiographic examination revealed normal periapical tissue (Fig. 6).
Figure 3. Working length confirmation
These four canals were completely instrumented and cleaned thoroughly in one visit using pathfile (Dentsply) and Mtwo rotary Niti files (VDW) until 40/0.04 for each canal. 2.5% Sodium hypochlorite and 17% EDTA were used as irrigants alternatively. Final irrigation was 3%
Figure 6. Twelve months follow-up
Case 2 A 28 year-old female patient presented to
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the Dental Clinic at Department of Conservative Dentistry, University of Sumatera Utara with a chief complaint of discomfort and pain while chewing with his right maxillary first molar for past few weeks. History revealed a diffuse pain and discomfort with biting on the tooth. On clinical examination pain on percussion and negative response to thermal tests were present in relation to with restoration. Pre-operative radiograph showed slight periapical radiolucency (Fig. 7).
Morita MFG. Corporation, Kyoto, Japan) and then confirmed radio graphically with initial files (Fig. 9).
Figure 9. Working length confirmation
Figure 7. Pre operative radiography
During the access cavity preparation, the pulpal floor was inspected for the canal opening. Examination with an operating microscope (JedMed/Kaps, St Louis, MO, USA) showed the anatomy of the right maxillary first molar was determined as follows: two canals in the mesiobuccal root, one canal in distobuccal root and one canal in palatal root (Fig. 8).
All canals were initially cleaned using smaller K-files ISO 10 and 15 as glidepath followed by ultrasonic files. 2.5% Sodium hypochlorite and 17% EDTA were used as irrigants alternatively. Final irrigation was 3% Chlorhexidine. Cleaning and Shaping were completed using rotary Mtwo instruments with crown-down technique until 40/0.04 for palatal canal and 35/0.05 for buccal canals. The master cone was selected and the root canals dried with absorbing paper points (Fig. 10). Root canals were obturated using combination of cold lateral condensation technique and compaction technique of warm gutta percha with MTA based sealer (Fillapex, Angelus Brazil). After obturation, glass ionomer cement was used to seal coronal portion (Fig. 11).
Figure 8. Clinical view of access preparation Figure 10. Master cone fitting
The negotiation of canals began with no. 10 and 15 ISO file. On closer inspection with 4.5 times magnification prismatic loupes the pulp chamber floor was carefully examined. The working lengths of all root canals were estimated using an electronic apex locator (Root ZX, J.
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Figure 11. Obturation
The tooth was then restored with composite resin onlay restoration with polyethylene fiber reinforced. Follow-up was done for one year. There was good prognosis with no clinical symptom and the radiograph showed complete periradicular healing (Fig. 12).
Figure 12. Follow-up radiography
Discussion Endodontic treatment aims at the complete elimination of microbial invaders of the root canal system.1-4 Studies have shown that instrumentation and irrigation of the root canal system substantially reduce the number of cultivable microorganisms but rarely lead to a total eradication.1-3 Minute differences in periapical healing were observed among individuals undergoing single visit and multiple visit root canal treatment and bacterial growth at the second appointment had a significant negative impact on healing of the periapical lesion.4-5 In addition to this, the clinical efficacy of sodium hypochlorite irrigation in the control of root canal infection is much more than the effectiveness of inter-appointment calcium hydroxide dressing, in disinfecting the root canal system and treatment outcome, indicating the
need to develop more efficient inter-appointment dressings.6-7 E. faecalis is the most resistant bacterium against calcium hydroxide while sodium hypochlorite is effective against it in both buffered and unbuffered states.8 However, quantity of the irrigant is more important than type of the irrigant, therefore copious irrigation is recommended.9 Intra-canal medicaments can only work efficiently if they are in direct contact with microorganisms.10 Most of the microorganisms causing endodontic failure, resides deep in dentinal tubules or accessory canals and multiple visits allow them to proliferate resulting in poor apical healing and endodontic failure.11 Therefore these days it is considered a better option to disinfect the canals with copious irrigation of sodium hypochlorite and sealing the canals resulting in elimination of the sources which will allow the multiplication of micro-organisms and therefore allow better periapical healing and better treatment outcome.12 In recent years, single-appointment endodontics has gained increased acceptance.3-6 Recent studies have shown little or no difference in the quality of treatment or success rates between single- and multiple-visit root canal treatment.5-9 However, Nair et al. found that 14 of 16 (88%) mandibular molars that were treated in a single-visit endodontic treatment harboured intracanal microorganisms immediately after completion of the treatment.8 Other studies have also recommended that endodontic treatment of non-vital teeth with infected root canals should be completed in one session, without any intracanal microbicidal dressing.9 Intraradicular microbes surviving root canal treatment are argued to be entombed by obturation of the root canal and die off as a result of inadequate nutrients.10 „These microbes may no longer interfere with the periapical healing process.11 According to Sjögren et al., the periapical healing of some teeth occurs even when microbes are present in the canals at the time of obturation.12 Although this may imply that the organism may survive post-treatment, it is possible that the microbes may be present in quantities and virulence that may be subcritical to sustaining the inflammation of the periapex, or
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that they remain in a location where they cannot communicate with the periapical tissues.10-12 Conclusion The single-visit root canal treatment is safe in terms of endodontic flare-ups as far as results of this study are concerned. It is safer in both vital and non-vital teeth, and even teeth with periapical pathosis. A thorough understanding of the basic endodontic principles is important in considering each case on an individual basis before making a decision as to whether or not it can be completed in one visit. The effectiveness of single-visit and multiple-visit root canal treatment is not substantially different. Therefore, the use of an interappointment intracanal medication might be unnecessary when the operator, during a single visit, carefully debrides the canals, uses an adequate antimicrobial irrigant, and accomplishes an effective obturation of the root canal system. The incidence of post operative discomfort/pain is also similar, although patients undergoing single visit RCT might experience a higher frequency of swelling and are more likely to take analgesics. Long term success using radiographic assessment is also similar to both the groups. References 1. Kakehashi S, Stanley H, Fitzgerald R. The effect of surgical exposures of dental pulps in germ free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1965; 20: 340–9. 2. Moller AJ, Fabricius L, Dahlén G, Ohman AE, Heyden G. Influence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scandinavian J Dent Res 1981; 89: 475–84.
3. 3. Weiger R, Rosendahl R, Löst C. Influence of calcium hydroxide intracanal
dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000; 33: 219–26. 4. CohenS, BurnsRC. Pathways of thepulp.8th ed.StLouis, MO: Mosby; 2002. 5. Sathorn C, Parashos P, Messer HH. Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and metaanalysis. Int Endod J 2005; 38: 347–55. 6. Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J 2002; 35: 660–7. 7. Field JW, Gutmann JL, Solomon ES, Raakusin H. A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment. Int Endod J 2004; 37: 70– 82. 8. Nair PNR, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after „one-visit‟ endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Endod 2005; 99: 231–52. 9. Pekrun RB. The incidence of failure following single-visit endodontic therapy. J Endod 1986; 12: 68–72. 10. Peters LB, Wesselink PR, Moorer WR. The fate and the role of bacteria left in root dentinal tubules. Int Endod J 1995; 28: 95–9. 11. Weiger R, Rosendahl R, Lost C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000; 33: 219–26. 12. Sjögren U, Figdor D, Person S, Sundqvist G. Influence of infection at the time of the root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997; 30: 297–306.
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The selection of final restoration for endodontically treated right mandibular first molar with mesial drifting of the second molar: a case report Teddy*, Trimurni Abidin** * Resident at Conservative Dentistry Specialist Program ** Lecturer at Conservative Dentistry Department Faculty of Dentistry, University of Sumatera Utara Jln. Alumni No. 2, Kampus USU, Medan 20155
Abstract The choice of final restoration for endodontically treated teeth presents a challenge in endodontics. The final restoration functions to replace missing tooth structure due to caries and broken restoration removal and during endodontic treatment process itself. Prognosis of endodontically treated teeth depends not only on the quality of endodontic treatment itself, but also on the amount of remaining tooth tissue, but the most important is the final restoration placed on the tooth. This case report aims to present a case of choosing the proper final restoration for endodontically treated right mandibular first molar with mesial drifting of the second molar in a 21-year-old male patient. Customized post and PFM crown was made as the final restoration with the correction of the second premolar and the second molar drifting due to long-term coronal loss of the first molar to improve the prognosis of endodontically treated teeth. Key words: endodontically treated teeth, final restoration, customized post, PFM crown Contact Person: Teddy / 0819 210 3824 e-mail:
[email protected]
INTRODUCTION Before initiating root canal treatment, a dentist should examine the tooth for caries and fracture. Assessment should also be evaluated on its for restorability, occlusal function, periodontal health, biological width, and crown-to-root ratio. All previous restorations and existing caries should be removed before initiating root canal treatment. This allows more accurate assessment of its restorability and evaluation for fractures. Teeth with extensive destruction of tooth structure may need crown lengthening or orthodontic eruption prior to root canal treatment.1 Final restoration of endodontically treated teeth aims not only to promote coronal sealing and to avoid microleakage, but also to replace the lost tooth structure and to protect the remaining tooth structure, mainly against fracture. Final restoration of endodontically treated teeth may vary from a small direct restoration to complex indirect restorations, involving the placement of an intraradicular post and core. Factors which directly influence on the
option for the final restoration type, for example, the amount of the remaining coronal tissue after root canal treatment, patient‟s prosthetic and esthetic needs. A dentist also should verify whether the tooth would be used as a removable or fixed partial denture abutment. Moreover, the tooth‟s periodontal and supporting tissue condition should be also checked. The restorative treatment planning of tooth undergoing endodontic therapy must be carefully performed and, sometimes, it would involve a multidisciplinary team.2 The purpose of placing a post is to retain a core that is needed because of extensive loss of coronal tooth structure. A post placement should be avoided when anatomic structures are still available to retain the core. Molars may not require posts because a core can be retained by the pulp chamber and canals. When a post is necessary, it should be placed in a distal canal of mandibular molars and the palatal canal of maxillary molars, because the other canals tend to be thinner and more curved.1 In teeth with little or no remaining coronal structure, final restorations usually
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involve full crowns, such as metallic, metalceramic, or all-ceramic crowns. In cases with remaining coronal is present and can be preserved, onlay restorations may be used in endodontically treated teeth.2 This case report aims to present a case of choosing and designing the final restoration for endodontically treated right mandibular first molar with mesial drifting of the second molar. CASE REPORT A 21-year-old male patient was referred to Conservative Dentistry Clinic, Faculty of Dentistry, University of Sumatera Utara in order to fix the detached right lower molar full crown. Clinical examination revealed crownless right mandibular first molar and mesial drifting of the second molar with a Class-II mesio-occlusal amalgam filling (Figure 1). Radiographic examination revealed that the first molar was previously endodontically treated (Figure 2). Tooth #46 was diagnosed as an endodontically treated tooth. The treatment planning for tooth #46 was customized metal post with PFM crown as the final restoration and PFM onlays for tooth #45 and #47.
were removed. Gutta percha in the distal and mesio-lingual root canal were removed by using Peeso reamer (FKG Dentaire SA). Violet wax (Inlay Wax Soft, GC Corporation) was heated, then lubricated on the plastic pin (DuraLay, Reliance Dental), later the plastic pin was inserted to the root canal to reproduce the root canal anatomy. Upper and lower jaw were impressed with alginate, then the impressions were casted with dental stone (Fujirock, GC Corporation), later the model were sent to the laboratory to fabricate a customized metal post. The cavity was temporarily filled with glass ionomer cement (Fuji IX, GC Corporation). At the second visit, temporary filling on tooth #46 was removed, then the customized metal post was fitted in the root canal. The customized metal post was cemented with GIC luting cement (Fuji I, GC Corporation) (Figure 3), then was prepared for PFM crown as the final restoration. Amalgam filling on tooth #47 was removed, then tooth #47 was prepared for PFM onlay. Tooth #45 was also prepared for PFM onlay (Figure 4). Retraction cord (Ultrapak, Ultradent) was packed, then the lower jaw was impressed with double impression (putty and wash) technique (Exaflex, GC Corporation). The impression was casted with dental stone (Fujirock, GC Corporation), then the model were sent to the laboratory to fabricate PFM crown and onlays. Temporary crown (Revotek LC, GC Corporation) for tooth #46 was cemented with temporary cement (Freegenol, GC Corporation), tooth #45 and #47 was temporarily filled with temporary filling (Cavit, 3M ESPE).
Figure 1. Clinical view of the right mandibular first molar before treatment
Figure 3. Radiographic view after customized metal post was cemented on tooth #46 Figure 2. Radiographic view of the right mandibular firstmolar before treatment
At the first visit, composite resin filling and lining cement on the orifice of tooth #46 111
Figure 4. Tooth #46 was prepared for PFM crown, tooth #45 and #47 for PFM onlays
At the third visit, temporary crown and fillings were removed, then PFM crown on tooth #46 and PFM onlays on tooth #45 and #47 were fitted , later were cemented with GIC luting cement (Fuji I, GC Corporation). (Figure 5 and 6).
Figure 5. Clinical view after PFM crown on tooth #46 and PFM onlays on tooth #45 and #47 were cemented
Figure 6. Radiographic view after PFM crown on tooth #46 and PFM onlays on tooth #45 and #47 were cemented
DISCUSSION The structure of endodontically treated teeth were different from vital teeth. This occurs because these teeth generally have carious lesion history (small or extensive), previous restorative treatment, fracture and trauma, and also the root canal treatment itself. To plan and perform the restorative treatment of endodontically treated teeth, a dentist should know these alterations and their effects, should predict possibilities that might happen and should plan the most proper
approach for each case treatment.2 Moreover, a dentist should also consider the restorative prognosis, the periodontal prognosis, the skill of the dentist, available technology, and the patient‟s desires.3 Endodontically treated teeth are weakened due to decreased or altered tooth structure attributed to caries and/or previous restorations, fracture or trauma, endodontic access and instrumentation, decreased dentin moisture. The weakness is directly correlated to the quantity of loss dentin.4 Basic principles in the restoration of endodontically treated teeth are :1 1. Posterior teeth with root canal treatment should receive cuspal coverage restorations. Adhesive restorations provide only short-term strengthening of the teeth 2. Anterior teeth with minimal loss of tooth structure can be restored conservatively with adhesive restorations 3. Coronal and radicular tooth structure must be preserved as many as possible 4. The purpose of a post is to retain core buildup 5. A ferrule is highly desirable when a post is used, with a minimum of 2 mm of vertical height and 1 mm of dentin thickness Peroz et al. formulated a classification of the final restoration selection depending on the number of remaining axial cavity walls :5 1. Class I describes the access preparation with all 4 axial cavity walls remaining 2. Class II describes loss of 1 cavity wall, commonly known as the mesio-occlusal (MO) or the disto-occlusal (DO) cavity 3. Class III is an MOD cavity with 2 remaining cavity walls 4. Class IV describes 1 remaining cavity wall, in most cases the buccal or oral wall 5. Class V describes a decoronated tooth with no cavity wall remaining The minimal thickness of the axial wall should be 1 mm to provide an amount of hard tissue sufficient to stabilize the core material after crown preparation and the minimal height of the axial wall should also be 2 mm to provide sufficient ferrule effect. If these two conditions
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cannot be attained then the axial wall should be considered missing.5 Class I-III Two to 4 cavity walls remaining
Post Core Final restoration
No Adhesive Direct / Indirect
Figure 7. No post is needed in cases with at least 2 axial cavity walls remaining5 Class IV One cavity wall remaining
Post Core Final restoration
Fiber Adhesive Crown
Fiber / Metal Adhesive / Cast Onlay / Crown
Figure 8. A post should be inserted if only 1 cavity wall is remaining. Fiber posts are preferable in anterior teeth, but in posterior teeth, fiber or metal posts can be used. The core can be made of composite or metal. The final restoration should be crowns in anterior teeth and crowns, onlays, or overlays in posterior teeth5 Class V No cavity walls remaining
Post Core Final restoration
Fiber / Metal Adhesive / Cast Crown
Figure 9. A post must be inserted if there is no cavity wall remaining. A ferrule of 2 mm is needed to provide a lower risk of root fracture5
This case was a Class-V case because tooth #46 was decoronated (with no axial cavity wall remaining). For this reason, a post was needed because there was no axial cavity wall remaining to retain the core material. The post was a customized metal post. Customized metal post is rarely used now because it is difficult to adjust and predispose the tooth to root fracture. Moreover, it also requires two visits and laboratory fabrication fee.6 A customized metal post may be indicated when a tooth is misaligned and the core must be angled in relation to the post
to achieve proper alignment with the adjacent teeth.7 In this case, the posts were placed in distal and mesio-lingual roots. If post and core are needed in molars, post are best placed in roots that has the greatest dentin thickness. The most appropriate roots in maxillary molars are the palatal roots, and in mandibular molars, they are the distal roots. The buccal roots of maxillary molars and the mesial root of mandibular molars should be avoided if at all possible. If these roots must be used, then the post length should be short (3 to 4 mm).8 In this case, the final restoration for tooth #46 was PFM crown, whereas for tooth #45 and # 47 were PFM onlays. Tooth #47 was mesially drifted so there was an alteration in occlusion. An onlay is a very good restoration to restore occlusal plane of a tooth with mesial drifting. The preparation of the tooth is performed to increase the height of the tooth, mainly the mesial aspect, and also maintain the facio-lingual dimensions of the restored occlusal surface and good contours of the facial and lingual surfaces. The mesio-facial and mesio-lingual margins should often be extended to the facial and lingual surfaces to help in recontouring the mesial surface to good proximal contact and contour. This extension can be accomplished with a minimal loss of tooth structure by preparing facial and lingual extensions on the proximal margins, which will increase the resistance and retention forms.9 Good proximal contact area will help prevent food impaction and protect the interdental papillae by shunting food towards buccal and lingual areas. Improper proximal contact area will create abnormal forces that will harm the periodontal tissue.10 CONCLUSION The selection of final restoration for endodontically treated teeth should consider the amount of the remaining coronal tissue after root canal treatment, patient‟s prosthetic and esthetic needs. Moreover, a dentist should also consider the restorative prognosis, the periodontal prognosis, the skill of the dentist, and available technology. With proper considerations then a
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dentist can make a proper final restoration for each specific case. REFERENCES 1. Schwartz R, Jordan R. Restoration of endodontically treated teeth: The endodontist‟s Perspective. Endodontics: Colleagues for Excellence. 2004: 1-6 2. Gonzaga CC, de Campos EA, Baratto-Filho F. Restoration of endodontically treated teeth. RSBO. 2011; 8(3):e33-46 3. Schwartz R, Jordan R. Disassembly of endodontically treated teeth: The endodontist‟s Perspective. Endodontics: Colleagues for Excellence. 2004: 1-4 4. McComb D. Restoration of the Endodontically Treated Tooth. Dispatch. 2008: 1-20
5. Peroz et al. Restoring endodontically treated teeth with posts and cores – a review. Quintessence Int. 2005; 36:737-746 6. Cheung W. A review of the management of endodontically treated teeth – Post, core and the final restoration. JADA. 2005; 136:611619 7. Schwartz RS, Jordan JW. Post Placement and Restoration of Endodontically Treated Teeth: A Literature Review. J Endod. 2004; 30(5): 289-301 8. Goodacre CJ, Kan JYK. Restoration of Endodontically Treated Teeth. In: Ingle JI, Bakland LK, editor. ENDODONTICS. 5th ed. Hamilton: BC Decker; 2002:913–950 9. Sikri VK, Textbook of Operative Dentistry. 2nd ed. New Delhi: CBS Publishers; 2008:61-83 10. Sikri VK, Textbook of Operative Dentistry. 2nd ed. New Delhi: CBS Publishers; 2008:113-126
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Pathogenesis of periapical lesion and discoloration caused by Traumatic injury: case report Member Reni Purba* Trimurni Abidin ** * Resident of Specialist Program of Conservative Dentistry **Lecturer of Specialist of Conservative Dentistry Faculty of Dentistry , University of North Sumatra Jln . Alumni no. 2 Kampus USU Medan 20155
Abstract Dental trauma can cause damage to the pulp although root and crown are not involved . Pulp can survive or undergo necrosis , depending on the severity of the trauma where the reaction can cause damage to the periapical tissues . Trauma to the teeth can also cause discoloration , the cause is due to bleeding in the pulp and rupture of blood vessels . Treatment of traumatized teeth with periapical lesions and discoloration can be done with conventional root canal treatment and intra coronal bleaching to discoloration teeth. The purpose of this case report is to describe two dental trauma cases of two men age 24 years old that occurred 10 years ago at teeth 11 are still intact and suffered severe discoloration in the absence of periapical lesions and other cases of fracture of the teeth 11,21 dan 22 on incisal enamel with periapical lesions but without discoloration. In these two cases, we know that in cases of dental trauma without pulpal involvement, periapical lesion without discoloration and discoloration without periapical lesion can likely occure so the case management differs from each other. Key words : trauma, periapical lesions, discoloration of teeth, root canal treatment
Dental trauma can pulpal damage. The pulp may survive or undergo necrosis depending on severity of the trauma and the type of inflammatory reaction that follows1,4. Trauma may lead to extensive destruction of the periapical tissue and an ensuing periapical lesion. Generally accepted if pulp has been necrosis, microorganism can grow and develop and release toxins into the pulp and periapical tissue 1,2,3,4,13. Dental trauma can cause haemorrhage in the pulp chamber owing to rupture of blood vessel. Blood is driven into the dentinal tubules and the red blood cells undergo haemolysis, releasing haemoglobin that can cause tooth discoloration5,7,9. In the traumatized tooth, the main cause of discoloration is accumulation of haemoglobin or hematin molecules in the tubules dentin5,7. This paper explains about the pathogenesis of periapical lesion without discoloration caused by trauma in the first case and the second case is trauma causes teeth discoloration without periapical lesions.
Case report 1 A twenty four year old man came to faculty of dentistry University of Sumatra Utara want to treat upper front teeth are pain and swelling several weeks ago and the swelling has repeatedly ± 6 times in the last few years. Patients said he fell 10 years ago and fracture on front teeth. On clinical examination : scratching test with explorer showed cold tes, percussion and palpation showed negative response, no presence of mobility. Fracture occurred on enamel incisal teeth 11, 21 and 22 (figure 1). On the radiographic examinations it showed widening of lamina dura and presence of periapical lesion in the region 11, 21 and 22 (figure 2).
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Fig 1. Trauma on teeth 11,12 Fig 2. Pre – op of teethand 22 on enamel 11, 12 dan 22
Fig 3. Trauma caused Fig 4. Radiography pre-op Discoloration on tooth 11
Based on anamneses, examination of subjective, objective and radiographic on 11, 21 and 22 are chronic apical periodontitis caused by pulpal necrosis. The treatment in this case is non vital root canal treatment. At the first visit, acces opening using a round bur (edenta Sweden). Working length determination using apex locater confirmed by radiography, then Initial Apical Filing (IAF) was done with the ISO file 11 # 25/23mm, 21#25/23mm and 22 #20/21mm and then it is followed by root canal preparation with step back method, irrigation with 2,5% NaOCl and 17% EDTA, after that root canal was dried and medication with calcium Hydroxide and sealed with temporary filling. Replacement medicaments every month and obturation until progress of periapical lesion.
Based on anamnesis, subjective and objective examination of the teeth 11 are pulp necrosis caused by trauma. Treatment in this case is non vital root canal treatment and followed by bleaching treatment . on the first visiting made opening access, working length determination using apex locater confirmed by radiographic, Initial Apical Filing with ISO file on the teeth 11 # 25/23,5mm, following root canal treatment by step back method, irrigated with 2,5% NaOCl, dried with paper points, medication with calcium hydroxide, sealed with temporary filling. On the second visit, fitting the Master Apical Cone (MAC), obturation was done with sealer AH 26 by lateral condensation method. Following treatment is intra coronal bleaching with walking bleach method.
Case report II
Disscusion
A twenty four year old man came to the clinic of Conservative dentistry faculty of Dentistry University of Sumatra Utara want to have whitening tooth of discolored the upper right front tooth. Patien said that he fell 10 years ago and touched his front teeth. On clinical examination : scratching test with explorer showed cold tes not sensitive, percussion and palpation showed negative response, no presence of mobility. Tooth intact , there is no fracture, but discoloration of teeth 11(figure 3). At the radiographic examination discontinued of lamin dura and no periapical lesion (figure 4).
Case I: The trauma that causes periapical lesions without discoloration Dental injury can be classified based on the situation of the teeth and supporting tissues involved. In the first case is classified as enamel fractures (Uncomplicated crown fracture) is a fracture that involves only the enamel (Figure 1). Periapical lesions caused by exogenous factors is trauma8. Severe trauma to the periapical tissues can cause damage to the protective layer of cementum on the root surface so that the open dentinal tubules and pave the way for the entry of bacterial toxins into root canal 4, 8. Bacterial toxins and metabolic products can activate the immune system through receptors that can lead to inflammatory reactions 3,4 . When inflammation occurs many immune cells release inflammatory mediators such as 116
sitokine, kemokine and neuropeptides. Clinically seen a widening of the periodontal ligament space and apical lesions develop due to bone resorption caused by osteoclasts active. Many sitokine such as interleukin (IL) -1, IL-11, IL-17 and tumor necrosis factor α (TNF-α) was found that has the ability to induce osteoclast differentiation and activation. Bone resorption due to periapical inflammation occurs caused by immune cell response as a defense system against bacterial invasion 8. Pulpal responses to traumatic injuries are affected by the severity of injury to the neurovascular supply which for the most part enter through the apical foramen 4. The presence of bacteria is also a significant factor in the outcome2,3,4. There are three possibilities outcomes that occur after trauma : healing the pulp, pulp necrosis and pulp obliteration. Three circumstances may occur at the different time 4. If there is a neurovascular dirupture that results in reduced blood supply, the function of the pulp is reduced and the bacteria which play an important role. If a luxated developing tooth also suffers a crown fracture (with or without pulpal exposure) bacteria can gain entrance to the pulp and the reduction or the absence of blood supply will allows bacteria to colonizes are hindered. In these situaton pulp necrosis will result8. Pulp necrosis in traumatized teeth are at risk for the formation of inflammatory (root resorption) 4.8. The third type of the pulp response to trauma is the obliteration of the root canal. This is frequently observed in the case of teeth luxation. In case of pulp necrosis after obliteration of the root canal, the diagnosis is made based on symptoms and the presence of osteitis periradikular4. Type of injury resulting in resorption is due to an infection in the root canal and was described as an infection due to root resorption (inflammatory) 6. Subluxation and avulsion likely to cause a reduction or termination of the blood supply to the pulp followed by bacterial invasion of the pulp can be an early occurrence of root resorption (external or internal). Failure to eliminate bacteria from the root canal can produce the kind of rapid resorption of inflammatory root resorption that occurs in rapid time 4,6,8.
In the first case the possibility of severe trauma to the tooth and supporting tissue resulting in interruption of blood supply to the pulp and periodontal ligament. This can lead to bacteria entering through an accessory canal and dentinal tubules were open into the root canal resulting in pulp necrosis causing odontogenic infections causing periapical lesions (chronic apical periodontitis). Case II. Trauma caused teeth discoloration In the second case, discoloration due to trauma were classified as intrinsic discoloration due to staining occurred within the dentinal tubules 9. The presence of trauma to the tooth causing direct damage to the blood vessels resulting in bleeding (haemorhagie) resulting in inflammation and damage to the pulp5,7,9. In 11 teeth look gray caused of bleeding due to trauma. Pulpal haemorrhage may be temporary if the pulp survive the traumatic incident but also continue in which case extravasated blood is present in the crown of affected tooth 7,9. Eritrosit of haemorrhage in the pulp will be hemolysis and releasing hemoglobin. This liberated hemoglobin will be degraded into hemosiderin and hemotoidin which upon entering the dentinal tubules will show a darker color on the crown. If the pulp does not undergo necrosis following haemorhage, the crown will return to its former color with in three to four weeks 5,7. Stanley et al (1978) describe severed apical blood supply in trauma is whereby the occlusion of the apical blood vessel leads to ischemi and damage to the capillary wall, thus causing haemorrhage into dental tissues. Usually this occurs when trauma causes particularly intrusive luxations. Andreasen (1981) who found that the development of pulpal necrosis after injury, particularly luxation injuries, was significantly related to the diameter of apical foramen. For extruded and laterally luxated teeth, a greater probability of pulpal necrosis occurred with apical foramine of a smaller diameter 4,8. Pulp degeneration in the absence of bleeding leading to degradation of proteins that cause brown discoloration 5, 8. Slow color changes may occur if the pulp undergo obliteration and color becomes more yellow crown. The color gray -
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gray indicate Transient Apical Breakdown (TAB). TAB happened the first year and usually followed by resorption surfaces and or pulp canal obliteration 5. The process produces variety of colors after the trauma. Pink crown indicates the presence of blood in the crown. Prolonged discoloration indicates pulp necrosis and tooth turns brown, blue or black. Feinman et al (1987) suggest this occurs because of the release of hemoglobin degradation products of iron (iron) which reacts with hydrogen sulfide to form a black compound is iron sulfide5. Pulpal response to trauma vary depending on the severity. Discoloration and periapical lesions was also observed in the case of sub subluxation, and the subluxation extrusive lingual. The color change to pink in five days after injury, greyish discoloration within six days to three weeks, For those teeth changing from normal to a greyish color the diagnosis is made after three weeks to three month 5. Consequently it is clear that the severity of the injury suffered by the blood vessels that supply the pulp affects the severity of necrosis and discoloration crown5, 9 . In this second case, the possibility of trauma to the teeth causing bleeding in the pulp. Eitrosit of bleeding in the pulp will experience hemolysis and release hemoglobin. The released of Hemoglobin will be degraded into hemosiderin and hemotoidin that when entering the dentinal tubules will show a darker color5. Treatment In both cases the treatment will be done by non vital root canal treatment due to necrosis teeth. The main purpose of root canal treatment is performed should be able to restore the condition of the tooth involved will be healthy and have function 4. All cases of inflammatory periapical root canal treatment should be done by conventional root canal treatment 1, 2.3. After root canal preparation, using of calcium hydroxide medicament at regular intervals and replaced every month until seen the progress of the lesion 1, 2 . Ca (OH) 2 (Calcium Hidrokside) is an ingredient medicaments recommended in cases of periapical lesions because of its low toxicity,
are bactericidal and biocompatible so as to accelerate the healing of periapical lesions. Suggested the use of calcium hydroxide in direct contact with tissue or apex 2,3,13. Beside of root canal preparation and the proper administration of medicaments, use of irrigation is also very important in determining the success of root canal treatment14. Irrigation that already done during treatment endodontically as debridement to dissolve debris and as an antimicrobial can help heal periapical lesions. Irrigation solution used was a solution of NaOCl Irrigation is still the best solution (the gold standard) because it is a broad-spectrum antimicrobial that can dissolve pulp tissue remnants and debris that is effective against bacteria, spores, fungi and virus 2,14. Tooth discoloration treatment is very important because it involves aesthetic and psychosocial patient, bleaching is a conservative technique to restore color 10,11. Non-vital tooth bleaching in the second case can be done by intra coronal bleaching. There are three techniques that are used in teeth bleaching non-vital : thermocatalytic, walking bleach and a combination of both. Thermocatalytic technique using 30-35% hydrogen peroxide were placed in the pulp chamber and activated by heating10. Walking bleach technique introduced by Spasser using sodium perborate and water paste which is placed in the pulp chamber until the next visit. Modifications walking bleach by Nutting and Poe, 1963, using a 30% - 35% hydrogen peroxide to enhance the bleaching effect, and the latest method using 10% carbamide peroxide 12. Recent study states that 35% carbamide peroxide is as effective as 35% hydrogen peroksida11. Conclusion Traumatic injury frequently occurs and often involved of the anterior teeth. Pulp necrosis is a condition that often occurs as a result of trauma and if there is a microbial infection eventually formed periapical lesions. Discoloration is often caused by trauma to the tooth and usually also become necrotic. The purpose of treatment of dental trauma injury is to restore the function and appearance of the teeth.
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Non-vital root canal treatment carried out in both cases because the tooth is necrotic, and intracoronal bleaching was performed. Conservative treatment in the trauma cases will result in long term success.
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Kandari AM, Quoud OA, Gnanasekhar JD. Healing of large periapical lesions following nonsurgical endodontic therapy : Case reports, Quintessence Int.1994; 25(2): 11519. Kalaskar R, MDS,Damle SG,MDS, Tiku A, MDS. Non surgical treatment of periapical lesions using intracanal calcium hydroxide medicament- A report of 2 cases. Quintessence Int. 2007; 38: 439.e 279-84. Dwijendra K.S., Deoyani Doifode, Devendra Nagpal, Nupur Ninawe. Nonsurgical treatment of periapical lesion using calcium hydroxide–A Case report, IJCDS. 2010; 85-8. Bakland LK, Andreasen JO. Dental traumatology : essential diagnosis and treatment planning. Endodontic topics 2004; (7):14–34. McCarthy JB. The Aetiology and Treatment of Intrinsically Discoloured Permanent Anterior Teeth.1989; 97–108. Trope M. Root Resorption Due to Dental Trauma. Endodontic topics 2002;(1):79–100
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Roy R, Chandler NP. Tooth Discoloration Following Dental Trauma, ENDO 2007; 1(3): 181-7. Cohen S, Hargreaves KM. Pathways of The Pulp. 10 th ed, Mosby Elsevier, Missouri. 2011; 530–32. Watts A, Addy M. Tooth Discolouration and Staining : a Review of The Literature. British Dent J 2001; 190(6): 309-16. Hara AT,DDS, Pimento LA, DDs,MS,ScD. Non Vital tooth bleaching : A 2 case report. Quintessence Int,1999; 30(11): 748-54. M.Y.Lim et al. An in Vitro Comparison of The Bleaching Efficacy of 35% Carbamid Peroxide With Established Intracoronal Bleaching Agents. Int Endod J: 2004;37:483-88. Teixeira et al. Use of 37% Carbamide Peroxide in The Walking Bleach Technique:A Case report, Quintessence Int. 2004; 35(2): 97-02. Athanassiadis B, Abbott PV, Walsh LJ. The use of calsium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics. Australian Dental Journal supplement 2007; 52: (1 Suppl):S64-s82. Sarkar S, Bazmi BA, Ghosh S. Sodium Hypochlorite Solution Enhance Healing of Periapical Lesion by Nonsurgical Method. Indian J. Dent. 2012; 2: 529-31.
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Management Of Mandibular Insicors With External Inflammatory Resorption And 2nd Degree Of Mobility Due To Traumatic Occlusion Used As Overdenture Abutments: A Case Report Martha Hasianna Purba * Trimurni Abidin** * Resident of Spesialist Program of Conservative Dentistry ** Lecturer of Specialist of Conservative Dentistry Faculty of Dentistry, University of Sumatera Utara Jln. Alumni no. 2 Kampus USU Medan 20155
Abstract Nowadays, It is needed to maintain the remaining teeth as overdenture abutment. This is also to preserve the alveolar bone height for denture retention. This case report is aimed to report a case of a woman with age 48 years old referred by Prosthodontic clinic, Faculty of Dentistry, USU for the purpose of treatment for the remaining four lower anterior incisors (teeth # 41, 31, 32, 33 ) with 2 nd grade mobility and external inflammatory resorption which will be used as overdenture abutments. Proper correction of traumatised occlusion and complete debridement during the root canal treatment with thorough cleaning and shaping including the use of anti inflammatory medicament can promote healing of external resorption and 2nd grade mobility. This case report demonstrated treatment success of teeth with healed external resorption and improved mobility thus they can be used as overdenture abutments. Keywords: Traumatic occlusion, overdenture abument, mobility, external inflammatory resorption
INTRODUCTION Healthy periodontal structures including root, cementum, periodontal ligament and alveolar bone forms a functional unit or organ. Periodontal ligament specifically forms the interphase between teeth and alveolar bone. Periodontal ligament retains the structure, nerves and food load that supports the normal function of the oral cavity4. Occlusion plays an important aspect in mastication, swallowing and speech. Occlusion is defined as the contact between upper and lower dentition, which creates a pressure that is being transmitted to the periodontal tissues. This tissue which surrounds the tooth, will support and absorb the occlusion load gained by the tooth. However this tissue has a threshold whereby when the occlusion load is greater than normal, will lead to destruction of surrounding periodontal tissues. Abnormal occlusion contact induces periodontal disease and temporomandibular joint disorder. This abnormal occlusion contact is caused by inappropriate denture design, bad habits, overhanging restorations and abnormal alignment of teeth4,5. Overdenture is used in preventive prosthodontic which functions to
retain as many natural tooth as possible2. Telescope is a type of overdenture which consist of primary and secondary coping, whereby primary coping is cemented on the abutment tooth while the secondary coping is attached to the metal cast/prosthetics9. This article will discuss on the case report of endodontic treatment being done on the lower anterior tooth with second degree mobility which will be made as an abutment tooth for the overdenture (telescope), and involves the integration of three speciality fields which are: periodontics, endodontics and prosthodontics. Case Report A female patient, aged 48 years old was being referred to Conservative Clinic by Prosthodontic Clinic of USU Dentistry Faculty, in order to treat her four lower anterior residual teeth (41 31 32 and 33). Those teeth were in a second degree state of mobility and will be used as abutment for an overdenture ( telescope). Clinical examination showed the lower left canine had previously undergone access opening, but perforated at the buccal and lingual region/an Iatrogenic Procedure (Figure. 2). Clinical 120
examination showed : all four lower anterior teeth (33, 32, 31 and 41) experienced second degree state of mobility. Objective examination showed that lower left canine showed no response to pulp vitality test, while both the lower central incisors and lower left lateral incisor showed positive response towards the vital test. All the four tooth showed no sensitivity to percussion and palpation. Panoramic radiography showed external inflammatory resoprtion at the apical region of all four lower anterior teeth (Figure. 1), which was caused by severe number of tooth loss, inappropriate denture design and accumulation of dental plaque and calculus found on those four teeth.
the upcoming treatment (Figure. 3). File ISO #8 with working length of 22 mm is later used for the negotiation of root canal, and Initial Apical File was obtained with ISO#25 with working length of 22mm (Figure. 4).
A
B
Figure 3. A. Built-up at perforated lingual region of lower left canine B. Buccal region
TMJ
Figure 1. Panoramic view before treatment Figure 4. Initial Apical File
A
B
C
Figure 2. A. Intra Oral periapical radiography, B. Lingual Perforation, C. Labial Perforation.
Non vital root canal treatment was done on lower left canine, while the rest of the lower mandibular teeth had undergone intentional endodontic treatment which means healthy tooth being treated endodontically to fulfil the criteria for denture making. First visit was referred to Periodontics for scaling, curettage and splinting using ligature wire for all the four teeth with second degree of mobility. An artificial wall was made using RMGIC ( Medicept Dental, UK ) at the perforated buccal and lingual region of the lower left canine tooth to prevent contamination of saliva and ease
Root canal preparation was done by Step back technique using the Hed Strom File with greater size and irrigation with NaOCL 2,5% and EDTA 17 % . Odontopaste (ADM) was used as root canal dressing for 2 weeks and was closed with temporary restoration. At the second visit, clinical examination has shown no reduction in mobility and once again was given odontopaste(ADM) medicament. At the third visit, clinical examination has shown reduction in mobilty to first degree. After the determination of the Master Apical Cone (MAC) # 45/22mm (Figure. 5) obturation was done using the lateral and vertical condensation technique with a sealer based resin (AH 26, Dentsply).
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Figure. 6 Root canal obturation . Figure 5. Master Apical Cone
Intentional endodontic treatment was done for both the lower central and left lateral incisors whereby healthy vital tooth was treated endodontically for the denture making. During the first visit, before access opening was done using the access bur ( Edenta, Swedia ), all three teeth were given articaine 4% anesthesia (Deltazine), and an apex locater is used to determine the working length, which is confirmed by radiographic. Lower right central incisor with working length of 16 mm, lower left central incisor with working length of 17 mm, and lower left lateral incisor with working length of 18 mm, and then continued with Initial Apical File (IAF) determination as follows: lower right central incisor with (IAF) ISO # 20/16mm, lower left central incisor with (IAF) ISO # 20/17mm, and lower left lateral incisor with (IAF) ISO 20/18mm (Figure. 4). After IAF was determined, Odontopaste ( ADM) was given as root canal medicament, and was left in root canal for duration of 2 weeks. During the second visit, clinical examination showed no reduction in mobility in all three teeth, therefore was once again was given odontopaste(ADM) medicament. At the third visit, the clinical examination showed reduction in mobility of second degree to first degree. After obtaining the Master Apical Cone determination was done as following: lower right central incisor with (MAC) # 30/16mm, lower left central incisor with (MAC) # 35/17mm, lower left lateral incisor with (MAC) # 40/18mm (Figure. 5) and later obturation was done using lateral and vertical condensation technique with a sealer based resin (AH 26, Dentsply), followed by sealing the pulp chamber with Glass Ionomer Cement ( GC , Japan ) (Figure. 6).
Discussion Root resorption may be caused due to some factors, either general or local. There is a change of balance between osteoblast and osteoclast on periodontal ligament where it forms additional cementum on the surface of root (hypercementosis) or lead to external resorption where loss of cementum and dentin takes place, termed as external resoprtion11. Greater tooth extraction process leads to change in alveolar bone dimension.Tooth extraction is one of the most common general procedure7. Inflammation process may be caused by infection, destruction of ligament periodontal tissue, post trauma hyperplastic gingivitis. Tooth trauma appears to be an important etiology factor for tooth resorption3. This case report involves the integration of Prosthodontics, Endodontics and Periodontics which is required for handling the overdenture leading to the retainment of all four lower anterior tooth for the need of overdenture retention. Tooth mobility may lead to destruction of function and healing process. Among several causes of tooth mobility are: loss of tooth supporting tissue (Bone Loss), traumatic occlusion and pathological process of jaw such as tumor5. Periodontal splinting is a technique used for immobilizing and stabilizing tooth mobility due to trauma, lesion or periodontal disease by combining two or more tooth to increase support. The purposes of splinting are: to stabilize mobility tooth and distribution of load, repair masticatory function and reduce discomfort. Type of splint used in this case is ligature wire, including the type of Bonded external splint. Due to cost issue, ligature wire splint was chosen which indeed causes greater resorption. Advantages using the ligature wire splint are as
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follows: cost effective, easy to manufacture and repair, effective and long-lasting, while the disadvantages are: ease of dental plaque accumulation, a higher risk of caries, and may increase the occurrence of resorption if usage is too long.12 Due to well done endodontic treatment in terms of maximal cleaning and shaping, therefore occurrence of resorption can be reduced and stimulate bone growth whereby mobility of all the four lower anterior tooth before treatment which was in second degree of mobility state, and 3 months after obturation, first degree state of mobility was achieved for both lower central incisors while lower left lateral incisor and canine showed no mobility. The patient was then referred to Periodontal clinic on the 10th September 2013, before endodontic treatment was done and to ease the treatment procedure, in this case the splint was worn only for 2 weeks. Endodontic treatment with manual approach, using Hed strom file was done using the Step-back technique. Irrigation was done using NaOCl 2.5 % and EDTA 17% which aimed to remove or dissolve debris which cannot be removed by file. Odontopaste was the medicament used and is composed of clindamycin antibiotic 5 % dan triamcinolone acetonide anti-inflammatory 1 %. Clindamycin does not give tooth discolouration, while triamcinolone acetonide can bond to inflammatory protein. Hence, maximal cleaning and shaping done throughout root canal treatment with the correct irrigation material selection and medicament which in this case the content of odontopaste containing triamcinolone acetonide and clindamycin, which can stop the process of inflammatory resoprtion and trigger the repair of dental hard tissue and selection of materials used in obturation will also affect the success of endodontic treatment done8. After 3 months of endodontic treatment, both lower central incisors which previously had second degree mobility and later achieved first degree state of mobility while lower left lateral incisor and canine which previously had second degree mobility, later showed no mobility and this indicates all the four tooth can be made as abutment for the telescope
overdenture. Clinical view after fixation of telescope overdenture ( Figure. 7).
Figure. 7. After overdenture fixation.
Overdenture is used in preventive prosthodontics to retain the residual natural tooth, overdenture is defined as removable prosthetics which compromise and focused on one or more residual natural tooth, natural tooth root, and /or on tooth implant. Overdenture provides better function compared to conventional dentures in terms of biting force, chewing efficiency and phonetics 2,9. Conclusion Integrated treatment in the case presented is required to achieve success and in accordance with the needs of the patient. Endodontic treatment was done to retain the four lower anterior tooth whereby before treatment which was in second degree of mobility, and 3 months after obturation, lower left canine and lower left lateral incisor showed no mobility and both lower central incisors achieved first degree of mobility . Integration of periodontics was needed at initial stage of treatment in order to support the treatment and accelerate the healing process. Cleaning and shaping is an essential procedure in endodontic treatment which should be done at maximum phase. Selection of root canal medicament and irrigation material influences the success of an endodontic treatment. References 1.
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Endodontics. Australian Dental Journal Supplement 2007; 52:(1 Suppl):S64-S82 Shah SD, Vaishnav K, Harish P. Matani PH , Pankaj Pate P. Overdenture: conventional to contemporary: a review. Journal of Research and advancement in Dentistry vol.2, no.1,nov-feb 2013. Dr. Peeran WS, Thiruneervannan M, Abdalla AK, Mugrabi HM. Endo- Perio Lesions. International Journal Of Scientific & Technology Research Volume 2, Issue 5, May 2013. Gopal S, Kumar PK, Shetty PK, Jindal V, Saritha M. Interrelationship of EndodonticPeriodontal Lesions- An Overview. Indian Journal of Dental Sciences, June 2011 Issue:2, Vol.: 3. Branschofsky M, Beikler T, Schafer R, Flemmig FT, Lang H. Secondary Trauma From Occlusion and Periodontitis. Quintessence International Volume.42. Number 6. June 2011. Boever DJ, Boever DA. Occlusion and periodontal Health In : Occlusion and clinical practice : An evidence-based
approach. Klineberg I, Jagger R (eds) , Elsevier. China. 2004: 83-9. 7. Van der Weijden F, Dell‟Acqua F, Slot DE. Alveolar bone dimensional changes of postextraction sockets in humans :a systematic review. J Clin Periodontol 2009; 36: 1048– 1058. 8. Ørstavik D. Materials used for root canal obturation: technical, biological and clinical testing. Endodontic Topics 2005, 12, 25–38. 9. Shah M. Telescopic Denture : A Case Report. Journal of Dental Sciences & Oral Rehabilitation 2013, 47 – 50. 10. Gaikwad B, Banga KS, Thakore AJ. Effect of Calcium Hydroxide as an Intracanal Dressing on Apical Seal – An in Vitro study. Endodontology, Vol. 12, 2000. 11. Heithersay GS. Management of tooth resorption. Australian Dental Journal Supplement 2007;52:(1 Suppl):S105-S121. 12. Puri SM, Grover SH, Gupta A, Puri N, Luthra S. Splinting- A Healing Touch for an Ailing Periodontium. J Oral Health Dent 2012;6(3)145-148.
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Root Canal Treatment with Limitation of Radiographic Procedure: Two Case Reports Widi Prasetia, Trimurni Abidin Department of Conservative Dentistry Faculty of dentistry University of Sumatera Utara Jl. Alumni No. 2 kampus USU Medan
Root canal treatments need proper device to support the outcome such as periapical radiography. In certain condition, sometimes a radiograph cannot be done. However, the treatment has to execute. This paper reports some root canal treatments that had been done without series of routine peripical radiograph due to confirm the working length and master cone. The outcome of root canal treatment after obturation procedure was evaluated by an apical radiograph. Instruments and supporting device can play important role in root canal treatment; nevertheless operator‟s knowledge and experience concerning basic principles of root canal treatment have major influence in the outcome of root canal treatment. Keywords: Root canal treatment, periapical radiograph, treatment outcome. Contact id; Widi Prasetia, drg; Hp: 0821 6211 5550; Email:
[email protected] Introduction The rationale for endodontics states that any endodontically involved tooth can be saved if the root canal system can be sealed nonsurgically or surgically, in condition where the periodontal condition is healthy or can be made healthy, and the tooth is restorable. Endodontic treatment may have a 100% “capacity” for healing and success, in reality, the success rate is 100–X, where X represents the clinician‟s endodontic knowledge and skill as well as their “willingness” to stay focused on the desired outcome while there may be pressures to do otherwise.1-3 Knowledge and skill will work if supported by proper means and equipment where radiograph is one of the most important mean in root canal treatments either in diagnostic phase or in the treatment procedure. Providing an x-ray dental unit in a private practice has a lot of consideration where safety is the main concern. According the safety regulation of utilizing x-ray device for diagnostic and interventional radiology issued by the Indonesian Nuclear Energy Control Board, there are a lot of pre-requirements and conditions that have to be fulfilled by any institution to provide x-ray dental unit. These requirements include
license, radiation safety, trained radiation personnel etc. The x-ray dental unit is also has to be certified by a certain standard.5 These issues caused providing radiography become difficult and expensive. On the other hand, demands for endodontic treatment are increasing from time to time along with the need of dental radiography. Clinicians have to refer to another institution to get a radiograph for the patients which in case of diagnostic and post treatment are possible. But in other case such as working length determination with radiograph technique is unable to be done. During root canal treatment, periapical radiographs are used to determine canal working lengths, biomechanical instrumentation; and master cone adaptation. After completion of the root canal procedure, a radiograph should be exposed to determine the quality of the root canal filling or obturation. Follow-up radiographs exposed at similar angulations enhance assessment of the success or failure of treatment.5 The report in this paper presented two cases of root canal treatment that were done by skipping some x-ray procedures and have considerably good treatment outcome.
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Case report 1 A 38 year old female, with non contributory medical history came to a private clinic to treat her lower right posterior tooth. Clinical examination showed that tooth 46 was unresponsive to cold test and slightly responsive to percussion and palpation. The tooth was diagnosed as chronic apical periodontitis under a leakage composite restoration. A radiograph was taken before the treatments begin to assist diagnostic procedure at a referral clinical laboratory. Radiographic image on tooth 46 showed large periapical lesion. Treatment on tooth 46 begun with coronal access preparation with high speed-endo access diamond bur. Canal patency established with a stainless steel K-file #10 and working length determination done with Electronic apex locator (Raypex 5, VDW, Germany). Cleaning and shaping done with hand file (Protaper, Dentsply Maillefer, Switzerland) to size F2 with copious irrigation 2,5 % of NaOCl. Root canal irrigation was done by positive pressure technique with a double site vented needle size 0,3 x 25. After final rinse with saline solution, the root canal was dried with paper point #25.06 (Spident, Korea). The first visit was completed with the application of Ca(OH)2 (Diapaste, Diadent, Korea) as root canal medicament and the coronal access was sealed with temporary filling (Tempotec, PD, Switzerland). Second visit was completed 2 weeks after the first visit. Tooth 46 was asymptomatic and the treatment continued to fill the root canal. The root canal was filled with root canal sealer (MTA Fillapex, Angelus, Brazil) and Gutta percha (Spident, Korea) with lateral compaction technique. The orifice sealed with GIC (Ketac Molar, 3M ESPE, Germany) and the cavity was filled with posterior composite resin (Tetric N Ceram Bulk fill, Ivoclar vivadet, Liechtenstein). The treatment was completed by establishing a Porcelain fused metal crown for the tooth. The patient asked to make a periapical radiograph for tooth 46 but she didn‟t do it. Five months after the treatment the patient came with another complain at the right region of the mandible which later diagnosed as pericoronitis at 48. The patient asked again to make a periapical radiograph for the tooth. After the
radiograph taken, the 48 was extracted. At the final peripaical radiograph was seen that the root canal treatment for 46 is successful, the periapical lesion was resolved and the tooth was in asymptomatic condition and according to the patient the tooth was function very well.
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Figure 1. A. Tooth 46 before treatment. B. Tooth 46, five months after treatment. Radiograph was taken when patient complain about tooth 48
Case repot 2 A 34 year old male with non contributory medical history came to a private clinic with chief complain of painful tooth at the lower left mandible. The patient treated the tooth at another dentist 3 days before the visit with the same complain. The dentist only cleaned the cavity, sealed the cavity with temporary filling and prescribed antibiotic and analgesic. After removal of temporary filling, clinical examination showed deep caries with pulp exposure on tooth 36. The tooth diagnosed as symptomatic irreversible pulpitis and submitted for vital root canal treatment. The main goal for the first visit was to relief pain. The treatment was explained to the patient step by step and the patient agree to proceed the treatment. The treatment begun with injection of 4 % articaine (ARTICAINE 100, DFL, Brazil) for the inferior nerve combined with intra-semental injection at mesial and distal site of tooth 36. After the pain relieved, the treatment continued with coronal access preparation with high speedendo access diamond bur. Canal patency was reached with a stainless steel K-file #10 and working length established with Electronic apex locator (Raypex 5, VDW, Germany). Cleaning and shaping was done with rotary instrument (Mtwo, VDW, Germany) to size #25.06 with copious irrigation 2,5 % of NaOCl. Root canal irrigation was done by positive pressure technique with a double site vented needle size
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0,3 x 25. After final rinse with saline solution, the root canal was dried with paper point #25.06 (Spident, Korea). The first visit was completed with the application of corticosteroid based medicament (chresophen) and sealed with temporary restoration (Tempotec, PD, Switzerland). The patient was referred to make a periapical radiograph to a private clinical laboratory and asked to bring the radiograph at the next visit scheduled 5 days after the first visit. At the second visit, tooth 46 was asymptomatic and the treatment continued to fill the root canal. The root canal was filled with root canal sealer (MTA Fillapex, Angelus, Brazil) and Gutta percha (Spident, Korea) with lateral compaction technique. The orifice sealed with GIC (Ketac Molar, 3M ESPE, Germany) and the cavity was filled with posterior composite resin. The patient asked to make another periapical radiograph to evaluate the root canal filling and recommended to make porcelain onlay for final restoration. The patient came 2 months after the treatment and brought the periapical radiograph that he took just before the visit and asked for the final restoration. The tooth was in asymptomatic condition and function very well. The preparation for porcelain onlay was made immediately, impression was taken and send to a dental lab. A week later the onlay was finished and cemented to the tooth.
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Figure 2. A. Tooth 36 after the first visit treatment. B. Tooth 36, two months after root canal filling.
Discussion Essentially, endodontic treatment is concerned with the removal of diseased or infected pulp tissue, instrumentation and medication of the root canal system and, finally, the placement of a root filling. Although endodontic treatment is usually successful, some cases will fail and it is the responsibility of the individual clinician to minimize this number. Therefore, knowledge of
the various factors that will influence treatment outcome is very importance.5 Radiographs are essential to all phases of endodontic therapy. They contribute information important for the diagnosis and the various treatment phases and help evaluate the success or failure of treatment. In diagnosis this film is used to identify abnormal conditions in the pulp and periradicular tissues. It is also used to determine the number of roots and canals, location of canals, and root curvatures.5,6 There for, periapical radiograph for diagnosis in endodontic is mandatory. Providing an x-ray dental unit has to follow a complex regulations. These regulations mean to protect every person and environment from the radiation effects. Indonesian Nuclear Energy Control Board as the regulator of utilizing nuclear power issued some very strict rule about x-ray device icluding dental x-ray unit. The regulations straighten up criterias of medical facilities providing radiographic services. These rules include license, radiation safety and radiation personnel. These issues caused providing radiography become difficult and expensive. On the other hand, demands for endodontic treatment are increasing from time to time along with the need of dental radiography. Clinicians have to refer to another institution to get a radiograph for the patients which in case of diagnostic and post treatment are possible. There are various methods in working length determination. Radiographs, tactile sensation, the presence of bleeding on paper points, and knowledge of root morphology have been used to determine the length of root canal systems. Recently some clinicians have advocated the use of the electronically determined working length in lieu of working length estimations using the placement of a file in the canal and a radiograph. However, combined use of both of these techniques has been shown to result in greater accuracy. Recently, the use of electronic devices became popular and numerous devices have been introduced to the market. The advantages of electronic apex locators (EALs) include reduction in radiation dosage and procedure time, both of which aid in maintaining patient cooperation. The EALs are used to locate the minor constriction. Studies have proven that apex
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locators were similar to the radiographic WL determination technique.7-12 Together with diagnosis and treatment planning, the knowledge of common root canal morphology and its frequent variations is a basic requirement for endodontic success.10 The operator must develop a mental, threedimensional image of the tooth from the pulp horn to apical foramen. Unfortunately, radiograph only provide a two dimensional image of pulp anatomy. Understanding inseparable relationship between root canal treatment and pulp anatomy is a basic key to the success of the treatment.8
5.
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7.
Conclusion 8. Tools, equipment and material sometime have impact to the outcome of root canal treatment, on the other hand, skills, knowledge and experience have more significant influence in the success of the treatment.
9.
References 1. Bellamy R. Endodontic success: 100%X. Irish Dentistry July/Agustus 2012 2. Mantri shiv P., success rate of root canal treatment. Annals and'Essences of Dentistry. 2010; Vol II: 114-6 3. Ng YL. Mann V. Gulabivala K. Tooth survival following non-surgical root canal treatment: a systematic review of the literature. Int. Endod J, 201043, 171– 189 4. Peraturan kepala badan pengawas tenaga nuklir nomor 8 tahun 2011 keselamatan
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radiasi dalam penggunaan pesawat sinarx radiologi diagnostik dan intervensional Glickman GN. Vogt MW., Preparation for Treatment in Cohen‟s Pathways of the pulp. Ed; Hargreaves KM, Cohen S, 10th ed. Mosby Elsevier; 2011; 99 Reit C., Endodontic decision making; in Text book of Endodontologi Ed.; Bergenholtz G. Horsted-Bindslev P. Reit C., 2nd ed. Wiley-Blackwell; 2010; 20110 Metzger Z. Basrani B, Goodis H. Instruments, materials and device; in Cohen‟s Pathways of the pulp. Ed; Hargreaves KM, Cohen S, 10th ed. Mosby Elsevier; 2011;243 Ingle JI. et al. Endodontic Cavity Preparation; in Endodontics. Ed. Ingle JI. Bakland LK. 5th ed. B.C. Decker Elsevier; 2002; 510-24 Koçak S., Koçak MM., Sağlam BC., Efficiency of 2 electronic apex locators on working length determination: A clinical study. J. Conserv Dent. 2013. 16: 229-3 Miletic V., Beljic-Ivanovic K. Ivanovic V., Clinical reproducibility of three electronic apex locators. Intl Endod J., 2011;44,; 769–76, Vertucci FJ. haddix JE., Tooth Morphology and Access Cavity Preparation in Cohen‟s Pathways of the pulp. Ed; Hargreaves KM, Cohen S, 10th ed. Mosby Elsevier; 2011; 139 Ingle JI. et al. Preparation for endodontic treatment; in Endodontics. Ed. Ingle JI. Bakland LK. 5th ed. B.C. Decker Elsevier; 2002; 358, 385.
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Endodontic treatment on mandibular first molar with radix entomolaris: a case report Kurniawan1, Endang Suprastiwi2 1 Postgraduate Student of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta 2 Lecturer at Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta
ABSTRACT Introduction: Mandibular molars can have an additional root located distolingually (the radix entomolaris) or mesiobuccally (the radix paramolaris). An awareness and understanding of this unusual root and its root canal morphology can contribute to the successful outcome of endodontic treatment. Aim: To report a case of endodontic treatment on mandibular first molar with radix entomolaris. Case: A 39-year-old female patient with a complaint of pain on chewing in the lower left back tooth region, sensitive on percussion test. An additional third root located distolingually (the radix entomolaris) was confirmed clinically and radiographically. Root canals were prepared using ProTaper Next and obturated using downpack-backfill technique with Elements. Conclusion: Successful of treatment on mandibular first molar with radix entomolaris using ProTaper Next and downpack-backfill obturation technique showed a good result for this case. Key Words: Endodontic treatment, mandibular molar, radix entomolaris.
INTRODUCTION The prevention and healing of endodontic pathology depends on a thorough cleaning and shaping of the root canal system, hermetic root canal obturation, and adequate coronal restoration.1-7 An awareness and understanding of the presence of unusual root canal morphology can contribute to the successful outcome of endodontic treatment.1-9 Mandibular first molar can have several variations of root anatomy.1, 3, 4, 6, 8, 10 The majority of mandibular first molars are tworooted with two mesial and one distal canal.1-8, 10 According to Vertucci et al. (2006), in 90% cases the mesial root has two root canals that ending in two distinct apical foramina, but sometimes these merge together at the root tip to end in one foramen.2 The distal root typically has one kidney-shaped root canal, although if the orifice is particularly narrow and round, a second distal canal may be present.1, 4, 7, 8 Moreover, the presence of three mesial canals and three distal canals has also been reported in the mandibular first molar.1, 2, 4 Like the number of root canals, the number of roots may also vary.1, 3, 4, 6-8, 10 An additional third root, first mentioned in the
literature by Carabelli in 1844; is called the radix entomolaris by Bolk (1915). This supernumerary root is located distolingually in mandibular molars, mainly first molars.1-11 An additional root at the mesiobuccal side is called the radix paramolaris.1-3, 6, 7, 10, 11 The clinical approach to diagnosis and endodontic treatment on mandibular first molar with radix entomolaris will be discussed and illustrated in this case report. CASE A 39-year-old female patient was referred for endodontic treatment of the mandibular left first molar, with a chief complaint of pain on chewing in the lower left back tooth region. In clinical examination, the pulp chamber was opened (Fig. 1B, C) and the tooth was sensitive on percussion test. The radiographical examination showed curved canals and signs of apical periodontitis on mesial and distal roots. A further inspection of the preoperative radiograph can be seen two outlines of the distal root contour and an unclear view of the distal root canal (Fig. 1A); can indicate the presence of an additional third root.
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Figure 1 A, Preoperative radiograph; can be seen two outlines of the distal root contour (arrow). B, C, Preoperative clinical images.
CASE MANAGEMENT Upon opening the pulp chamber, the outline form was found more trapezoidal in shape than triangular, with two mesial and two distal canal orifices. The root canals were explored with a #10 K-file (Dentsply) and the working length of these canals were determined electronically using an apex locator (Raypex 6, VDW) and radiographically. The initial file for mesiobuccal root canal was #10/20 mm, mesiolingual root canal was #10/20.5 mm, distobuccal root canal was #10/18 mm, and distolingual root canal was #10/20 mm. From the unusual location of the orifice far to the distolingual (Fig. 2A) and working length determination radiograph (Fig. 2B), the presence of the radix entomolaris can be confirmed.
Figure 3 A, Clinical image after root canal preparation. B, Gutta percha cone fit radiograph (arrow: radix entomolaris).
During the cleaning and shaping procedure, root canals were irrigated with a combination of 2.5% sodium hypochlorite and 17% EDTA (MD-Cleanser, Meta Biomed). Root canals were dried and calcium hydroxide (Calcipex II, Nishika) as an intracanal medicament was inserted to the root canal space. In the second visit, the irrigation was done to remove the calcium hydroxide residues from root canals. Obturation with gutta percha and epoxy resin sealer (AH Plus, Dentsply) was completed using downpack-backfill technique with Elements (SybronEndo) (Fig. 4A, B).
Figure 4 A, Clinical image after root canal obturation. B, Radiograph after root canal obturation.
Figure 2 A, Occlusal view of the pulp chamber floor with the orifice of the radix entomolaris (arrow). B, Working length determination radiograph; can be seen a superimposition of two distal roots (arrow: radix entomolaris).
The tooth was prepared for the composite onlay in the third visit (Fig. 5A). Indirect composite onlay was performed in the dental laboratory and cemented using resin cement (Breeze, Pentron Clinical) (Fig. 5B, C).
An artificial wall has been made with composite resin (Filtek Z350 XT, 3M ESPE). Glide path was done using K-file (Dentsply) to size #15, root canals were prepared using ProTaper Next (Dentsply) to size X2 (Fig. 3A, B).
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Figure 5 A, Occlusal view of the onlay cavity. B, Clinical image after composite onlay cementation. C, Radiograph after composite onlay cementation.
Figure 6 A, Preoperative radiograph; with signs of apical periodontitis (arrow). B, Radiograph after root canal obturation. C, Radiograph after composite onlay cementation. D, Two months postoperative radiograph; showed no signs of apical periodontitis (arrow).
DISCUSSION In this case, an additional third root located distolingually in mandibular left first molar, is in accordance with that mentioned by Carabelli in 1844; it is called the radix entomolaris by Bolk (1915). A thorough inspection of the preoperative radiograph and interpretation of particular marks or characteristics, such as an unclear view or outline of the distal root contour or the root canal, can indicate the presence of a hidden radix entomolaris.1, 3, 4, 6, 7, 9-11 Such characteristics were seen in this case, from the preoperative radiograph can be seen two outlines of the distal root contour and an unclear view of the distal root canal. In the presence of radix entomolaris, an extension of the triangular opening cavity to the distolingual results in a more rectangular or trapezoidal outline form.1-7, 9, 11 Upon opening the pulp chamber, the outline form was found more trapezoidal in shape than triangular, with two mesial and two distal canal orifices. The separate radix entomolaris is mostly situated in the same bucco-lingual plane as the distobuccal root, so a superimposition of both roots can appear on the radiograph.1, 4, 7, 9, 11 On working length
determination radiograph, can be seen a superimposition of two distal roots. From the unusual location of the orifice far to the distolingual and working length determination radiograph, the presence of the radix entomolaris can be confirmed. The dimensions of the radix entomolaris can vary from a short conical extension to a mature root with normal length and root canal.1-4, 7-11 In this case, the radix entomolaris showed a mature root with normal length and root canal. A classification by Carlsen and Alexandersen (1990) describes four different types of radix entomolaris according to the location of the cervical part of the radix entomolaris: types A, B, C, and AC. Type A refers to a distally located cervical part of the radix entomolaris with two normal distal root components. Type B refers to a distally located cervical part of the radix entomolaris with one normal distal root component. Type C refers to a mesially located cervical part, while type AC refers to a central location, between the distal and mesial root components.1-4, 7-11 This classification allows for the identification of separate and nonseparate radix entomolaris.1, 3, 4, 7, 8, 10 According to the classification of DeMoor et al. (2004), based on the curvature of the separate radix entomolaris variants in buccolingual orientation, three types can be identified. Type I refers to a straight root/root canal, while type II refers to an initially curved entrance which continues as a straight root/root canal. Type III refers to an initial curve in the coronal third of the root canal and a second curve beginning in the middle and continuing to the apical third.1, 3-7, 9, 11 Gutta percha cone fit radiograph was taken from a more mesial angle using SLOB (same lingual, opposite buccal) rule. The radiograph showed the radix entomolaris was separated from the distobuccal root. According to Carlsen and Alexandersen (1990), radix entomolaris in this case was classified as type A; and type III according to DeMoor et al. (2004). Radix entomolaris, due to variations and complexities in its anatomy, can cause perforation or stripping, weakening of root, vertical root fracture, straightening of the root canal, ledge formation, loss of working length,
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root canal transportation, and instrument separation, particularly in the apical third of the root with a severe root inclination or canal curvature (as in a type III radix entomolaris).1, 6, 7, 9-11 Therefore, initial root canal exploration with small files (#10 or less) and the creation of a glide path before preparation should be taken to avoid procedural errors.1, 2, 6-9, 11 In this case, glide path was done using K-file to size #15. The use of flexible nickel-titanium rotary files with crown down technique allows a more centered preparation shape.1, 6-11 ProTaper Next with crown down technique were used in this case. In crown down technique, the coronal aspect of a root canal was prepared first before apical instrumentation commenced. Moreover, by first flaring the coronal two thirds of the canal, apical instruments are unimpeded through most of their length.12 ProTaper Next are made with proven M-Wire nickel-titanium alloy for increased flexibility and resistance to cyclic fatigue compared to traditional nickel-titanium rotary instruments. ProTaper Next also has an off-centered rectangular cross section design for greater strength, with unique asymmetric rotary motion that further enhances ProTaper canal shaping efficiency. In this case, 2.5% sodium hypochlorite and 17% EDTA were used to irrigate root canals. Sodium hypochlorite is an effective antimicrobial agent, but it can only remove the organic components of the smear layer. EDTA can remove the inorganic components of the smear layer, so a combination of sodium hypochlorite and EDTA must be used to remove the smear layer effectively.13, 14 To increase the rate of bacterial elimination in the root canal system and improve therapeutic efficacy, calcium hydroxide has been used as an antimicrobial intracanal dressing. It was a substance that inhibits microbial growth in canals. The antibacterial effect of calcium hydroxide was due to its alkaline pH from the hydroxyl ion. It was also dissolves necrotic tissue remnants and bacteria and their byproducts. Another therapeutic effect of calcium in calcium hydroxide was cellular stimulation and production, and mineralization.15 Obturation was done with downpackbackfill technique. Downpack-backfill technique
is a combined system of warm vertical compaction technique (downpack) to provide an apical seal and thermoplastic injection technique (backfill) in order to fill the coronal two thirds of the root canal. In order to seal the whole root canal system, it is indispensable that the obturation should be three dimensional and hermetic; particularly in the last few millimeters of the apical area.16 The epoxy resin sealer was used because its good adhesion and sealing ability.17 The final restoration for the tooth was cuspal coverage onlay that covers part or the entire external surface of a tooth to recreate form and also fit within the tooth. This restoration was a reliable method for preventing fracture and provides a restoration with cuspal coverage in order to protect the remaining tooth structure. CONCLUSION The radix entomolaris in this case was detected on the preoperative radiograph with the appearance of two outlines of the distal root contour. Conventional endodontic treatment on mandibular left first molar with radix entomolaris showed lack of any symptoms and normal radiographical presentation on two months follow up. REFERENCES 1. Calberson FLG, DeMoor RJG, Deroose CAJG. The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics. Journal of Endodontic 2007;33(1):58-63. 2. Ballullaya SV, Vemuri S, Kumar PR. Variable Permanent Mandibular First Molar: Review of Literature. Journal of Conservative Dentistry 2013;16(2):99-110. 3. Verma S, Aggarwal R, Aggarwal R, Aggarwal S, Bala S, Goel M. Locating the Hidden Treasures in Endodontics: Radix Entomolaris: An Overview and a Case Report. Indian Journal of Dental Sciences 2013;5(5):98-100. 4. Dhoot R, Zakirulla M, Tejaswi SKL, Nayak R, Choudhury GK, Manglekar SB. Radix Entomolaris: Clinical Approach in
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Endodontics. International Journal of Health Sciences and Research 2013;3(11):151-56. DeMoor RJG, Deroose CAJG, Calberson FLG. The Radix Entomolaris in Mandibular First Molars: An Endodontic Challenge. International Endodontic Journal 2004;37:789-99. Pawar AM, Kokate SR, Hedge VR. Contemporary Approach in Successful Endodontic Intervention in Radix Entomolaris. World Journal of Dentistry 2013;4(3):208-13. Gupta S, Raisingani D, Yadav R. The Radix Entomolaris and Paramolaris: A Case Report. Journal of International Oral Health 2011;3:37-42. Alrahabi M. Clinical Management of a Mandibular First Molar with Supernumerary Distal Root (Radix Entomolaris). Journal of Taibah University Medical Sciences 2014;9(1):81-84. Pai ARV, Jain R, Colaco AS. Detection and Endodontic Management of Radix Entomolaris: Report of Case Series. Saudi Endodontic Journal 2014;4(2):77-82. Irodi S, Farook AZ. Three Rooted Mandibular Molar: Radix Entomolaris and Paramolaris. International Journal of Dental Clinics 2011;3(1):102-04. Nagaveni NB, Umashankara KV. Radix Entomolaris and Paramolaris in Children: A
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Review of the Literature. Journal of Indian Society of Pedodontics and Preventive Dentistry 2012;30(2):94-102. Peters OA, Peters CI. Cleaning and Shaping of the Root Canal System. In: Hargreaves KM, Cohen S, Berman LH, editors. Pathways of the Pulp. 10 ed. St. Louis: Mosby Elsevier; 2011. p. 283-348. Kandaswamy D, Venkateshbabu N. Root Canal Irrigants. Journal of Conservative Dentistry 2010;13(4):256-64. Basrani B, Haapasalo M. Update on Endodontic Irrigating Solutions. Endodontic Topics 2012;27:74-102. Lin J. Intracanal Medicaments Revisited. New Zealand Endodontic Journal 2006;34:415. Robberecht L, Colard T, Claisse-Crinquette A. Qualitative Evaluation of Two Endodontic Obturation Techniques: Tapered Single-Cone Method Versus Warm Vertical Condensation and Injection System: An In Vitro Study. Journal of Oral Science 2012;54(1):99-104. Johnson WT, Kulild JC. Obturation of the Cleaned and Shaped Root Canal System. In: Hargreaves KM, Cohen S, Berman LH, editors. Pathways of the Pulp. 10 ed. St. Louis: Mosby Elsevier; 2011. p. 349-88.
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Management Of Vertical Crack On Mandibular Molar (Case Report) Hirania Soraya*, Nilakesuma Djauharie** * Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia ** Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
Background: Cracked tooth is an incomplete fracture, involving dentine and may reach the pulp. Found in patients older than 40 years old, especially on second and first mandibular molars and upper premolars mesiodistally. Cracked tooth is a clinical condition difficult to diagnose. Crack diagnosis requires proper diagnostic tools. Objective: To understand the etiology and classification of cracked tooth, to recognize the symptoms and proper diagnosis in order to provide appropriate treatment and preventive measures. Case Report: Female patient, 64 years old with mandibular second molar that had been painful for a month when used for mastication. No caries was present. Radiograph and Betadine staining did not show any cracks. The tooth was diagnosed with traumatic occlusion and had occlusal adjustment. The pain resolved but one month later the patient came back with pain. Vitality test was negative, percussion positive. The tooth was diagnosed with chronic apical abscess caused by pulp necrosis. The crack was detected during access preparation. It appeared as a thin line on the distal of the crown which reached the floor of the pulp. For tooth stabilization, the tooth was cemented with an orthodontic band during root canal treatment. Obturation was done with gutta percha and MTA based sealer. Conclusion: Cracked tooth may cause pulp necrosis. The earlier the diagnosis, the earlier the treatment, the better the prognosis. The most important is to stabilize the tooth and use MTA based sealer. Six months after final restoration, there were no subjective nor objective complaints. Keyword: Cracked tooth
INTRODUCTION Crack is an incomplete fracture of the tooth involving dentine and may reach the pulp. Prevalence of patients with crack is mostly found in patients older than 40 years old.1 Crack happens mostly in the mandibular second molar, followed by mandibular first molar and the least in maxillary premolars. Cracks usually go mesiodistally. According to Lynch and McConnel, cracked tooth are mostly found in teeth with no restoration, teeth with class 1 (site 1) restoration, teeth with extensive intracoronal restoration, teeth with inlay, and teeth that have undergone multiple occlusal adjustments.1 Crack diagnosis requires the proper diagnostic measure which is applying pressure on individual cusps with “bite test”. It is done by biting on a toothpick or cotton roll which will cause pain, and than relieved as soon as the pressure was gone.1,2 Moreover, vitality test usually gives positive response while percussion gives negative result axially. It is important to make sure that the pain did not come from the pulp, periodontium, nor periapex.1,3 These are found in patients who just experienced the crack.
During intraoral examination, dentists should use loupe, transilluminatuin, staining with dye or methylene blue. Staining must also cover the mesial and distal marginal ridge to make sure whether there are any crack lines. Other than that, if the crack has been going on for a few months, dentists may find periodontal defects in subgingival areas. Radiographic examinations are usually inconclusive due to crack lines usually go mesiodistally.3,4 CASE REPORT Female patient 64 years old of Batak decscent, her mandibular second molar has been painful for a month when used for mastication. During examination, no caries was present, crack was suspected. In radiographic examination and staining with Betadine, crack was not evident. The tooth was diagnosed with trauma from occlusion and treated with occlusal adjustment. The pain resolved, but after a month, the patient came back with pain and gingival swelling. Clinical examination found negative tooth vitality, percussion test was positive, palpation test was positive, and there was a swelling on the 134
cervical area of the buccal gingiva. The tooth was diagnosed as chronic apical abscess caused by pulp necrosis. Crack was still not seen. Crack was detected during access preparation. It appeared as a thin line at the distal part of the crown which reached the floor of the pulp. To avoid separation of the tooth, orthodontic band was cemented and root canal treatment was performed. CASE MANAGEMENT On the first visit, the patient complained pain on her left posterior teeth since 2 months ago and that her gum was swollen. In intraoral examination, vitality test on 37 was negative, percussion test postive, palpation test positive. Access preparation was done, crack line was found at the distal of the crown, vertically to the floor of the pulp. The crack did not cause tooth separation and the tooth was still intact. To avoid tooth separation, occlusal reduction was done and orthodontic band was cemented. Found only two root canals, mesial and distal which were very narrow, with initial file number 10. Exploration and preparation of the root canal needed lubrication by EDTA-gel (RC-Prep). Root canal preparation was done with hand use ProTaper untuk S2 file with the working file of distal rppt 21 mm, and mesial root 19 mm. Irrigation with 2,5% NaOCl every file change. Medication between visits was Ca(OH)2 (Calciplex) and the tooth was temporary filled (Cavit).
Figure 5. Working length determination
On the second visit, subjective complaint was nonexistent, percussion and palpation test negative, welling was smaller. Root canal preparation was continued with hand use ProTaper until F2 file in both of the canals. Master cone radiograph was taken. Tooth was medicated with Ca(OH)2 (Calciplex) and temporarily filled (Cavit).
Figure 6. Master cone radiograph
On the third visit, there was no subjective complaints, percussion and palpation test was negative, gingival swelling was gone. Obturation of the root canal was done with gutta percha ProTaper F2 using MTA based sealer (Fillapex). GIC basis was applied and the tooth was temporarily filled (Cavit).
Figure 1. Clinical appearance before treatment Figure 2. Diagnostic radiograph.
Figure 7. Obturation radiograph. Figure 3. Access preparation. Figure 4. Crack, orthodontic band
On the fourth visit, control on obturation did not find any complaints subjectively nor
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objectively. On the fifth visit, core was made with GIC and tooth was prepared for full metal crown, impression was made with elastomeric impression material (Exaflex) and temporary acrylic crown was cemented.
Figure 8. Impression with elastomeric impression material
On the sixth visit, full metal crown was cemented with luting GIC. Previously, gingival adaptation, proximal contact, occlusion, and articulation were examined. On the last visit, six months after crown cementation, no subjective nor objective complaints were found.
Figure 9. Crown try in radiograph. Figure 10. Crown cementation.
Figure 11. Crown cementation
DISCUSSION Two months after the first complaint, the patient returned with painful tooth and swelling gingiva. Diagnosed as chronic apical
abscess caused by pulp necrosis. Clinical examination showed tooth without caries, negative vitality test, positive percussion test, positive palpation test, and no pocket. During access preparation, crack line was found at the distal part of the crown, vertically to the floor of the pulp. Pulp necrosis pathogenesis in cracked tooth is caused by the entry of bacterias in the crack line that continue to enter the pulp, causing inflammation and finally necrosis. Pulpnecrosis is an irreversible condition which is marked by permanent pulpal defect. It may happen partially or fully.5,6 The etiology of crack in this patient is suspected as heavy occlusal force and bad habits such as clenching and bruxism. This can be seen in the paitent‟s teeth which showed atrition and facets all over the occlusal surfaces. 7 This case reviews the management of chronic apical abscess caused by necrosis pulp in cracked tooth. In determining the treatment plan of cracked tooth, there are a few things that must be considered before deciding wheter the tooth is still salvageable. Tooth with hopeless prognosis must be extracted, which are tooth with big central vertical crack on the pulpal floor, big central crack on a tooth with poor crown-root ratio, or tooth with big central crack that exceeds the alveolar bone level. If the cracked tooth is still treatable, with or without pulpal involvement, immediate tooth stabilization must be done by orthodontic band or acrylic crown. 1,8 In this patient, after the crack was detected, immediately an orthodontic band was cemented for tooth stabilization. Orthodontic band was placed to avoid tooth separation during root canal treatment before the final restoration. It was done considering the pumping pressure on cracked tooth during mastication that may cause tooth separation and entry of bacteria. Obturation was done with gutta percha and MTA (Mineral Trioxide Aggregate) based sealer. This sealer was chosen because of its ability to form a hydroxiapatite layer or carbonated apatite and create biologic seal on dentine that will reunite a cracked tooth.9 This hydroxiapatite layer has very good marginal adaptation. Moreover, the advantage of using
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MTA based sealer is that it is higly biocompatible, stimulates mineralization, has antimicrobial abilities,and able to help the regeneration of periodontal ligament. Its bioactive properties, induce the formation of hard tissue with differentiation and hard tissue producing cell migration. MTA as a sealer is also able to form calcium hyroxide and releases calcium ions for cell attachment and proliferation. 9 The final restoration is full metal crown. It was chosen because the patient‟s heavy occlusal load, therefore it is considered to be able to protect and unify all the tooth‟s surfaces and diminish the risk of further cracks later on. Morover, cracked tooth must be restored with minimal preparation.1 Tooth preparation for full metal crown restoration is more minimal than preparation for porcelain crown. Durin tooth preparation, attention should also be payed into rounding the edges to minimize the risk of new crack formation.1,10 The success of cracke tooth treatment is affected by early diagnosis and treatment plan, also proper restoration. Six months after the final restoration, no subjective nor objective complaints were found. Radiographic examination showed that the radiolucency on the periapex was gone.
6.
Ingle, Bakland. Endodontics 5th Ed. BS Decker Inc. London: 2002 7. Banerji S, Mehta SB, Millar BJ. Cracked Tooth Syndrome Part 1: Aetiology and Diagnosis. British Dental Journal Volume 208 No. 10. May 22 2010 8. Krell KV, Rivera EM. A Six Year Evaluation of Cracked Teeth Diagnosed with Reversible Pulpitis: Treatment and Prognosis. JOE — Volume 33, Number 12, December 2007 9. Holland in Rawtiya M, Verma K, Singh S, Munuga S, Khan S. MTA-Based Root Canal Sealers. J Orofac Res 2013;3(1):16-21 10. Banerji S, Mehta SB, Millar BJ. Cracked Tooth Syndrome Part 2: Restorative Options for the Management of Cracked Tooth Syndrome. British Dental Journal Volume 208 No. 11. June 17 2010
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Lynch CD, McConnell RJ. The Cracked Tooth Syndrome. J Can Dent Assoc 2002; 68(8):470-5 Cross I, Walker RT. Management of Acute Problem. In: Stock CJR, Gulabivala K, Walker RT, editors. Endodontic London: Elsevier Mosby; 2004. p. 253-54. Boushell LW. Cracked Tooth: Talking with Patients. Journal Compilation 2009, Wiley Periodicals, Inc.Volume 21, Number 1, 2009 Chakravarthy PVK, Telang LA, Nerali J, Telang A. Cracked Tooth: A Report of Two Cases and Role of Cone Beam Computed Tomography in Diagnosis. Hindawi Publishing Corporation. Volume 2012 Cohen S, Hargreaves K. Pathways of the Pulp 10th Ed. Mosby Elsevier. Maryland: 2011
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Crown lengthening for dowel crown restoration on maxillary premolar tooth with subgingival fracture Crown lengthening untuk restorasi mahkota pasak inti pada gigi premolar rahang atas yang mengalami fraktur subgingiva Jennifer Fortiana*, Dini Asrianti ** * PPDGS Ilmu Konservasi Gigi, Fakultas Kedokteran Gigi, Universitas Indonesia ** Staf Pengajar Departemen Ilmu Konservasi Gigi, Fakultas Kedokteran Gigi, Universitas Indonesia
Background: One of the key element for a successful endodontic treatment is to establish a good marginal adaptation of post-endodontic restorations. On the teeth with subgingival margin restoration and extensive loss of coronal structure, that can be challenging. Objective: To evaluate the success of dowel crown restoration placement on maxillary first premolar with palatal cusp fractures reaching subgingival using crown lengthening method. Case Report: 58-year-old female patient came to RSKGM-P FKG UI with complaint of upper left back tooth fillings which fell out. When the patient was biting hard food, she felt something was broken in the tooth. After subjective, objective, radiographic examinations, and diagnosis establishment, a vital root canal treatment and placement of dowel crown restoration with crown lengthening procedures on the maxillary first premolar was planned. At 1 week control after endodontic procedure, there was no subjective complaints. Percussion and palpation tests were negative. Thus, post and core build up and crown preparation with crown lengthening was performed. At 3 and 6 months follow-ups, there was no abnormality on subjective and objective examination of the good palatal soft tissue area. Conclusion: Crown lengthening procedure can be an alternative choice for the improvements of marginal restoration adaptation in cases with extensive loss of tooth structure reaching subgingiva. Keywords: post-endodontic restoration, crown lengthening
INTRODUCTION The goal of endodontic treatment is to retain natural teeth with maximum function and pleasing esthetics.1 Endodontic success depends not only on the quality of the root canal treatment, but also on the coronal restoration of the compromised tooth and harmonious relation with the supporting structures.2,3 Endodontically treated teeth are structurally different from vital teeth. The major changes include loss of tooth structure (from carious lesions/trauma and cavity access ppreparation), altered physical characteristic and altered esthetic characteristic.1,4,5 Restorations for endodontically treated teeth are designed to replace the missing tooth structure, protect the remaining tooth from fracture, enable full coronal and apical sealing, and fulfill functional and esthetic criteria.1,2,4
The amount of remaining tooth structure was a significant factor in endodontically treated tooth survival. One of the cause of failure of endodontically treated teeth is fracture, and the fracture resistance of endodontically treated teeth is related to the amount of healthy tooth structure remaining.6 Teeth with extensive loss of structure need an additional support in the form of post and core. The goals are to replace the loss of dentin, provide internal support and retention for the crown, and ensure resistance against cervical tooth fracture.6 To obtain a good marginal seal and prevent fractures in endodontically treated teeth as a result of uneven occlusal load, a circumferential ring of sound tooth structure that is enveloped by the cervical portion of the crown restoration is needeed, and it is called ferrule.6 The minimum height of ferrule is 1,5-2 mm.7 The presence of adequate ferrule at the crownroot interface is critical for the long term success 138
of the tooth.6 A tooth with inadequate remaining structure to obtain minimum height of ferrule, should be evaluated for crown lengthening or orthodontic extrusion.1,6 Crown lengthening is a surgical procedure to expose adequate clinical crown to prevent the placement of the crown margin into the area of the biologic width, and to gain an adequate height to establish a “Ferrule Effect”.3,8 The aim of this study is to evaluate the success of dowel crown restoration placement on maxillary first premolar after endodontic treatment using crown lengthening method due to palatal cusp fracture reaching subgingival.
abutment for the denture. She has a habit of chewing on the left side of the jaw. On the clinical examination, it was found that the carious lesion had reached the pulp chamber on tooth 24. There was also oblique palatal cusp fracture reaching subgingival with 03 mobility. Vitality test was positive, percussion test was positive, and palpation test was negative. The pulp chamber and root canal were narrow, as seen on the radiographic image. There was a widening on the periodontal membran on the servical third until apical third of the root. There was also a thickening on the lamina dura on the apical third of the root.
CASE REPORT A 58-year-old female patient came to Department of Conservative Dentistry RSKGMP Universitas Indonesia on February 2014 with complaint of upper left back tooth fillings which fell out about 3 months ago. She had experienced pain in the past, but then dissapeared. Three days before, when the patient was biting hard food, she felt something was broken in the tooth. She wanted the tooth to be repaired and mantained, because it acts as an Figure 1. Preoperative clinical view of tooth 24 Figure 2. Preoperative radiograph of tooth 24
Figure 3. Clinical view of tooth 24 after fracture element extraction Figure 4. Radiographic view of tooth 24 after fracture element extraction
CASE MANAGEMENT The working diagnosis of tooth 24 is chronic pulpitis with chronic apical periodontitis. The treatment plan for the tooth is vital root canal treatment and dowel crown restoration which preceeded by crown lengthening procedure.
The fracture element was extracted on the first visit. Clinically, the fracture margin on the mesial and palatal areas was reaching subgingiva and at the level of alveolar crest. Cavity access preparation was carried out and 139
followed by root canal preparation using hand use ProTaperR until F2 file for both of buccal and palatal roots. The decuspation was performed on the remaining crown. The tooth was obturated on the second visit, after no subjective complaint was found and percussion and palpation tests showed negative response. At 1 week control after endodontic procedure, there was no subjective complaints. Percussion and palpation tests were negative. Thus, post and core build up and crown preparation with crown lengthening was performed. Crown lengthening procedure was preceeded by local anesthetic administration with infiltration technique on buccal and palatal mucosa. The soft tissue was cauterized, and the alveolar bone was reducted for about 1,5 mm using low speed carbide bur to expose the tooth structure. Bone height reduction was only performed on the palatal and mesial area of the root. After the procedure was completed, a
The porcelain fused metal crown was cemented after the soft tissue was healed, and then followed by occlusion and articulation adjustment. On May 2014, 3 months after crown lengthening procedure, follow up evaluation was carried out. The margin of the restoration was good and soft tissue healing were showed good result. There was no subjective complaints and no inflammation signs. Percussion and palpation tests were negative. Pocket depth measurement was normal. On September 2014, 6 months after crown lengthening procedure, another follow up evaluation was carried out. The margin of the restoration was still good and the soft tissue was healthy. There was no subjective complaints and no inflammation signs. Percussion and palpation tests were negative. Pocket depth measurement was normal.
custom made post and core was fabricated using direct intraoral technique with duralay. The post and core was cemented and followed by dowel crown preparation on the following visit. The gingival margin was retracted using retraction cord and impression was taken with rubber base impression material.
Figure 5. Clinical view of tooth 24 1 week after crown lengthening procedure Figure 6. Radiographic view of tooth 24 1 week after crown lengthening procedure
Figure 7, 8 and 9. Cinical and radiographic view of tooth 24 on 3 months follow-up evaluation after crown lengthening procedure
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Figure 10, 11 and 12. Clinical and radiographic view of tooth 24 on 6 months follow-up evaluation after crown lengthening procedure
DISCUSSION The clinical longevity of endodontically treated posterior teeth (molars and premolars) is significantly improved with coronal coverage.6 In this case, tooth 24 had lost extensive structure due to palatal cusp fracture reaching subgingiva. Therefore, the post endodontic restoration should be able to provide coronal marginal seal, adequate retention, and ferrule in order to obtain long-term success of the tooth.6 When a crown is placed on a tooth with optimal ferrule, the crown and root function as one integrated unit and occlusal forces are transmitted in normal physiological fashion to periodontium. Where inadequate ferrule exists, occlusal stresses are transferred directly to the core and/or post with highly likelihood of tooth, root or post fracture or post dislodgement.6 Without sufficient tooth tooth structure, the absence of a ferrule was reported to be a determining negative factor on cervical tensile stress.1 The fracture resistance increases significantly with the presence of retained coronal dentin and the longer the ferrule, the higher the fracture resistance.1,6 In this case, the fracture margin was reaching subgingiva and at the level of alveolar crest. Therefore, crown lengthening should be performed. The main aim of crown lengthening
procedure is to establish a harmonious relation between the tooth supporting structures and to expose about 2 mm of sound tooth structure to allow for a “Ferrule Effect”.3 Crown lengthening procedure enable the clinician to expose adequate clinical crown in order to prevent the placement of the crown margin into the area of the biological width.9 Biologic width is the junctional epithelium and connective tissue that attach to the root surface. Studies have indicated that the average lengths of the connective tissue attachment and junctional epithelium are 1,07 and 0,97 mm. Therefore the average length of biologic width is about 2 mm. If the restorative margin is placed into this area, the crestal bone will be lost to re-establish the biological width. The other consequence of margin placement into this area is gingival inflammation, lost of attachment and pocket formation.3,8 Three methods of cutting oral soft tissue in dentistry are the use of scalpel, electrosurgery and laser.10 Cutting soft tissue with a scalpel is a technique that commonly used by every practitioner. The negative characteristic associated with cutting soft tissue with scalpel include excessive blood flow, inadequate visibility caused by the blood in the operating field, and recession of gingival margin following the procedure.3,10 Some of the main advantages of using laser include hemostatis, improved visualization due to minimal blood flow during the procedure, minimal tissue displacement, more stable gingival margin and minimal collateral tissue damage.11 But this method is not cost effective compared to other methods. Another minimally invasive procedure that can be used for cutting the soft tissue is electrosurgery/cauterization. In this case, the soft tissue was cut using the cauter. Some of the main advantages of this procedure are simple and easy to use, cost effective, provides recontour of the gingival tissue very accurately, provokes coagulation and minimize bleeding, and causes very little post operative pain for most of the patients after the procedure.3,10 Bone height reduction is carried out after the soft tissue was openned. The reduction of the bone is usually not necessary around the entire circumference of the tooth.8 In this case, the fracture margin on the mesial and palatal area was reaching subgingiva, but there was still 141
adequate height on the distal area for about 2mm. Therefore, the bone height reduction was only performed on the palatal and mesial areas of the root. After the procedure was completed, a custom made post and core was fabricated using direct intraoral technique with duralay. In cases with extensive lost of tooth structure, the fabrication of post and core is necessary in order to replace the loss of dentin, provide internal support and retention for the crown, and ensure resistance against cervical tooth fracture.2,6 The porcelain fused metal crown was cemented after the soft tissue was healed and stable. Follow up evaluations are necessary in determining the long term success of the tooth. The interval between visits is initially set at 3 months, but may be varied according to the patient‟s needs. At 3 and 6 months follow ups, there was no abnormality on subjective and objective examination. The margin of the restoration was good and the soft tissue was healthy. There was no inflammation signs. Percussion and palpation tests were negative. Pocket depth measurement was normal. Therefore, it was shown that the crown lengthening procedure has been successful and able to provide support for post endodontic restoration on tooth 24.
REFERENCES 1.
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8. CONCLUSION Based on the previous discussion, it can be concluded that endodontic success also depends on the adequate coronal restoration of the compromised tooth and harmonious relation with the supporting structures. Crown lengthening procedure can be an alternative choice for the improvements of marginal restoration adaptation in cases with extensive loss of tooth structure reaching subgingiva.
9.
10.
11.
Cohen S, Hargreaves KM. Pathways of the Pulp. 9th ed. St. Louis: Mosby, Inc; 2006:787-795. Johnson WT. Color Atlas of Endodontics. Iowa: W. B. Saunders Company; 2002:131-2. Dadlani H, Grover HS, Yadav S. Electrosurgery as an aid to crown lengthening in the management of a multilated tooth: A case report. Indian J Dent Educ. 2012;5(1):43-7. Segovic S, Galic N, Davanzo A, Pavelic B. Postendodontic Tooth Restoration Part I: The Aim and the Plan of the Procedure. Acta Stomat Croat. 2004;38(1):81-6. Gonzaga CC, de Campos EA, BarattoFilho F. Restoration of endodontically treated teeth. RSBO. 2011;8(3):33-46. McComb D. Restoration of the Endodontically Treated Tooth. DISPATCH. 2008:1-18. Bergenholtz G, Horsted-Bindslev P, Reit C. Textbook of Endodontology. 2nd ed. West Sussex: Willey-Blackwell; 2010:328-9. Newman MG, Takei HH, Carranza FA. Clinical Periodontology. Philadelphia: Saunders; 2003:945-6. Anand PS, Ashok S, Nandakumar K, Varghese NO, Kamath KP. Surgical Exposure and Crown Lengthening for Management of Complicated Fractures of Maxillary Anteror Teeth. N Y State Dent J. 2013;79(6):41-6. Bashetty K, Nadig G, Kapoor S. Electrosurgery in aesthetic and restorative dentistry: A literature review and case report. J Conserv Dent. 2009;12(4):139-144. Dyer BL. Minimally Invasive Ossesous Crown-Lengthening Procedure Using an Erbium Laser: Clinical Case and Procedure Report. J Cosmet Dent. 2008;23(4):84-91.
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Management Of Flare-Up On The Mandibular Right Second Premolars (Case Report) Nova Elvira1, Kamizar2 1 Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia 2 Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
ABSTRACT Background: The incidence of flare-up cases during root canal treatment is very rare, but if it happens will cause patient discomfort. Flare-up can be caused by microorganisms, irrigation or filling materials stirred up into the periapical tissue by over-instrumentation. The management of flare-up includes immediate root canal debridement as well as medicamentation with calcium hydroxide. Objective: This paper aims to report the successful management of an overinstrumentation flare-up case Case: A 58-year-old man came with secondary caries on the edge of a five years old tooth filling on the mandibular right second premolar. Post filling toothache was reported. The tooth did not hurt by the time he came and barely used to chew due to the fact that it was often causing food impaction. The diagnosis is chronic apical periodontitis etcausa pulp necrosis. Then root canal treatment was done with 22.5 mm working length. On second visit, patient complained of pain. Reevaluation showed a working length of 21.5 mm. Debridement was repeated with reduction of the working length. Calcium hydroxide as medicament and temporary filling were used. The pain was no longer present at the next visit and therefore a root canal filling using a sealer guttap and MTA can be performed. A final restoration of a metal onlay restoration was applied at the next visit. Conclusion: The treatment of flare-up condition consists of repeated debridements and use of calcium hydroxide as a medicamentation is proven to be effective. Keywords: Flare-up, management, calcium hydroxide
INTRODUCTION Flare up is one of endodontic treatment complications in form of pain and or swelling during endodontic treatment that require unscheduled appointment and operator‟s active intervension.1 Flare up alone has low incidence, around 1.8 to 3.2%.2 However, flare up is a situation that makes patients feel mildly to moderately uncomfortable after treatment courses. Usually, patients begin to feel disappointed and think that the treatment has failed and the tooth must be extracted. The most important aspect of the treatment is to calm the patients down. Give patient understanding that flare up is not something unusual or that flare up cannot be corrected and the case would be treated immediately. Flare up cause can be multifactorial, microorganisms may be the primary etiologic if supported by another factors such as:1 inadequate debridement could lead to persistent pain from
acute condition signing there are remnants of pulp tissue from inadequate instrumentation or undetected root canal, debris extrusion from apical foramen, overinstrumentation, overfilling, one-appointment therapy, re-treatment, pain intensity before treatment course and patient understanding also related with the degree of pain after treatment. Overinstrumentation may cause debris extrusion in form of dentin shards, pulp fragments, necrotic tissue, microorganisms, and intracanal irrigants into periapical tissue. This must be noted because it may trigger flare up between appointment, pain after instrumentation, acute inflammation respons, and slowed periapical healing.3.4 This case report would discuss about flare up management caused by overinstumentation on mandibular right second premolar diagnosed with chronic apicalis periodontitis etcausa pulp necrosis.
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CASE Patient, male, 58 year old came complaining that his lower right posterior tooth decayed on the edge of restoration, he once feel pain after restoration around 5 years ago. The tooth is not in pain now but food often slips in between so the tooth is rarely used to chew. On clinical examination there is secondary caries on the edge of restoration on the mandibular right second premolar. From vitality test the tooth was nonvital, negative when palpated, but positive when percussion test was performed. On radiographic examination there is an overhanging restoration, radiolucency on the lower edge of proximal restoration in the disto-occlusal mandibular right second premolar, one straight root with one root canal, there‟s thickening of periodontal ligament at the apical, but the tip of apical couldn‟t be seen clearly.
Figure 1. Initial clinical photo of 45 Figure 2. Dental radiographs of 45
The mandibular right second premolar then diagnosed with chronic apicalis periodontitis etcausa pulp necrosis. Treatment plan for the tooth was nonvital endodontic treatment with metal onlay as final restoration. The prognosis for the tooth was good because the tooth still could be treated with root canal treatment and the remaining hard tissue of the tooth could still be restored after endodontic treatment. CASE MANAGEMENT Treatment started by removing the overhanging restoration along with access preparation, determining the working length and taking radiograph image. Root canal preparation was done with crown-down hand technique with initial file #20 and last file F4 with 22.5 mm working length, measured from buccal cusp to
apical constriction. Irrigation was done with 2.5% sodium hypochlorite (NaOCl) solution. Afterwards, the root canal was dried using paper points. ChKM was used as intracanal medication and then temporary restoration was placed.
Figure3. Primary guttap cone radiograph
During subjective examination at second appointment, patient complained about pain when chewing. On clinical examination, percussion test on the tooth resulted positive which showed periodontal lesion have not disappeared. Temporary restoration was removed, followed by irrigating the root canal with 2.5% sodium hypochlorite solution, and when dried off with paper points there was blood on the tip of the paper points. These findings signified that the length of paper points that being inserted has reached the junction of apical and alveolar bone. It showed that overinstrumentation had happened. To overcome this, the last file was enlarged one level up into F5 with 1 mm reduction of working length to reform the apical constriction with new working length so that tug back and apical stop could be achieved, therefore the new last file was F5 with 21.5 mm working length.10 Afterwards, root canal was irrigated with 2.5% sodium hypochlorite solution and dried using paper points. Calcium hydroxide (calciplex) used as intracanal medication and then temporary restoration was placed. Later 1 mm occlusal reduction was carried on to reduce occlusal force on the tooth. On the next appointment, the subjective and clinical examination showed no complain nor sign of infection or inflammation (negative when palpated and percussion) so obturation of root canal could be performed. Obturation was done with F5 cone guttap and mineral trioxide aggregate/MTA (filapex, Dentsply) as a sealer.
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Preparation for metal onlay restoration was carried on the next appointment.
Figure 4. Root canal obturation radiograph Final clinical photo after restored
Figure 5.
DISCUSSION Overinstrumentation is one of the causes of flare up, it may cause tissue damage, periradicular bleeding, temporary inflammation, microorganisms exchange from root canal into periapical tissue so that may reduce treatment success.4 Overinstrumentation also may cause periodontal healing progress to slow down because of imperfect regeneration on cementum, periodontal ligament, and alveolar bone.5 Flare up management on chronic periodontitis apicalis et causa pulp necrosis caused by overinstrumentation is with debridement and remeasure working length, followed by root canal preparation with the new working length,6 irrigation with 2.5% sodium hypochlorite slowly and carefully, then calcium hydroxide paste as intracanal medication and lastly temporary restoration was placed. Occlusal reduction may be carried out to reduce occlusal force on the tooth. The flare up symptoms would then be subside. Calcium hydroxide has low solubility in water, high pH (12.5-12.8), and insoluble on alcohol. Its low solubility in water is advantageous because then longer period is required before calcium hydroxide dissolve in tissue fluids when it‟s directly in contact with vital tissue. Calcium hydroxide paste could kill bacteria in direct contact through pH effect, and its placement must cover apical area with adequate quantity to give biological effect to the tissue. Its antimicrobial activity occur because extrication and diffusion of hydroxyl ion that makes the environment with high alkaline, not conducive for microorganisms.7
Antimicrobial mechanism of calcium hydroxide occur when extrication of ion OH would inactivate microbes‟ cytoplasm membrane enzyme and chemically change organic component and nutrition transfer that are toxic for microbes. This inactivation of microbes‟ cytoplasm membrane enzyme would affect growing process, cell division also metabolism activities. Chemical changes in microbes‟ cytoplasm membrane may be related to destruction of unsaturated fatty acids and phospholipids that disturb fats peroxidation w saponification in microbes.8 process and i Another mechanism that explains antimicrobial effectiveness of calcium hydroxide is its ability to absorb carbon dioxide inside root canal which is important for certain microbes such as Capnocytophaga, Eikenella, and Actinomyces. When carbon dioxide absorbed by calcium hydroxide then the microbes that depend on carbon dioxide could not survive.9 Calcium hydroxide has high pH and able to kill main bacteria Bacteroides that mostly found in flare up cases.10 Calcium hydroxide may also be used to control exudates for tooth with persistent periapical lesion. High concentration of calcium ions (Ca2+) can cause pericapillar contraction that lessen blood flow into capillary. This would affect reduction of plasm fluids quantity that comes out of tissue as inflammation reaction. This condition would allow healing process and calcification.11 Root canal obturation may be carried on if both subjective and clinical examination shows no sign of infection or inflammation. Obturation may use MTA sealer, filapex. MTA sealer is indicated for overinstrumentation cases because it features effective closing and stimulated reparation and regeneration of periodontal ligaments, it also has antimicrobial with high pH, and insensitive towards humidity and blood contamination.12 Therefore encourage repairing and restoration on periapical area after MTA sealer application. Keeping patient calm is a determining factor. Information about the probability of discomfort for a couple days ahead can already reduce patient‟s anxiety significantly and prevent overreaction about the discomfort that patient might feel later.13 145
CONCLUSION Flare up management caused by overinstrumentation could be corrected with enlarging the last file one level up and reducing 1 mm of working length. It would form the new apical constriction with new working length so tug back and apical stop would be achieved, application of calcium hydroxide paste as intracanal medication could reduce symptoms that patient complained about, also with obturation using MTA sealer. Occlusal reduction could lessen patient‟s sensitivity by reducing occlusal force. This treatment could overcome the pain that patient felt. Up until the last appointment, placement of metal onlay as final restoration; and on follow-up appointment two weeks after, patient didn‟t show any complaints nor any signs of persistent infection or inflammation. REFERENCES 1.
2.
3.
4.
Cohen, A.S. dan Brown Clifford D. 2000. Orafacial dental pain emergencies: endodontik diagnoses and management. In Pathways of the pulp. Cohen S, Ed. Ke-8, United States: Mosby. Hlm. 62-3. Walton R, Fouad A: Endodontic interaappointent flare-ups: a prospective study of incidence and relaed factors, J Endod 18:172, 1992 Chugal NM, Clive JM, Spångberg LSW. Endodontic Infection: Some Biologic and Treatment Factors Associated With Outcome. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2003;96(1):81-90. Seltzer S, Naidorf IJ. Flare-ups in endodontics: I. Etiological factors. 1985. J Endod 2004;30(7):476-81
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Nisha G, Garg A. Textbook of Endodontics. New Delhi: Jaypee Brothers Medical Publishers. 2014: 235-245. Diunduh dari http:www.jaypeebrothers.com, cited 03/26/2014 Mardewi S. Perawatan endodontik konvensional seri 1. Jakarta. UI-Press. 2008: 33-36 Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics. Australian Dental Journal Supplement. 2007; 52(1 Suppl):S64-S82. Signoretto C, Tafi MC, Canepari P, et al., 2000. Cell wall chemical composition of Enterococcus faecalis in the viable but nonculturable state.Appl and Enviromental Microbiology;66(5):1953-9 Sidharta W., 2000. Penggunaan Kalsium Hidroksida di bidang Konservasi Gigi. JKGUI Edisi Khusus;7:435-43 Mickel AK, Sharma P, Chogle S., 2003. Effectiveness of Stannous Fluoride and Calcium Hydroxide Against Enterococcus faecalis. Int Endod J;29(4):259-60. Leonardo MR, Silveria FF, Silva LAB, Fiho M, & Utrila LS: Calcium hydroxide root canal dressing. Histopatological evaluation of periapical repair at different time period. Bras Dent J. 2008;13.1.17-22 Ricucci D, Langeland K. Apical Limit of Root Canal Instrumentation and Obturation, Part 2. A Histological Study. Int Endod J 1998;31(6):394-409. Walton RE, Torabinejad M. Prinsip dan Praktik Ilmu Endodonsia. Edisi 3. Sumawinata N (Alih bahasa). 2003. Jakarta: Penerbit Buku Kedokteran ECG. Hal. 394395.
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Direct composite laminate veneer on maxilary anterior teeth due to discoloration post endodontic treatment and secondary caries: a case report Inez Hanida1, Nilakesuma Djauharie Setyopurnomo2 1 Postgraduate Student of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta 2 Lecturer at Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta
ABSTRACT Background: Direct composite laminate veneer has become a prominent topic in today‟s dentistry. Treatment of choice are including crown and direct composite laminate veneer. Direct composite laminate veneer has several advantages than the indirect technique. It conserves sound tooth structure with minimal invasive preparation, low cost for patients compared with indirect techniques, reversibility of treatment, intraoral polishing is doable and any cracks or fractures on the restoration may be repaired intraorally. Color, shape, structure and position of the anterior teeth are among major factors in direct composite laminate veneer. Objective: The purpose of this case report is to report the use of direct composite laminate veneer in patient with discoloration due to caries and post endodontic treatment. Case report: A 25-year-old female referred to University Dental Hospital-Faculty of Dentistry Universitas Indonesia with complaint of color alteration in nearly all of her upper front teeth. Treatment sequences for tooth 21 post endodontic treatment are intracoronal bleaching, fiber post, and direct composite laminate veneer. Tooth 11, vital, restored with direct composite laminate veneer. Tooth 12 restored with direct resin composite. Conclusion: Direct labial veneer is one of esthetic restorations that possesses conservative approach but could satisfy patient. Keywords: direct composite laminate veneer, discoloration, post endodontic treatment
INTRODUCTION Direct composite laminate veneer is among the important topics of today‟s dentistry as the increasing demands of dental esthetics and the advancements of adhesive restoration. Position, color, shape, structure and contur of anterior teeth are the factors associated within direct composite laminate veneer restoration.1 Presently, the treatment of choice are crown and laminate veneer. However, excessive preparations of teeth, damages to surrounding tissues, e.g. gingiva, relatively more costly, are several disadvantages of crowns.2 In the other hand, laminate veneer tend to follow minimal preparation concept. Laminate veneers restorations can be distinguished into two types: direct and indirect laminate veneers. Direct laminate veneers indications including fracture, discoloration, diastema closure, erosion, shape and malposition correction. Minimal preparation technique, low cost for patients compared with indirect techniques, reversibility of treatment, no need for an additional adhesive cementing system, repaired may be done intraorally and could be
done in single visit are some advantages of direct laminate veneers.3 However, the disadvantages of this technique are low resistance to wear, discoloration and fractures.2 The increasing patients‟ demands for dental esthetics might lead to the development of advanced technologies for superior dental materials by applying nano-ceramic technology to develop new nano-ceramic restorative Ceram X (Dentsply, USA). It offers superior esthetics with excellent durability and mechanical characteristics achieved by an easy procedure, superior handling, and high polishability.5 This case report demonstrates a clinical technique for enhancing the appearance of three anterior teeth, 11 with secondary caries and staining, 21 with discoloration post endodontic treatment, and 12 with secondary caries post endodontic treatment. Direct composite laminate veneer technique used in tooth 11 and 21, intracoronal bleaching and fiber post placement previously done in tooth 21, and resin composite restoration in tooth 12, is described.
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CASE A 25-year-old female patient with color alteration and brownish staining in several anterior dentition, and therefore with esthetic complaints, referred to the conservation clinic RSKGM University of Indonesia. The right central incisor presented with D4 caries lesion, site 3 size 4, staining and iregularity on labial surface. The left central incisor presented with secondary caries and discoloration on labial surface. The right lateral incisor presented with secondary caries. According to the patient‟s history, tooth 12 and 21 had done endodontic treatment 4 years ago. In the absence of periapical and gingival lesion, hermetic obturation was detected subsequent to clinical and radiographic examinations. Highly caries risk factors, frequent daily sugar consumption and habitual absence of tooth-cleaning at night, were obtained from the patient. All teeth prognosis is good due to the amount of remaining tooth structure. Treatment plan for 21 are intracoronal bleaching to gain maximum esthetic result due to non vital discoloration, followed by fiber post placement due to heavy occlusion load with edge to edge contact. Fiber post is not necesary in 12 due to open contact, thus a resin composite restoration could be done directly. Direct approach with composite laminate veneer was favored over porcelain crown for 11 and 21.
bleaching and fiber post placement, then 11 and 21 direct composite laminate veneer and 12 direct resin composite restoration were undertaken. After written consent from the patient, treatment for 21 was initiated. Walking bleach technique was performed with 35% hydrogen peroxide gel (Opalescence Endo, Ultradent, USA). Access to the orifice was gained from the palatal old composite restoration, then 2 mm guttapercha from cemento-enamel junction (CEJ) was removed with Peeso Reamer (Dentsply, USA) in a lowspeed handpiece. After adequate 2,5% NaOCl irigation, RMGIC Vitrebond (3M, USA) applied and cured for 20 seconds, then bleaching agent application and seal with zinc phosphate temporary cement. Evaluation was done one week after treatment.
Figure 3. Guttapercha removal evaluation Figure 4. 21 post intracoronal bleaching
Second step was initiated with fiber post space preparation minimal 5 mm below the orifice and evaluation radiograph taken, then 1,25 mm diameter FibreKor (Pentron, USA) cemented with Breeze (Pentron, USA) self adhesive resin cement. Prior to cementation, fiber post was pretreat with 30 seconds 37% hydrofluoric acid (porcelain etch, Ultradent, USA) and 60 seconds silane (Ultradent, USA).
Figure 1. Pre operative condition Figure 2. Diagnostic radiograph
CASE MANAGEMENT Radiographic and clinical examination confirmed that endodontic treatment had been adequately performed, with no need for retreatment in 12 and 21. Treatment sequences consists of four steps. Initially, 21 intracoronal
Figure 5. Guttapercha removal. Figure 6. Fiber post trial. Figure 7. Fiber post post cementation
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Prior to tooth preparation, email E3 and dentin D2 shade selection performed in hydrated tooth and absence of dental unit lamp with Ceram X (Dentsply) shade guide. A polyvinylsiloxane mock up was fabricated intraorally in normally shaped 21 without the build up as a guiding restoration of the palatal and incisal surfaces. Tissue management, for retraction and avoidance of gingival crevicular fluid contamination in the restoration steps, performed with gingival retraction cord (KnitTrax, Pascal, USA) inserted for 5 minutes to the gingival sulcus. Faulty restoration in 21 was removed with a cylindrical diamond bur in a highspeed handpiece, then the entire tooth preparation for 11 and 21 followed the window technique. This technique is aid to reserves the palatal, proximal, and incisal surface of anterior teeth in order to protect the fina restoration from occlusal forces. The final thickness of the preparation was 0,5 mm on the labial surface with cylindrical diamond bur and chamfer on the cervical margin paragingivally. Chamfer preparation was chosen to facilitate good polshing procedure with bold preparation edge.
Figure 8. Shade selection
Figure 9. 11 and 21 Window preparation technique8
To begin the resin composite placement, celluloid matrix is inserted in both proximal surfaces of each tooth prior to etch and bond
steps. Selective etch was performed 15 seconds on the dentin and 30 seconds on the enamel with 37% phosphoric acid etch (Dentsply, USA), then rinse and air dry leaving moist dentin condition. One-step bonding agent X bond (Dentsply, USA) applied with microbrush, then air-thinned and 20 seconds light cured. Ceram X (Dentsply, USA) nano-ceramic resin composite was applied in a layering manner. Initially to restore 21, mock up was placed and first layer of E3 composite applied with teflon plastic instrument to build the palatal surface, then dentin D2 layered applied and formed until 2-3 mm from the tooth edge to allow email translucency, followed by last enamel layer to form the labial surface. The enamel layer is applied with previous plastic instrument and smoothen with Comporoller (KerrHawe, USA) from cervical to incisal edge. Oil-painting brush was also used to give natural appearance of the teeth. Light curing was done for 20 seconds after each layer has been applied. Operative procedure for 21 was done in the same manner as in 11 except the absence of palatal surface to be built. Nano-ceramic resin composite was chosen for its mechanical strength, marginal integrity, good handling properties due to reduced stickness to metal intruments, high polishability due to low surface roughness and high gloss resulted in superior esthetic restorations. Ceram X merges organically modified ceramic nano-particles, inorganicorganic hybrid where the inorganic part that provides strength and the organic part makes the particles compatible and polymerisable with the resin matrix, and nanofillers combined with conventional glass fillers.5 To reproduce the perceived color of a tooth which is a combination of an inner substrate (dentin) and an outer substrate (enamel), direct composite laminate veneer restoration mainly consists of three different layers, palatal enamel, dentin, and labial enamel. Dentin is 20% more opaque than enamel, providing most of tooth‟s hue, which falls in the red-yellow spectra.6 Enamel is a layer that adjusts the perception of the underlying dentin color and its translucency based on factors like enamel thickness, genetics, and age. Enamel translucency influences the chroma and value. Highly translucent enamel (low value enamel) 149
allows light to eb transmitted through it to reach a high-chroma dentin without much change in its color. More opacious enamel (high value enamel) act as a barrier that disperses, absorbs, and reflects light such that a minimal amount of color is perceived.6
a
b
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d
e Figure 10. Teflon plastic instrument Figure 11. Comporoller (KerrHawe, USA)
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Figure 14. Finishing and polishing steps a-b.carbide finishing bur, c.12-surgical blade, d.metal polishing strip, e.rubber, f. Occlubrush (Kerr, USA), g.aluminium oxide strip Epitex (GC, USA)9
Figure 12. 21 Resin composite layering technique with mock up
Figure 15. Final appearance
CONCLUSION Figure 13. Resin composite application with Comporoller (Kerr, USA)
Finishing and polishing restoration procedure was achieved in several steps. First, pointed-tapered carbide finishing bur to smoothen the labial surfaces and flame carbide finishing bur to adjust occlusion after occlusion check with articulating paper. Proximal surfaces contured with the 12-surgical blade, then smoothen with metal polishing strip. Final polishing was performed with rubber, Occlubrush (Kerr, USA) and aluminium oxide strip Epitex (GC, USA).
Discoloration due to caries and pulp necrosis treated with direct composite laminate veneer restoration gives satisfying esthetic result for the patient with minimal preparation procedure and lower cost compared to the indirect technique. REFERENCES 1. Korkut, Bora. Yanıkoğlu, Funda. Günday, Mahir. Direct Composite Laminate Veneers : Three Case Reports. Journal of Dental Research, Dental Clinics, Dental Prospects. Spring 2013, Vol. 7 Issue 2, hal. 105-111. 2. Fahl, Newton. A Polychromatic Composite Layering Approach for 150
Solving a Complex Class IV/Direct Veneer-Diastema Combination: Part I. Pract Proced Aesthetic Dent 2006;18(10):A-G 3. Zorba, Yahya O. et.al. Direct Laminate Veneers with Resin Composites : Two Case Reports with Five-Year Followups. The Journal of Contemporary Dental Practice, Volume 11, No.4, July 1, 2010. 4. Heymann HO. Additional Conservative Esthetic Procedures. In: Roberson TM, Heymann HO, Swift EJ, editors. Sturdevant's Art and Science of Operative Dentistry. 4 ed. St. Louis: Mosby; 2002. hal. 616-617. 5. Ceram x, Nano Ceramic Restorative, Scientific Compendium. Dentsply De Trey Gmbh. Konstanz, Germany. 2007. www.dentsply.co.uk.
6.
Fahl, Newton. Coronal Reconstruction of a Severely Compromised Central Incisor with Composite Resins : A Case Report. Journal of Cosmetic Dentistry. Spring 2010 Volume 26 Number 1. Hal 92-113. 7. Bernardon, Jussara Karina, et.al. Composite Resin in anterior Teeth. Journal of Cosmetic Dentistry. Spring 2014 Volume 30 Number 1. Hal 92-102. 8. http://keats.kcl.ac.uk/pluginfile.php/487 681/mod_book/chapter/29933/M4U7As sets/M4U7fig50.jpg 9. Nash, Ross W. The Direct Composite Resin Veneer : A Conservative Approach to Elective Esthetics. Contemporary Product Solutions Evaluator. http://cpsmagazine.com/wpcontent/uploads/Shein_2014_DirectCom positeREsine-Veneer.pdf.
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Type III weine configuration on endodontically treated maxillary second premolar Putie Ambun Suri *, Kamizar ** *Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia **Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
ABSTRACT Background: Though the maxillary second premolar generally known to have one canal from orifice to apex, there was found an anatomic variation in which there were two canals but the preparations were performed on only one of the canals which creates a failure of endodontic treatment. This case discusses the tooth with type III Weine configuration which is the same as the type IV Vertucci that has two separate canals from orifice to apex. According to Vertucci, this kind of case was found by as much as 11%. Objective: The purpose of this study is to report endodontic treatment of the maxillary second premolar with two canals. Case: A 62 years old female patient, came with complaints of pain in upper left tooth since a week ago. Her tooth felt sore when contacting with the opposing teeth. The diagnosis was chronic apical periodontitis e.c. chronic pulpitis with plan for an endodontic treatment and dowel crown restoration. After access opening, the tooth appeared to have two orifices located in the buccal and palatal. After exploring, it was discovered two separate canals from orifice to apex. The shaping of canals were done using crown-down technique, irrigation with 2.5% NaOCl, ChKM medication, gutta percha filling material and Endomethasone sealer. Conclusion: The orifices were located parallel to the direction of buccal-palatal indicates that it had two canals. The treatment is carried out successfully overcome pain, maintaining function and improving aesthetics. Keywords : treatment, maxillary second premolar, type III Weine configuration
INTRODUCTION The purpose of endodontic treatment was to eradicate infected pulpal tissue in the root canal dan dentinal tubules thus inhibiting recontamination after endodontic treatment. A clinician should understand root canal morphology and anatomical variances to support the success of the treatment. It is important to recognize the varied routes of root canal to apex for there are plenty of differences such as number of root(s) and root canal configuration in human permanent dentition.(1) According to several in vitro and in vivo researches, the majority of cases reported various complex configurations on root canal(s). Among them were found race specific root canal morphology.(2) Vertucci‟s research showed around 24% of upper second premolar has one
root canal from orifice to apex, or categorised as type I Vertucci or type I Weine classification. For the teeth with two root canals from orifice to apex, Vertucci categorised it as type IV Vertucci which is equal to type III Weine, were found by as much as 11%.(2) The shortage of clinicians‟ knowledge on permanent dentition‟s root canal morphology and configuration will complicate in determining the location of root canal(s) and achieving adequate debridement therefore influencing the successfulness of endodontic treatment.(3) To identify the variations of root canal, one can use the help of thorough radiographic interpretation with technique and angle of radiation exposure. Sufficient cavity access and internal tooth exploration is also serve as an important reasoning to comprehend the anatomy and
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morphology of each teeth that are going to be treated.(2) In 1969, Weine et al. created the first clinical classification of teeth that has more than one root canal system on single rooted teeth using the speciments from mesiobuccal root of upper first molars.(1) Root canal configuration is the several combinations of root canals in permanent dentition. To Weine, it is very possible to categorised root canal system on a single root into four: Type I --- single root canal from pulp chamber to apex Type II --- two separated root canals leaving pulp chamber but joined shortly near the apex making it one. Type III --- two separated root canals leaving pulp chamber and exiting from two different apical foramen. Type IV --- single root canal leacing pulp chamber but separated shortly near the apex making it into two separated root canal with different apical foramen.(4)
CASE A 62 years old female patient came to the RSGMP FKGUI with complaint of an upper left posterior tooth that has been aching since a week ago. The pain was felt especially during chewing and contacting with the antagonist tooth. Clinical examination on the complained tooth showed poorly shaped amalgam filling, the buccal cusp was fractured, and abfraction. The vitality test was (+), percussion (+), and palpation (-). Radiograph imaging revealed widening of periodontal space and thickening of lamina dura. Based on the examination results, the diagnosis for the 25 tooth was chronic apical periodontitis e.c. chronic pulpitis. The treatment plan for the tooth was vital root canal treatment and dowel crown restoration.
Figure 2. Preoperative radiograph of 25 tooth
CASE MANAGEMENT Figure 1. The four types configuration of root canal(s) found in upper premolars by Weine et al.(4)
The understanding of root canal system configuration will benefits clinicians to comprehend the idea of root canal system and determining treatment techniques. Many endodontic treatment failure cases were reported to be caused by undetected root canal hence the preparations were not carried out. Therefore, the knowledge of general and variations of root canal morphology is very important to achieve success in endodontic treatment.(2) This case report will further discuss on the endodontic treatment of upper second premolar with type III Weine configuration.
Local anesthetic by infiltration was first administered on buccal and palatal mucosa. Then access was performed by removing the poor amalgam filling and secondary caries by round or fissure bur. Afterwards, make the initial external cavity perpendicular to the tooth axis with high speed bur. Pulp chamber roof penetration was done by fissure bur on the middle of central groove. Bur movement to the buccal and palatal will shape the cavity into oval in accordance with the general cavity of upper premolars. During the penetration of pulp chamber roof, safe ended fissure bur can be used to open the orifice therefore creating a direct access to apex. The access preparation was done, the pulp chamber base with two darker colored buccal and palatal orifices was clearly seen, endodontic files can entered and moved in the root canals 153
without trouble, the shape of cavity has good retention for temporary filling. Next irrigate with 2,5% NaOCl, extirpate to remove the pulp tissue, reirrigate, and fill the cavity with temporary filling. On the next visit, the temporary filling was removed. Working length was determined with the help of radiograph and apex locator. The root canals were prepared by using Universal ProTaper (Dentsply Maillefer, Ballaigues, Switzerland). The buccal root canal was prepared until F2/17 mm and the palatal root canal was with F3/21 mm, then irrigated with 2,5% NaOCl and dry the cavity with paper points. After that, the primary cone was determined and the radiograph was taken, it showed the preparation was lacking by as much as 2 mm, therefore the preparation needs to be redone until F2/19 mm and F3/23 mm reached. Irrigate with 2,5% NaOCl, medicate with ChKM, and the cavity was temporary filled again. On the third visit, the subjective and objective examination was carried out, there were no more complains on the 25 tooth, percussion and palpation was negative. The temporary filling was removed. Root canal filling was performed by single cone technique with F2 non-iso, 8% tapering gutta percha on the buccal root canal and F3 non-iso, 9% tapering gutta percha on the palatal root canal; also Endomethasone N (Septodont, St. MaurdesFosses Cedex, France) and Eugenol as sealer. Cavity was obturated with cotton pellets and closed with zinc phosphate cement. During the patient control, three weeks since root canal obturation, there were no complains, with negative result of percussion and palpation. Dowel was made on palatal root canal with working length of 23 mm, hence 18 mm of gutta percha was planned to be removed and leaving 5 mm gutta-percha acting as apical seal. The gutta-percha was removed by low speed gates glidden drill bur, starting from number 2 (diameter : 0,7 mm) then number 3 (diameter : 0,9 mm). To clean the root canal from dentinal and filler residue, the root canal was irrigated by 2,5% NaOCl. For the next step, which is dowel crown, the crown of the tooth was prepared. The tooth structure that remained was more than 1/3 crown
therefore the dowel was made with partial core. The preparation steps follows full crown preparation procedure. The root canal was reirrigated with 2,5% NaOCl then rinsed with water, next the root canal impression was made using Duralay (Reliance Dental Manufacturing, Worth, Ill.). The cavity was shut using temporary acrylic crown. Next visit, the post was tried in then cemented using type I GIC. Next the full crown preparation was undertaken. Afterwards, twophase impression compound on the tooth region and opposing jaw with alginate was done. The try in of full metal porcelain crown done by checking the crown retention, good marginal edge and crown articulation with the opposing teeth. Cementation was done with type I GIC.
Figure 3. Orifices Figure 4, 5. master cone radiographs in different x-ray angulation
Figure 6. Obturation Figure 7. Metal Porcelain Crown Insertion
DISCUSSION The purpose of endodontic treatment is to eliminate microorganisms from the root canal complex, by holding onto the tooth structure conservational principles and conserve the shape of root canal. That goal is achieved through endodontic triad which consists of biomechanical preparation, microbial control, and perfect obturation of root canal space. Biomechanical preparation method, along with microbial control of root canal can be achieve by the removal pulpal and dentinal tissues that are mechanically infected, root canal irrigation, and 154
intra canal medication.(5) The root canal treatment in this case used corona-apical preparation technique, the crown-down, the advantages from this technique are better debridement, deeper penetration of irrigation liquid, and shorter preparation time than the apical-corona or step-back technique.(6) Root canal obturation followed with appropriate coronal restoration will prevent recontamination by creating obstacles to the microorganisms and their products.(7) The purpose of root canal obturation is to create barrier for the entrance of microorganisms from oral cavity to the periradicular tissues, isolating microorganisms remained after cleaning and shaping process, prevent leakage of potential nutrition to the root canal system which can support the bacterial growth, and reducing the risk of movement of bacteria and fluid into the root canal system from gingival sulcus or periodontal pocket.(1) There are several conditions that needs to be taken in mind before performing root canal obturation: absence of pain and swelling or asymptomatic tooth, absence of exudates in the root canal, root canal system that has been cleaned thoroughly, and adequate time to finish obturation procedure.(7) In this case the 25 tooth has two separated root canal to the apical foramen, which is an anatomical variation that belongs to the type III Weine classification.(2) Clinically the canals are placed in the buccal and palatal. Afterwards, the radiograph imaging was done with SLOB (Same Lingual Opposite Buccal) technique. When the X-ray cone moved distally, the palatal object would appear on the distal side and buccal object appeared on the mesial side.(4)(8) Generally, upper second premolars are single rooted with one root canal. However, there are several variations with one, two, or three roots and root canals.(2) When there are two root canals, access preparation of upper second premolars would be identical to the access preparation of upper first premolars. Since this tooth usually has single root, so when there are two both of the root canals would almost be parallel to one another and the external cavity shape has to be made buccopalatally. When there is only one, the
buccopalatal cavity shape would focus in the middle. If there are three, the cavity shape would be oval with orifices located triangularly.(2) CONCLUSSION AND SUGGESTION This case showed two separated root canals to the apical foramen, categorized as type III in Weine configuration. This is an anatomical variation on upper second premolars which usually have one root canal. After the opening of pulp chamber, the orifices were located parallel to one another with cavity outlined buccopalatally, it was a guidance that this tooth has two orifices located in the buccal and palatal aspect. In addition, clinically by entered endodontic files into the root canal throughout the work length, both files on the buccal and palatal could reached until the apical foramen, this was a sign that the tooth has two separate root canal, the other thing that can be done is taking a master cone radiograph from different directions so the root canal will be seen separately. The treatment had successfully eliminate any symptoms until 4 months after the endodontic treatment was performed. Clinically, percussion and palpation test yield negative results. Radiographs showed both root canals were hermetically sealed down until the apical foramen, the lamina dura and periodontal ligament also showed improvement. The success of treatment can help maintain tooth function in the oral cavity and improve aesthetics. Moreover, knowledge of anatomical variations for clinician is required for the success treatment. REFERENCES 1.
2.
3.
John I. Ingle LKB and JCB. Ingle‟s Endodontics. 6th ed. Connecticut: pmph usa; 2007. p. 151-53, 997-1007 Frank J. Vertucci JEH. Tooth Morphology and Access Cavity Preparation. In: Cohen S HK, editor. Pathway of The Pulp. 10th ed. St. Louis: Mosby Inc; 2011. p. 136–44, 186–7. Neelakantan P, Subbarao C. Root and Canal Morphology of Indian Maxillary
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4.
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Premolars by a Modified Root Canal Staining Technique. 2011;18–21. Franklin S. Weine. Endodontic Therapy. St Louis: Mosby Inc; 2004. p. 106-10, 213 V Gopikrishna, M Kundabala AK. Cleaning and Shaping of Root Canal System. Textbook of Endodontics. Haryana: elsevier; 2010. p. 154.
6.
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Jayshree Hegde. Shaping and Cleaning of Root Canal. Endodontics: Prep Manual for Undergraduates. Noida: Elsevier; 2008. p. 113. Stock C, Walker R GK, editor. Endodontics. 3rd ed. London: elsevier; 2004. p.181 Walton RE TM, editor. Principles and Practice of Endodontics. 3rd ed. Philadelphia: Saunders; 2002.p.190-1
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Treatment Of Palatal Cusp Fracture On Maxillary Second Premolar (Case Report) Sylva Dinie Alinda1, Gatot Sutrisno2 1 Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia 2 Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
ABSTRACT Background: Appropriate treatment of tooth fracture can provide a good prognosis to preserve remaining teeth healthy tissue so as to restore the function of teeth as before. In the sub-gingival crown fractures with pulp involvement, required root canal treatment and gingival cauterization to expose the cervical and fracture margin. The proper restoration plays a major role in maintaining a healthy tissue and restore teeth function. Aim: To report that root canal treatment and metal porcelain crown with metal post core restoration in the case of premolar palatal cusp fracture provide good results because it preserve remaining healthy tissue and restore teeth function. Case: A female 59 years, consult to the University Dental Hospital-Faculty of Dentistry Universitas Indonesia with right maxillary second premolar palatal cusp fracture extended up to 5 mm subgingivally with pulp involvement. Performed root canal treatment and gingival cauterization with restoration metal porcelain crown and metal post core Conclusion: Consideration of these treatment based on adequate amount of tooth tissue can be maintain and fracture segments can be separated so remaining healthy tissue able to preserved and restored to normal teeth function Keywords: Cusp fracture, root canal treatment, cauterization, metal post core, metal porcelain crown
INTRODUCTION Tooth fracture is a common natural phenomenon along with aging. 80% of tooth fracture cases occur primarily on patients older than 40 years. Different dentinal structures have great influence towards the force that acceptable by dentin. Otherwise, patient heavy biting force and diet habit also influential towards the occurring of tooth fracture.1,2 Fractured tooth with pulp involvement certaintly require appropriate treatment, thus remaining tooth healthy tissue able to preserved and restore to normal teeth function. Root canal treatment and restoration that protect remaining tooth healthy tissue are major role to conserved fractured tooth. In this report, we present case of a maxillary second premolar with a functional cusp fracture. Maxillary premolar is one of highest incidence fractured tooth especially on palatal cusp. In this case, patient feel discomfort sensation because of fractured tooth with pulp involvement and periodontal lesion that become patient‟s complain. We also suspect this tooth has history of crack before the fracture occurred.
Proper examination, diagnosis and treatment on crown fractured case will give better prognosis, preserved the tooth and bring normal teeth function. CASE A female patient, 59 years old, consult to the University Dental Hospital-Faculty of Dentistry Universitas Indonesia complaining that her upper right tooth broken when biting chips. At the time there are no pain but there‟s feeling of something woobly on the inside and sometimes there‟s pain when pressed. When patient felt that her tooth was broken, she feel pain for a moment and the it‟s gone after she brushed her teeth. Patient feel discomfort when chewing and being touched by the tongue. CASE MANAGEMENT At first appointment, full examination was done to establish right diagnosis and prognosis and appropriate treatment plan. In extraoral examination there‟s no sign of infection or inflammation. In intraoral 157
examination, there were plaque and calculus found in mandibular teeth. On dental examination, there‟s palatal cusp fracture up to cervical section on maxillary right second premolar. The tooth was insensitive when palpated and lightly tapped with instrument also towards thermal test. On radiographic examination, there are narrowing of pulp chamber with normal root and its canal, widening of periodontal space, thickening of lamina dura and radiolucency on the distal part of the apical third of the root. The tooth was diagnosed with Chronic Apical Periodontitis et causa Pulp Necrosis. The treatment plan for this case was nonvital root canal treatment and metal porcelain crown with metal post core as its final restoration.
Figure 1. Pre-treatment clinical photograph. Maxillary right second premolar with palatal cusp fracture up to cervical section
After establishing diagnosis and determining the treatment plan, at first appointment, the fracture segment, the palatal cusp of maxillary right second premolar, was removed, whereas previously local anesthetic was infiltrated on palatal part of the tooth. The edge of fracture was examined with periodontal probe and later it found that the edge of fracture was 5 mm subgingiva. Next, palatal cusp was detached from periodontal ligament with dental tweezers. After palatal cusp was removed, the pulp chamber was seen and found out that there‟s pulp involvement in the fracture segment. The treatment for the tooth was nonvital root canal treatment. Because the edge of fracture segment subgingivally, the palatal section of the gingiva had to be cauterized first.
Figure 3. Clinical photograph of maxillary right second premolar after removing fracture segment
Figure 4. Clinical photograph of maxillary right second premolar after cauterization. Cauterization was done until the edge of fracture segment was seen. Figure 2. Pre-treatment dental radiograph. There‟s widening of periodontal space at the apical third of the root of maxillary right second premolar‟s root.
On this tooth, the pulp chamber has opened, so no access preparation was needed and straightaway irrigating the pulp chamber using 2,5% sodium hypochlorite solution. Localization of orifice using straight explorer 158
and two root canals were found on the buccal and palatal. Afterwards, root canals were probed using file no. 15 for buccal canal and file no. 10 for palatal canal until it reached along of its working length, 20 mm for buccal canal and 19 mm for palatal canal. Continued with establishing glidepath on both canals until file no. 20 could be inserted throughout of its each working length and then periapical radiograph was taken with file no. 20 inserted on both canals throughout of its working length, 20 mm for buccal canal and 19 mm for palatal canal.
Figure 5. Dental radiograph of maxillary right second premolar to re-affirming its working lengths.
Then proceed with intracanal preparation using crowndown technique with Revo-S rotary file.3 Previously, root canals were irrigated with 2,5% sodium hypochlorite solution, washed off with water then irrigated with 17% EDTA solution. During intracanal preparation, RC-Prep as chelating agents was used. Intracanal preparation with Revo-S file was started with two-thirds of working length preparation with SC1 file (#25, 6%). Followed with preparasi along working length up to AS40/20 file (#40, 6%) on buccal canal and AS30/19 file (#30, 6%) on palatal canal. Afterwards periapical radiograph was taken to evaluate main guttapercha cone using non ISO 6% gutta percha no. 40/20 for buccal canal and no. 30/19 for palatal canal. From the last radiographic examination, intracanal preparation has reached all along working length. Continued with irrigating both canals using 2,5% sodium hypochlorite solution and Ca(OH)2 was used as intracanal medication and last zinc phosphate cement was placed as temporary restoration to end first appointment.
Figure 4. Dental radiographic of maxillary rihjt second premolar to evaluate main cone gutta percha.
At the second appointment, a week after the previous appointment, patient had no complain, and from clinical examination showed no signs of infection or inflammation, also the gingiva post-cauterization had healed. At this appointment, the treatment continued with obturation of root canals. Previously the temporary restoration was removed, both canals irrigated using 2,5% sodium hypochlorite solution and the intracanal medication (Ca(OH)2) was cleansed. Followed with irrigation using 2% chlorexidine then dried off using paper points. Non ISO 6% gutta percha were used for obturation with resin-based sealer AHPlus. When the obturation finished, periapical radiograph was taken to evaluate the filling. The radiograph showed that the obturation were filled until ± 0.5 mm from the tip of apical. Afterwards, RMGIC was placed as base continued with temporary restoration.
Figure 5. Clinical photograph of maxillary right second premolar at second appointment after intracanal preparation. Gingiva post-cauterization had healed.
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Figure 6. Dental radiograph of maxillary right second premolar to evaluate root canal obturation.
Two weeks later, patient came for followed up to evaluate the endodontic treatment. Patient showed no complain after the last appointment, and from clinical examination the tooth showed no signs of infection or inflammation. Carried on with the treatment plan, temporary restoration was removed to set up preparation for metal post on palatal canal. The post working length was 14 mm, 5 mm distance from apical. Filling materials were removed using Gates Glidden Drill up to post working length, continued with smoothing and widening the root canal with Peeso Reamer. After post preparation at palatal canal, Duralay was used to make post and core impression. Lastly, cavity was closed with temporary restoration. The impression then was sent into laboratory to fabricate metal cast post core.
Figure 8. Clinical photograph of maxillary right second premolar post-cementation of metal cast post core.
At third appointment, the metal cast post core was tried into the palatal canal until the post could be inserted along its working length with good retention and resistance, followed by radiograph examination to evaluate the post core inside the root canal. Afterwards, the metal cast post core was cemented using type 1 Glass Ionomer Cement. Later continued with preparation of cast core for the crown. Elastomer double impressions was used to make accurate impression of the tooth along with alginate impression for the mandibular. Bite registration was made using wax. Followed by choosing the shade of the porcelain crown using the adjacent teeth as reference which is A3. Lastly, temporary crown was placed.
Figure 9. Clinical photograph of maxillary right second premolar after preparation for metal porcelain crown.
Figure 7. Dental radiograph maxillary right second tooth after post preparation.
At the fourth appointment, the metal porcelain crown was tried on the tooth. The crown has good retention, occlusion, and articulation with good shade compared with the adjacent teeth. The radiograph examination, taken right after the crown was tried on the tooth, also showed that the crown has good proximal contact with the adjacent teeth. Afterwards the crown was cemented into the tooth using type 1 Glass Ionomer Cement.
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Figure 10. Dental radiograph and clinical photograph of maxillary right second premolar at the end of treatment.
DISCUSSION Tooth fracture on this patient was longitudinal fracture where tooth was cracked until it fully broken that‟s affected by etiologic exposure duration and vertically directed fracture. The main etiology longitudinal fracture mostly because of pressure, even from chewing pressure, when biting hard things or foods, patient bad habit also poor restoration that weaken tooth structure.1,2,4 Facets at some teeth were found in this patient particularly on premolar and molar that show patient chewing pressure is quite big. This thing very influential and became the main etiology of the crack followed with fracture on maxillary right second premolar. Longitudinal fracture classified into five categories that affecting each other. In this case, maxillary right second premolar was splitted because the fracture start from the occlusal towards under cervical with directionof the fracture was oblique. After further anamnesis, patient said that she already felt pain on the tooth few months ago especially after chewing and drinking cold also when brushing her teeth. According to these, the tooth most likely had cracked before finally became necrosis followed by periodontitis before finally it‟s fractured. There are two crack patterns, first from central following dentinal tubule and spreading into the pulp. The second one, the crack position is more peripheral and causing cusp fracture. Pressure on the crackec crown trigger fluid movement inside dentinal tubule, stimulating odontoblast inside pulp that later stimulate pulp nosiceptor. Saliva that seeping into the tooth through the crack line increasing dentinal sensitivity. Direct stimulation into pulp tissue occur when crack prolonged into the pulp.5 Age factor also has an affect on the occurring of tooth fracture on this 59 years old patient where her pulp chamber also had
narrowed. The strength towards fracture and tensile fatigue strength on older dentin are lower and more brittle compared with younger dentin. It also because of lower water content.3 On this case, the tooth necrosis without any remnants if necrotic pulp tissue as heavy chewing pressure compensation. Longitudinal fracture mostly occur around the age of 30 to 50 years old on mandibular molar and maxillary premolar.5 On this case, the tooth splitted up until cervical with pulp involvement, therefore the endodontic treatment was chosen as appropriate treatment planning. The tooth‟s prognosis was good because fracture only up to cervical third of the tooth, with mobile fracture segment that could be removed, while the other dental structure may be maintained.1 Before the endodontic treatment, cauterization was done on the palatal gingival for crown lengthening because fracture reached up into subgingva at cervical third of the tooth to support its final restoration1 so an optimal ferrule could be made later for post and crown preparation to prevent vertically root fracture.6 Final restoration for this case was detached metal cast post core with metal porcelain crown. It‟s chosen because the remnants of tooth structure was less than a half, with heavy chewing pressure, also the tooth was endodontically treated so it will require final restoration that could protect all of the tooth‟s cups.7 When post was chosen as a treatment, the recommended post length is up to 5 mm from the apical tip, keep an optimal amount of healthy dentin wall, combined with extracoronal support from an optimally ferrule effect would make good prognosis.6 Post was placed on palatal canal because occlucal force was fall into palatal cusp so the post will function to detain the occlusal force. During the treatment procedur of this case, rubber dam couldn‟t be used for aseptic prevention because the tooth condition with palatal cusp fractured towards into subgingiva made it impossible to place rubber dam. Moreover, artificial wall also couldn‟t be built because the edge of subgingiva fracture couldn‟t hold up the restoration on that area. Aseptic condition was maintained using cotton rolls and suction and because it‟s maxillary tooth so it wouldn‟t be flooded by saliva. 161
CONCLUSION Management of tooth fracture requires precise anamnesis and clinical examination to establish exact diagnosis and appropriate treatment planning. Moreover, the pain history that patient experienced also play important role to help determining the fracture pathogenetic. In this case, patient have dentin hypersensitivity pain history and supported by facets on some teeth supposing that patient has heavy chewing pressure that resulted in cracked tooth and affecting pulp and periodontal tissue. Along with the time, the continuous heavy pressure along with patient‟s aging causing tooth fracture from excessive pressure stimulation. The treatment chosen for this case was considered on the remnants of tooth structures that could be maintain which is still pretty much and that the fracture segment could be removed therefore the healthy tissue still could be treated and restored back to its function normally.
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Rivera EM, Walton RE. Longitudinal Tooth Fractures. In: Torabinejad M, Walton RE, eds. Endodontics Principles and Practice. 4th ed. Missouri: Saunders Elsevier; 2009:245-297. Kahler W. The Cracked Tooth Conundrum: Terminology, Classification, Diagnosis, and Management. Am J Dent.
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2008;21(5):275-82. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19 024251. MicroMega. Revo-STM Operating Protocols. 2008;33(0). Available at: http://micro-mega.com/en/wpcontent/uploads/2012/10/RevoS_protocole.pdf. Dietschi D, Bouillaguet S, Sadan A. Restoration of the Endodontically Treated Tooth. In: Cohen’s Pathway of The Pulp. 10th ed. Missouri: Mosby; 2011:777-807. Mccomb D. Restoration of the Endodontically Treated Tooth Restoration of the Endodontically Treated Tooth. Pract Enhanc Knowl. 2008;February/M(March):16. Available at: www.rcdso.org. Rivera E, Walton ER. Cracking The Cracked Tooth Code: Detection and Treatment of Various Longitudinal Tooth Fractures. Endod Colleagues Excell. 2008;Summer:2-7. Available at: www.aae.org. Lynch CD, McConnell RJ. The Cracked Tooth Syndrome. Can Dent Assoc. 2002;68(8):470-5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12 323102. Kishen A. Mechanisms and Risk Factors for Fracture Predilection in Endodontically Treated Teeth. Endod Top. 2006;13(17):57-83.
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The endodontic management of maxillary first molar with curved root canal (case report) Medwin Setia1, Munyati Usman2 1 Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia 2 Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
ABSTRACT Background: The maxillary first molar has the largest volume compared to any other teeth and has one of the most complex root and canal anatomy, especially its mesio-buccal root canal. Ocassionally, this condition increased treatment diffculties as well as possibility of iatrogenic errors. Objective: This case report was aimed to present the endodontic management of a maxillary first molar with a curved mesio-buccal root canal. Case Report: A woman, 52 years old, had chief complaint of her upper right back tooth for having a big cavity. It had temporary restoration and was not in pain at present. Radiographic examination showed that the mesio-buccal root canal was curved. This tooth was then treated with two different endodontic file systems, HERO Shaper and Protaper Universal. Conclusion: The utilization of endodontic file with smaller taper has better adaptation for a curved canal rather than the one with bigger taper.
BACKGROUND A tooth that have advanced caries reaching the pulp will cause the pulp become necrose, even the pathogen condition may progress to the periapical region and extend into the surrounding periodontal tissues. Therefore, it takes for a treatment that might eliminate the bacteria which create pathological conditions and their products. The tooth which had been infected should be treated by endodontic treatment. However, it is quite often to have difficulties within the process of endodontic treatment. One of them is curved root canal. It has risk of changing the curvature of the root canal and lead to iatrogenic errors.1 The maxillary first molar has the largest volume compared to any other teeth and has one of the most complex root and canal anatomy, especially its mesio-buccal root canal.2 Mesiobuccal root canal have various anatomy and still continues to be further investigated regarding its complexity, about the number and its curvature. Mesio-buccal root canal are generally oval and wider in its bucco-lingual aspect. In general, there is a concavity on the distal aspect, which thinner. Anggriani (2012), shows that 65% from 100 subject‟s teeth in West Java has a curved root canal.3 The big percentage of the curved mesio-buccal root can also increase the risk of
iatrogenic errors, such as root canal transportation, ledge, or a broken needle. The use of nickel titanium endodontic file is quite popular nowadays due to the ease and adaptability with the variation of the root canal. In this case report will be discussed further on case report with the maxillary first molar mesiobuccal root curvature next. CASE REPORT Female patient, 52 years old, came to University Dental Hospital-Faculty of Dentistry University of Indonesia, had a chief complain about her upper right back tooth and had a big decay since one year ago. The patient told that she had temporary filling at the Community Health Center (Puskesmas). At the moment, the patient did not feel any pain. According to clinical and radiographic examinations, tooth 1.6 was found with caries involving the pulp cervico-distopalatally, vitality test was negative, there were no subjective complaints. Radiographic examination of tooth 1.6 showed a radiopaque area cervico-distally, without any radiolucency on the periapex. In conclusion, the tooth was diagnosed with the pulp necrosis.
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Picture 1. Pre-operative clinical and radiograph.
On the first visit, opening of the pulp chamber was carried out by removing all the roof of the pulp chamber, continued by access preparation and orifice exploring with an endo explorer (Osung, Korea), exploration of the 3 root canals with K-file #10 (Dentsply, Indonesia). During the mesiobuccal root canal exploration, the K-file‟s shape was became curved when it was taken out from the root canal. The root canal preparation was cotinued for 2/3 of the working length with crown down technique. Working length was then determined using the apex locator, confirmed by radiograph, however the radiograph showed that the distobuccal root canal was 2 mm under the working length and it was also to be found that the mesiobuccal root canal was curved distally. The curvature was measured using Digora application and showed an angle of 47.6o. Irrigation of 2.5% sodium hypochlorite was done on this case. At the end of the first visit, root canal was medicated with ChKM and temporarily filled with Caviton (GC Dental Products Corp., Tokyo, Japan).
treatment was being done by using of two endodontics file systems which are ProTaper Universal hand use on the palatal root and HERO Shaper hand use (MicroMega, France) on the mesiobuccal and distobuccal roots. Preparation was finished, followed by master cone radiograph. Afterwards, the tooth was medicated with calcium hydroxide/ Ca(OH)2 (Calcipex II, NISHIKA, Shimonoseki, Japan) and the cavity was temporarily filled.
Picture 3. Master cone radiograph.
On the third visit, the temporary filling was removed and the medication was cleaned. At the time, the patient did not have any complaints, percussion and palpation test was negative, therefore obturation was carried out. Root canal was dried using paper points, obturation used single cone technique and resin based sealer, AH26 (Dentsply Maillefer, Tulsa, OK), the tooth was based with glass ionomer cement Fuji IX ( GC, Tokyo, Japan). Obturation radiograph was taken, followed by temporarry filling with caviton.
Picture 4. Obturation clinical and radiograph.
Picture 2. Radiograph is showing curved canal.
After the endodontic treatment, onlay (cast metal restoration) was chosen for the final restoration.
On the second visit, endodontic treatment was continued and root canal 164
Picture 5. Restoration of 1.6 clinical and radiograph.
DISCUSSION The various anatomy of the root canal may cause problems in endodontic treatment. Therefore, knowledge of tooth anatomy, endodontic tools and technique become very important during endodontic treatment. In this case, the mesiobuccal root of 1.6 tooth has a curvature of 47.6o, the challenge of this case is the biomechanical cleaning process for the root canal. Endodontic files have a risk of breakage, transportation of the root canal, or even ledge. The curvature angle of the maxillary first molar mesiobuccal root was measured using the Schneider method, which involved a reference point on the file at the orifice (point a). Then, a straight line was drawn parallel to the file‟s image up to the middle point of the curvature (point b). From point b, the line was continued to the apical foramen. The angle that was formed from these lines were then measured as the root‟s curvature.4
Picture 6. Schneider method for determination of canal curvature.
NiTi (Nickel Titanium) files are 2-3 times more flexible and more resistant towards torsional stress compared to stainless steel files.5 NiTi files are also providing more predictable, more centered, and faster preparations compared
to stainless steel.6 With those advantages, NiTi files were used in this case to provide optimum result during root canal preparation, especially on the curved root canal and also avoid the possibility of failure during preparation process. In this case, two systems of NiTi files were applied, which were ProTaper Universal and HERO Shaper. Both systems have blunt and non-cutting tips.2 Both are also files which can be moved by hand and machine, though in this case, hand files were chosen. ProTaper Universal was used from S1 through F3 on the palatal root. The mesiobuccal and distobuccal root used HERO Shaper files #20.06 until 2/3 of working length, then #20.04, #25.04 until the working length for the apical third. On the mesiobuccal root, the author prefered HERO Shaper than ProTaper Universal, because NiTi files has a straightening tendency, especially on files with big tip and tapering.7 Files with 25 mm tip diameter or #25, in which ProTaper has 8% tapering, while HERO Shaper has 6% or 4% tapering on the same tip diameter, which result in more less risk of ledge.2 A study done by Maitin (2013) showed that ProTaper Universal files have more risk of root canal transportation compared to the other systems (Mtwo, K3, dan RaCe), whereas those other systems have smaller taper.8 A study done by Love (2013), showed that HERO Shaper prepares the dentinal wall the least compared to the other systems (Twisted Files and ProFile) caused by the taper and sequence that is relatively small, that the debridement was considered less optimum.9 However, usage of HERO Shaper will become optimum when used on narrow root canals. According to a research by Uyanik et al (2006), ProTaper significantly cleans more debris compared to HERO Shaper (p<0.05).10 Therefore, palatal root preparation used ProTaper Universal files in order to clean the root canal more optimally. Moreover, palatal root canal generally has bigger diameter compared to mesiobuccal and distobuccal root, and usually has a straight root.2 CONCLUSION Usage of HERO Shaper and ProTaper Universal endodontic files each has its own 165
advantages and disadvantages, therefore a comprehensive and thorough understanding regarding its specification, characteristics, and physical properties. The taper of a file affects its ability in root canal cleaning, especially on curved canals. The bigger the taper of a file, the bigger the risk of straightening and breakage of file inside the root canal. REFERENCES 1.
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Arora A, Taneja S, Kumar M. Comparative evaluation of shaping ability of different rotary NiTi instruments in curved canals using CBCT. J Conserv Dent. 2014;17(1):35-9. doi:10.4103/0972-0707.124127. Hargreaves KM, Cohen S, Berman LH. Cohen’s Pathways of the Pulp. Mosby Elsevier; 2010. Available at: http://books.google.co.id/books?id=170B QgAACAAJ. Anggriani s. jumlah dan bentuk akar serta konfigurasi saluran akar gigi molar satu rahang atas dan bawah di jawa barat (survey odontometri). 2012:59. doi:r16kon-135. Zhu Y, Gu Y, Du R, Li C. Reliability of two methods on measuring root canal curvature The Ninth People ‟ s Hospital , School of Stomatology , Shanghai Second Medical. 2003:118-121. Johnson WT. Color atlas of endodontics. W.B. Saunders; 2002. Available at:
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http://books.google.co.id/books?id=7RBq AAAAMAAJ. Guelzow A, Stamm O, Martus P, Kielbassa AM. Comparative study of six rotary nickel-titanium systems and hand instrumentation for root canal preparation. Int Endod J. 2005;38(10):743-752. doi:10.1111/j.1365-2591.2005.01010.x. Setzer FC, Kwon TK, Karabucak B. Comparison of apical transportation between two rotary file systems and two hybrid rotary instrumentation sequences. J Endod. 2010;36(7):1226-1229. doi:10.1016/j.joen.2010.03.011. Maitin N, Arunagiri D, Brave D, Maitin SN, Kaushik S, Roy S. An ex vivo comparative analysis on shaping ability of four NiTi rotary endodontic instruments using spiral computed tomography. J Conserv Dent. 2013;16(3):219-223. doi:10.4103/09720707.111318. Ovini V. Masi RML. Shaping Ability Of Twisted File, HERO Shaper And Profile .06 Ni-Ti Instruments In Simulated Curved Root Canals. Dentistry. 2013;03(03):3-6. doi:10.4172/21611122.1000171. Uyanik MO, Cehreli ZC, Mocan BO, Dagli FT. Comparative evaluation of three nickel-titanium instrumentation systems in human teeth using computed tomography. J Endod. 2006;32(7):668671.
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Diastema closure by proximal build-up technique (case report) Dimas Mahardika Generosa*, Gatot Sutrisno** * Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia ** Lecturer, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia
ABSTRACT Background: The presence of diastema in the region of the anterior teeth can interfere a person's appearance. There are several methods to close the diastema, one of them is proximal build-up technique. This case discusses the diastema closure by proximal build-up technique with adhesive composite resin material. The results of treatment can improve the appearance of teeth and give satisfaction to the patient. Objective: The purpose of this paper is to evaluate the success of proximal build-up in the treatment of diastema closure. Case: A 36 year old woman came with left upper front teeth diastema between the central and lateral incisor teeth. Post orthodontic treatment in 2011 and the result still showed diastema between the teeth. In this case proximal build-up was performed to close the diastema so the teeth looked natural. Conclusion: This method proved to be more conservative, practical and have aesthetic value that it gives satisfaction to the patient. Keywords: diastema closure, proximal build-up BACKGROUND CASE The presence of diastema on anterior teeth could disrupt someone‟s appearance, that it drives patients to improve the look. There are several methods to close diastema between teeth that hangs on the etiology. The applicable treatment is by using orthodonthy tools and direct or indirect restorations, or by both combinations.1 Closing diastema by restoration depends on the length of diastema so it creates an aesthetical result that is harmonious with the face, not just closing the diastema itself. A number of restorations to close diastema are veneer, crown, and composite resin.2 Composite resin is a restoration material that is widely used in practical, due to its good aesthetic and physically bio-compatible.3 Closing space between teeth using composite resin by proximal build-up technique is a favorable treatment and may sound conservative; however it gives the best result.4 This case report discusses the closing diastema between incisive central and top left lateral teeth caused by imperfect orthodonthy treatment.
A 36 year old woman came with a complain of her top left teeth that looked unaesthetic caused by diastema between central incisive and top left lateral. She was an orthodonthy patient back in 2011 and still resulting diastema between those teeth. The diastema then being restorated by orthodontist using composite resin. One month ago during scaling treatment the patch fell off and and the composite resin dislodged, the patient came to get the diastema closed because she was uncomfortable with the condition. The general health condition was good and no abnormality was founded from the extra oral examination. By oral intra examination there was no debris, plaque, calculus and the teeth was caries free. There was 2 mm diastema between central incisive and top left lateral teeth, normal gingiva, and composite resin left from restoration was discovered on the mesial lateral incisive.5 The relation of top and bottom jaw occlusion was normal. (Figure 1)
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A
B
C
5,5 8,5 8,5 2 5,5 Figure 1. Front clinical figure (A) and left (B), palatal (C)
CASE IMPLEMENTATION Clinical examination was carried out during the first visit, as well as analyzes the former restoration failure cause. Then explain the patient of the treatment plan and steps. After the patient agreed all the treatment stages and its costs, the teeth mold was made by using alginate to make the study model. The study model then used to make mock ups of the planned treatment. Mock ups were made as preparation experiments and restoration before the implementation on the real teeth.6 (Figure 2)
Figure 2. Study model mock ups
On the next visit the mock-up of study model shown to the patient to give a close description of the treatment result. After the patient agreed, the treatment procedures then started. The material and tools necessities being prepared and the teeth color being analyzed by Vita shade guide and the color was A3. To reassure the color, the A3 composite resin was placed on the teeth surface. After the color matched, mold teeth were created for the palatal by using rubber-base as a reference to the treatment procedures. (Figure 3)
Figure 3. Template mold and rubber base
Proximal build-up started by roughing the surface of facial line angle until the lingual line angle central incisive distal teeth and lateral incisive mesial teeth using long tapered diamond bur in high speed. The surface that has been coarsen then being etched for 15 seconds using phosphoric acid 37% Scothbond Etchant Gel (3M-ESPE, St Paul, USA) after that being rinsed with running water until it is cleaned and then dried by air spray. Moreover, a thin layer of bonding Adper™ Scotchbond™ 1 XT Adhesive (3M-ESPE, St Paul, USA) was applied by using microbrush, then air sprayed and beamed for 20 seconds. A template then being placed on the palatal teeth and composite resin Filltek Z350 (3M-ESPE, St Paul, USA) (Figure 4) was applied using plastic filling to form a palatal and final forms of the composite resin using Comporoller (Kerr Corp., Orange, USA) to create a labial form by using freehand technique. Each of the extra composite applications was always followed by 20 seconds of beaming. The last stage of this treatment is polishing the restoration by using Optidisc (Kerr Corp., Orange, USA) (Figure 5) which was applied by steps started with the roughest discs to the smoothest to produce a smooth and shiny restoration. (Figure 6)
Figure 4. The materials used for diastema closure
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Figure 5. The treatment and polishing procedures
Figure 6. The result of the treatment
DISCUSSION In regards of this case, the cause of diastema is unfinished or orthodonthy treatment failure. Diastema closure is important referring to the patient whom a woman aged 36, whereas aesthetic is considered as a main priority to improve their appearance. Proximal restoration is able to close diastema nicely at a 1-2 mm space, thus each tooth may cover spaces between teeth.7 The diastema spaces between incisive central and lateral in this case is 2 mm, therefore the application of diastema closure was performed by using direct adhesive material. Precision is needed to apply the closure so the teeth would not seem bigger or wider, hence in this case the central teeth being slide nearer to the retorted area to create illusion line.6 Diastema closure in this case was applied by using two-steps direct technique using template, because the result would be better and proportional.7 Proximal build-up was started by preparation to roughing the email on the proximal area along the facial line angle and lingual line angle which useful to strengthen the tie between teeth and composite. Furthermore, composite resin was applied on each surface of teeth proximal that faces one another to form
new proximal shape that close space between teeth. Composite resin that was utilized in this diastema closure was nano-composite resin Filtek Z350 (3M-ESPE, St Paul, USA). The reason is because this nano-composite resin is one of a good material of composite resin. Nanocomposite uses nano-technology technique, has a good polish result close to micro composite but has a strong wearness like hybrid composite.8 This resin is known for having a good aesthetic appearance. Nano-composite is a merged of nano fillers become nano cluster that produce particles in nano sizes and has better resilience to wear with smooth surface like microfil. According to some researches, the application of composite resin with nano cluster generates a high flecsural strength, surface with micro solidity, and easily polish surface.9 Nano filler technology said to be better than any other composites because this composite shrinkless during polymerization, minimalize a change of color, also the forming of microporus on the restored surface which known to causes edge leak, thus it is a decent material to restore anterior and posterior teeth.10 To improve the aesthetic result and the successful of nano-composite restoration, it is necessary to do the polishing procedure, because a rough surface would likely lead to biofilm accumulation, secondary caries risk, and color change restoration. Appointing to nanocomposite restoration research, disc polishing believed to create the smoothest surface compare to other composite polishing types.11 CONCLUSION Diastema closure restoration technique using proximal build-up with composite resin material is the most conservative treatment compared to veneer and full crown. Diastema closure using proximal buildup technique described in this case indicates that it satisfies patient, primarily to enhance the appearance. After restoration procedure and polishing being executed, it immediately showed that nano-composite resin has a good aesthetical eminence.
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Kenyon BJ, Louie KG, Surti B. Direct Composite Restorative Techniques. In: Geissberger M, editor. Esthetic Dentistry In Clinical Practice. San Fransisco: Blackwell Publications; 2010. P. 183 Ho, Christopher CK. Diastema Closure With a Micro-hybrid Composite Resin. Dental Practice Journal September/October 2006. p. 156-160. Neo JCL, Yap AUJ. Composite Resins. In: Mount GJ, editor. Preservation and Restoration of Tooth Structure. Queensland: KBS; 2005. P. 199-217. Hwang SK. Diastema closure using direct bonding restorations combined with orthodontic treatment: a case report. Restor Dent Endod. August 2012. p. 165-169 Patil R. Esthetics with Composites. In: Patil R, editor. Esthetic Dentistry - An Artist's Science. Mumbai: PR Publications; 2002. p. 98-117. Patil R. Esthetics Diagnosis and Treatment Planning. In: Patil R, editor. Esthetic
Dentistry - An Artist's Science. Mumbai: PR Publications; 2002. p. 47-70. 7. Albers, Harry F. DDS. Tooth-Colored Restoratives Principles And Techniques. London: BC Decker Inc, 2002 8. 3M ESPE. Technical product profile Filltek Z350 universal restorative, St paul. 2005 9. Chan KHS, Mai Y, Kim H, Tong KCT, Ng D, Hsiao JCM. Review : Resin Composite Filling. Materials 2010;3:1228-43. 10. Hervas-Garcia A, Martinez-Lozano MA, Cabanes-Vila J, Barjau-Escribano A, FosGalve P. Composite resins. A Review of the Materials and Clinical Indications. Med Oral Patol Oral Cir Bucal 2006; 11:E21520. 11. Vera Lucia Schmitt VL, Puppin-Rontani RM, Naufel FS, Ludwig D, Ueda JK, Sobrinho LC. Effect of finishing and polishing techniques on the surface roughness of a nanoparticle composite resin. Braz J Oral Sci. 10(2):105-108
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Root Canal Treatment of Mandibular Right First Molar with Endo-Perio Lesion (Case Report) Mazhar alamsyah*, Endang Suprastiwi** *Postgraduate student, Department of Concervative Dentistry, Faculty of Dentistry, Universitas Indonesia **Lecturer, Department of Concervative Dentistry, Faculty of Dentistry, Universitas Indonesia
Background: The pulp and the periodontium are closely related as they are of communications between these structures. Objective: This case report to presents succesfully root canal treatment of endo-perio lesions. Case: A 57-year old with the complaint there was a mild pain beside mandibular first right molar and mild swalling on furcation area. The medical history was noncontributory. Intra oral examination revealed deep 4 mm pocket in the furcation area, fistula on gingiva bucal mesial portion and grade II mobility. Radiographic examination revealed severe bone loss around the mesial root and interradicular area. An root canal treatment was taken. Mobility of tooth and depth of pocket reduced to grade I and 2 mm after 2 weeks obturation. Conclusion: root canal treatment on this case demonstrated succesfully. The endo-perio lesion can be healed by root canal treatment, radiographic examination revealed evidence of regeneration of periradicular bone. Keywords: endo-perio lesions, root canal treatment
INTRODUCTION The dental pulp and periodontium are originally from ectomesenchymal, which are the precursors of the pulp and periodontium. If the disease occurs in one tissue it will be affect to other tissues. Endo-perio lesions are a lesion with characteristics of pulp and periodontium disease on the same tooth. The relationship between the pulp and periodontal disease was first described by Simring and Golberg in 1964.1 Since then, the term endo-perio lesions began to be used for a lesion of the pulp and periodontium.1,2 In endoperio lesions there were various kinds of organisms involved. Bacteroides, Fusobacteria, eubacteria, spirochaeta, Wolinellas, Selenomonas, Campylobacter, and Peptostreptococcus were the organisms most frequently involved.2-4 Endo-perio lesions according to Simon et al5 can be classified into 5: 1. Primary endodontic lesions, 2. primary endodontic lesions with secondary involvement periodontium, 3. primary periodontium lesions, 4. Primary periodontium lesions with secondary endodontic involvement, 5. True-combined lesions, both endodontic lesion and periodontium lesion independently developed and evolved together then met and joined at a point along the root surface of the tooth. The pathogenesis of endo-perio lesion begins when the pulp is infected, it will cause an
inflammatory response through foramen of periodontium ligament around the apex or accessories root canals.2,4 The Inflammatory of periodontium tissue can be effect on the dental pulp is still being debated researchers. It is estimated that the periodontium disease had no effect on inflammation of the pulp before there was an inflamation to apex. However, some researchers believe the effect of the periodontium disease to the pulp ie pulp degenerative in nature, including increase in calcification, fibrosis and collagen resorption. Endo-perio lesions caused such as bacteria, fungi and viruses, as well as trauma. The presence of root resorption, perforation and malformations play an important role against the development of endo-perio lesions.2-4 To determine the diagnosis of periodontium and pulpal disease sometimes is difficult, but very important to make a definitive diagnosis to produce a proper treatment plan. Endo-perio lesions provide a challenge for the clinician in diagnosing and determining prognosis. To obtain good treatment results, determination of definitive diagnosis is the most important factor before performing endo-perio lesion treatment.24,6
In this case report will be explained of root canal treatment on the mandibular right first molar with endo-perio lesions. 171
CASE A 57 year old male came to Specialist Clinic of Conservative dentistry, University Dental Health-Faculty of Dentistry Universitas Indonesia with complaint of lower right posterior tooth has a history of swollen gums several times, and there was a mild pain beside it. The tooth has been inserted metal crown since 6 years ago. Objective examination, appears a fistula on the buccal gingival mesial portion of tooth 46 and there was a pocket 4 mm in the bifurcation area. The tooth was not sensitive to vitality test, sensitive to percussion and 2 degree mobility. Radiographic examination, it appears a radiolucency at the apex with irreguler border and obliteration root canal. Periodontium ligament space widening in the apical third and periapical lesions appear on the mesial side with diameter of 6 mm and there was discontinuity of lamina dura .
1a
1b
Picture 1a: Appears a fistula on the buccal gingival mesial portion of tooth 46 and there was a pocket 4 mm in the bifurcation area, 1b: radiographically, it appears a radiolucency around apex mesial with irreguler border and obliteration root canal
Based on the analysis of subjective, objective and radiographic, diagnosis of tooth 46 is a chronic apical abscess et causa pulp necrosis. The treatment plan is root canal treatment with replacement of crown restoration. The prognosis is good because the alveolar bone resorption had less than half the length of tooth root, 2 degrees of tooth mobility, patient cooperative. CASE MANAGEMENT At the first visit, after all examination and diagnosis is done, first step is opening of access
to the metal crown of tooth 46 using metal round bur no. #8 (Dentsply, Switzerland), occlusal reduction of crown using fissure bur metal no.#4 (Dentsply, Switzerland) followed by using access bur (endo Z™, Dentsply, Switzerland ). To negotiate root canals using C+ files no. #8 (Dentsply, Switzerland) with chelation agent (RC-Prep®, Premier Dental) and NaOCl 2,5% using as irrigation. Coronal third preparation is done using ProTaper® Sx (Dentsply, Switzerland), obliteration occurs in mesiobuccal root canal and coronal two-thirds mesiolingual, as well as in the apical third of distal root area. At the end of the first visit, negotiating of root canal can not be reached within the working length, root canals were dried with paper points and cotton pellet. Medicament using Ca(OH)2 (Calcipex®, Nippon Sika - Yakuhin, Japan) and then filled with temporary filling material (Caviton®, GC, India).
2a 2b Picture 2a: acces cavity preparation, 2b: Obliteration on apical third root canals
At the second visit, negotiating root canal will be continued to reach the working length, with watch-winding movement, light pressure using C+ files no.#8 (Dentsply, Switzerland) with a chelation agent (RC-prep® Premier Dental). Finally, working length of mesiobuccal root and mesiolingual root was obtained 17 mm, working length of distal root was 18 mm. Root canal preparation will begins by using C+ file no.#10, no.#15 and then will be continued using ProTaper® (Dentsply, Switzerland) with the sequence Sx, S1, S2, F1 and F2, irrigation was done each turn of files using NaOCl 2.5 %, then performed radiographic by using guttap ProTaper® F2 (Dentsply, Switzerland) to confirm of working length. Root canals were dried using cotton pellets and paper points (Dentsply, Switzerland), Ca(OH)2 (Calcipex®, Nippon Sika-Yakuhin, Japan) as medicament 172
intracanals and then filled with temporary filling material (Caviton®, GC, India).
5a 5b Picture 5a. Radiographically, control after 2 week obturation, 5b. regeneration of periodontium achieved around the apex after 3 mounth control
DISCUSSION Picture 3. Radiographically, working length is obtained, master cone guttap Protaper® F2
At the third visit clinically complaints disappear, objective examination: percussion, palpation negative, there was no fistula again. Then will be planned to obturation. The remains of Ca(OH)2 is cleaned using EDTA 17% (MD-Cleanser™, Meta Biomed Co.,Ltd), and final irigation by using NaOCl 2,5%. Obturation techniques using a single cone with a resin-based sealer (AH Plus®, Dentsply), then based using Glass ionomer cement (Fuji II®, GC) and filled using temporary filling (Caviton®, GC, India).
Picture 4. Obturation hermetically as long as working length
2 weeks after obturation: no complaints either subjective or objective examination, radiography: the apical lesions healing. Temporarily filling replaced with composite resin (Filtek ™ Z250, 3M ESPE)
Endo-perio lesion in this case due to loading of occlusion on the teeth was too heavy, because a posterior teeth 45 and 47 has extracted so that most of the load received of tooth 46. The traumatic occlusion is received by tooth 46 causes trauma to the pulp which continues to be pulp necrosis. Calcific metamorphosis is a response tertiary dentine to trauma with irregular dentin formation and calcification, consisting of small irregular space that extends from the pulp chamber to the apical foramen. Dentinal deposition occurs only on the periphery of pulpa chamber.7,8 According to Fischer that calcific metamorphosis was a response dentin to trauma with progressive formation of hard tissue, with the aim of keeping vitality of pulp tissue in the pulp chamber to foramen apeks9. Obliteration of the root canal, alveolar bone resorption, and mobility are sign of traumatic occlusion7,9,10. This is in accordance with the signs contained in this case. Endo-perio lesions usually dominated by a mixed of anaerobic bacteria infection because the pulp lesion most often initiated and obtained through the apical foramen, lateral and accessories canals, and tubules through dentin.2-4,6,11 A periapical lesions may perforate the cortical bone near to the apex, elevate the periosteum and overlying soft tissues. It can be drainage out into gingival sulcus and forms a pseudopoket that simulate periodontium disease.2-4,6,12,13 If drainage acute periapical lesions become chronic and continuing drainage through the gingival sulcus, epithelial downgrowth along the sinus tract can result in periodontium pocket in which secondary periodontal disease may complicate the lesion.2,3,6 Simon, Glick and Frank further categorized endodontic lesions into two 173
subcategories. The first subcategory was primary endodontic lesions, occurs when a sinus tract has formed to establish drainage. Second subcategory was primary endodontic lesions with secondary periodontal involvement, when plaque formation occuring in the sinus tract with progression to periodontitis and associated with calculus formation.2,5 In this case fistula was formed in the mesio buccal and the presence of a pocket depth 4 mm in the bifurcation area, it is accordance with the second subcategory of Simon et al. Although the disease has been shown to have a role periodontium damage to pulp tissue, the role of bacterial plaque on the apical foramen will reduce the vascular supply of the pulp.2,12 Obliteration all of root canals is a factor complicating the treatment process in this case, but with the use of appropriate instruments, chelation agent and operator skill, working length can be achieved. The use of C+ file no.#8 (Dentsply, Switzerland) because it has a small dimension with a taper of 0.2 and it has mechanical resistance to torsion and bending during weight-bearing pressure acting on the file.14 To reduce friction between files with root canals walls by using chelation agent (RC-prep®, Premier Dental). Preparation of root canals will produce of organic and inorganic particles. Using a chelation agent will help eliminate an inorganic particles (smear layer) in the root canals.7,8,15 Irrigation solution used in this case was NaOCl 2,5%. Todays, this solution often used in endodontic treatment because the ability to dissolve organic tissue within the root canal, as well as having good antibacterial against microbes within an infected root canals .16,17 Crown-down technique using ProTaper® handuse instrument because the instrument was designed for preparation of obliteration or calcified root canals, with crown-down technique straight access will be achieved, reduces the risk of separated files.18 Medicament interappointment is Ca(OH)2 because it has an advantages of alkaline high, antibacterial activity, as well as having the ability to induce hard tissue deposition.12 After 2 weeks, fistula was absence then obturation can be done. Fistula usually can lost about 5 to 15 days after root canal preparation is done.12 Single cone method
is used to obturate a root canals because the cross-sectional shape of the root canals after preparation using ProTaper® F2 was round so it was not necessary any accesories guttap.19 Patient complaints either subjective or objective lost after root canal preparation is done, this is due to inflammation produced by bacteria and their products has gone.2,3,11,12,20,21 Radiographically taken after control 3 mounth obturation, regeneration of periodontium achieved around the apex. This indicates the process of healing. Healing in this case is less than optimal due to patients not using a denture. Occlusal loading that received of tooth 46 still heavy due to the loss of teeth 45 and 47 and the lack of replacement dentures, thus slightly affecting the periodontium tissue healing process. According to Alan B.C and David T.B, the fourth phase of treatment removable partial dentures in patients that obtaining functional and harmonious occlusion. Harmonious occlusion between the adjacent natural teeth with removable partial dentures are a major factor in maintaining tissue structure.22 Replacement of the old crown restoration will be done until healing periodontium achieved optimally and no mobility again. In this case the endodontic lesions are the primary source of disease with involving periodontium secondary because of tissue healing achieved after root canal treatment is done, it is characterized by disappeared of fistula and reduced depth poket2,3,11,12,20,21 CONCLUSION According to Simon et al, this case is included in the classification of type 2 endo-perio lesions, since the endodontic lesion is the primary source with involvement periodontium tissues secondary. After root canal treatment, tissue healing occurs both pulp and periodontium. It is characterized by disappeared of fistula and pocket depth reduction and regeneration of bone tissue around the apex of the tooth 46. REFERENCES 1. Simring M, Goldberg M. The Pulpal Pocket Approach: Retrograde Periodontitis.; 1964:35:22-48.
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2.
Singh P. Endo-Perio Dilemma: a Brief Review. Dent Res J (Isfahan). 2011;8(1):39-47. Available at: http://www.pubmedcentral.nih.gov/article render.fcgi?artid=3177380&tool=pmcentr ez&rendertype=abstract. 3. Abbott P V, Salgado JC. Strategies For The Endodontic Management of Concurrent Endodontic and Periodontal Diseases. Aust Dent J. 2009;54 Suppl 1:S70-85. doi:10.1111/j.18347819.2009.01145.x. 4. Kumar R, Patil S, Hoshing U, Medha A, Mahaparale R. Non-surgical Endodontic Management of The Combined Endoperio Lesion. 2011;3(2):82-84. 5. Simon JH, DH G, AL F. The Relationship of Endodontic-Periodontic Lesions. J Periodontol; 1972:202-8. 6. Shetty A, Ramachandra VK, Swamy SN, Kaiwar A. Diode Laser Assisted Management of Endo-perio Lesion in Maxillary incisor using LANAP : A Case Report. 12(080). 7. Thomas B, Patidar A, Deosarkar B, Kothari H. Calcified Canals – A Review. IOSR J Dent Med Sci. 2014;13(5):38-43. 8. Luciano W, Tavares F, Carvalho R, Lopes P. Non-Surgical Treatment of Pulp Canal Obliteration Using Contemporary Endodontic Techniques : Case series. 2012;2(1):52-58. 9. Fischer C. Hard Tissue Formation of The Pulp in Relation to Treatment of Traumatic Injuries. Int Dent J; 1974:85;588-598. 10. Amir, Faisal A, Gutmann J WD. Calcific Metamorphosis: A Chalenge in Endodontic Diagnosis and Treatment. 2001;32(Quintessence Int):447-456. 11. Walton R., Torabinejad M. Principles and Practice of Endodontics 3rd edition. 3rd ed. (J S, P R, eds.). W.B Saunders Company; 2002:206-301. 12. Unal GC, Kaya BU. Endodontic treatment of large periradicular lesions with and
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without cutaneous sinus tract: Report of two cases and review. 2011;(1). Review PAA. Periodontal Abscess : A Review. 2013;1(1):13-17. Van der Vyver PJ, Paleker F. Endodontic and restorative management of a lower molar with a calcified pulp chamber. SADJ. 2013;68(10):450-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/246 60419. Singh sandeep, Acharya S R, Ballal V RM. “ Evaluation of the effect of EDTA , EDTAC , RC-Prep and BioPure MTAD on the Microhardness of Root Canal Dentine- An in vitro study .” 2007:35-41. Aubut V, Pommel L, Verhille B, et al. Biological Properties of A Neutralized 2.5% Sodium Hypochlorite Solution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(2):e120-5. doi:10.1016/j.tripleo.2009.09.022. Bosch-Aranda ML, Canalda-Sahli C, Figueiredo R, Gay-Escoda C. Complications Following An Accidental Sodium Hypochlorite Extrusion : A Report of Two Cases. J Clin Exp Dent. 2012;4(3):e194-8. doi:10.4317/jced.50767. Oraru M, Heorghiţă LEG, Ndrei VIA. For Practitioner The Mechanic Canal Treatment Using the Protaper Manual System. 2009;35(2):140-142. Pereira AC. Single-Cone Obturation Technique : A Literature Review. 2012;9(4):442-447. J.I. I, Bakland L K. Endodontics. 5th editio. California, USA: B.C Decker Inc; 2002:236. doi:10.1016/S03005712(96)90011-1. C, Stock, R, Walker, K G. Endodontics. 3rd ed. United Kingdom: Elsevier Mosby; 2004:135-249. Carr AB, Brown DT. Occlusal Relationships for Removable Partial Dentures. In: McCracken’s Removable Partial Prosthodontics. Elsevier Inc.; 2011:242-243.
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Management of root canal treatment and restoration of anomaly left maxillary central incisor by using cold flowable filling system and fiber reinforced direct composite Desy Maulia*; Taofik Hidayat** *PPDGS Konservasi Gigi Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung ** Staf Pengajar Departemen Konservasi Gigi PPDGS Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung
ABSTRACT Background: Anomalies of anterior teeth with idiopathic etiology and large root canal in radiographic examination are common occurrence and disturbing appearance. Many ways and techniques that can be done for root canal treatment and filling, as well as restore the aesthetic function. One of them is the technique by using cold flowable gutta-percha filling system and direct composite restoration. Cold flowable gutta percha filling system is the most frequently used technique of obturation of root canal system, because large root canal can be obturated hermetically, easy, does not require any specialized expensive equipment and short application time. Fiber reinforced irect composite restoration was chosen because it does not require long processing time, and can provide satisfactory aesthetic. Case Report : 19-year-old female patient attended RSGM FKG, Padjadjaran University, complained of teeth #21 has abnormality in shape compared to other teeth. Clinical examination revealed anomalies in teeth #21 and radiographic examination showed a large canal accompanied by abnormalities in periapical. Root canal treatment was performed and filled with cold flowable gutta-percha and restored with fiber reinforced direct composite restoration. Conclusion: Obturation with a cold flowable gutta-percha and direct composite restorations provide satisfactory results and an alternative treatment in clinical anterior crown anomalies with a large root canal. Keyword: Large root canal, cold flowable gutta percha, anomalies of teeth, direct composite, aesthetic.
INTRODUCTION Anomalies of anterior teeth with idiopathic etiology and large root canal in radiographic examination are common occurrence and disturbing appearance. These anatomic changes can occur in the tooth crown, root and root canal.1 There are many acquired and inherited developmental abnormalities that alter the size, shape and number of teeth.2 Root canal morphology is highly complex and has extreme variations. Successful endodontic treatment of this complex infrastructure poses a great challenge in teeth with odontogenic anomalies, which makes the case more interesting. Anamolies may be in shape of the teeth, size or number and it requires additional care to treat these cases successfully.3 Present case report described the management of anomalies teeth imvolved large root canal and anomalies in shape conservatively.
CASE 19-year-old female patient Attended PPDGS Conservation Specialist clinic of the Hospital Dentistry, Padjadjaran University, complained teeth #21 have an anomalies in shape compared to other teeth. The patient also complained pain in teeth #21 7 days ago, and she has been getting treatment and filling but the patient was not satisfied. Patients wanted her teeth treated. Clinical examination revealed anomalies in shape teeth #21, dental caries has reached pulp chamber, percussion and bite test showed a positive response, palpation examination showed a negative response, the condition surrounding tissues was normal and no mobility.
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sodium hypochlorite and 0.9% NaCl were used. The canal was filled with Calcium hydroxide (Calcipex, Japan) as intracanal medicaments and the access cavity was closed with Cavit G(3M ESPE). a b Figure 1a. Labial view of teeth # 21; 1b. Palatal view of teeth #21
Pre-operative radiographic examination of the teeth #21 revealed radiolucency in crown until the pulp chamber. Root canal presence large space and diffuse radiolucency in the apical region. Periodontal ligament space widening around apical two thirds. Laminadura disappeared along the root. Alveolar bone crest in the normal range (Figure 2). The diagnosis of teeth #21 was pulp necrosis with the periapical abscess. The treatment plan was root canal treatment for dental necrosis followed-up with direct composite restorations. The prognosis was good.
Figure 2. Pre-operative radiography
CASE MANAGEMENT The first visit (November 12, 2013), the access cavity preparation was performed on the palatal teeth #21 by using sterile burs and endo access bur (Endo Access Bur, Dentsply). Pulp chamber was cleaned (Figure 3) and placement of Trikresol formalin (TKF) and temporary fillings (caviton, GC). Temporary filling was cleaned and the working length was determined in second visit (November 16, 2013). The working length was performed by using the K-file # 130 (K Files, Dentsply) and apex locator (VDW), the working length of 18 mm was obtained. After this procedure, chemomechanical preparation was done by the circumferential with K-File #30 (Dentsply-Maillefer). For irrigation 5.25%
Figure 3. Access cavity preparation of teeth #21
Third visit (November 28, 2013), the patient complained of pain at the beginning of the application of calcium hydroxide, percussion and bite test still gave a positive response. Rubber dams was placed, temporary fillings was removed then irrigated with 5.25% NaOCl and saline water, dried using Capillary tips and Luer Vacuum Adapter (Ultradent) and paper points, then the application of calcium hydroxide medicaments (Calcipex, Japan) into the root canal and the access cavity was sealed with Caviton (GC). Fourth visit (December 5, 2013) subjective and objective examination was obtained no complaints of pain, percussion, bite test gave negative results. Calcium hydroxide is still wet. Rubber dam was placed, root canals irrigated with 5.25% NaOCl and saline water, dried with Capillary tips and Luer Vacuum Adapter (Ultradent), subsequent application of calcium hydroxide medicaments into the root canal. The access cavity was sealed with Caviton (GC).
Figure 4. Root canal was dried with Capillary tips and Luer Vacuum Adapter (Ultradent)
The intracanal dressing was changed between visits, five months from the initial visit 177
(10th visit). At this visit , subjective and objective examination found no complaints, percussion, bite and palpation test gave negative result. After placement of a rubber dam, temporary fillings was opened, the calcium hydroxide in the root canal was taken. Calcium hydroxide in a dry state, and clean. Root canals irrigated with 5.25% NaOCl and saline water, dried with Capillary tips and Luer Vacuum Adapter (Ultradent). Trial photos was performed with the master cone of gutta percha, created by fusing gutta percha #60 and #70. X-ray radiography showed that the master cone gutta percha was along working length and periapical lesion appeared changed (Figure 5a). Tooth was obturated by using cold flowable gutta percha system (Coltene) dan master cone, access cavity was sealed with SDR (Dentsply) and temporary filling. Radiography examination was performed and revealed hermetic obturation (Figure 5b)
a b Figure 5a. X-ray of trial #21; 5b. X-ray of obturation #21
Figure 6. Gutta Flow Devices
The patient was observed for 1 months through clinical and radiographic examination and the tooth was asymptomatic (May 23, 2014). Periapical radiolucency showed significant changes (Figure 7).
Figure 7 Overview radiography 1 month after the obturation
The restoration was delayed for two month after completing endodontic therapy (July 23, 2014) . The treatment plan was fiber reinforced direct composite restoration. A rubber dam was placed and the existing temporary filling removed. A starter drill was used to initiate removal of the gutta percha by using penetration drill with a depth of 13mm. The post space was created with appropriate size taper drill (Figure 8).
Gambar 8. Fiber Post Angelus and Penetration Drill for Gutta Percha Removal
Root canal was cleaned with 2.5% NaOCl and dried with sterile paper points. Furthermore, the work area was isolated, post was inserted into the root canal to be tested (tryin), then the root canal walls was prepared for cementing. After root canal was irrigated and dried, dual cure resin core built-it fiber reinforced core build-up material (Built-it FR, Pentron) (Figure 9a) was applied to the canal walls (Figure 9b), post and polyethilene fiber was inserted into the root canal (Figure 9c) and light cured was performed with a high power, broad spectrum LED curing light for at least 30 second. Then the post was cut below 2 mm of incisal teeth (teeth reference point #11) (Figure 9d).
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Figure 11 a. Application of etching material on teeth #11 and 21; b. application of bonding material on teeth #11 and #21
(a)
(b)
(c)
Anatomical tooth surface was done with comporoller (Kerr), to minimize the formation of voids in the composite. Finishing and polishing procedures were performed by extra fine diamond bur, polishing disk ( Optidisc, Kerr), rubber and paste for polishing composite (Prisma Gloss, Densply) to make the restoration shiny.
(d)
Figure 9a. Build-it material for cementing the canal wall; 9b. Application to the root canal using a syringe; 9c. A polyethylene fiber and fiber post insertion into the root canal; 9d. Polyethylene fiber and fiber post been cemented and cut in teeth #21. Figure 12. Polishing with paste and rubber polisihing disc
Dental restoration was completed using an incremental technique with composite resin nanofil A1 ( Filtex Z350XT, 3M ESPE ) for teeth #11, and A2 body, D2 dentin and A1 email for teeth #21 ( Filtex Z350XT, 3M ESPE ). a b Figure 13a. Labial view before restoration; b. Labial view after restoration
Figure 10 Preparation of teeth #21 and reshaping intraenamel teeth #11.
Restoration using Z350XT composite (3M ESPE), teeth #21 was etched with 37% phosphoric acid in the labial surface, the core and the incisal, while the teeth #11 in the labial and incisal for 15 seconds, and then etching material was cleaned with water spray, and dried. Bonding material was applied (Adper Single Bond, 3M ESPE), sprayed with a light air pressure and then irradiated with light cure for 20 seconds.
a
b
In the last appointment, (August 05, 2014), subjective and objective examination was performed. Patient was satisfied with the results of the restoration.
Figure 14. Evaluation of restoration in one week
DISCUSSION Anomalies of teeth development are relatively common and may occur as an isolated condition or in association with other anomalies. Developmental dental anomalies often exhibit patterns that reflect the stage of development during which the malformation occurs. For example, disruptions in teeth initi-ation result in 179
hypodontia or supernumerary teeth, whereas disruptions during morphodifferentiation lead to anomalies of size and shape (eg, macrodontia, microdontia, taurodontism, dens invaginatus). The problems range from esthetic concerns that impact self-esteem to masticatory difficulties, teeth sensitivity, financial burdens, and protracted, complex dental treatment.4 The central incisor tooth anomali probably a dens invaginatus case, based on clinical crown and root canal anomalies feature. It has been investigated by Altundal, et.al in his study, the central incisor had morphological anomalies such as crown dilacerations and hypoplasia and radiographic examination revealed the root anomaly of the central incisor.4 Root canal should be well cleaned to prevent re-infection and supported by proper obturation. Re-infection of the root canal system is one of the crucial factors that influence treatment outcomes. In root canal treatment, complete sealing of the root canal system after cleaning and shaping is critical to prevent oral pathogens from colonizing and re-infecting the root and periapical tissues.5 For that reason, obturation to present case, need material with high homogeneity and flowable material, and should be adapted to root canal with a large space. De-Deus et. al advised that the root canal space should be completely and densely filled with a biologically inert material.6 To seal this system, the obturating material must adapt to all the portions of the root canal.7 Gutta-percha and root canal sealer are currently the filling materials of choice, but they can be used in a variety of ways to fill the root canal system. Laboratory studies have shown that guttapercha seals significantly better when used in combination with a sealer.6 One of the most recent technique which uses cold flowable filling system for obturation of the root canal system is Gutta Flow. GuttaFlow is a cold, fluid obturation system that combines sealer and guttapercha in a single material.6 It consists of polydimethylsiloxane matrix highly filled with finely ground guttapercha. Several studies have shown that GuttaFlow® offers excellent flow and satisfactory physical properties according to ISO standards.7
The finely ground gutta-percha powder and the silicone-based matrix are distributed homogeneously after mixing. GuttaFlow has very promising properties because of its insolubility, biocompatibility, post-setting expansion, great fluidity, and for providing a thin film of sealer.6 Gutta- Flow has nano-silver in its composition. Nano-silver is a metallic silver which is distributed uniformly on the surface of the filling. The chemical type and concentration of the nano-silver do not cause corrosion or colour changes in the GuttaFlow. There is sufficient nano-silver in the material to prevent further spread of bacteria and nanosilver is highly biocompatible.6 Restoration clinical anomalies crown can be used by using direct methodes. Because this technique simply, easy, not require long processing time compared with porcelain, and can provide satisfactory aesthetic like porcelain. Vargas suggested aesthetic enhancement of the maxillary dentition can be accomplished using a variety of direct and indirect methods.8 Composite resin procedures enable the clinician to follow a predictable, conservative, and reliable chairside protocol for improving patients smiles.8 The use of resin composite to build anterior indirect restorations is more recent, only in the last few years has research identified materials that offer good polishability, hardness, and wear resistance.9 Halley‟s investigation in 2012 stated that direct composite additions or direct composite veneers have often been heralded as a more conservative alternative to porcelain, and with the advent of microhybrid and nano-hybrid composites, the finishing and polishing of these restorations can rival that of porcelain.10 The tooth preparation used intraenamel reduction only. Ideally, the preparation should be confined to enamel, though Pippin et al1 confirmed the need to remove the aprismatic enamel isles located mainly in cervical areas, and by other authors in anterior teeth at a distance of 0.4 mm from the cementoenamel junction. This is the same area where many clinicians commonly position the finishing line, which is why it is often difficult to obtain a solid bond in this area. According to Caleffi and Berardi, enamel removal should not exceed 0.3 180
to 0.6 mm, depending on teeth dimension, shape, and pathosis. According to Ferrari et.al, the enamel thickness and extension in the cervical area of anterior teeth do not allow a 0.5-mm reduction without dentin exposure.9 Regardless of whether a porcelain (indirect) or direct resin technique is used, the ultimate goal is to produce a restoration that is indistinguishable from the rest of the dentition. If this goal can be achieved with a more conservative, direct resin restoration, then the patient will receive the best possible treatment.11 CONCLUSION
8. Vargas. Conservative aeshetic enhancement of the anterior dentition using a predictable direct resin protocol. Pract Proced Aesthet Dent 2006;18(8):501-507. 9. Mangani, et. al. Clinical approach to anterior adhesive restorations using resin composite veneer. The European Journal of esthetic dentistry, 2007;2(2). 10. Halley. Direct composite veneers–an aesthetic alternative. Private Dentistry, 2012; 1 11. Peyton. Direct resin veneers using Esthet X micro matrix restorative. Sullivan-Schein Dental. 2004
Obturation with a cold flowable guttapercha and direct composite restorations provide satisfactory results and an alternative treatment in anomalies anterior clinical crown with a large root canal. Consideration of materials and techniques for this cases is needed to get results was expected by the operator and the patient. REFERENCES 1. Faria, et. al. Endodontic treatment of dentalformation anomalies. Rev Odonto Cienc, 2011 2. Charles Dunlap, DDS. Abnormalities of Teeth. 2004 3. Geethapriya, et.al. An Unusual Case Report of Maxillary Lateral Incisor Fused with a Supernumerary Tooth. Biosciences Biotechnology Research Asia, 2014; 11(1): 99 4. Altundal, et.al. Severe dens invaginatus in the maxillary central incisor. OHDMBSC, 2003; 4(6) 5. Bouillaguet, et.al. Long-term sealing ability of Pulp Canal Sealer, AH-Plus, GuttaFlow and Epiphany. International Endodontic Journal, 41, 219–226, 2008 6. De-Deus G, et.al. The sealing ability of GuttaFlowTM in oval-shaped canals: an ex vivo study using a polymicrobial leakage model. International Endodontic Journal, 2007; 40, 794–799, 7. Kumar, et.al Evaluation of guttaflow and guttapercha in filling of lateral grooves and depressions in a single rooted tooth- An in vitro study. Endodontology. 181
Indirect composite onlay using fiber reinforcement technique on second molar mandibula Fadli Azhari *; Grace Virginia Gumuruh ** * Participants PPDGS Conservative Dentistry Faculty of Dentistry, University of Padjadjaran, Bandung ** Lecturer of Department of Conservative Dentistry, Faculty of Dentistry, University of Padjadjaran, Bandung
ABSTRACT Introduction. Tooth structure remaining after root canal treatment will greatly influence the design and the selection of restorative materials that will be used to restore the function of the teeth in the oral cavity. Onlay restorations using fiber reinforcement technique is an alternative to creating a cuspal coverage indirect restoration that can withstand chewing power. Case. A woman 44 years require a restoration on the tooth after root canal treatment 47. Clinically visible large occlusal cavity of 47 was visible with the loss of the entire distal wall extended to the buccal, reaching the gingiva. The thickness of the remaining tooth structure on the lingual, mesial and buccal portion is still quite adequate. Indirect composite onlays using techniques of fiber reinforcement has been selected as the restoration on the tooth 47 to replace lost tooth structure. Discussion. The design of cuspal coverage restoration on indirect composite onlays using fiber reinforcement techniques should provide enough space in the cavity for fiber and composite sheets were used. Suffix proper preparation and the selection of the size and number of pieces of fiber that will be used as well as the location and direction of its placement needs to be adjusted to the space available. Post curing is done to produce a composite by polymerization of restorations that perfectly. Conclusion. Indirect composite onlays using fiber reinforcement techniques to construct an indirect cuspal coverage restoration, able to replace lost tooth structure in order to form a unity with the remaining tooth structure so that it can withstand the load of chewing. Keywords: Indirect composite onlays, fiber reinforcement, cuspal coverage indirect restoration
Introduction Endodontic treatment failure can occur due to improper restoration elections, particularly with regard to the type of restoration that is selected. Failure restoration is often the case, among others, leakage edges, loose and break of restoration or tooth.1,2 Selection of dental restorations after root canal treatment is necessary to consider many things, including: 1,2,3 1. Structure of remaining teeth 2. The function of the teeth 3. The position or location of the tooth Tooth structure remaining on posterior teeth due to the access cavity and extensive of cavity often need cusp protection. Composite onlay is one alternative restoration option after
the root canal treatment that can cover the cusp on posterior teeth, so the teeth can be a coherent whole to withstand the load of chewing. Making onlays can be done in a way; direct, semidirect and indirect technique. Direct and semidirect technique can be done in just one visit, while the indirect technique requires a minimum of two visits. 1,2,3,5,7 The use of onlay composite reinforced with fiber (fiber reinforcement) have been widely used in recent years. Research by Mozartha M, et al (2010) showed that the use of fiber in the restoration can increase the flexural strength. The strength of the composite onlay restorations is influenced by the strength of the composite coating the adhesion between the fiber and composites.4,10,11 Indirect composite onlays with fiber reinforcement technique be the choice in this
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case because of the placement of fiber capable of supporting the power of the composite that replaces lost tooth structure and post-curing action can increase the strength of the resulting composite onlays. In the indirect technique enabled operators to work more closely and working time models are available relatively more..6,10,11,12 Another aspect that contributes to the strengthening of the fiber is the thickness and shape of the woven fiber. The form can be woven polyethylene fiber unidirectional like strands (strands) or multidirectional form of woven or braided. 4
Figure 2. (A) Before root canal treatment, (B) After root canal treatment Case procedure
The first visit (February 5, 2014) Based on the information given, the patient opted for indirect composite onlays made as the final restoration. Impresion was made with double impression technique using materials polyvinylsiloxane (Exaflex, GC) was performed after the preparation of onlays.
Figure 1. (A) Woven polyethylene fiber, (B) Braided glass, (C) Woven glass fiber, (D) Glass fiber. (http://openi.nlm.nih.gov/detailedresult.php?img=3081502_ LJM-1-073-g001&req=4) Case
A woman 44 years require a cuspal coverage restoration on the tooth 47 after root canal treatment; asymptomatic teeth. Clinically visible large occlusal cavity of 47 was visible with the loss of the entire distal wall extended to the buccal, reaching the gingiva. The thickness of the remaining tooth structure is still quite adequate (± 3mm). Diagnosis of tooth 47: non-vital teeth after root canal treatment. Prognosis: Good
Figure 3. Impression materials. Light-Body. (Exaflex, GC)
(A) Heavy-Body, (B)
Working model was made using dental stone type III (Moldano Bleau, Heraeuz Kulzer) and then the model is used for build the indirect composite onlay restorations. Onlay restorative material consist of fiber reinforcement (Construct, Kerr) and nanohybrid composite resin (Premise Indirect, Kerr).
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measuring tool). In this case use 2 sheets of fiber (2 mm wide), placed cross.
Figure 4. Work model. (A) Occlusal view, (B) Buccal view
Figure 8. Determine of fiber length (A) Bukolingual measurement, (B) Mesiodistal measurement
Figure 5. Composite resin Premise Indirect (Kerr)
Figure 6. Fiber reinforcement kit (Construct, Kerr)
The build procedure of indirect composite onlay: 1. Outline The outline was made using a pencil to clarify the lines of onlay preparation.
3. Application the sealer Materials sealer applied over the surfaces of the teeth on the working model for seal pores contained in dental stone.
Figure 9. Aplication the sealer
4. Application the separator Rubber-based separator material is applied by using a brush to prevent the attachment of composite materials to model and facilitate the release of onlay.
Figure 7. Outline (A) Lingual view, (B) Occlusal view
2. Determination of fiber length Measurement of fiber length to be used according to the length and width of the room is available at the cavity to the cusp would be covered with composite (paper used as a
Figure 10. Application the separator
5. Cutting the fiber Cutting is done using pliers / scissors specifically so as not to damage the fiber.
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Figure 11. (A) Pieces of fiber, (B) Specifically pliers
6. Application of resin to fiber The entire surface of the fiber lubricated with resin using the applicator as a medium to increase the adhesion between the fiber and the composite.
Figure 12. The entire surface of the fiber lubricated with resin
Figure 14. Indirect composite onlay restoration on work model
9. Post curing Curing is done for 20 seconds on each surface using LED light cure (Valo, Ultradent), then were post cured at a temperature of 120 C for 20 minutes. 10. Finishing and Polishing Finishing is done by using a finishing disc (Optidisc, Kerr) for smoothing rough surfaces, followed by polishing to give a glossy look to the onlay (Jiffy polishing, Kerr).
7. Placement of fiber Composite resin was applied to the base of preparation in working model, then the fibers placed cross and each placement cure by LED light cure (Valo, Ultradent) for 20 seconds. Figure 15. Finishing and polishing tools. (A) Optidisc, (B)Jiffy polishing (Kerr) The second visit (February 14, 2014)
Figure 13. Placement the fiber lubricated by resin. (A) Fiber in buko-lingual, (B) Fiber in mesio-distal
8. Building the onlay Onlay is done by the incremental technique using composite resin nanofill (Premise indirect, Kerr).
Temporary fillings in the teeth 47 is opened and cleaned, try-in procedure to check the occlusion using articulation paper (40 μ, Bausch). Teeth were isolated using cotton rolls in the buccal and lingual to prevent saliva contamination. 37% phosphoric acid was used as an etching for 20 seconds and then rinsed with water and cleaned with a spray of wind. Bonding is applied to the tooth surface and spray until it looks evenly distributed, then light cure for 20 seconds. The inside (intaglio) onlay composite material was etched with acid hidrofluoric 9% 185
for 20 seconds to get microporosity on the surface of the composite. Silanes are applied evenly on the surface of the intaglio for 20 seconds, then the bonding material and light-cured for 20 seconds. Luting material used is a dual cure resin cement (Biscem, Ultradent) were placed on the entire surface of the intaglio, then place on the teeth carefully, until onlays are in the right position. Cement excessive cure for 3 seconds and the proximal portion is cleaned with the explorer dan dental floss, Furthermore, the entire surface of the onlay in light cure for 20 seconds.
Figure 16. Onlay has been placed on the teeth Third visit (February 26, 2014)
Control was done on the third visit. Subjective examination showed no complaints. Objective examination, percussion test was negative, Pressure test was negative, mobility was negative, no abnormalities in the tissue around the teeth, no premature contact, adaptation of restoration was good, the tooth was functioning properly and the patient was satisfied.
Figure 17. Control was done Discussion
Endodontically treated teeth often leave minimal tooth structure, while on the other hand should the tooth can be restored to provide coronal coverage and adequate retention, to ensure success. Many factors must be considered in the selection of the final restoration after endodontic treatment. These factors include the amount of remaining tooth structure, occlusal function, in contact with the opposing teeth and tooth position in the arch. In this case composite onlay restorations has been selected after root canal treatment. 1,2,3 The ideal restoration after root canal treatment must meet the requirements, namely: 1,2,3 1. Covering cusps (cuspal coverage) 2. Protect the remaining tooth structure 3. Have adequate retention 4. Have resistance to be able withstand load of chewing Onlay is a type of restoration that can be used to restore the function and form of the posterior teeth that have been damaged; includes missing one or more cusps. Endodontically treated teeth requires support both retention and resistance intrakoronal and ekstrakoronal.1,2,6,7 Cuspal coverage is an option on the teeth after endodontic treatment because according to McComb D (2008), the placement of restorations with the involves whole cusp can improve resistance to fractures in the teeth. 186
Distribution of occlusal forces to be distributed over the cusp of the teeth into a single entity to receive the masticatory load, thereby increasing resistance to fractures.7
Figure 18. Distribution of load masticatory. (A) Distribution of load masticatory on restoration that not involving whole cusps, (B) Cusp fracture occure not involving cusp coverage, (C) Load of masticatory distributed in all part of teeth
Premise Indirect composite resin has been selected as restorative material onlays, being able to combine nanotechnology with sub-micron particles, so that it can generate good strength onlay restoration and polishing results are better.6 In this case the fiber is placed from buccal wall to the base of the cavity to the lingual cusp and from mesial cusp to distal wall as a wall reinforcement and increase resistance to fracture due to the use of fiber can improve the flexural strength of restorative materials.4,10 Rocca GT et al (2012) reported that in addition to increasing the strength of the restoration, a combination of glass fiber with resin composite materials can prevent fractures in restoration because fiber layer can act as a stress breaker and can stop the propagation crack.11 Post curing action can increase the bonding chain that results in an increase in the degree of conversion of composites so as to allow free radicals and methacrylate groups to form a covalent bond. It has been proven that the composite hardness is associated with increased the degree of
conversion.12 Post curing by heating at temperature of 120o C for 20 minutes on indirect techniques can improve the mechanical properties of composite resins and relieve stress during polymerization. Fruits et al (2006) in his study mentioned that indirect techniques can reduce the occurrence of microleakage in composite restorations. The occurrence of stress during the polymerization process can lead to the formation of a gap between the restoration and the tooth surface will lead to microleakage. Use of luting cement at the time of adaptation to the tooth restoration is able to eliminate the stress so as to reduce the formation of microleakage at teeth.9 Conclusion Indirect composite onlays using fiber reinforcement techniques to build a cuspal coverage restoration was able to replace lost tooth structure in order to form a unity with the remaining tooth structure so that it can withstand the load of chewing. Suggestion Full coverage of the postendodontic restorations on posterior teeth need to be designed to get the optimal resistance.
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REFERENCE 1. Goodacre CJ, Baba NZ. Restoration of Endodontically Treated Teeth. In: Ingle JI, Bakland LK, Baumgartner JC. Ingle‟s Endodontics. 6th ed. Ontario: BC Decker; 2008. p 1431-1473. 2. Dietschi D, Bouillaguet S, Sadan A. Restoration of the Endodontically Treated Tooth. In: Hargreaves KM, Cohen S. Pathways of The Pulp. 10th ed. Maryland: Mosby Elsevier; 2011. p 777807. 3. Garg N, Garg A. Textbook of Endodontic: Restoration of Endodontically Treated Teeth. 2nd ed. New Delhi: Jaypee Brothers Medical Pub; 2010. p 391-407. 4. Mozartha M, Herda E, Soufyan A. Selection of Resin Composite and Fiber to Increase Flexural Strength of Fiber Reinforced Composite. Jurnal PDGI. 2010; 59(1): 29-34. 5. Shorey RD. Indirect Composite Resin Restoration: Single Appointment Procedure. In: Dentaltown.com. 2005. Available at : http://www.dentaltown.com/images/dent altown/magimages/nov05/dtnov05pg38. pdf. Accessed April 28,2014. 6. Penn D. Indirect Composite Inlays and Onlays. Available at: http://www.scdlab.com/download/cpd/ar ticles/clinical/4_9.pdf. Accessed April 28, 2014. 7. McComb D. Restoration of the
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Endodontically Treated Teeth. Canada: Royal College of Dental Surgeon of Ontario; 2008. Available at : https://www.scribd.com/doc/168456130/ PEAK-Restoration-of-theEndodontically-Treated-Tooth. Accessed April 28, 2014. Lowe RA. Premise Indirect. [http://www.dentalartslab.com/]; 2009. Available at: http://www.dentalartslab.com/wpcontent/uploads/2011/08/PremiseIndirect-Tech-Sheet.pdf. Accessed September 8, 2014. Fruits TJ et al. Mickroleakage In The Proximal Walls Of Direct And Indirect Posterior Resin Slot Restorations. Oper Dent J. 2006; 31 (6):719-27. Shivana V, Gopeshetti PB. Fracture Resistance Of Endodontically Treated Teeth Restored With Composite Resin Reinforced With Polyethylene Fibres. MedIND J. 2012; 24(1): 71-77. Rocca GT, Rizcalla N, Krejci I. FiberReinforced Resin Coating For Endocrown Preparations: A Technical Report. J Operative Dentistry. 2012; 38(1):1-7. Poskus LT, Latempa AMA, Chagas MA, Silva EM, Leal MPS, Guimaraes JGA. Influence of Post-Cure Treatments on Hardness and Marginal Adaptation of Composite Resin Inlay Restorations: An In Vitro Study. J Appl Oral Sci. 2009;17(6): 617-22
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Crown fracture management of maxillary right central incisor with prefabricated direct composite veneer (componeer): a case report Danica Anastasia*; Irmaleny** * Peserta PPDGS Konservasi Gigi Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung ** Staf Pengajar Departemen Konservasi Gigi PPDGS Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung
Background: Fractures of the anterior teeth are common and can interfere with a person's appearance. There are many ways that can be done to restore the teeth with aesthetic problem, such as a veneer. Componeer as a direct veneer restoration can be used by easy application, but does not require a long working time, and give a better aesthetic. Case: A 28-year-old female patient came to the Department of Conservative Dentistry and Endodontics, University of Padjadjaran, Bandung, with major complaint of her maxillary right central incisor were broken in an accident while riding a bike. The tooth has been treated, and then restored with direct composite veneer (Componeer). Conclusion: Componeer is the best alternative for restoration of endodontically treated teeth with fracture, because the costs are economical, short working time, and has a good aesthetic qualities. Keywords: Direct composite veneer, Componeer, Dental fracture, Aesthetic
INTRODUCTION
CASE REPORT
The most common causal factors of fracture in the permanent dentition are injuries caused by falls, contact sports, car crashes, or foreign bodies hitting the teeth.1 Management of patient‟s with anterior tooth fracture provides great challenge to the clinicians both from a functional and an esthetic perceptive.2 Treatment objectives may vary depending on the age, socio-economic status of the patient and intraoral status at the time of treatment planning.2 The choice of restoration for an endodontically treated tooth is dependent on the amount of coronal tooth tissue left.3 There are various treatment modalities for restoration of fractured teeth like composite restoration, fixed prosthesis, reattachment of the fracture fragment (if available) followed by post and core supported restorations, or with the newest technique: veneer.2,3 Veneer is an aesthetic restoration technique, divided into two main categories; indirect and direct. Indirect veneer was made extra oral and attached to the teeth with resin cement (for example, porcelain veneers). Direct veneer was made directly in the mouth, usually using one or more layers of resin composites.3
A 28-year-old woman came to the Department of Conservative Dentistry and Endodontics, University of Padjadjaran, Bandung, reporting a dental fracture of the maxillary right central incisor. Dental history revealed that she had a trauma as the result of an accident while riding a bike few weeks earlier. The tooth had been treated with endodontic treatment. The intraoral examination showed that the tooth 11 had a complicated crown fracture in the half incisal. Thermal and Electric Pulp Tester showed no response (Figure 1).
Figure 1. Clinical aspect of the traumatized central incisor.
Radiographic examination showed crown fracture in the half incisal of tooth 11, root canal had been obturated, and there is no abnormalities in the periapical area (Figure 2).
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Figure 2. Radiographic examination of maxillary right central incisor.
The tooth was diagnosed with endodontically treated teeth, and direct composite veneer using Componeer (Coltene/Whaledent, Germany) was selected as final restoration. The initial phase produce the study and working models with dental stone. Confirm Componeer desired size with contour guide and a “L” size was selected (Figure 3).
and inclination achieved, the working area was isolated with a rubber dam, and then start the prepared tooth 11. Depth marker diamond bur are used to guide the depth of preparation, followed by a two-grid diamond bur on the entire surface of the tooth. Labial surface reduced to fit the normal alignment of teeth. Labial surface were etched with 30% phosphoric acid for 15 seconds, then rinsed, and bonded (Adper Single Bond Plus Adhesive, 3M ESPE, USA), then sprayed the air slowly and irradiated for 10 seconds. Bonding was applied to the inside of the shells as well as a thin layer of composite (Z350XT, 3M ESPE, USA). Componeer attached to the tooth that has been prepared and adjusted its inclination with tooth 21, and then irradiated for 10 seconds (Figure 5).
Figure 5. Final result after bonding Componeer to the tooth 11.
Figure 3. Componeer contour guide – Preoperative evaluation tooth 11.
Mock-ups are made on a working model using the composite (Figure 4). Selection of colors using the shade guide (VITAPAN), and A2 color was selected.
Polishing with Sof-Lex Extra Thin Contouring and Polishing Discs (3M ESPE, USA) to achieve the shape and inclination corresponding to tooth 21 (Figure 6).
Figure 6. Final situation.
Three weeks after treatment, the patient came back and still satisfied with her tooth. Figure 4. Mock-ups on working model.
DISCUSSION
Componeer was prepared according to the size of the original tooth, reducing the edge using a super fine bur. After the appropriate size
Banerjee (2003) and Dietschi (2011) stated that direct composite veneer present an obvious potential in the following indications: 190
non vital, discolored teeth; large restorations/decays with loss of natural tooth buccal anatomy/color, severe/extended tooth fracture, and extended tooth dysplasia or hypoplasia.4,5 Direct composite veneer was the right choice in this case because, compare to porcelain veneer, it usually need less reduction of the dental tissue (minimal invasive technique), the treatment can be completed in only one session, not abrasive to the opposing tooth, and easy to perform repairs in case of damage.6,7 The use of contemporary composite resin with the layering technique allows restorations with nuances and shades of color similar to the adjacent dental structures. However, to achieve good results, this technique requires knowledge of field of the restorative material, knowledge of dental anatomy, and the manual skills to reproduce all the characteristics of the tooth.8,9 Grenigt (2011) suggest that the veneers has a difficult colour composition to create various surface structures. There are also disadvantages associated with the direct use of composite. Some examples are wear-and-tear and degradation of the material over the course of time, loss of surface shine and cohesive cracks in the material.8,10 In this case, Componeer was selected as the restoration for tooth 11 that fractures can overcome the deficiencies that occur in conventional techniques. Componeeer‟s are polymerized, prefabricated nano-hybrid composite enamel shells which combine the advantages of direct composite restoration with the advantages of laboratory fabricated veneers. Industrial fabrication ensures excellent homogeneity and stability of the composite shells.11 Also, the outside (buccal side) of the shells are smooth and fully hardened. Because these shells are only 0.3 mm thick, they can also be applied to the teeth with minimal filling.10 Furthermore, its physical properties are remarkably similar to the tooth layers we are replacing. The compressive strength of enamel is 384 MPa, the compressive strength of Componeer is 392 MPa. The flexural strength of dentin is 165.6 MPa, the flexural strength of Componeer is 127 MPa.7 Based on these numbers, it can be said that Componeer is quite capable of functioning like a natural teeth.
CONCLUSION Componeer is the best alternative for the restoration of teeth after endodontic treatment with fracture, because the costs are quite economical, short working time, and has the aesthetic quality and good physical properties. SUGGESTION Need to be more selective in choosing cases for restored teeth using Componeer. REFERENCE 1.
2.
3.
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Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. St. Louis, Missouri: Mosby Inc. 2007; 28 – 31. Rajavardhan K, et al. A Novel Technique in Restoring Fractured Anterior Teeth. Journal of Clinical and Diagnostic Research. Feb 2014; Vol-8(2): 244 – 245. Chong BS. Harty‟s Endodontics in Clinical Practice. 6th Edition. London: Churchill Livingstone Elsevier. 2010; 271. Banerjee A, Watson TF. Pickard‟s Manual of Operative Dentistry. 8th Edition. New York: Oxford University Press Inc. 2003; 128. Dietschi D, Devigus A. Prefabricated Composite Veneers: Historal Perspectives, Indications and Clinical Application. The European Journal of Esthetic Dentistry. 2011; 6: 2 – 11. Albers HF. Tooth-Colored Restoratives. Principles and Techniques. 9th Edition. London: BC Decker Inc. Hamilton. 2002; 239. Tam C. Semi-direct Application of a Prefabricated Composite Veneering System in The Smile Design of a Post Trauma Case. User Report – Componeer. Oct 2012: 1 – 6. Peyton JH. Direct Restoration of Anterior Teeth: Review of The Clinical Technique and Case Presentation. Pract Proced Aesthet Dent. 2002; 14(3): 203 – 210. Anchieta RB, et al. Recovering The Function and Esthetics of Fractured Teeth Using Several Restorative Cosmetic 191
Approaches. Three Clinical Cases. Dental Traumatology. 2011; 1 – 7. 10. Gresnigt MMM. Minimally Invasive Treatment Method is The Deciding Factor – Composite Veneers. User Report –
Componeer. May 2011: 1 – 5. 11. Besek M. The Great Leap Forward in Front-Tooth Restoration. User Report – Componeer. May 2011: 1 – 4.
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Make Over The Teeth, Make Over The Performance By Componeer Irmaleny Lecturer, Conservative Dentistry, Padjadjaran University,Bandung Email:
[email protected]
ABSTRACT Having a beautiful smile which is supported by healthy and beautiful teeth is an everyone‟ wishes. To achieve restoration with good aesthetic is not easy because necessary skill in tooth color selection and formation of anatomy of tooth. Componeer as a new technique in restoring anterior teeth can overcome the aesthetic problems. This case report discusses the aesthetic dental restoration 13, 12, 11, 21 and 22. Base on anamneses of the patient, it is known that discoloration/color change that occurs in his teeth as a result of the influence of drugs consumed in childhood so that the tooth color be darker and anatomical of the tooth is not good. There is diastem between the right maxillary central Insisive and left. In addition there are few caries in mesial and distal on the anterior maxillary teeth and there is less aesthetic composit restoration. Tooth 24 with caries under gingival has been extraction, then all of the teeth was restored by componeer, With the componeer, restoration has more aesthetic that can be accomplished rapidly and easily, and give the best form and color so can make change the appearance of being better. Keywords: Componeer, Aesthetic, Discoloration
INTRODUCTION Everyone wants the teeth look white with the good appearance. The good appearance is very important because it can improve ones selfconfident. There are many things that can disrupt aesthetic to the teeth like a discoloration. Discoloration teeth was caused by using antibiotic drugs during pregnancy and during its growth of teeth within certain limits can be overcome by doing the act of bleaching or can also by making craown of a tooth. However, the procedure of bleaching is not usually gives satisfactory results. Beside that, making tooth crown requires removal hard tissue a lot. It is contrary to minimally principle intervention. To overcome the foregoing can be used componeer. The restoration of using componeer first introduced in Cologne, Germany in 2011, and is currently widely used by the dentist. 1 As a new method in terms of anterior teeth aesthetic restoration, Componeer can be an alternative for patients whose teeth need aesthetic without need removing a lot of hard tissue. 2 Componeer becomes a new challenge world restoration dentistry in creating a satisfying aesthetic composition. Componeer (Coltene/Whaledent AG) is a material polymerized, in form of layer (shell) enamel
composite nano hybrid that combines the advantages of composite restoration direct and artificial veneer fabricated. A thin layer of veneer has range from 0,3 mm, does not require much tooth tissue disposal and can provide results in the preparation dental hard tissue ideally. 3 Some of the advantages the use of componeer is a restoration can be done easily, resulting in a restoration form more aesthetic, and can reduce maintenance time. This case report discussed the use of componeer to solve the problem aesthetic of the teeth in order to achieve the perfect aesthetic to the anterior teeth. CASE A female patient aged 43 years came to the private dental clinics have complained throughout the color darker teeth and would like to change the color whiter. In addition, there are several fillings in front teeth colour is not the same as an existing tooth colour. There are gaps between the two of his fronth teeth caused the patient was not confident with his performance. Patients want his teeth bleached for better appearance and performed the tooth gap closure so that can increase his confidence (figure 1).
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Figure 1 Clinical Photograph of The Teeth
CASE MANAGEMENT Case management in these patients was done in one visit to the restoration of the five anterior maxillary teeth 13, 12, 11, 21, and 22. The first therapy was extraction on tooth 24 with caries under the gums on the palatinal and the patients were given oral analgesics. After the bleeding stopped, then started to work on componeer. The first step is to conduct an examination of the anterior teeth condition (Figure 2 and Figure 3).
Figure 2 Clinical Condition Of Anterior Teeth from left
the appropriate componeer by componeer counter guide. Transparant bluish color guide makes it easy to choose the form of componeer which corresponds to the contour of the teeth and can be selected according to the anatomical shape. The type of the selected componeer are componeer enamel Bleach. The teeth were preparated for composit veneer restoration. The teeth requires only minimally intervention because of thin componeer. Preparations carried out in succession by starting work on the anterior teeth 11 and 21 (Figure 4).
Figure 4 Veneer Preparation on tooth 11 and 21
After preparating the tooth, etching procedure then bonding applied and curing by using LED Unit. Componeer was taken in a desired position using the same material componeer with material componeer use componeer holder (holdres) with bearing on end for holding componeer when applied to the componeer. The final shape of the teeth perfected using componeer MBCOMPONEER ON TOOTH 21 and 22, Instrument modelling MB 5, the tip of the tool instrument was straight very thin and sharp so that easy in design, and will produce a good design because it can rotate during treatment. Next componeer placer is used with an emphasis on light componeer to align and create the position of veneer right and wthout slippage. After that followed the restoration of the teeth on 22 with the same steps as for the teeth 11 and 21 (Figure 5).
Figure 3 Clinical Condition Of Anterior Teeth from Right
The next step is the determination of the exact tooth colour and the tooth size selection of 194
Figure 5 Placement Componeer For Teeth 21
The next procedure was restoring teeth 12 and the last was restoring teeth 13 (Figure 6).
Figure 6 Placement Componeer For Teeth 12 and 13
After all componeer was mounted, the teeth was polished (Figure 7).
Figure 7 The Final result of The Componeer
DISCUSSION In this case, componeer was choosen as alternative in tackling the problem aesthetic dentistry because it can overcome the discoloration happens on the teeth and can close a diastema of anterior teeth in the upper jaw. Discoloration of the teeth due to the consumption of antibiotics, including the bad category so that can not be do bleach. Using the componeer enamel type bleach then the discoloration can be solved. The second type of componeer is a transparant enamel on the teeth can be used without discoloration. 1
Another consideration, the outermost layer of the componeer enamel is nanohybrid a polymerize composite materials which combines the advantages of composite restorations and direct artificial veneer factory. The advantages of direct composite veneer is require less composite material, and restoration can be completed in just one visit .3 Artificial direct veneer is a thin layer about 0,3 mm, so the removal of dental hard tissue less. Thus enabling the preparation of dental hard tissues is minimum (minimally invasive techniques.2,3 Different with technique direct free hand bonded composite resin veneer, componeer having an excess such a surface, texture and form teeth can be made based on the hope without removing the quality of its surface componeer can also be used to extend teeth insisif, close teeth discoloration, close diastem, and restore form aesthetic teeth. 1 Thus componeer is a restoration that can be overcome the aesthetic in this case. Componeer as a new method in the aesthetic restoration world, handling is fairly simple, just need a little adjustment surface labial only. 2,3 In this case restoration of anterior teeth was made on five anterior teeth. Componeer in one visit because not complicated and Gresnight said that the reduction of the labial slightly so it takes a little restoration materials, and can be completed in just one visit only.4 The result of the componeer restoration in this case can satisfy the patient, and the patient‟s appearance looks better. There are benefits afforded componeer as it does not cause pain in patients, do not need anesthesia procedure, no laboratory techniques cost, can be done easily and efficiently, fast, guality of the restoration has a perfect aesthetic result, quality of the edge and surfaces of restoration has good quality, can reduce stress on the patient, the optimal adjustment in color selection of the teeth, the tooth structure and anatomy of the tooth.2,3 According to Besek (2011) Componeer is an ingredient that already available, factorymade (prefabricated), made of composite layers of nanohibrida, increase the marginal adaptation, can be bonded with composite, preventing air into restoration because made by machine, 195
homogenouse, can be made thinner that is only 0,3 mm.5 Componeer has a good hardness as a restoration because componeer is derived from the composite nanohybrid and attached to the surface of the tooth using the same composite as well, so the term restoration monoblock. The restoration monoblock of the tooth cause componeer has a very high hardness againts fracture and simultaneously be reapairs.6 Componeer are used as material for the restoration of anterior teeth for aesthetics in this patients give advantages for patients and dentists because it is more economical, and more aesthetic, and facilitate in attaining a perfect aesthetics. Componeer are used as material for the restoration of anterior teeth for Aesthetics in this patient. This is in accordance with Ruscher (2011) that by using componeer for anterior tooth restoration, makes it easy to achieve a more aesthetic restoration results and can easily be performed by each operator.7 RESULT Componeer can become choice care in overcome aesthetic because give satisfies and can be easily, not requiring much time in forming anatomy and the surfaces the teeth, and no complicated preparation.
SUGGESTIONS In the case tooth discoloration that cannot be overcome by bleaching and a diastema on the anterior teeth, should use componeer to acquire aesthetic desired. REFERENCES 1. www.componeer.info 2. Wong T. A Perfect Complement to the Aesthetic Dental Practice. User ReportComponeer. July 2012: 1-4. 3. Gresnight M. Minimally invasive treatment method using composite veneers. Dental Asia. March/April 2012: 28-31. 4. Gresnight M. Minimally invasive treatment method using composite veneers. Dental Asia. March/April 2012: 28-31. 5. Besek M. The Great Leap Forward in FrontTooth Restoration. User Report-Componeer. May 2011: 1-4. 6. Tam. Semi-direct application of a prefabricated composite veneering system in the smile design of a post-trauma case. User Report-Componeer. Oct 2012:1-6. 7. Ruscher G. Direct Restoration of Lower Anteriors with Componeer. User ReportComponeer. June 2011:1-3.
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The treatment perforation bifurcation using mineral trioxide aggregate (MTA) in the lower left molar tooth case report Sulistianingsih*, Milly Armillia** * Students PPDGS Conservative Dentistry ** Lecturer Department of Conservative Dentistry Faculty of Dentistry, University of Padjadjaran , Bandung**
ABSTRACT Furcation perforation can occur on multiple rooted teeth due to surgeon error if the surgeon lacks understanding of root canal anatomy (iatrogenic). The perforation of the furcation can be a line of communication between the root canal and the periodontal tissues. A 44 year old, female patient is referred from the Hospital Clinic of Dentistry Student Conservation UNPAD with perforations on the base of the tooth pulp chamber 36. The radiographic examination shows a perforation in the base area of the pulp chamber. The treatment implimented was as follows; first, the length of the procedure was determined, then a biomechanical preparation of the root canal, followed by the MTA application area perforations, then a root canal medicaments with calcium hydroxide, a root canal filling, and lastly indirect composite onlay restorations on tooth 36. In conclusion, the application of MTA in the furcation perforation area resulted in satisfactory closure and repair of the tissue in the furcations. Keywords: furcation perforation, Mineral trioxide Aggregate (MTA)
Introduction One of the accidents that occur during endodontic treatment is perforation. 1 Perforation may occur at the base of the pulp chamber and root canals. Perforations on the base of the pulp chamber occurs when looking orifice or drilling in the wrong direction, whereas the root canal perforation occurred at the time of preparation for the installation of post. 1,2 Perforation is defined as a communication path between the root canal system with the teeth or the supporting tissues of the oral cavity.3 Perforation treatment should not always be done with surgery, replanted intentional or revocation. Actions can be done conservatively. The decision to take action, surgical or nonsurgical treatment and prognosis of the success of the treatment, depends on the location, size, and time of occurrence.4 Some of the material used as a covering for the perforation, of which is zinc oxide eugenol, amalgam, calcium hydroxide, glass ionomer cement and composite resin.4 The ingredients for the perforated cover should have no toxic properties, insoluble (non-absorbable), radiopaque, bacteriostatic or bactericidal, and good sealing abilty. 5 In addition, the material also has the ability to heal and reconstruct the bone (osteogenesis) . 6,7 In 1993, Torabinejad
and colleagues developed materials, Mineral trioxide Aggregate (MTA). MTA meets all the criteria as cover material for the perforation.7 Procedures for Cases A female patient, age 44, came to the clinic of the Hospital Dental Conservation PPDGS Sekeloa referral of Conservative Dentistry Student Clinic UNPAD, with complaints of her left lower teeth hurting and the pain not ceasing during the treatment. Good general health condition and history of systemic diseases is undeniable. During the intra-oral examination of tooth 36, temporary fillings and teeth sensitivity to percussion and pressure was found; There was no unsteadiness (Figure 1).
Figure 1. The Clinical Dentistry 36.
Radiological examination showed the crown radiopaque picture as patches to the pulp chamber. The radiolucent area at the base of the 197
pulp chamber shows the area of perforation. There were two roots; they were straight and widened at the periodontal membrane on 1/3 of the apical . The lamina dura interrupted at 1/3 of the apical. In areas of diffuse, radiolucent periapical images were visible (Figure 2).
Figure 3. The regional clinical overview perforation.
Figure 2. The Preliminary Dental Radiographic 36.
From the test results, a diagnosis, treatment plan and prognosis can be developed. Diagnosis for tooth 36 is pulp necrosis with periapical lesions with the basic perforation pulp chamber for tooth 36. The treatment plan is a dental root canal treatment, closure of the perforation region with MTA and a final restoration by making indirect composite onlays. The prognosis is good because the location of perforations at the bottom of the pulp chamber is so easily accessible without a surgical procedure, the size of the perforation would be small and it would not take long for the perforation to be fixed. The teeth can be restored with a cooperative patient. Once the diagnosis is established, patient(s) were given an explanation of the state of the tooth and the treatment plan to be carried out. Then the patient(s) signed informed consent. Teeth were isolated with a rubber dam, temporary fillings were opened and visible regions of perforations bled. Bleeding control was done by pressing a sterile cotton pellet soaked in a solution of local anesthetic Xylestesin-AR (1: 80,000). Emphasis is done repeatedly until the bleeding stops. After the bleeding stopped, perforation holes on the base of the pulp chamber were visible and an application of calcium hydroxide was added (Calxyl, Praparate OCO) and the perforations were closed with a temporary patch (Figure 3).
Her second visit was one week after her procedure. After cleaning the cavity and calcium hydroxide, the perforation area has not bled. Afterwards, a biomechanical preparation technique Crown down Pro Taper rotary (Dentsply Maillefer) was done. The procedure begins with an assessment of the root canal with file #10, to the approximate length of the root canal. Then do an initial preparation to widen the channel by using the files in the coronal S1 and SX 2/3 along the length of the root canal. Furthermore, the working length measurement using Apexlocator with K-file # 15 root canal length, obtained distolingual 16mm, 18mm distobuccal, mesiolingual 17 mm, and 17.5 mm mesiobuccal. Lubrication is used with 15% EDTA gel and every turn of the files made irrigation with 2.5% NaOCl and the last irrigation is with 2% chlorhexidine. The entire root canals were dried with sterile paper point (Figure 4).
Figure 4. After Biomechanical Preparation Guide.
There was a root canal covered with a master gutaperca (F2), and then it made an application MTA (Angelus) in the perforation area (Figure 5).
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(a) (b) Figure 5. (a) MTA Materials. (b) Application to the Local MTA perforation.
Afterwards, gutaperca removed from the root canal(s), the application of calcium hydroxide (Ultracal, Ultradent Inc.) as a medicament in root canal(s), MTA was placed above a layer of moist cotton pellet and temporary cavity was covered with patches. The patient were instructed to return 2 weeks later. On the third visit (2 weeks in control), the cavity was opened and cleaned, the MTA has been hard, but calcium hydroxide is still wet so it was decided to be done with calcium hydroxide medicaments back. Substitution of calcium hydroxide is carried out until the fifth visit, the patient had no complaints, the tooth is not sensitive to percussion and press. Calcium hydroxide is dry, so it decided to do a trial charging the picture by using the master apical file (MAF) F2 (Figure 6).
Figure 6. the radiographs Trial Overview Charging MAF (F2).
The root canal filling with a single cone technique on each channel, used an endomethasone sealer. This Sealer is inserted into the root canal with the help of lentulo marked with a rubber stop during the process, then the master gutapercha cut below the orifice of 2 mm using a heated plugger and compactor, covered cavity with glass ionomer cement. The results charging with radiologically was confirmed (Figure 7).
Figure 7. The overview of Dental Radiographs Charging 36 results.
The sixth visit (1st week after the charging control), there was no complaints of the patient(s), the tooth is insensitive to pressure and percussion, and there is no tooth mobility. It doesn‟t go back radiologically (Figure 8).
Figure 8. The overview Radiographs 1st Week After Charging.
The results of radiographic examination showed that hermetic obturation, and lusen in periapical areas shrunk, network improvements in the area of perforation. Furthermore, the indirect composite Onlay preparation and printing done with the elastomeric material on the lower jaw and the upper jaw made use of alginate bite recording. The seventh visit conducted trial composite onlays. Onlay retention examination, adaptation, colors and shapes, occlusion and articulation examination and adaptation proximal (point of contact). Furthermore, an onlay cementation used dual cure resin cement (Breeze, Kerr) (Figure 9).
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Figure 9. Photos Clinical Dental Composite onlay 36.
DISCUSSION Root and furcation perforations, which are artificial communication system with a root canal or tooth supporting tissues of the oral cavity can be caused by perforation endodontik.1,14 treatment failure can be caused due to the slope of the crown, the presence of calcified tissue in the pulp chamber and orifice area, anatomic variations, making the dentin too luas.8 in this case, the perforation occurred is at the base of the pulp chamber perforation caused by a previous operator error during the search orifices in the tooth 36. Clinically in these cases, patient(s) do not feel comfortable with the condition of her tooth. The tooth ache and abscesses continues to occur. Perforation may be a way for the bacteria invaded from the root canal to the periodontal tissues or vice versa, this has resulted in delays in the process of healing, inflammation, periodontal tissue damage, bone damage alveolar.4,8,9,14 In this case the action is non-surgical treatment of perforations in consideration of which the location of the perforations at the bottom of the pulp chamber, it is not difficult to be applied MTA and root canal endodontic treatment can be carried out, as well as the tooth can be restored. The next consideration is the size of a small perforation diameter + 1.5 mm. Perforation of the small possibility of a better healing process. The next consideration is the time of perforation, perforation occurred in this case is for a week before coming to the clinic PPDGS Conservative Dentistry, Padjadjaran University. Perforation occurs
with patches temporarily covered by previous operators. To minimize bacterial infection then the closure of perforation should be done as soon as possible after the perforation occurs so that the prognosis terbaik.14 In this case, the closure of the perforation with MTA region. MTA has biocompatible properties, hydrophilic, and has the ability to stimulate healing and bone formation. 6,7,10 In addition, the MTA also has a radiopaque properties, bacteriostatic or bactericidal, sealing ability that good .5 Chemical reaction when mixed with aquades MTA powder 2Ca₃OSiO₄ + 6H₂O → 3CaO.2SiO₂.3H₂O + 3Ca (OH) ₂. From the reaction, the release of calcium ions and increase the pH, calcium hydroxide is the major byproduct. MTA has a pH of 10.2 after mixing time and increased to 12.5 in the first 3 hours. With the creation of very high pH conditions, the MTA is not only a bacteriostatic, it can even be bakterisid.13 MTA does not irritate periapical tissues, but it can induce regeneration of cementum and periodontal ligament tissue. An osteoinductive agent and sementogenik.4,11,12 Biomechanical preparation with crown down technique that starts by moving coronal 2/3, it can prevent the debris pushed into the apical direction and flow of irrigation solution flows more easily .15 Calcium hydroxide is used as a medicament with a view to eliminating inflammation, disinfection and prevent granulation tissue invagination.4, 12 Calcium hydroxide is a strong base with a pH of 12.5 to 12.8 has antimicrobial properties through the release of hydroxyl ions. Hydroxyl ions which have the effect of killing bacteria by destroying the bacterial cytoplasmic membrane, leading to protein denaturation and also causes damage to the DNA of bacteria. Calcium hydroxide can reduce osteoclast differentiation, accelerating the healing process in the periapical region and stimulate the formation of hard tissue .16 In this case, experience loss of tooth requiring restoration distolingual snag that protects the whole lump (cuspal coverage). The composite onlays was chosen because 200
the structure of the remaining network is still much more economical than a full porcelain crowns, and aesthetic can be achieved. 17 CONCLUSION Applications MTA in furcation perforation area shows the results of the closure and repair of tissues in furcations satisfactorily.
VADVICE 1. Knowledge of the variation operators anatomy of the root canal needs to be improved, to prevent mistakes when endodontic treatment. 2. It should be given the knowledge of the care provider perforation. 3. The use of the cover perforations should use materials which have good sealing ability and stability in humid conditions to prevent microleakage at the perforation area.
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Treatment of crown fracture of maxillary right central incisor with one visit endodontik and direct composite restoration: a case report Triana Agustanti*, Milly Armilia** * Student of Postgraduate Conservative Dentistry Department, Padjadjaran University. **Head of Postgraduate Conservative Dentistry Department, Padjadjaran University.
ABSTRACT Crown fracture caused by trauma usually happened on anterior maxillary teeth and surrounding tissue. One visit endodontik treatment is a root canal treatment process which completed in one visit. It gives the advantage to minimize the risk bacterial contamination of root canal, time and cost saving. Male, 18 years old with crown fracture caused by trauma with normal periapical tissue and the diagnosis is irreversible pulpitis. One visit root canal treatment performed with pehacain 2% infiltration anasthetic. The used of rubber dam during treatment to prevent the bacterial contamination. Accces opening was followed by measuring working length using apeks locator. Root canal preparation conducted using proTaper rotary with F4 as master apical file. Single cone guttapecha with AH plus sealer and glass ionomer cement lining was used for obturation. One week evaluation showed asymptomatic, percussion and bite test was negative. It followed by fiber post insertion and direct composite restoration with satisfied outcome. Conclusion : One visit endodontik treatment of crown fracture with diagnostic irreversible pulpitis followed by fiber post insertion and direct composite restoration gived satisfied outcome. Key words : Crown fracture, one visit endodontik, fiber posts , direct composite
INTRODUCTION Self-confidence is influenced by the appearance of individual. Crown fracture that caused by trauma often occurs in the anterior teeth. Restoration on teeth with crown fracture needs to be done to restore stomatognatic and aesthetic function. One visit endodontic treatment is non surgical endodontic treatment which includes cleaning, shaping, and obturation of the root canal in one appointment.1 The treatment give advantages to minimize the risk from bacterial contamination of root canal, time and cost saving.1,2 Lost of teeth structure and changes in the characteristics of tooth can lead fracture after root canal treatment. The use of fiber posts can increase retention and resistance until final restoration.3 Recently, the use of composite restorative material grows rapidly and it gives good aesthetic. This composite can be selected as dental restorative materials for anterior teeth.4 This paper will discuss about patients with crown fracture, caused by trauma at the anterior teeth. The teeth are vital with normal periapical tissue, then one visit endodontic
treatment followed by fiber posts inserted and direct composite restoration will be done. CASE Male, 18 years old visited Conservative Dentistry Department, Faculty of Dentistry Padjadjaran University, complaining about his broken maxillary right front teeth. The teeth was broken because of accident when he fall down from skateboard 3 months before. He feel pain one week before coming to the clinic, however he did not feel pain anymore when he visit the clinic. The objective examinations 11 are cold tests and Electric Pulp Tester (EPT), showed a positive response. However, examination of percussion and bite test showed a negative response. The clinical examination showed 1/3 crown fracture (Figure 1). Oral hygiene of the patient was average. Radiographic examination showed one of third crown fracture from the incisal, intac lamina dura, and normal periapical tissue (Figure 2). The diagnosis of this case is irreversible pulpitis 11, and then the treatment plan is one visit endodontik treatment followed 202
by inserted fiber post and direct composite restoration. One visit endodontik was considered for treatment because of vital teeth, straight canal and no periapical lesions. The prognosis is good because general condition is good and the patient is cooperative and motivated to restore his esthetic function.
Acces preparation on foramen caecum using endo acces bur (Dentsply) to get root canal orifice. Barbed nervbroach #35 and #40 (Dentsply), used for extirpation then inserted the root canal with slight pressure until it stopped, and rotated clockwise, withdrawn slowly so the entire pulp tissue was picked up (Figure 4). It was repeated several times, that no pulp tissue left behind, and then the root canals irrigated with 2.5% NaOCl. The root canal was dried by using paper points.
Figure 1. Clinical Feature 11 Before Treatment
Figure 4. Pulp Tissue Extirpation
Figure 2. Initial Radiograph
MANAGEMENT CASE Subjective and objective examination, intra oral photo, radiograph examination, treatment plan of 11 were done on the first visit (November 21st ,2013). Patient signing the infomed consent. Result of blood pressure checks before anesthesia procedure was normal (120/80 mmHg). Asepsis treatment in the work area used povidone iodine on the labial and palatinal region. Anesthesia procedure used 2% pehacain solution 0,5cc each side. After the gingiva looks pale the work area was isolated using a rubber dam (Figure 3).
The root canal explored by using K file #10 and K file #15 has any ressistance. The working length measured using apeks locator (VDW) and the result was 25mm. Root canal preparation was using crown down technique with ProTaper rotary (Dentsply). Coronal preflaring using S1 and SX file 2/3 of working length and followed by the file S1, S2, F1, F2, F3 until the last file F4 as Master Apical File. 17% EDTA gel (Glyde, Dentsply) was used for lubricants. Root canal irrigated every instrument rotation with 2.5% NaOCl and dried using paper points. Trial radiographic examination using appropriate gutta-percha F4 as Master Apical File with 25 mm working length showed guttapercha well fitted in root canal (Figure 5).
Figure 5. Trial Radiograph
Figure 3. Isolation with Rubber Dam
The obturation was using a single cone technique and AH plus (Dentsply) sealer. Excessive sealer and guttapercha were remove 203
and Glass Ionomer Cement (GC, Gold Label) applied. Final radiograph showed a hermetic obturation (Figure 6). Analgesic drugs (mefenamic acid 500 mg) was prescribed for patients and it instructed to consume at any time if there is pain. Patients was instructed one week later to come to the clinic.
canal, after the possition was well fitted, then light cured.
Figure 8. Insertion Of Fiber Post
Figure 6. Final Obturation Radiograph
Figure 7. One Week Radiographic Evaluation
On second visit the tooth was asymptomatic. Percussion, bite, mobility test are negative. Radiographic examination showed a hermetic obturation and no periapical abnormalities (Figure 7), then fiber post was inserted followed with direct composite resin. The working area was isolated using rubber dam. Before fiber post insertion, guttapercha was taken by largo #3 and 6mm guttapercha left as apikal seal. Root canal was irrigated with 2.5% of NaOCL to clean debris and dried with sterile paper point. Fiber post (FibreKleer, Kerr) was inserted for try in into the root canal (Figure 8), irrigated using aquades and 2% chlorhexidine solution, then dried using paper point. Root canals was etched with 37% phosphoric acid for 15 seconds, then rinse with water and dried with paper point. Self-adhesive resin cement (Breeze) was applied to the root canal using lentulo spiral instrument. Fiber post inserted into the root
The tooth surface was cleaned using a rotary brush and pumice powder which mixed with water. Then, match the color of the teeth with shade guide (Vita pan) and found the color is A3. Class IV preparation with 2 mm bevel extension all over the margin using a fissure tappered bur. Etching procedure with 37% phosphoric acid on the prepared tooth surface for 15 seconds, and rinsed with water and dried. Bonding agent (Adper Single Bond, 3M ESPE) applied then cured for 20 seconds. A thin layer A3 enamel shade nanofill composite resin (Filtek Z350 XT, 3M ESPE) applied on palatal surface and light cured for 20 second. A4 dentin shade composit resin applied and light cured, A3 enamel shade applied and light cured and incisal shade composit resin applied on incisal surface then light cured for 20 second. Anatomical tooth surface was done by comporoller (Kerr). The final adjustment used extra fine diamond burs and polishing using a polishing strip on the proximal surface and polishing disks (Optidisc, Kerr). Composite brush used to made the restoration shiny (Figure 9).
Figure 9. Final Restorations of Direct Composit 11
On third visit, one week evaluation after restoration procedure, the tooth was asymptomatic. Objective examination, there was no premature contacts, good proximal contacts, 204
good color restoration and the patient was satisfied with the results of the restoration (Figure 10).
Figure 10. One Week Evaluation Direct Composit Restoration 11
DISCUSSION One visit endodontics implies to cleaning, shaping and disinfection of a root canal system followed by obturation of the root canal at the same appointment.4 The consideration of one visit endodontics treatment are vital teeth,straight canal, no periapical lesion, fractured anteriors where esthetics is the concern,and patient motivated to restore esthetic function. One visit endodontic treatment has several advantages compared with multiple visits endodontic treatment, which can reduces the number of patient visit, limiting bacterial contamination, time and cost saving.4.5,6 In this case, Root canal preparation was using the crown-down technique because it could reduce and minimize the risk of debris into the apical by coronal preflaring begins in 2/3 workinglength. Maximal irrigated would reach to clean and disinfect the root canal. 7,8 The used consideration of AH plus sealer because it has a stable color and its great option for esthetic reason. This sealer has good sealing ability and antimicobial action.4,8 Tooth structure lost during endodontic treatment increases the risk of crown fracture. In this case the used of fiber posts can increase retention and resistance endodontically treated teeth with direct composite restoration.9 Fiber posts have a modulus elasticity which equivalent to dentin so it can improve the distribution of forces aplied along the root, thereby decreasing the risk of root fracture and contributing to the reinforcement of the remaining tooth structure. It has esthetic and
translusent characteristic may conduct the light for polymerization of resin based luting cement. A light post transmitting result in better polymerization of resin composites in the apical area.9 In this case, composite materials was chosen nanofill composite, because high filler levels can be generated in the restorative material, resulting in good physical properties and esthetics. The small primary particle size also makes nanofills highly polishable.10,11 Some advantages of direct composite restoration are esthetic, conservative of tooth structure removal, repairable, cheaper cost compared to ceramic restorations. The disadvantages were a longer processing time, while the possibility of polymerization shrinkage .10,11 The individual teeth have their unique, shape, form, surface, and dimensions of color. The dentin and enamel has different opacity and translucency. The different tooth color depends on the enamel and dentin thickness of that tooth location. That is why an individual tooth is unique and has different color, so it composite restorations require a different shade layers. In this case, to produce a natural color was used composite resin, enamel, dentin and incisal shade. CONCLUSION One visit root canal treatment on crown fracture patients with a diagnosis of irreversible pulpitis and continued with the insertion of fiber post and direct composite restorations was giving satisfactory results. SUGGESTION. 1. Ireversible pulpitis without periodontitis for the anterior teeth, should be done by one visit endodontic treatment in order to prevent bacterial contamination. 2. Fiber posts in endodontically treated teeth and direct composite restorations for 1/3 crown fracture should be done to increase the retention and resistance .
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REFERENCES 1. Nandakishore KJ, Shija AS, Vinaychandra R. Single Visit Endodontics – A Review. Journal of Health Sciences and Research. 2011; 2(1) 23-28. 2. Malhotra n, et al. Incidence of Post Operative Pain Following Single Visit Endodontic Therapy in Single and Multi Rooted teeth. Malaysian Dental Journal. 2010;31(2): 71-77. 3. Gurcan E, Sema B. Use of Bondable Reinforcement Fiber post and core Build up in an endodontically Treated tooth : A case report. Quintessence Int. 2002. 4. Nisha Garg, Amit Garg. Textbook of endodontics. 2nd ed. New Delhi, India : Jaypee Brothers Medical Publishers ; 2010. Chapter 18 -19. P. 265-303. 5. Bayram Ince, Ertugrul Ercan, et al. Incidence of post operative Pain After Single and Multi Visit Endodontic Treatment in Teeth with Vital and Non Vital Pulp. Eur J Dent. Oct 2009;3(4): 273-279. 6. Richardo Machado et al. Endodontists perceptions of single and multiple visit root canal treatment : a survey in Florianopolis – Brazil. RSBO.2014 JanMar;11(1):14-9.
7. Kumar CS, Sengupta CJ. Endodontic Treatment for Mandibular Molars Using Protaper. MJAFI.2011;67(4):377-379. 8. Eleazer PD, Rosenverg PA. Endodontic Emergencies and Therapeutics dalam Torabinejad M, Walton RE. Endodontics Principles and Practice.5 th ed. Elsevier Saunders .2014. Chapter13. P.229-263 9. Johnson WT. KulildJC. Obturation of the Cleaned and Shaped Root Canal System dalam Hargreaves KM & Cohen S. Pathway of the Pulp 10th Ed. Mosby Elsevier.2011. P.349-388, 777-781 10. Murali Mohan, E. Mahesh Gowda. M.P Shashidhar. Clinical evaluation of the fiber post and direct composite resin restoration for fixed single crowns on endodontically treated teeth.AFMS. Feb 2012. Published by Elsevier Inc. All rights reserved. 11. Theodore M. Roberson, Harald O.Heymann, Andre V . Ritter. Indroduction to Composite Restoration dalam Sturdevant‟s Art and Science of Operative Dentistry 5th. Mosby Elsevier.2006. Chapter 11. P. 495-526. 12. Chalermpol Leevailoj. The Art of Anterior Tooth-Colored Restoration With Resin Composites . August 2004. Chulalongkorn University, Thailand P.15-40
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Management of curved canal with reciprocal technique in lower right third molar Christy Maria Hermawan*; Rahmi Alma Farah Adang** * Peserta PPDGS Konservasi Gigi Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung ** Staf Pengajar Departemen Konservasi Gigi PPDGS Fakultas Kedokteran Gigi Universitas Padjadjaran, Bandung
ABSTRACT Introduction: Curved canal or root dilaseration is a bend relationship of a crown to the root in the linear directions. Reciprocal technique may be an option for curved canal instrumentation. Advantages of reciprocal technique are maintain the nature of root canal curvature, prevent apical transportation and ledge, smaller possibility of broken files, and faster working time. Case Report: 26-year old female patient reffered from Department of Orthodontics, Faculty of Dentistry, Padjadjaran University to treat big cavity on her 48 that should be preserved because its position will be corrected using fixed braces. 48 mesioversion with profunda caries in the mesial. Radiograpic examination showed there are diffuse lesion around both roots of 48 so that diagnosed periapical abscess and the distal root bent to mesial 60 0 calculated by Schneider method. Root canals prepared by Reciproc (VDW) and calcium hidroxide is given for intracanal medicamen. A class II composite restoration performed as final restoration and will be substituted into onlay composite if 48 has achieved desired position of occlusion. Conclusion: Reciprocal technique is an alternative for curved root canals instrumentation due to its ability to keep nature form of the root canals and increased the success of treatment. Keywords: Curved canal, Reciproc technique, Schneider method
INTRODUCTION Curved canal or root dilaseration is a bend relationship of a crown to the root in the linear directions. Curved canal is one of the difficulty factors in endodontic treatment. The most important things for succesful curved canal endodontic treatment are understanding about root canal anatomy by knowing root canal curvature degree and number of curved. Nikel Titanium has been found along with the development in dentistry technology that increasing succesful curved canal endodontic treatment. NiTi instruments reducing procedural error because its flexibility so it is safe for curved canal preparation. Reciproc from VDW is a new concept for root canal preparation that only use one instrument with reciprocal motion. Reciprocal motion based on balanced forced technique with clockwise and counterclockwise movement that reduce instrument torsional fractures. Advantages of reciprocal technique are maintain the nature of root canal curvature, prevent apical transportation and ledge, smaller possibility of broken files, and faster working time.
This case report is reported about reciprocal technique for curved canal endodontic treatment for mandibular third molar. CASE 26 year old female patient reffered from Department of Orthodontics, Faculty of Dentistry, Padjadjaran University to treat big cavity on her 48 that should be preserved because its position will be corrected using fixed braces. The patient feel uncomfortable because there are food impaction on that tooth. Three days ago, the gum was swelling but patient did not consume any medication. There was no pain history. Patient want a treatment for her tooth. Intraoral examination, 48 mesioversion with profunda caries in the mesial. Cold test negative. Percussion, bite and palpation test show positive respon. Average oral hygiene.
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Picture 1 Clinical Feature of 48 before Treatment
Radiograpic examination showed radiolucent on the crown of 48 close to the pulp horn and it has two root which the distal root bent to mesial on the third apical. There was a ligament periodontal widening from mesial, apical and distal. Lamina dura disappeared in all regio. A diffuse radiolucent lesion seen beside both root from servical to apical (Picture 2)
Picture 2 Initial Radiograph
48 diagnosed pulp necrotic with combination endo perio lesion (AAE, 2013). The treatment plan is an endodontic treatment for non vital tooth with follow-up onlay composite restoration. Prognosis is good. MANAGEMENT CASE Subjective, objective, and radiographic examination was done on the first visit (10 Desember 2013), then the patient signed the informed consent. Local scaling was done around 47 and 48 to remove plaque and food leftover. All caries removed using stainless steel burs (Stainless Steel Bur, Mani, Tochigiken, Japan) and continued by access preparation using access burs (Endo Access Bur, Dentsply). Mesiobuccal, mesiolingual, and distal canal was founded. SX (Protaper, Dentsply) was used for orifis widening. Because of the patient limited
time, root canal preparation can not be done. The cavity irrigated by NaOCl 2,5%, aquades, and ended by chlorhexidine 2%, then dried. Artificial wall was built maded from glass ionomer. Cresophen applied by cotton pellet and the cavity sealed by temporary filling. The degree of the curvature must be counted The measurement of the curvature degree must be done before treatment to determine appropriate treatment. The patient reffered to Department of Periodontic for her periodontal management. Second visit (14 Desember 2013), the tooth was asymptomatic. Clinical test on 48 showed positif percussion, bite and palpation test negative. Temporary filling opened, wet calcium hidroxide was cleaned by NaOCl 2,5% irrigation. Working length measurement was done by apex locator (Morita) using K-File #8. The working length on mesiobuccal was 19 mm, mesiolingual was 19 mm and distal was 17 mm. Precurved K-File #10 and 15 is used for negotiate the root canal to get glide path. Root canal preparation continued by Reciproc R25 (VDW). EDTA 17% (Glyde, Dentsply) was used as lubricant. Root canal irrigate every instrument rotation with aquades and NaOCl 2,5%. Chlorhexidine 2 % used for last irrigation solution. Root canals were drain and applied with calcium hidroxide paste, the cavity sealed by temporary filling. On the third visit (8 Janiary 2014), patient did not complain about any symptom, percussion positive and palpation negative. Temporary filling opened, calcium hidroxide is seen still wet. Root canal irrigate by NaOCl 2,5%, aquades, and ended by chlorhexidine 2%, then dried. Calcium hidroxide applied to the root canal and the cavity sealed by temporary filling. On the fourth visit (20 January 2014), percussion, bite and palpation test negative. Temporary filling opened, the wet calcium hidroxide was visible. Root canal irrigate by NaOCl 2,5 \%, aquades, and ended by chlorhexidine 2%. Paper point was used to dry the root canal. Calcium hidroxide applied to the root canal and the cavity sealed by temporary filling. On the fifth visit (6 February 2014), the tooth was asymptomatic, percussion, bite and palpation test negative. Temporary filling opened, dry calcium hidroxide was seen. 208
Calcium hydroxide cleaned and the root canal irrigate by NaOCl 2,5%, and paper point was used to dry the root canal. Reciproc guttapercha (VDW) #R25 measured according to the working length and inserted to the root canal, then took a trial radiograph. The result of trial radiograph showed guttapercha well fitted in root canal (Picture 3).
In this case, 48 restorated by a direct composite filling because the difficult access to build composite onlay. Direct composite restoration will replace with onlay composite after the position of 48 repaired by an orthodontic treatment. DISCUSSION
Picture 3 Trial Radiograph
Root canal irrigate by NaOCl 2,5%, aquades, and ended by chlorhexidine 2%. Paper point used to dried the root canal. Canals were obturated using a single cone guttapercha and with Endomethasone sealer. Excessive guttapercha was cut from the orifis. Excessive sealer was removed and glass ionomer cement applied (GC, Gold Label). Final radiograph showed a hermetic obturation (Picture 4).
Curved canal is a challenge because it is one of a difficulty factors endodontic treatment. To achieve a succesful curved canal endodontic treatment, the most important thing is realizing the anatomy of the root canal before treating a tooth by knowing the degree and number of root canal curvature. Radiological examination can help determine the degree and number of root canal curvature, although it has a weakness which is only provide two dimention information. The measurement of the curvature degree must be done before treatment to determine appropriate treatment.8 Schneider curvature measurement method using three points and two lines. Point a is midpoint marking of root canal orifice, point b is the starting point of the canal deviation, and point c is at the foramen apical. The first line that connects point a and b, while the second line connects point b and c. The angle formed between the two lines was measured as the canal curvatures (Figure 6).
Picture 4 Final Obturation Radiograph
On the sixth visit (3 March 2014), the tooth was asymptomatic. Percussion, bite and palpation test negative. A control radiograph showed a hermetic filling and no periapical abnormalities (Picture 5).
Picture 5 Control Radiograph
Picture 6 Schneider Method
Curvature measurement in this case was using Schneider method because of the smaller error rate than Weine method. The clasification, according Schneider method, are straight (50 or less), moderate (100-200), and severe (250-700). After being measured by using Schenider method, the curvature measurement was 600, so that was classified as severe (Picture 7). 209
Picture 7 Curvature Measurement Using Schneider Method
One of the factors, that determine the success of treatment on the curved root canal, was depended on cleaning and shaping which is safe and effective.5 Good cleaning and shaping can keep the shape of root canal anatomy, facilitate maximum irigant solution, and well obturation.6 Glide path must be obtained before ratary instrument introduce to the root canal. Negotiation root canal using hand file to working length was useful to reduce procedure error during preparation even more in the curved root canal case.9 Small stainless steel K-File can be used in initial negotiation in root canal with watch-winding movement to remove debris and blockage so that glide path can be achieved.7,10 Small size K-File still has a flexible characteristic so that can keep the nature shape of the root canal and minimizing procedural errors.8 Procedural errors on curved canal endodontic treatment such as apical transportation, ledge, perforation, blockage, and fracture instrument can reduce the succesful of endodontic treatment. Reciprocal movement based on balanced force technique consisting clockwise and counterclockwise motion which is continously releasing bind instruments on dentin during root canal preparation procedure.3,5 Reciprocal movement was considered able to increase fatique resistance with clockwise rotation acting release stress instrument.4 Reciprocal movement reduce screw-in effect on rotation movement which is usually causing overinstrumentasi and apical transportation. Reciprocal movement using NiTi instruments have been selected because was considered able to maintain the natural shape of the curved root canal so that the possibility of apical transportation or ledge became minimum, reduce the risk of fractures of the instrument, and faster working time.5,6
In this case, post endodontic restoration for 48 was class II direct composite. Ideal restoration for posterior post endodontic treated teeth is composite onlay restoration. Composite onlay restoration can not be done because 48 mesial drifting position that difficult for composite onlay to prepared and inserted. When 48 reach a good occlution with orthodontic treatment, the class II direct composite will replace to composite onlay. CONCLUSION Reciprocal technique is an alternative to curved root canal instrumentation as it can keep the shape of the natural curvature of the root canal so that the success of the treatment is enhanced. SUGGESTION Case with curved root canal is recommended using NiTi instruments with reciprocal movement to maintain the natural curvature of the root canal, preventing apical transportation, ledge, and the smaller possibility of broken files. REFERENCES 1. Dastmalchi N, dkk. Definition and Endodontic Treatment of Dilacerated Canals: A Survey of Diplomates of the American Board of Endodontics. The Journal of Contemporary Dental Practice. 2011; 12(1): 8-13. 2. Estrela C, Bueno MR, Sousa-Neto MD, Pecora JD. Method for Determination of Root Curvature Radius Using ConeBeam Computed Tomography Images. Braz Dent J. 2008; 19(2): 114-8. 3. You SY, dkk. Shaping Ability of Reciprocating Motion in Curved Root Canals: A Comparative Study with Micro-Computed Tomography. Journal of Endodontics. 2011; 37(9): 1296-1300. 4. Meireles DA, dkk. Endodontic Treatment of Mandibular Molar with Root Dilacerations Using Reciproc Single-File System. The Korean Academy of Conservative Dentistry. 210
2013; 38(3): 167-71. 5. Yoo YS dan Cho YB. A Comparison of the Shaping Ability of Reciprocating NiTi Instruments in Simulated Curved Canals. Restor Dent Endod. 2012; 37(4): 220-7. 6. Dingra A, Kochar R, Banerjee S, Srivastava P. Comparative Evaluation of the Canal Curvature Modifications After Instrumentation with One Shape Rotary and Wave One Reciprocating Files. Journal of Conservative Dentistry. 2014; 17(2): 138-41. 7. Bogle J. Endodontic Treatment of Curved Root Canal Systems. Oral
Health Group. 2013. 1-2. 8. Zhu Y, Gu Y, Du R, Li C. Reliability of Two Methods on Measuring Root Canal Curvature. Int Chin J Dent. 2003; 3: 118-21. 9. Yared G. Canal Preparation with Only One Reciprocating in Instrument without Prior Hand Filing: A New Concept. 2010; 1-8. 10. Berutti E, dkk. Use of Nickel-Titanium Rotary PathFile to Create the Glide Path: Comparison With Manual Preflaring in Simulated Root Canals. Journal of Endodontics. 2009; 35(3): 408-12
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Periapical curettage of overfilling of the root canal: A case report. Margareta Rinastiti, Wignyo Hadriyanto, Diatri Nari Ratih Department of Conservative Dentistry, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia Corresponding author :
[email protected]
ABSTRACT Background: The success of root canal treatment (RCT) depends on complete debridement and obturation of the root canal system. Overfilling of the root canal is one of the common error in RCT. The presence of gutta percha in periradicular tissue as a foreign body may lead the negative effect on endodontically treated teeth. Purpose: to present the surgical removal of overfilling gutta percha of a first maxillary incisive. Case: a 35-year-old woman complained of pain when the finger is pushed on the gum of maxillary anterior sector after endodontic treatment. Periapical radiograph of 11 revealed radioopaque material suspected extruded endodontic filling and apical radiolucency, while percussion test showed a positive response. Case Management: under local anesthesia following a routine surgical protocol, a bone corticotomy with curettage of extruded material and fibrous tissue were performed The bone graft was applied on the surgical area to enhance the healing process. At the 1 month recall, the patient had complete resolution of the symptoms and good soft-tissue healing Conclusion: periapical curettage followed by bone graft application is a plausible approach to remove extruded gutta percha in periapical area. Keywords : overfilling, gutta percha, periapical curettage, endodontic surgery
INTRODUCTION The basic principles of endodontic treatment are consist of the elimintion of all diseased pulp and dentin, adequate cleaning and shaping of the root canal system and its 3dimensional obturation and sealing.1 The objective of filling the root canal system are to prevent the passage of microorganisms and fluid along the root canal and to fill the whole canal system, blocking the apical foramin, the dentinal tubules and accessory canals.2(2) On the basis of biologic and clinical principles, nstrumentation and obturation should not extend beyond the apical foramen or other neighboring structures.3 Wu et al4 reproted that the highest success rates of pulpectomy were achieved when root filling ending 2-3 mm short of the radiographic apex, while for the cases of pulp necroses were 1-2 mm short of apex.5 However, an overextension of filling substance overpassing the apical foramen can be occurred due to the failure in determine the exact location of the apical foramen, an absence of apical stop or constriction in mature teeth, incorrect selecting master cone or open apices.6. Root canal materials may generate the inflammatory and neurotoxic effects. All
obturation sealers are irritants in their mixed states. However after setting and curing, some sealers lose their irritant components, become relatively inert and resorbable that is managed by the immune system.7 Gutta percha is approximately 20% of total volume with the remainder mostly zinc oxide and proprietary additives. Compared to other material used in endodontic obturation, it has a low degree of toxicity.(3) However, However, Sjögren and colleagues 41 demonstrated that small particles of gutta-percha implanted subcutaneously in guinea pigs induced intense tissue reaction, characterized by the presence of macrophages and giant cells. The excess root filling materials extruded into the periradicular tissues were capable of inducing periradicular inflammation or necrosis of the periodontal ligament. It has been reported that even in the absence of microbial factors, root filling substances can evoke foreign body reaction leading to the inflamation reaction which causing development of periapical lesions, ligament breakage, swollen tissue accompanied by severe pain that may be refractory to endodontic therapy.8 Other effects are necrosis of alveolar bone in the periapical area of the discoloration mucosa membrane covering tooth apex, or even a 212
neurological complication such as paresthesia.9,10 The failure associated with overfilled teeth is usually caused by a comcomitant intraradicular and/or extraradicular infection. In most cases, apical sealing is inadequate in overfilled root canals.11 The degree of the damage depends on the filling material. One of the treatment choice for overfilling is curettage that is intended to remove diseased tissue and/or foreign material from the alveolar bone in the apical or lateral region surrounding a pulpless tooth. The procedure is rarely used alone and only when the root canal system has been considered satisfactorily disinfected and filled. 2 Periapical curettage is a surgical procedure to remove diseased or reactive tissue and/or foreign material around the root.12
with widening periodontal ligament and the presence of a periradicular lesion in association with teeth 21. Based on the medical report, RCT of the tooth had been carried out using step back technique, followed by filling with endomethasone and gutta percha.
CASE
CASE MANAGEMENT
A 35-year old woman was appeared at the RSGM Prof. Soedomo, Universitas Gadjah Mada, Yogyakarta.She reported a pain when the finger is pushed on the gum of maxillary anterior sector after endodontic treatment of tooth 21 which was carried out by her dentist 8 months ago. She also experience discomfort when she is biting the food by using her anterior teeth. No swelling, redness, or other signs of infection were observed at intraoral exploration. Extraoral examination likewise failed to identify swelling, alterations in skin color, or adenopathies. The oral hygiene was good, saliva consistency was sticky and frothy, resting saliva evaluation showed hydration less than 60 seconds and pH 5.0 – 5.8, while stimulated saliva showed the quantity was < 3,5 ml and buffering was 0-5 points. 14,26 and 32 showed the active caries, while the caries secunder were found in 46 and 47. Resin composite filling materials were seen at the mesiopalatl, distopalatal and servikopalatal of 21. The restorations were in a good condition without fracture, chipping neither discoloration. Pain on percussion was present with the left first incisivus and the patient complained of pain when the gum in periapical area of 21 was palpated. A routine periapical radiograph revealed a good obturation, but overextended gutta-percha
One day before surgery, the patient was instructed to use the mouth rinse containing clorhexidine gluconate. Prior to the periapical surgary, the vital sign of patient was measured. The blood pressure was 110 / 70 mmHg, respiratory rate: 18x/min, pulse: 70x/min, temperature : afebris (36,5o C). Topical anaesthetic gel is applied on the area of 11, 21 and 22 to reduce the pain during injection. Anesthetic agent contains vasoconstrictor was injected to block the n. Alveolaris inferior. The needle tip was then moved peripherally and small amount were slowly injected in adjacennt area. Following the admnistration of the anesthesia, the surgical area was disinfected with povidone iodine. Incision with no. 15 blade was performed to cut through mucosa, connective tissue and periosteum. The semilunar flap was formed by a curved incision in the alveolar mucosa and the attached gingiva. The incision begins in the alveolar mucosa extending into the attache gingiva and the curve back unto the alveolar mucosa, terminated at the line angles of a tooth to preserve intesoft tissue, i.e gingiva, mucosa and periosteum from the surface of the alveolar bone. Retractor is meant to hold soft tissue away. To uncover the apex of 21, osteotomy was done with slow speed carbide burs.
a.
b.
Figure 1 a) Preoperative clinical photograph and b) Preoperative periapical radiograph showed an overextended filling material and raduiluscency surrounding the apex.
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Figures 2. The incision of semilunar flap
Figure 5. Curretage of endodontic filling material and granulation tissue
The final step was suturing with atraumatic silk suture non resorbable, using the single interrupted suture technique. The gingival surgical pack was applied on the surgical area to protect the wound.The antibiotic, antiinflamation and analgetic were given to the patient.
Figure 3. Osteotomy
Once the root and the root apex have been identified, the overextended gutta-percha and the granulation tisseue was removed from the peroradicular bony lession by using surgical curett and angled periodontal curette. The currette was inserted into the crypt to cleave the granulation tissue. Stream of saline solution was used for irrigation. After the removal of infected tissue and gutta-percha, the bone graft was applied to enhance the healing process, next to that, the elevated mucoperiosteal tissue was gently replaced to its original position with the incision lines approximated as closely as possible.
Figure 4. Intraoperative view showing an endodontic filling into the bone
Figure 6. Radiograph of post-operative periapical area showing a clear area around apex of 21
Clinical examination after 1 month post operative showed a complete gingival healing, the patient did not complain about the pain and percussion test revealed nonresponsive result. Periapical radiograph show the reduction of radioluscent in apex area.
Figure 7. Radiographic one month postoperative, periapical area showing a smaller lesion than before curretage DISCUSSION Overfilling root canals may cause damage to the surrounding anatomic structure. 214
Totally biocompatible materials are not available. In order to the toxicity of the product, the extrusion of filling material beyond the apical foramen can give rise to clinical manifestations.13 Endomethason that containing paraformaldehyd may lead the necrosis of periapical tissue.14 Equally important, guttapercha may act as a foreign body or hapten, but it is more biocompatible with the periradicular tissues than are root canal cements15. Even so, Sjögren and colleagues16 demonstrated that small particles of gutta-percha implanted subcutaneously in guinea pigs induced intense tissue reaction, characterized by the presence of macrophages and giant cells, capable of inducing periradicular inflammation or necrosis of the periodontal ligament. In accordance to those facts, this case showed that the overextended gutta-percha causing periodontal ligament breakage, periapical lesion and pain when the gingival surrounding the complained tooth was pressed. As can been seen in the radiograph, a periapical lesion was rise due to the biologic response to the filling materials. There are several factors to cause overfilling: failure in determine the exact location of the foramen apical, an absence of apical stop or constriction in mature teeth, incorrect selecting of master cone, open apices, too much cement in the root canal, no X-ray photo prior, during, and after the treatment process, over-instrumentation, excessive pressing to filling, resistency disappearance due to inadequate root canal preparation and the use of injection technique to fill the root canal.6,10,17 Based on the preoperative radiograph and past dental history, there are no complexity of root canal anatomy and the deviation of foramen apical of 21. It seems that overfilling in the present case was due to inadequate working length measurement so that causing overinstrumentation. Over instrumentation of the apices may produces apical fracture following by loose pieces of cementum, as a result, a widening foramen apical is performed. With this in mind, overinstrumentation frequently precedes over-filling, which inevitably poses the risk of forcing infected root canal contents into the periradicular tissues, thereby impairing the healing process.18 Noiri and colleagues19 used the scanning electron microscope to examine
extruded gutta-percha cones retrieved from teeth that had undergone failed endodontic treatment. They demonstrated that biofilms had formed and attached to the extruded gutta-percha cones. Therefore, they believed that biofilms were the cause of persistent periradicular inflammation. It is clear that a positive respond to percussion test showing the inflammation of the periodontal tissue. Bacteria and dental chips on the file and overextended gutta-percha are pushed out of the foramen, for this reason postoperative pain, clinical discomfort and periodontitis was observed. Inert gutta-percha have been reported as causal factores of sensory alterations in the mental region after endodontic treatment of premolars and molars 13,20 The inconvenience symptom that was reported by the patient probably was influenced the sensory of n. alveolaris superior, hence, our patient frequently aggravate the problem by rubbing the annoying imtated area with their fingers which is in accordance with the report of Boucher, et al.21 They reported a slight projection of excess filling material past the apex, will cause further irritation to the mucosa over the apex. The tooth is rarely spontaneously sensitive, and pain is perceived primarily during masticatory 21 movements or palpation. A period of post-operative observation following root canal therapy ranging from 6 months to 4 years has been advocated by various investigators.17 Based on the fact that the overfilling gutta-percha caused clinical symptom eventhough the root canal treatment had been done for eight months, the endodontic surgery should be performed to remove the overextended gutta-percha and granulation tissue. Sjögren and colleagues22 demonstrated that slightly overfilling (< 2 mm beyond the radiographic apex) have no influence on the treatment outcome, while overfilling of this case was ±9m, thus, removal by surgery is the only treatment option. In addition, Brkic stated that in case of injury or presence of obturating material in soft tissues a surgical approach is necessary.23 One of the factor that influence the healing of periradicular surgery is flap design. Surgical access is a compromise between the need for visibility and the risk to adjacent structures. In order to that goal, semilunar flap 215
was choosen, because it provides rapid access to the apices of the teeth.24 Besides, semilunar flap avoids the gingival margin, and there is less risk of recession of the gingival tissues after surgery, thence this method is appropriate for anterior teeth. Ideally, if the pathological tissue is removed in one piece, there is less bleeding and less disseminaton of the infection into adjacent bonde and soft tissue. Therefore appropriate currets was considered. For a complete removal of the periapical pathological tissues, larger osteotomy should be created thus resulting in larger bone cavity that should heal, which can influence both the postoperative quality of life25 , therefore the application of bone graft is a must to enhance the healing of bony defect.
5)
6)
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CONCLUSION Overfilling in this current case probably caused by overinstrumentation which effect inflammation reaction of the periapical tissue, ligament breakage resulted pain when the gingival was palpated and uncomforted feel during mastication. Clinical treatment consists of raising a semilunar flap trimming the excess filling and affected tissues showed a succesfull treatment. Additionaly, the use of bone graft was considerd to enhance bony defect healing. The gingival tissue and bone then repair itself, and the pain disappear.
9) 10)
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REFERENCES 1) González-Martín M, Torres-Lagares D, Gutiérrez-Pérez J, et al. Inferior Alveolar Nerve Paresthesia after Overfilling of Endodontic Sealer into the Mandibular Canal. J Endod. 2010;36:1419-1421. 2) European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39:921-930. 3) Gluskin AH. Mishaps and serious complications in endodontic obturation. Endod Topics. 2005;12:52-70. 4) Wu MK, Wesselink PR, Walton RE. Apical terminus location of root canal
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24) 25)
Filling and Apical Fenestration: A Case Report. J Endod. 2000;26:242-244. Sjögren U, Hägglund B, Sundqvist G, et al. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16:498-504. Brkic A, Gürkan-Köseglu-¦lu B, Olgac V. Surgical approach to iatrogenic complications of endodontic therapy: A report of 2 cases. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009;107:e50-e53. Lieblich S. Endodontic surgery. Dent Clin N Am. 2012;56:121-132. Tsesis I, Shoshani Y, Givol N, et al. Comparison of quality of life after surgical endodontic treatment using two techniques: A prospective study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005;99:367-371.
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HEMISECTION FOR TREATMENT OF ENDO-PERIO LESION: a case report Mutiara Anindita *. Adioro Soetojo**. Ketut Suardita** *Resident of Conservative Dentistry Department **Staff of Conservative Dentistry Department Dentistry Faculty . Airlangga University
ABSTRACT Introduction: The human periodontium and dental pulp are closely connected by their proximity and by the presence of apical and lateral radicular foramen. The disease of one tissue might lead to the involvement of the other. The term of ‘endo-perio lesion’ has been used to describe lesions due to inflammatory products found in both periodontium and pulpal tissues in varying degrees. Endo-perio lesions are challenging and sometimes found dilemmatic to the clinician due to various factors which play an important role in the development and progression of such lesions. Knowledge of this disease has an important role in deciding diagnosis, treatment, and prognosis of the disease. Hemisection is an alternative treatment of endo-perio lesions. Aim: to emphasize the importance of primary endodontic treatment when dealing with endo-perio lesions and to demonstrate the considerable healing potential of the endodontic aspect. Case report: 35 year old healthy female patient reported to Conservative Clinic of Airlangga University Dental Hospital with chief complaint of continues pain and mobility of mandibulary left first molar and second premolar since six months. No history of trauma. Pain is localized, dull type. Patient was treated by periodontist about a year ago for the same case but there is no improvement in result. Treatment: Root canal treatment was performed in second premolar and the tooth prepared for a splint crown restoration. Root canal treatment also performed in the distal canal of the first molar continued by insertion of fibre post and hemisection procedure of the mesial root. Both teeht are restored by splint crown. Result: hemisection can be used as an alternative treatment of endo-perio lesion.Conclusion: hemisection can be considered as an alternative treatment for endo-perio lesions. Keywords: Hemisection, endo-perio lesions, splint crown. Introduction Periodontium and dental pulp are inter-related. There are three main pathways for exchange of infectious elements and other irritants among the pulp and periodontal tissues, dentinal tubules, lateral and accessory canals, and the apical foramen.1 When the pulp is inflamed or infected it cause an inflammatory respond of the periodontal ligament at the apical foramen or adjacent to openings of accessory canals, vice versa.2 Simring and Goldberg (1964) were the first to describe the relationship between periodontal and pulpal disease. Since then, the term endo-perio lesion has been used to describe lesions of both the periodontium and the pulpal tissues.3
Endo-perio lesions are often difficult to diagnose and remain persistent if not treated completely. Endo-perio lesions may presence in various degrees which involve the treatment and the prognosis of the disease. The treatment may involve combining restorative dentistry, endodontic, and periodontics so that the teeth may be retained.4 Hemisection procedure is known as an alternative treatment of endo-perio lesions. Hemisection represents a form of conservative procedure, which aims at retaining as much of the tooth structure as possible, needed for restorative abutments or occlusal support.5 In this article hemisection procedure is performed as a treatment of endo-perio lesions in lower left first molar.
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Case 35 year old healthy female patient reported to Conservative Clinic of Airlangga University Dental Hospital with chief complaint of continues pain and mobility of mandibulary left first molar and second premolar since six months. No history of trauma. Pain is localized, dull type. Pain sensation increased during mastication. Patient said these teeth were surgically treated by periodontist about a year ago, but she doesn‟t feel any significant improvement.
Root canal was lubricated with glyde, and irrigated by NaOCl 2,5% and aquadest 10ml. Metapaste used as dressing in both root canal before the teeth are temporarily filled. The dressing process repeated twice between one week, until the teeth are reported asymptomatic, then the root canals were obturated using appropriate MTwo gutta Percha and Topseal.
Fig 3. Root canal obturation of 36 and diagnostic wire photo of 35
Fig. 1 Radiographic examination of 36
One week after obturation, the treatment continued to 35. As the 36, operator performed a root canal treatment on 35. The root canal opened using pathfile, then cleaned and shaped using reciproc #25.
Intra oral examination shows profound carries and gingival recession in mesio-palatal aspect of 36. Profound carries also reported in 35. Surrounding gingival appears redish, and grade II tooth mobility reported in both teeth. Radiographic findings a fracture line on root‟s bifurcation of 36. Radiolucent appears apically of 35 and 36. Fig. 4 Obturation of 35
Case Treatment On the first meeting, root canal treatment is performed in distal root of 36. The root canal first opened using pathfile (#10, #15), then cleaned and shaped using MTwo File (#10 #25).
After obturation of 35, operator performed the hemisection procedure. Pehacain is use to block the left mandible nerve and the tooth is separated by fissure shape bone bur, precisely in the bifurcation. No flap needed in this procedure. After the roots are separated, the mesial root is extracted using root forceps. Curretage is performed in the mesial socket to clean up the area from necrotic tissues or granulomes. Bovine bone graft is added in the defect area and the gingival are sutured using resorbable nylon suture. The remain tooth is not splint because it has no antagonist tooth above.
Fig.2 Diagnostic wire photo of 36
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Discussion
Fig. 5 36 after hemisection procedure
Two week after, patient was called to control. The healing is excellent and the tooth is asymptomatic. The tooth color record by vita 3D . Then fibre posts were inserted to the distal root of 36 and 35, continued by the preparation of these teeth for the restoration. The tooth is prepared using chamfer-end-cylindric bur, preparation end in the gingival sulcus. The tooth impression taken by elastomere and the bite registration record using Regiseal. Two week after, the splint crown is ready to inserted. In trial insertion patient feel comfort with the new restoration. The aesthetic aspect is good and it has a good contact point with the tooth surround. The splint crown cemented using luting cement
(a)
(b)
In many cases, the diagnosis of pulpal disease is easy to establish, but involvement of periodontal disease makes it more complex. To obtain excellent result patient‟s case history with all possible routes, an accurate diagnosis and correct treatment are necessary.6 Hemisection have been used by many clinicians to treat all types and gradations of bone loss and furcation involvement.7 Hemisection provide a suitable abutment for fixed partial dentures or tooth splint crown due to less oclusal forces, and proper crown margin.8 In this case the mesial aspect of 36 is hopeless so hemisection perform to retain the distal aspect of 36 which well supported by the alveolar bone so that this tooth can use as an abutment for tooth splint crown restoration. The decision of hemisecting the tooth should be based on the extent and pattern of bone loss, root trunk, and length, ability to eliminate the osseous defects and endodontic-restorative consideration.9 The tooth had to be endodontically treated before hemisection. This is because tooth preparation can invade the pulp chamber and jeopardize control of the coronal seal of the endodontic access opening complicating the completion of endodontic therapy.10 According to Buhler et al., hemisection can provide a good absolute biological cost savings with good long-term success. Shin-Young Park said that resected molars used as intermediate abutments of a fixed bridge had a higher survival rate. Conclusion
(c) Fig. 6 Splint crown restoration after hemisection procedure
Three month after patient call back for control. The tooth is asymptomatic, and patient feels comfort with her new teeth. The gingival become normal and the tooth mobility decrease. Patient feel an improvement in her mastication process and glad for it.
The prognosis for hemisection depends on a proper case selection. This paper concludes hemisection can be considered as an alternative treatment for endo-perio lesions. References 1. Chander S., Sharma N.,Soni S., Sankhla B., Khandelwal R : Hemisection An Alternative Treatment Modality-Case Report. Int. J. Dent. Clinics. 2012;4(2):8283.
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2.
3.
4.
5.
6.
7.
Simon J, De Deus Q. Endodonticperiodontal relations. Pathway of the pulp 4th ed St Louis: Mosby.1987:553-76. Simring M, Goldberg M. The pulpal pocket approach: Retrograde Periodontitis. J Periodontal. 1964; 35:22-48. Rosten I, Simon JH. The endo-perio lesion : a critical appraisal of the disease condition. Ednodontic Topics 2006; 13 (1): 34-56 Srindhi, Gauri. Unusual endo-perio lesion: A case report. Int. J. Dent. Clinics. 2011: 3(1):87-89. Kurtzman GM, Silverstein LH, Shatz PC. Hemisection as an alternative treatment for vertically fractured mandibular molars. Compend Contin Educ Dent 2006; 27(2): 126-9. Newman, Takei, Fermin A Carranza. Furcation: involvement and
treatment;Willium F IN: Clinical Periodontology, X Ed. WB Saunder‟s Co. 200:996. 8. Shin-Young Park, Seung-Yun Shin, SeungMin Yang, Seung-Beom Kye. Factors Influencing the outcome of Root Resection Therapy In Molars: A 10-year Retrospective Study. J Periodontol 2009;80(1):32-40. 9. M Najeeb Saad, Jorge Moreno, Cameron Crawford. Hemisection as an alternative treatment for decayed Multirooted Terminal Abutment: JCDA 2009; 75: (5)-387 10. Meister Jr F, Haasch GC, Gerstein H. Treatment of external resorption by a combined endodontic-periodontic procedure. Journal of Endodontic 1986; 12(11) : 542-5
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Complex Aesthetic Treatment for Fracture and Dental Trauma Anterior with Open Apex central incisor on Maxillary : a case report Nurul Puspita Sari*.Karlina Samadi**.Devi Eka Yuniarti** *Resident of Spesialist Program of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background: Trauma in anterior teeth is one of case that needed complex aesthetic treatment. The most traumatic dental injuries are dental fracture and pulp involvement. This case report describes complex aesthetic treatment in order to recover aesthetic and masticatory function that adjusted to psychological aspects of the patient. Purpose: The purpose of this paper is to describe complex aesthetic treatment on dental fracture and trauma on anterior maxillary. Case: In this case, a patient 46 year-old man with dental fracture on anterior maxillary with mobility can be treated with complex aesthetic treatment. Case management: Endodontic pulpectomy treatment on anterior maxillary teeth and post construction with fiber splint, apeksification treatment and fabricated post on 11 and fiber post on 21, 22, and 23, and all porcelain crowns on 11, 21, 22, and 23 to correct the position into normal position. Conclusion: Dental fracture and dental trauma on anterior with open apex central incisor can be treated with complex aesthetic treatment. Keyword : complex aesthetic, splint, Apeksification, Endodontic, Fiber post, Porcelain crowns Koresponden ( correspondence ) : Nurul Puspita Sari, Residen PPDGS Konservasi Gigi, Fakultas Kedokteran Gigi Universitas Airlangga. Jl Mayjend. Prof. Dr. Moestopo 47 Surabaya 60132, Indonesia Introduction Nowadays, complex aesthetic treatment in dentistry is being popular and well known to society. It needs logical approach and good treatment plan determination regarding to patient need in order to get aesthetic treatment that meets patient expectation. Some of the influencing factors to aesthetic dental are form and tooth‟s proportion, color, size, and position of teeth. The other related factors are smile line and the relation of tooth middle line with face and lips, oral hygiene, and stomatognatik function. In this case, the patient is having a trauma on anterior teeth due to accident which cause four anterior teeth experience fracture and mobility on the three teeth. The patient wants to preserve the four teeth. In this case, it needs interdisciplinary approach to recover function and aesthetic on
anterior maxilla teeth after trauma. Teeth restoration where the canal root has been treated by using post will add some strength in crown reconstruction after endodontic treatment because it gives retention and stabilization to last restoration either direct or indirect. Case Report Male Patient, 46 years old with complaints on broken teeth in the forefront due to trauma which happened two weeks ago. Clinical picture is shown on teeth number #11, #21, and #22 that fractures on its crown. An incisive tooth on left maxilla (#21) is having a fracture 2/3 crown, mobility 2 degree, normal gingiva, non-vital of vitality teeth, discoloration of teeth, and pain on percussion. The second incisive tooth on left maxilla (#22) is having a fracture 1/3 crown, unsteadiness 2 degree, normal gingiva, vital of vitality tooth, 222
and pain on percussion. An incisive tooth on right maxilla (#11) is having fracture on the crown, normal gingiva, no pain, non-vital of vitality tooth. In radiographic picture there is a canal root with open apex. According to medical history, the patient suffers hypertension with blood pressure: 150/90 mmHg, over bite 2 mm, and over jet 4 mm. Figure 3 : Mock up Model
Figure 1 : anterior teeth condition before treatment
On tooth #11, opening access was made (diamendo and micro opener), determination of work length which confirmed with radiograph picture resulting in 21 mm work length, than we did the debridement, cleaning the root canal with circumferential motion, irrigation by using NaOCl 2.5% and aquadest, dressing with Calcium hydroxide pasta.
Figure 2 : Panoramic radiography
Radiographic picture shows wide canal root with open-end root on teeth #11, normal periodontal tissue, there is no lesi periapical. Subjective examination was done in the first examination, intra oral photo, preoperative radiograph, and diagnosis, determination of #11, #21, #22, and #23 teeth treatment plan, maxilla molding, mandible for study and diagnostic model and also filling the informed consent, molding for mock up model, making temporary crown and installing splint (fiber splint) in order to prevent mobility on teeth number #21, #22, #23 and also giving medicine for premedication and relieve pain (PROLIC 300 mg 2 times a day, MEFINAL 500 mg three times a day). In the next visit, examination was done to control the unsteadiness of the teeth; local anesthesia was done using lidocaine in order to treat the root canal.
Figure 4 : working leght #11
On teeth #21, #22, & #23 root canal treatment began with access opening (diamendo and micro opener), work length determination with K-File #15 with apex locator confirmed with radiograph picture resulting in work length for tooth #21: 23 mm, tooth #22: 25 mm, tooth #23: 31 mm, and then using path file #13, #15, #17 in order to get good glide path. File#20 (C-pilot) could be inserted passively until work length, therefor tooth #21 will be prepared using file #R-40, & for tooth #22 using file #R-25 (reciprocal) with lubricant pasta (EDTA Pasta) and for tooth #23 using single length technic with file MTWO until file #40 accompanied by NaOCl 2.5% irrigation and 223
Aquadest, and dried with sterile paper point, and then dressed using Calcium Hydroxide pasta. On the next visit, the control was done, fiber splint was mobility due to there was no mobility, trial gutta point was done on tooth #21 (gutta point reciprocal #R40), on tooth #22 (gutta point reciprocal #R25) and on tooth #23 (using gutta point MTWO #40), Confirmation was done by Rontgen photo, then dressing using Calcium hydroxide pasta and temporary crown incersion.
Figure 8 : Thermoplastis obturation #11
Single point gutta point obturation was done on tooth#21 ( reciprocal #R40 ), single cone gutta point obturation was done also on tooth #22 ( reciprocal #R25 ), single cone gutta point on tooth #23 ( MTWO #40 ) using sealer with base material from resin and confirmed by radiography.
Figure 5 : Trial gutta point #21, #22, #23
Figure 9 : Obturation #21, #22, #23 Figure 6 : Temporary Crown insertion
On the next visit, tooth #11 apexsification was applied with MTA at the thick 4 mm. After that Confirmation was done by radiograph, and wet cotton was put in the root canal. After one week, obturation was done with thermoplastized gutta percha on tooth #11.
On the next visit, gutta point on tooth #11 was taken by using drill penetration and fabricated post was casted by using disposable post (uniclip plastic post) and then casted with double impression casted material and temporary crown was installed. On teeth #21, #22, #23, gutta point was taken by using drill penetration on 2/3 length of the root tooth and drill calibration, and prefabricated post insertion was done by using adhesive cement resin material. Apply core-it to create corebuild up and temporary crown installation.
Figure 7 : Apeksification with MTA
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Figure 10 : trial Prefabricated Post Figure 12 : Crown Porcelain (Zirconia)
Figure 11 : Preparation core built up
On the next visit, fabricated post insertion on tooth #11 was done by using lutting cement, retraction cord was installed on anterior area (tooth#11, #21, #22, and #23) and crown preparation was done for preparation. Gingival cord was installed on tooth #21, #22, and #23 and then preparation was done by using flat end tapered diamond boor to sub gingiva area. Casting on maxilla was done by using double impression material and while for mandible using irreversible hydrocolloid casting material, the making of bite registration, and also tooth color determination using side guarde (3M2). In the last visit, Crown was tried to install and it showed crown had a good selfretention, good form anatomy, good marginal integrity, good occlusion, and there is no complaint about the comfort from the patient. Therefore, the porcelain crown (zirconia) was cemented permanently on teeth #1, #21, #22, and #23 by using resin adhesive cement, and also adapted to right curve. Oral hygiene was instructed and re-control after six months.
Figure 12 : Insersi Crown Porcelain (Zirconia) #11, #21, #22, #23
Discussion In this case, the tooth has experienced post trauma & had a lot of occurring problem such as loss of tooth structure, clinical condition of short crown due to fracture, remaining tooth structure lays below margin gingiva, and there was a wide root canal with open apex due to trauma occurred on growth ages. When trauma occurs on growth of the tooth, it will stop dentin production and in the end will stop the root production. This makes the root canal wider with open apex and sometimes the root will be shorter.1,5 This case shows an aesthetic rehabilitation using fiber splint treatment post trauma due to unsteadiness and endodontic treatment, core and porcelain zirconia crown installation. Endodontic treatment was done to all four post trauma teeth & open-end apex was closed by using apex fixation procedure with MTA (tooth#11).3,4 The using of fabricated post on tooth #11 in order to maintain tooth‟s strength and retention due to all crown has lost and also to repair the inclination of the tooth. Pre-fabricated post (fiber post) has modulus elasticity similar to dentin and more aesthetic compare to metal post. Pre-fabricated post (fiber post) has better 225
aesthetic, able to bond with dentin and core material, able to absorb pressure therefore protects the root from fracture. The modul elasticity of fiber pivot is low (17.5 – 21.6 GPa), near to dentin modul elasticity (14.0 – 18.6 GPa) so that able to increase resistance on root fracture, while fabricated post on tooth #11 was selected because the remaining teeth tissue is to little which is impossible to form a core.2 Loss of teeth structure extensively due to trauma will make the restoration plan more difficult. It needs interdisciplinary approach to evaluate, diagnose, and overcome aesthetic problem. Porcelain Zirconia Crown was selected due to it has good strength and aesthetic for patient.4 Oral hygiene instruction was given to patient for caring his teeth, check-ups regularly, and avoids excessive contact. Conclusion The purpose of complex aesthetic treatment is to generate ideal tooth with color,
form, structure, & stomatognati function, achieves healthiness, and optimal reliability. References 1. Dogra, S., Mukunda, A.S., Arun A., Rao, S.M., 2007, Apexification, J. dent Scie Research, 3, 41-44 2. Gutmann J, Kuttler S and Niemczyk S, 2010, Root Canal Obturation: An Update, Academy of Dental Therapeutics and Stomatology, a division of PennWel, 2010 3. Himel V dan DiFiore P, 2009, Obturation of Root Canal Systems, ENDODONTICS: Colleagues for Excellence, American Association of Endodontists (AAE). 4. Walton ER, Vertucci, Internal anatomy. In Principle and practice of endodontic. 3rd Ed. WB Saunders. 2002: 166-180 5. Witherspoon DE, Ham K : One-visit apexification: technique for inducing rootend barrier formation in apical closures. Practical Periodontics and Aesthetic Dentistry 13,455–60, 2001.
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Endodontic SurgicalTreatment of Posterior Teeth with Bifurcation Perforated : a case report Buyung Maglenda*. Karlina Samadi**. Devi Eka Yuniarti** *Resident of Conservative Dentistry Department **Staff at Department of Conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background : Perforations represent pathologic or iatrogenic communications between the root canal space and the attachment apparatus. The causes of perforations are resorptive defects, caries, or iatrogenic events that occur during and after endodontic treatment. Regardless of etiology, a perforation is an invasion into the supporting structures that initially incites inflammation and loss of attachment and ultimately may compromise the prognosis of the tooth. Objective :To describe endodontic surgical treatment (hemisection) of poserior teeth with bifurcation perforated. Case Report : This case presented an 23 years old male patient who referred to the Hospital in Airlangga University Dental Faculty for treatment mandibular first molar.Tooth was tender to percussion. Treatment :The first molar however was badly damage, only left the mesiobuccal wall portion. The treatment choosen was hemisection of distal part of the tooth and endodontic treatment of the mesial canal. The restoration was crown. Conclusion :Hemisection is an appropriatee alternative treatment for tooth with bifurcation perforated and should be discussed with patient during consideration of treatment option. Key Word : Hemisection, Bifurcation Perforated, Endodontic Treatment, Crown INTRODUCTION The efforts to maintain the teeth as long as possible in the mouth cavity have been improving along with the increase of the patients‟ awareness to treat their teeth. The advanced teeth conservation treatment like endodontic retreatment and endodontic surgery intend to maintain the teeth so that they can be in good condition for a long time. Generally, the molar especially the first mandibular molar, is a tooth which is frequently pulled out because of caries or periodontal diseases. It should not happen actually. On some cases, the molar with severe damage on bifurcation or on one of the root can be maintained by endodontic surgery treatment, using bicuspidation or hemisection procedure. Hemisection is a surgical separation of a multi-rooted especially on the molar or mandible. Hemisection is done making a cut on the furcating with the bukal-lingual direction so that the damaged root or crown of the tooth can be pulled out. The main purpose is to maintain
the healthy part of the tooth so the restoration can be undergone. The indications of hemisection are: 1) the severe alveolar or periodontium damage which can‟t be cured by non surgical treatment; 2) the root which can‟t be cured because of broken instrument, perforation, caries, resorption, vertical fracture, orcalsificated the root canal; 3) the remainder root and crown which is important and able to be restored. Contraindication: 1) the endorsement of the bone to the remainder root which is preserved is insufficient. 2) The roots are fusion or closed each other so they can‟t be separated with this procedure. 3) The endodontic treatment can‟t be undergone to the preserved root. This case report describes hemisection on the first molar mandible where the mesial part is maintained while the distal part is pulled out.
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STUDY CASE A twenty three year old male patient came to the PPDGS Clinic RSGMP dental conservation of Airlangga University with a complaint the cavity on his left inferior molar. The patient wanted his damaged tooth was treated and was maintained. The clinical description was a big distooklusal cavity wass seen, only a little mesiobuckal wall left with a polyp whose diameter was more about 4 mm on the tooth bifurcation (picture 1). The percussion test was positive. Moreover, on the radiography test, there was radiolucent area on the distal root which was widening up to bifurcation area, the profound lesion caries (Picture 2). The diagnose of the tooth's condition was pulp necrosis. The plan of the treatment was hemisection, the use of fiber pin, and ceramic crown restoration with metal fusion in the premolar form.
18mm and it was confirmed by the x-ray film (Picture 3). Next, preparation of the root canal by single length technique using M-two file until red file (25.06). In the preparation processat, lubricant EDTA was used, the canal irrigation using NaOCL 2% and rinsed by aquades. After the preparation got the working length, the trial gutta percha picture was taken. And the result was hermetic gutta percha in the root canal (picture 4). After that, the tooth was dressed using calcium hydroxide paste and then and temporarily filled. Patient was asked to return the following week.
Picture 3. The confirmation of the working length and bifurcation perforation.
Picture 1. The clinical condition of the thirty sixth tooth.
Picture 2. Radiography, the radiolucent on the distal root widen into bifurcation.
The first visit, after the patient signed consent inform, the infiltration anesthesia was done using pehacain. Then the access to the orifice of mesial root canal and distal was cleaned using excavator. Afterward the cavity was irrigated by NaOCL 2%, rinsed by aquades and dried by pellet cotton. The determination of the working length and perforation bifurcation used K-file #15 and apex locater. From the measurement it was gotten the working length of mesiolingual (ML) canal root 14 mm, mesiobuckal (MB)
Picture 4. The dressing trial of gutta percha
On the second visit, a week later, patient didn‟t feel any pain. The temporary filling was in good condition, the tissues around the tooth were fine. When the percussion test was done, the patient didn‟t feel painful. Moreover, the mobility test was negative. The temporary filling was opened, and then the dressing material was cleaned by irrigating the sterile NaOCL 2 % to it and rinsed using sterile aquades. After that the root canal was dried by sterile paper point. The filling of the canal root was done by single cone technique using gutta percha point which was appropriate with the file size. The resin base sealer was added, and then the gutta percha was cut to orifice by excavator which was heated and condensed by plugger. After that it was temporarily filled and was taken picture of the root canal filling (Picture 5)
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Gambar 5. Radiografi pasca pengisian saluran akar
The third visit wass the Hemisection stage. However, the post treatment review was done to the root canal on the distal. results were the subjective symptoms were negative, the condition of temporary filling was good, percussion was negative, and the tooth mobility was negative. Then the blood tension of the patient was measured; it was 120/70 mmHg. Asepsis was done on the operation area, the block anesthesia on the left mandible nerve and infiltration anesthesia on the vestibulum 36 using pehacain. The thirty sixth tooth was separated to the lingual buccal using high speed handpiece with long tappered diamond bur. After the tooth was divided into two parts, mesial root was taken using elevator (picture 7), the mesial root socket was scrapped then irrigated using sterile saline. Bone graft was applied into the mesial root socket then it was sutured using silk thread. Splinting was applied into the crown of the thirty sixth(36th) and the thirty fifth (35th) using splint fiber (picture 8). The operation area was cleaned then was taken picture post hemi section. The patient was instructed to clean operation area using soft toothbrush and he was prescribed Albiotin 300 mg, Indexon 0,5 mg, and mefinal 500 mg. The patient was also instructed to return the following week (Picture 6).
A Picture 6. A. Asepsis B. Anasthesia
B
A
B
Picture 7. A. Separation B. The lifting of distal root.
A
B
Picture 8. A. The Application of Bone graft B. Suturing
A
B
C
D
Picture 8. A.Application of fiber splint. B. The A D radiation C. Splint 35-36 D. Distal root
On the fourth visit, the post hemisection treatment control was done. The subjective symptoms were negative, the the condition of A B the suture and splinting were good; moreover, B C the percussion was negative. Next step was fixing of post fiber pin, calibrating the pin size with the template, picking up gutta percha with luxapost drill, the dressing trial of the fiber pin, core built up, gingival management and D The crown preparation Cfor metal fusion ceramic. mould for DIE used elastomers materials with double impression technique and antagonist mould used irreversible hydrocolloid material. Next step was making the dental record, calibrating the color, and fixing temporary crown on the prepared tooth. The last, the patient was asked to return one week later. (Picture 9)
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A
B
the mouth cavity. It needs well consideration, accuracy, and high skill of the operator. On this case, hemisection was successful not only because of the mentioned factors but also the good condition of the root anatomy and supporting tissues of the teeth. REFERENCES
C Picture 9. A. Fiber post insertion B. Fiber post radiography C. Temporary crown
On the fifth visit, ceramic metal fusion crown was fixed and trial, articulation was examined, A were calibrated. Ceramic B anatomy and the color metal fusion crown was still inserted using luting cement. (Picture 10).
Picture 10. The Insertion of metal fusion ceramic crown
1. Walton R & Torabinejad M : Prinsip dan Praktek Ilmu Endodontik (terj), 2 nd ed., Penerbit Buku Kedokteran EGC, Jakarta, 2008 2. Tarigan R : Perawatan Pulpa Gigi., Penerbit Widya Medika, Jakarta, 2012: 165-175 3. Shah S et all : Hemisection – A Conservative approach for a periodontally compramised tooth – A Case Report. Journal of 4. Advanced Oral Research, Vol 3; Issue 2: May-Aug 2012: 31-35 5. Shafiq K, Javaid A, Asaad S, : Hemisection: An option To Treat Apically Fracyured & Dislodged Part Of A Mesial Root of a Molar. JPDA Vol. 20 No. 03 July-Sep 2011: 183186
Discussion Hemisection is an alternative procedure which is beneficial especially to maintain multi rooted tooth which is indicated to be extracted. The success level of hemisection treatment was determined by the oral hygiene status of the patient, caries index, and the patient medical status. On this case, hemisection was finally taken by the consideration of the bad prognoses on the distal root of the thirty sixth (36th) teeth. The bad prognoses of the distal root are the size of the reminder root was short, there was a damage on the periodontal tissue, and there was a periapical lesion. The chosen restoration was metal fusion ceramic crown with the rest on the thirty seventh (37th) mesial. Conclusion Hemisection is one medical treatment which is done to maintain the teeth as long as possible in
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Non surgical endodontic treatment and internal bleaching on maxillary right central incisor with periapical lesion Irfan Dwiandhono*, Agus Subiwahyudi**, Mandojo Rukmo** * Resident of Conservative Dentistry ** Staff Department of Conservative Dentistry Faculty of Dentistry, Airlangga University Surabaya-Indonesia
ABSTRACT Background: Bacterial infection of dental pulp may lead to periapical lesion. The treatment periapical lesion is non surgical or surgical endodontic. Discoloration of the anterior teeth is an aesthetic problem that is often the reason for patients to seek improvement. Although it can be done restorative treatment such as crowns and veneers, discoloration can also be repaired with bleaching procedures. Bleaching procedure is more conservative than restorative methods, is relatively easy to do, and more affordable. Purpose: In this case the operator tried to do non surgical endodontic treatement and internal bleaching on maxillary right central incisor with periapical lesion. Case: Female, 37 years old complained tooth #11 discoloration, fracture Ellis class III that had filled composite, and unfinished endodontic. On radiograph examination, it appears radiolucence perioapical lesion. Case management: non surgical endodontic, internal bleaching, and then restoring composite. Result: Non surgical endodontic treatment and internal bleaching of the tooth with periapical lesions would seems the color change significantly from C4 to A3. Significant reduction on periapical lesion was seen on radiograph after control 1 year. Keyword : endodontic, bleaching, periapical, lesion Correspondence : Irfan Dwiandhono, Resident of Conservative Dentistry, Faculty of Dentistry, Airlangga University. Email :
[email protected] BACKGROUND Bacterial infection of the dental pulp can cause periapical lesions. The treatment periapical lesions is non-surgical or surgical endodontic. Consideration is needed when deciding on the treatment of periapical lesions in non-surgical endodontics are : 1) Proximity periapical lesions with surrounding anatomical structures (blood vessels, nerves, and maxillary sinus) which can lead to injury. 2) Patient anxious and uncooperative to the surgical procedure. 3) The general condition of patients who are less able to tolerate the surgical procedure. Surgery is recommended for cases that do not respond well to non-surgical treatments.1 Periapical disease or also known as apical periodontitis is a disorder that occurs as a result
of diseases of the pulp which continues due to caries or trauma. Of all cases of chronic apical periodontitis, radicular cysts had the highest frequency of between 52% to 68% .2 Radicular cyst is a pathological cavity in periapical area containing liquid, semi-liquid or gaseous materials and is often limited by the epithelial layer and in the outer part is covered by connective tissue and blood vessels. Cysts is formed by the chronic irritation on non-vital teeth. Cysts grow from epithelial rest of malassez which proliferate due to the inflammatory response which is triggered by bacterial infections of the pulp necrosis.3 Radicular cysts are divided into two categories: true cysts and cyst pocket (bay cyst). In true cyst there is no direct communication with the root canal. While in the pocket cyst, the cyst is directly related to the root canal. In the case of 231
pocket cyst may be performed non-surgical endodontic treatment.4 Discoloration of the anterior teeth is an aesthetic problem that is often the reason for patients to seek improvement. Although it can be done restorative treatment such as crowns and veneers, discoloration can also be repaired with bleaching procedures. Bleaching procedure is more conservative than restorative methods, relatively easy to do and more affordable.5 The causes of the discoloration are generally divided into extrinsic, intrinsic, and a combination of both. Extrinsic discoloration on the surface of the teeth is most commonly caused by tobacco, coffee, tea, or colorful food. Teeth that have microcracks is very susceptible to stains. Intrinsic discoloration is caused by bleeding in the pulp and decomposition of the pulp tissue, blood fractions and bacterial products. Discoloration also occurs through penetration of the tooth structure by discoloring agents, such as drugs given systemically, excessive fluoride during enamel formation, the product side of the body such as bilirubin that is released into the dentinal tubules during the process of disease, trauma, or pigmentation of drugs and materials used in dental treatment.6 Bleaching is a treatment of discolored teeth, in order to resemble the color of natural teeth. The repair process is using chemical and the aim to restore the aesthetic patient. Bleaching can be done in two ways, External Bleaching on discolored vital teeth and Internal Bleaching performed on non-vital teeth that have well treated root canal. This case report will describe the non-surgical endodontic treatment and internal bleaching on maxillary right central incisor with periapical lesion CASE Female, 37 years old complained discoloration at maxillary right central incisor. Teeth are often painful and swollen gums. Teeth have no history of trauma and about 9 years ago that had filled composite and unfinished endodontic On clinical examination looks at tooth #11, there is composite restorations (class IV). On the palate, the composite separated from the tooth so that the orifice is opened. There are differences
in the color of the other teeth. At tooth #11 the color is C4, while the other teeth are in color A3 (Figure 1). Positive percussion. Negative palpation, and negative thermal.
Figure 1 Preoperative view of tooth #11
Radiological examination shows pulp chamber is opened with one root canal. Periodontal ligament dilation and rupture of the lamina, accompanied with radiolucent image with clear boundaries (4 mm diameter) in the apical region (Figure 2)
Figure 2 Preoperative radiograph of tooth #11
The clinical diagnosis of periapical lesions is cysts pockets (Bay Cyst) because pulp necrosis tooth #11. The treatment plan is root canal treatment (non-surgical) and followed by internal bleaching and composite restorations CASE MANAGEMENT First Visit Do the access opening, irrigated with 2.5% NaOCl and sterile distilled water, then dried with paper points. Furthermore, making glide path use K-file #10 and working length was measured using an apex locator (Raypex 6, VDW) obtained 22mm working length. Furthermore, determining the appropriate file to the width of the root canal using a K-file # 30 and can reaches the working length passively. 232
Then the root canals were prepared by using rotary reciprocal R50 files with lubricant (MD ChelCream) and irrigation using 2.5% NaOCl and sterile distilled water X-rays guttap percha reciproc R50 tried in accordance with the size of the file used for root canal preparation. Then do the dressing with Ca(OH)2 (Metapaste) and closed with a temporary filling. Second Visit Control, from the subjective examination and objective examination no complaints. Fillings temporary removed, irrigated using 2.5% NaOCl and sterile distilled water to dispose of Ca(OH)2. Root canals were dried using sterile paper points R50 (Reciproc, VDW). Then do the obturation with lateral condensation technique using guttap percha master R50 (Reciproc, VDW) and TopSeal sealer (Dentsply), then given a temporary fillings (Figure 3)
Fourth Visit The color changes to A4. Then opening of filled cavity that had been temporarily GIC using round bur, cavity was cleaned with cotton pellet,, irrigated using sterile distilled water and dried, the application of hydrogen peroxide paste repeated, given a cotton pellet and closed with GIC. Fifth Visit One week later, the color changed to A3 (Figure 4a). Furthermore cavity was opened with round bur, the cavity was cleaned with cotton pellet. Etching 35% phosphoric acid (3MTM ESPETM) on tooth cavity #11 for 15 seconds, then rinsed, applied the bonding material, light activated 20 seconds. Composite aplicated in the cavity layer by layer and irradiated (Figure 4b). Patients were instructed to control after 1 year.
Figure 4 Tooth #11. a) Before filled composite b) After filled composite
Figure 3 Radiograph of tooth #11 had undergone obturation
Third Visit Determine and measured the depth of the location retrieval guttap percha using a periodontal probe. Cervical seals were made by applying glass ionomer thickness 2mm above guttap percha with basic shapes sloping labial direction. Layer of glass ionomer cement followed the outline of the cervical line. 35% hydrogen peroxide (Endo Opalescence, Ultradent) was applied to the labial pulp chamber and given a cotton pellet and covered with glass ionomer cement. Patients were instructed to come back 1 week later
Sixth Visit One year later, Evaluation was done to see the healing of periapical lesions. On subjective and objective examination did not reveal any abnormalities. Examination radiograph, the periapical lesion size reduced. The size of the lesion prior to treatment approximately ± 3mm. Lesion size was reduced to 1,5mm after treatment (Figure 5)
Figure 5 Radiograph and clinical evaluation (one year post treatment)
DISCUSSION Dental pulp is infected by microorganisms that enter the root canal and not treated can cause the infection to spread to apikal.7 It is an 233
irritant causes the antigen-antibody reaction and eventually can become periapical lesions. The etiology periapical lesions of these cases due to secondary caries continues until the dental pulp as result leakage of fillings, which became the entrance irritant bacteria, causing inflammation of the pulp, the death of the pulp, and periapical abnormalities. Periapical tissue responses against invading bacteria and pulp cover several phases. Initial phase is characterized by widespread acute inflammation and causing alveolar bone resorption at the tip apex. The process of defense hosted by periodontal ligament occurs after the acute phase. Bacterial invasion continues and periapical tissue perform tissue repair.4 Continuous bacterial irritation resulting loss of ability to perform periapical tissue defense reactions resulting in chronic reaction. At this stage, granulation tissue at the lesion area in the long term are able to develop into cysts radikuler.8 In this case the lesion has become a radicular cyst. In general, radicular cyst is a continuation of chronic apical periodontitis, but not every chronic lesions develop into cysts. The diagnosis of periapical lesions should be made carefully. Periapical lesions are generally much destroy alveolar bone which is so clearly visible on radiographic examination. According to Walton and Torabinejad radiographic periapical cysts bounded clear and unequivocal. The definitive diagnosis of cysts can be done with certainty by histological examination. In this case, the teeth 11 are clinically diagnosed as cysts pockets (Bay Cyst). In this case, the selected cyst treatment is non-surgical treatment (The conventional endodontic treatment). Preparation techniques were used that technique reciprocal, with consideration of the root canal wide and straight, so hopefully with this preparation technique covers all the walls of the root canal, so that all sources of infection in the root canal can be removed. The cleanness of the root canal from infection becomes very important to improve periapical cyst lesions. Irrigation in this case is 2.5% NaOCl because it has anti-microbial effect that are able to break the chains of proteins, damaging DNA synthesis activity of bacteria,
have the ability to dissolve the remnants of necrotic pulp tissue and organic component of dentin, and also can removes biofilm.1 Medicament between visits were used in this patient is Ca(OH)2. Selection of medicaments is based on several considerations, among others, because it is not irritating, has an alkaline pH (11 to 12.8) and its antibacterial capabilities, so it is a stimulator of biological hard tissue formation in the area of damage and is expected to accelerate the healing process.1 Obturation in this case using the master guttap R50 added accessories guttap percha with lateral condensation technique to get a solid and hermetic obturation. Sealer using TopSeal. Use of this sealer can result the hermetic obturation because good adaptation between the sealer and guttap and also with the canal walls.1 In this case report, the material for internal bleaching is 35% hydrogen peroxide bleaching (Opalescence Endo) because the gel is indicated for post-endodontic treatment of discoloration teeth, easy application and contact time to the tooth tissue to be longer so that the effects of bleaching teeth be better . In addition, the gel form is insoluble and not easily penetrate like the solution form. The effectiveness of this gel can be seen only one visit, the color of tooth is to be same with adjacent tooth. It is associated with this material can diffuse into the dentin tubules and email because small molecular weight (30g / mol).9 After 1 year, radiographic examination show healing periapical lesions, in which a reduction of the cyst size and began to appear radiopaque in the cyst. There are several factors that can support the healing of the cyst in this case. They are adequate root canal treatment, young patient (37 years old), the patient's general condition is good, not smoking, and not have a systemic disorder so that healing process is more rapid. Based on the above discussion it can be concluded that non-surgical endodontic treatment and internal bleaching of the tooth with periapical lesions will change the color significantly from C4 to A3. Significant reduction on periapical lesion was seen on radiograph after control 1 year.
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REFERENCES 1. Cohen S, Hargreaves KM. 2011. Pathway Of The Pulp. 10th ed. St. Louis : Mosby Elsevier. Pp. 175-84 2. Siquiera JF. 2005. Reaction Of Periradicular Tissues To Root Canal Treatment; Benefit And Drawbacks. Endodontic Topics; 10. Pp. 123-47 3. Danudiningrat CP. 2006. Kista Odontogen Dan Nonodontogen. Cetakan 1. Surabaya : Airlangga University Press. Pp. 39-42 4. Siquiera JF. 2005. Reaction of Periradicular Tissues to Root Canal Treatment; Benefit and Drawbacks. Endodontic Topics. 10:123-47 5. Walton RE, Torabinejad M. 2009. Principle and Practice of Endodontics. 4th ed. Philadelphia : WB Saunders Company. P. 391 6. Goldstein RE. 1998. Esthetic in Dentistry. 2nd ed. Hamilton : BC. Decker Inc. Pp. 245-74 7. Ingle JI, Bakland LK, Baumgartner JC. 2008. Endodontics. 6th ed. Chapter 5. Ontario: BC Decker Inc; Pp. 890-952 8. Lin LM, Huang TJ, Rosenberg PA. 2007. Proliferation of Epithelial Cell Rest, Formation of Apical Cyst , and Regression of Apical Cysts after Periapical Wound Healing. JOE. 33(8):908-16 9. Deliperi S. 2008. Clinical Evaluationof NonVital Tooth Whitening and Composite Resin Restoration. Five-Year Results. The European J of Esthetic Dentistry. 3:14-25
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Management of Maxillary Left Incisor with Large Periapical Lesion and Tooth Discoloration : a case report Shintya D Halim*. Moh.Rulianto**. Febriastuti Cahyani** * Resident of Conservative Dentistry Department **Staff at Conservative Dentistry Department Faculty of Dentistry. University of Airlangga
ABSTRACT Background : Pulpal tissue can become infected through various ways such as caries or trauma, making the pulpal tissue necrotic. The microbial aggregation or its by-products can infiltrate into periradicular tissues and stimulate the host defense system, resulting in periapical/periradicular tissue destruction. Through time, if trauma is the cause of pulpal necrosis, the discoloration becomes more severe. Purpose : The purpose of this case report was to demonstrate endodontic surgery and bleaching internal as management of maxillary left incisor with large periapical lesion and tooth discoloration. Case : A 31 years old woman presented for consultation at Dental Hospital, Faculty of Dentistry Airlangga University because of the discoloration of maxillary left central incisor. The radiograph examination revealed a large radiolucency extending from periapical of the central incisor to lateral incisor. Case management : The endodontic surgery planned as treatment for the periapical lesion and bleaching internal as treatment post endodontic surgery. Conclusion : Surgical endodontic treatments gives a good response for the periapical healing. As the bleaching internal gives a better esthetic for the discolored tooth caused by a trauma. Keyword : Endodontic surgery, Apical resection, Bleaching internal. Trauma to a tooth can damage the pulp when the crown and root are not fractured. Due to trauma, a vascular pulp may degenerate into vascular necrosis. The necrotic material then seeps out of the exit portals of the root canal system and into the supporting vascular attachment apparatus, generating lesions of endodontic origin.(1) Trauma of the pulp might result in tissue necrosis as well, causing release of noxious byproducts that can penetrate tubules and discolor the surrounding dentin (2). The degree of discoloration is directly related to the duration of time that the pulp has been necrotic. The longer the discoloration compounds are present in the pulp chamber, the greater the discoloration. The purpose of this case report was to demonstrate endodontic surgery and bleaching internal as management of maxillary left incisor with large periapical lesion and tooth discoloration.
Case A 31 years old woman presented for consultation at Dental Hospital, Faculty of Dentistry Airlangga University because of the discoloration of maxillary left central incisor. The patient concerned by the grayish color and had a will to have a treatment. Patient had an accident 20 years ago and had a dental treatment for these teeth before. During these 20 years she complained of pain that repetitive. The last time she had a swelling in upper vestibular and went to dentist. She appointed but didn‟t back to dentist. Clinically, the examination showed dark discoloration on maxillary and mandibulary left central incisor.
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Figure 1. The intra-oral condition of patient
There was a pain in palpation of upper buccal vestibulum. The discolored incisor was nonvital on thermal and electric pulp tester. The radiograph examination revealed a large radiolucency extending from periapical of the central incisor to lateral incisor.
Figure 3. The working length of central incisor was confirmed by the radiograph examination.
The preparation of root canal was done with reciproc #60 and EDTA as lubricant. Root canal irrigated by NaOCl and aquades. CaOH used as dressing. For the lateral incisor, access opening was done and determination of working length using apexlocater (18 mm). The working length confirmed by radiograph.
Figure 2. The radiograph examination of central incisor.
The examination continued to the lateral incisor. The lateral incisor was nonvital on thermal and electric pulptester. The available treatment options were discussed with the patient and endodontic surgery therapy and bleaching internal was selected. Treatment The access opening of central incisor was done. Root canal irrigated by NaOCl and aquades. There were many exudates from the canals. The orifice was plugged by cotton pallete and patient was told to change the cotton if needed. One week later, patient reported the pain was reduced. Determination of working length using apexlocater (22 mm) and being confirmed by radiograph.
Figure 4. The working length of lateral incisor was confirmed by the radiograph examination.
The preparation of root canal was done with reciproc #25 and EDTA as lubricant. Root canal irrigated by NaOCl and aquades. CaOH used as dressing. For the central incisor, patient reported persistent pain and swelling at the palatal which reduced. Root canal irrigated with NaOCl and aquades. The exudates reduced than the first irrigation. CaOH used as dressing agent. As the final point, final irrigation was done with 2.5% NaOCl and aquades. The canals was dried with paper points. Obturation was performed with reciproc gutta-percha and sealer, as for the central incisor by thermafil obturation technique and for the lateral incisor by conventional technique. A postoperative radiograph obtained. Patient appointed 2 weeks later. 237
Figure 7. The intra-oral condition of patient post bleaching interna.
Discussion Figure 5. The periapical radiograph of obturation.
Two weeks after obturation, patient returned and apical surgery was performed to remove apical lesion. The surgical intervention consisted of apical curettage, root-end resection, root-end preparation and retrofilling. A vestibular flap was raised, granulation tissue was removed, root-end was resected, mechanical retention provided and retrograde MTA inserted. Sutures were used to close and healing was uneventful.
Figure 6. The periapical radiograph post apical surgery
At 1-week follow-up examinations, the patient was asymptomatic. The sutures was removed. For the central incisor, the temporary restoration was unplaced. The gutta percha removed to a level about 1-2 mm below the CEJ. Glass ionomer was used to seal the Gutta percha point. The bleaching agent was inserted and the cavity was restored by GIC. For the lateral incisor, the cavity was restored by composite. One week later, clinically there was improvement in the color of central incisor.
It is generally agreed that if the pulp becomes necrotic, its environment becomes suitable to allow microorganisms to multiply and release various toxins into the periapical tissues, initiating an inflammatory reaction and leading to the formation of the periapical lesion. (1) As this case management, endodontic surgery was preferable as it consists the excision of pathological periapical tissue from root surface (including apical accessory canals), thus reaching the goal of creating the best conditions to the tissue health, regeneration and creation of new tooth structural support. The surgery goal is periapical lesion removal and the apical third sealing, allowing soft and hard tissue regeneration [3]. Parendodontic surgery is a widely studied procedure. According to the meta-analysis of Tsesis et al. [4], paraendodontic surgery success rate is 91.6%, while failure rate is 4.7%. However, its prognosis is influenced by several factors, such as: different surgical procedures and materials, clinical and radiographic evaluation, demography, systemic conditions, local quality factors, for example, the involved teeth and their anatomy, conventional treatment or previous root canal retreatment and restoration quality [3]. Surgical flap design is variable and depends on a number of factors, including: access to and size of the periradicular lesion, periodontal status (including biotype), state of coronal tooth structure, the nature and extent of coronal restorations, aesthetics, and adjacent anatomical structures.(5) Apical portion was cut in 45º related to tooth long axis [6]. Despite some authors [7] advocate that the larger the cut angle the larger will be 238
dentinal tubules exposure, this inclination degree was needed to allow total root surface exposure, aiming to facilitate the operative procedures. The root-end filling material should be compacted into the cavity with a small plugger to ensure a dense fill. There should be no excess material on the resected root face. A biologically compatible material should be used where possible. Mineral trioxide aggregate is an osteo and cement-inductive material and is associated with a high clinical success rate. (8) As for the discolored anterior teeth, it is often perceived as an esthetic detraction. Because of the growing need for beautiful, white teeth and the establishment of esthetic treatment methods, the bleaching of nonvital teeth has become increasingly important in recent years. Given the appropriate indication, the bleaching of nonvital teeth is a relatively low-risk intervention to improve the esthetics of endodontically treated teeth. Depending on the situation, the walking bleach technique can be an uncomplicated and convenient method for both patients and dentists.(9)
2.
3.
4.
5. 6.
7.
8.
Conclusion For successful surgical managemet, knowledge of the regional anatomy and surgery technique is mandatory. As for the esthetic, because the clinical results of other techniques have many disadvantages, the walking bleach technique, which is easy to perform, consumes the least time, relatively inexpensive and requires no special equipment, is the ultimate method of choice. It can be concluded from this case report that walking bleach technique is an important and valuable tool for discolored non-vital endodontically treated permanent teeth. Bleaching of endodontically treated teeth is a conservative alternative to a more invasive esthetic treatment such as placement of crowns or veneers.
9.
therapy: Two case reports and review of literature. Endodontology, 2000;Vol 12. Attin T, Paque F, Ajam F, Lennon AM. Review of the current status of tooth whitening with the walking bleach technique. Int Endod J 2003;36:313–29. Lorena Oliveira Pedroche, Apicoectomy after conventional endodontic treatment failure: case report. RSBO. 2013 ;10(2):1827. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a metaanalysis of literature. J Endod. 2009;35:150511 Glynis E Evans, Karl Bishop. Guidelines for Surgical Endodontics. 2012. Gilhe PA, Figdor D, Tyas MJ. Apical dentin permeability end microleakage associated if root end ressection end retrograde filling. J Endod. 1994;20:22-6. Kim S, Pécora G, Rubinsten R, DorscherKim J. Microsurgery in endodontics. W.B. Saunders Company,2001;p.172 Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod 2008; 34: 660–5. Brigitte Zimmerli, Franziska Jeger, Adrian Lussi. Bleaching of Nonvital Teeth. Schweiz Monatsschr Zahnmed 2010; Vol. 120(4)
REFERENCES 1. Thomas SB, Al Kandari AR, Abdul Rahem AA. Healing of a large periapical lesions following calcium hydroxide endododontic 239
Indirect porcelain veneer restoration for central diastema closure Hendra Christian Rusady1, Tamara Yuanita2, M. Mudjiono2 1 Resident of Conservative Dentistry, Faculty of Dentistry, Airlangga University, Surabaya – Indonesia 2 Lecture Department of Conservative Dentistry, Faculty of Dentistry, Airlangga University, Surabaya – Indonesia
ABSTRACT Background : Veneer restorations are well suitable for conservative and aesthetic improvement of the anterior dentition. Veneer, a thin coating placed over the outer surface of a visible tooth, is generally used to improve its appearance, although occasionally to provide protection to the tooth surface. It is useful in the handling of many dental problems such as diastema, tooth coloring and shaping, and rotating teeth. Objectives : To present the successful of central diastema closure using porcelain veneer restoration Case : This article presents a case report of a 50 years old woman wanted to improve her anterior maxillary teeth which had central diastema. Patient was treated with porcelain veneer in the maxillary arch for the closure diastema with minimal tooth preparation. Conclusion : The use of porcelain veneer for central diastema closure has been shown to be a valid management option. Indirect porcelain veneer have predictable, aesthetic, minimally invasive and longlasting result. Keywords : central diastema,esthetic, indirect porcelain veneer Correspondence: Hendra Christian R, Resident of Conservative Dentistry Airlangga University. Jl. Mayjen. Prof. Dr. Moestopo 47 Surabaya, Indonesia. Email:
[email protected]. Phone: 0817301767 BACKGROUND Esthetics enhancement of anterior teeth management is one of the most difficult tasks encountered by a dentist. The patient‟s demand for treatment of unaesthetic anterior teeth is steadily growing. Accordingly, several treatment options have been proposed to restore the aesthetic appearance of the dentition. For many years, the most predictable and durable aesthetic correction of physiologic spacing has been achieved either by the preparation of full crowns or orthodontic treatment. However, this approach of full crown preparation is undoubtedly the most invasive with the risk of substantial removal of sound tooth substance, possible adverse effects on adjacent pulp and periodontal tissues. The approach of orthodontic treatment is long time taking.1 The presence of diastemas between teeth is a common feature found in anterior teeth.
These diastemas may distort pleasing smile by diverting observer‟s attention to these spaces instead of overall composition of the facial features. A central diastema usually is part of normal dental development during the mixed dentition. However, several factors can cause a diastema that may require intervention. An enlarged labial frenum has been blamed for most persistent diastemas, but its etiologic role now is understood to represent only a small proportion of cases. Other etiologies associated with diastemas include oral habits, muscular imbalances, physical impediments, abnormal maxillary arch structure, and various dental anomalies.2 Restoring diastema in anterior teeth with laminate veneers is the most conservative and esthetic approach for management of anterior spacing. Veneers may be direct composite laminates or indirect porcelain laminates. However, the porcelain laminates not only have 240
a greater advantage of esthetics over the composites laminates but also give a life-like appearance to the restoration. The popularity of porcelain veneer has been increasing since their introduction in the early 1980s for two reasons: An impressively esthetics and conservative tooth preparation with the ultrathin laminate veneers retained with resinous cement.3 The use of porcelain veneers as a conservative method of restoring discolored, fractured, malformed or malaligned teeth is now a well recognized clinical technique.4 Reduced chair time, economic feasibility, increased patient compliance, minimal post-treatment discomfort or sensitivity and esthetics have all contributed to their increased use.5 The most important factor in the success of porcelain laminates veneers is the adhesion between the laminates and the underlying tooth surface. Therefore, the amount of enamel plays an important role in the success of porcelain laminate veneers.6 In order to achieve predictable results, the understanding of the esthetic dentistry philosophy, the indications and contraindications, selection of laminate material, knowledge of tooth preparation and luting of laminates are important CASE REPORT A 50 years old female patient reported to the Clinics of Conservative Dentistry, Airlangga University with a main complaint of spacing between the maxillary central incisor. The appearance of the teeth leads to selfconsciousness and low self-esteem which later restrained her from smiling. These healthy teeth have never had any treatment before. Medical history of the patient shows no systemic disorders. On clinical examination, physiologic spacing was found in maxillary central incisor (Fig.1). Overjet and overbite less than 2 mm and patient has good occlusion. Examination of the teeth vitality using EPT shows both of the control tooth and test tooth reacts on scale number 3, indicating that the teeth are in a vital condition.
Fig 1. Pre-treatment Clinical View
CASE MANAGEMENT Clinical condition of this case is maxillary central diastema. Treatment plan of this case is treating the patient with indirect veneer restoration in the maxillary arch for the diastema closure. Restorative materials that will be used in this case is all porcelain. On the first visit, the treatment given is informed consent, DHE (Dental Health Education), upper and lower diagnostic impressions and diagnostic wax up. Upper and lower diagnostic impressions were made in irreversible hydrocolloid impression material and poured with type III dental stone (Fig 2). A diagnostic wax up was done over maxillary anterior teeth to get the proper size, form and proportion of the teeth (Fig 3). This was presented to and approved by the patient.
Fig 2. Diagnostic Impression
Fig 3. Diagnostic Wax Up
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In the next visit, local infiltration anesthesia was performed. Shade selection was done prior to the tooth preparation and 2L2.5 was selected using shade guide (vita lumin 3D) (Fig.4). Gingival management was carried out using gingival retraction cord. The maxillary central incisor teeth (11 and 21) were then prepared. The tooth preparation was kept in enamel at a depth of 0.5 mm using a depth cutting diamond bur. Chamfer was maintained in the cervical region and the distal side (Fig. 5). The chamfer finish lines were kept at the level of gingival margin. No definitive finish line was placed on mesial side as diastema required to be closed. Incisal butt joint was given with minimal incisal preparation. Impression of the maxillary arch was made in vinyl polysiloxane impression material by single step technique. Impression of the mandibullary arch was made in irreversible hydrocolloid impression material.
Fig 4. Shade Selection (2L2.5 vita lumin 3D)
Fig 5. Teeth Preparation
Provisional restoration were made using composite resin after spot etching (Fig.6).
In the next visit, the provisional laminates were removed. The surfaces of all the prepared teeth were cleaned. The porcelain laminate veneers were tried intraorally using Variolink resin cement (LV-1) to see their fit, form, position, shape and shade (Fig.7).
Fig 7. Try In Porcelain Laminate Venee
The luting procedure, afterward, was carried out. The inner surface of the veneers was etched using 5% hydrofluoric acid for 60 seconds and rinsed thoroughly. A plumber‟s tape was placed on adjacent teeth to protect them while the tooth surface was etched using 37% Phosphoric acid (Etchant Gel, SS White, Germany) for 30 seconds and rinsed. Veneers were dried and Silane coupling agent (Silano, Angelus, Brazil) was applied over the etched surface. The tooth surface was coated with the bonding agent (Single Bond Universal, 3M ESPE, USA) and air dried. Resin cement (LV-1) (Variolink N, Ivoclar Vivadent, Amherst, USA) was coated over the veneers and was placed over the tooth surface. Care has been taken to position the laminate from the cervical to the incisal edge for proper fitting. A Five seconds short light curing was done to stabilize the position of the laminates and excess cement was removed to avoid the gingival irritation and fracture of the laminates. Interdental cement was removed. Later, the final curing was carried out for 60 seconds. On completion of the cementation procedure, the occlusion was checked in centric and eccentric positions for interferences. (Fig.8, Fig.9, Fig.10)
Fig 6. Provisional Restoration
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Fig 8. Post-Treatment Clinical View
Fig 9. Post-Treatment Clinical View (Right Side)
Fig 10. Post-Treatment Clinical View (Left Side)
The patient was scheduled for follow-up after 1 month. The treated teeth has been functioning satisfactorily. Intraoral examination shows no pain on percussion and normal gingival and no changes in the color of porcelain laminate veneers. On examination of the vitality of teeth using EPT, both of the control and test tooth reacts to scale number 3, which indicates that the teeth still in a vital condition. (Fig. 11)
Fig 11. Follow Up After 1 Month
DISCUSSION Esthetic dentistry is gaining better in natural contour, shape, and texture of the surface
of the teeth.7 Factors affecting the esthetic are shape and proportions of teeth, color, size, teeth position, the position of smile lines and lip lines, the relation of the teeth, gingiva, and dental midline relation to the midline of the face and lips.8 In central diastema cases, patients usually come to the dentist to improve the appearance and rule out the masticatory function. This happens because these diastemas usually distort pleasing smile by diverting observer‟s attention to these spaces instead of overall composition of the facial features. Since the restoration of the tooth with a central diastema is very concerned with aesthetic, a good restorative material which can produce good aesthetic is essential. 9 Several factors can cause a central diastema require intervention. An enlarged labial frenum has been blamed for most persistent diastemas, although its etiologic role now is understood to represent only a small proportion of cases. Other etiologies associated with diastemas include oral habits, muscular imbalances, physical impediments, abnormal maxillary arch structure, and various dental anomalies.2 Treating tooth with a central diastema should pay attention to the degree of severity, the distance between the central incisor teeth with the median line, and the position of the teeth in a curved line. In case where the distance between the central incisor teeth and the median line is large enough and severe tooth malposition presents, orthodontia treatment is needed. On the other hand, in case where the distance between the central incisor teeth and the median line is not large enough without requiring extreme changes in the size, shape, and position of the teeth, aesthetic treatments using veneer can be done.10 Besides veneer, there are several options for treating central diastema, such as direct composite restorations, and full crowns. Among these, the laminates veneer are proved to be ideal restorative option as it has benefits such as minimal invasive tooth preparation, resistance to discoloration unlike composites and high degree of success rate.11 In this case, a diagnostic wax up was done over maxillary anterior teeth to get the proper size, form and proportion of the teeth. 243
This saved the chair-side time. Minimum preparation of the tooth helped preserving the enamel to get a more effective bond between the laminates and the tooth surface when luted with the resin cements.6 In this case, a butt type of preparation for the incisal edge was carried out as a study in 2009 by Ghani Mirra and Salem Mahalawy, found out that incisal butt type of preparation had the highest mean values of fracture strength as compared to feather edge and incisal overlap type of preparation. They also found out that the marginal micro-leakage was higher in incisal overlap type of preparation.12 Porcelain laminate veneers which allowed successful restoration of function and esthetics with a minimal invasive procedure, results in a natural and pleasing smile. The highly glazed surface of the porcelain laminates prevents plaque accumulation, which is considered important to attain a healthy periodontal response. Excellent esthetics could also be achieved due to appearance of porcelain and scattering effect of the luting cement. 13
REFERENCES 1. Peumans M B.Van Meerbeek P. Lambrechts G. Vanherle. porcelain veneers: a review of literature Journal of Dentistry 28(2000): 163-177 2. Jones LA, Robinson MY. A Case Study: Esthetic and Biologic Management of A Diastema Closure Using Porcelain Bonded Restorations for Excellent and Predictable Results. The Journal of Cosmetics Dentistry 2002:18(3):72. 3. Garber DA, Goldstein RE.Porcelain Laminate Veneers. Chicago: Quintessence 2008;14-35. 4. Friedman MJ. Augmenting restorative dentistry with porcelain veneers. J Am Dent Assoc 2001;122;29-34 5. Chiche GJ, Pinault A. Esthetic of anterior fixed prosthodontics. Chicago:Quintessence 2004:442-4 6. Gurel G, Morimoto S, Calamita M, Coachman C, Sesma N. Clinical performance of porcelain laminate veneers: outcomes of the esthetic pre-evaluation
However, porcelain laminates have their own limitations too. They should not be used when remaining enamel is inadequate to provide adequate retention. Darkly stained teeth are not optimally restored with veneers. Even, if the laminates fail in the long run, the conserved tooth can still be treated with a full crown restoration. Porcelain laminate veneers offer a predictable and successful treatment modality that preserves a maximum of sound tooth structure. An increased risk of failure is present only when veneers are partially bonded to dentin.14 CONCLUSION The use of porcelain veneer for central diastema closure has showed a valid management option. With the latest in Dentistry, believing in the concept of minimal invasive procedures for preservation of tooth structure, porcelain laminate veneers would be the ideal option for restoring central diastema between the anterior teeth. Indirect porcelain veneers have predictable, aesthetic, minimal invasive and long-lasting result. temporary (APT) technique. Int J Periodontics Restorative Dent 2012;32(6):625-635. 7. Fellipe LA, Baratieri LN. Direct Resin Composite Veneers: Masking the Dark Prepared Enamel Surface.Quintessence Int 2000;31:557-62. 8. Qualtrough AJE, Burke FJT. A Look at Dental Esthetics.Quintessence Int 2004;25:7-14 9. Shah N, Nadgere J, Khanna T. Restoring Maxillary Lateral Incisors with Ceramic Laminate Veneers: An Esthetic Challenge. International Journal of Prosthetic Dentistry 2010:1(1):15-6. 10. Goldstein, RE. Esthetics in Dentistry. BC Decker Inc 2002;2:703-30. 11. Meijering AC, Roeters FJM, Mulder J, Creugers NHJ. Patient‟s satisfaction with different types of veneer restoration. J Dent 2007;25(6):493-497. 12. GhaniMirra AE, Mahalawy SE. Fracture strength and microleakage of laminate veneers. Cairo Dental Journal 2009;25(2):245-254. 244
13. Drummond JL, King TJ, Bapna MS, Koperski RD. Mechanical property evaluation of pressable restorative ceramics. Dent Mater 2000;16:226-233.
14. Meijering AC, Creugers NH, Roeters FJ, Mulder J. Survival of three types of veneer restorations in a clinical trial: a 2.5-year interim evaluation. J Dent. 2008;26(7):5638.
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Clinical Treatment of Hemisection Tooth with Mesioversion Position : a case report Sophian Abdurahman*. Moh.Rulianto**. Tamara Yuanita** *Resident Student of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Introduction: one way to maintain a tooth with a complex damage on the enamel and periodontal tissues is by hemisection treatment.Purpose: to explain the procedures of hemi-section treatment on inferior molar with mesioversion position. Report case: a nineteen years old man came to PPDGS Clinic RSGMP dental conservation of Airlangga University with a complaint about the cavity on his left inferior molar. He’s felt hurt since two weeks ago, but he didn’t want his tooth to be pulled out. There was a cavity on the oclusomesial of the first left molar where the tooth was tipping to the mesial and the second premolar crown came into the cavity so that the space became narrow. Treatment: the Hemisection procedure on the mesial root is done by splitting because it was blocked by the second premolar so that the treatment didn’t take the bone too much. Conclusion: the Hemisection treatment will get maximum result if the plan and the procedure are appropriate. It is effective to minimize the lost of alveolar and to maintain the remainder of healthy tooth tissue to make a good restoration. Keyword : hemisection, mesioversion, endodontic Introduction The conservative tooth treatment develops well together with the development of the dentistry and technology. Some cases found need the treatment in the tooth conservation, traditionally or surgery. Some cases need simple and easy treatment while the others need specific with the high difficulty level of treatment. All of them need knowledge, competency, skill, and the mastery of dentistry.7 At the wide caries case which spread until the pulp tissue involves the damage on the periodontium. If this condition is allowed, the tooth will endure the constant burden of mastication and will experience pathological movement from the normal position, like mesioversion or distoversion; depend on periodontal damage involved. The efforts to maintain the tooth with complex damage on the enamel and periodontium need endodontic surgery, which is a specific treatment of the tooth conservation. Endodontic surgery includes resection aspect, hemi section, bicuspidation, and replantation.5
Hemisectionis a surgical separation of a multi-rooted especially on the molar or mandible. Hemisectionis done making a cut on the furcating with the bukal-lingual direction so that the damaged root or crown of the tooth can be pulled out. The main purpose is to maintain the healthy part of the tooth so the restoration can be undergone.1 Hemisection treatment is indicated as follows; 1) the severe alveolar or periodontiumdamage which can‟t be cured by conventional endodontic; 2) there are problems on the root like dilateration, root caries, resorption, vertical fracture, and calsificatedthe root canal; 3) the procedure mistakes on the treatment such as the broken ledge which can‟t be accessed, root perforation, over filling.3 Contra indication indicates Hemisection as follows: 1) the endorsement of the bone to the remainder root which is preserved is insufficient. 2) The roots are fusion or closed each other so they can‟t be separated with this procedure. 3) The endodontic treatment can‟t be undergone to the preserved root.3
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This case report is aimed to describe about Hemisection treatment with mesioversion position. Case Report A nineteen years old patient came to PPDGS Clinic RSGMP dental conservation of Airlangga University with a complaint about the cavity on his left inferior molar. However, he didn‟t want his tooth to be pulled out. The clinical description was a cavity is seen on the oclusomesial the left first molar, the tooth was tipping to mesial and the second premolar crown entered into the cavity so that the space became narrow (Figure 1). On the objective examination was obtained the negative vitality test, negative percussion. On the radiography description appeared the radiolusention had spread to the mesial root until bifurcation, or lesion carious profunda (Figure 2) and the diagnose was necrosis pulp. The plan treatment was hemi section, fiber pin, and ceramic crown restoration with metal fusion in the premolar form.
the working length of the distal root 17 mm and it was confirmed by x-ray Figure (Figure 3. Afterward the preparation of the root canal by using crown down technique used protaper file to F3 file. On the preparation process used EDTA lubricant, canal irrigation used NaOCL 2%, and rinsed by aquades. After the preparation reach the working length, the trial guttapercha photography is done, and the result was hermetic guttapercha in the root canal (Figure 4). After that the tooth was dressed used calcium hydroxide paste and temporarily filled. Patient was asked to return the next week.
A
B
Figure 3: A; working length; B: working length confirmation
Figure 4: the trial of guttapercha Figure 1: the carious on the occlusomesial appears on the clinical description
Figure 2; Radiolusen is seen on the whole mesial root until distal premolar
At the first visit, the opening access to the root distal canal orifice used endoaccess diamond bur, the cavity was irrigated by NaOCL 2 %, rinsed by aquades and dried by cotton pellet. The determination of the working length used K-file #15 and apex locater. It was obtained
The second visit, a week later, the patient didn‟t feel hurt. The temporary filling condition was good, percussion test was negative, and mobility test was also negative. Then the temporary filling was opened, the dressing substance was cleaned by irrigating the sterile NaOCl 2 % and rinsed by using sterile aquades. Then the root canal was dried by sterile paper point. The filling of root canal was done with the single cone technique using guttapercha point which was appropriate file size. Sealer was added and guttapercha was cut along orifice using excavator which was heated and condensed by plugger. Then the root canal was filled temporarily and was taken the Figure. (Figure 5)
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Figure 6: A: Asepsis; B: anesthesia;C:separation;D:the lifting of mesial root; E: bone graft application; F: Suturing; G: splint fiber laying; H: mesial root
Figure 5: the X-ray of filling the root canal
The third visit is the Hemisection stage. However, the post treatment review was done. The results were the subjective symptoms were negative, the condition of temporary filling was good, percussion was negative, and the tooth mobility was negative. Then the blood tension of the patient was measured; it was 120/80mmHg. Asepsis was done on the operation area, the block anesthesia on the left mandible nerve and infiltration anesthesia using pehacain. The 36 tooth was separated to the lingual buccal using high speed handpiece with long tappered diamond bur. After the tooth was divided into two parts, mesial root was taken using elevator, the mesial root socket was scrapped then irrigated using sterile saline. Bone graft was applied into the mesial root socket then it was sutured using silk thread. Splinting was applied into the crown of the 36 and the 37 using splint fiber. The operation area was cleaned then was taken Figure post hemi section. The patient was instructed to clean operation area using soft toothbrush and he was prescribed clindamycin 300 mg and mefenamic acid 500 mg. He was also instructed to return one week later (Figure 6).
A
B
The fourth visit, the post treatment review was done before the next step continued. The results were good; subjective symptoms were negative, the condition of the suture was good, splinting condition was good, and the percussion was negative. Next step was fixing of post fiber pin, calibrating the pin size with the template, picking up guttapercha with penetration drill and calibrating the root canal calibration drill. After that, the pin cut in trial, core built up, gingival management and crown preparation using ceramic metal fusion were done. The Die used elastomers materials with double impression technique and antagonist mould used irreversible hydrocolloid. Next step was making the dental record, calibrating the color, and fixing temporary crown on prepared tooth. Finally, the patient demanded to check up one week later. (Figure 7).
A
Figure 7 : A X-ray of fiber pin; B: crown preparation
At the fifth visit, ceramic metal fusion crown was fixed and trial, articulation was examined, anatomy and the color was calibrated. Ceramic metal fusion crown was still inserted using luting cement. (Figure 8)
C
A D
E
B
B
F Figure 8 : A: PFM crown on the model; B : PFM crown insertion
G
H Discussion Hemisection is an alternative procedure which is beneficial especially in preserving multi rooted 248
tooth. Prognosis from endodontic treatment which uses hemisection gives various results. The results were determined by diagnose, the treatment planning, access assessment, and follow up evaluation. The success is usually characterized by the absence of unsteadiness on the tooth, no complaint of the pain, or periapical lesion.2 For this patient, the hemisection treatment faced some difficulties and constrains because the position of the tooth was mesioversion. This condition makes the taking of mesial root difficult while in hemisection treatment, the trauma had to be minimized so the healthy tooth remained was still many and the periodontal tissue was not much taken. Therefore, accurate planning was needed when the mesial root was taken.6 In this case, the revocation of the mesial root got difficulty because the out direction of the root was blocked by the second premolar so the mesial root was split in order the root could get out without reducing the bone too much. Distal root then was used as core ceramic metal fusion crown with the form of premolar so that the chewable burden received was less.4 Conclusion The space limitation in the hemisection treatment is not a big constrain to get maximum result. By accurate planning and precise procedure, the loss of alveolar can be minimized and the healthy tooth tissues remained has enough resistance to receive chewable burden.
References 1. Jain A, Bahuguna R, Agarwal V. Hemisection as an Alternative Treatment for Resorbed Multirooted Tooth-A Case Report. Asian Journal of Oral Health & Allied Sciences. 2011;1(1):44-6. 2. Santosh Kumar B.B, Sushama. R.Galagali. Hemisection with socket preservation surgery as an alternative treatment tor vertically fractured mandibular molars: A case report. IJCD, march 2011;2(2):16-20. 3. Savitha Akki, Sudhindra Mahoorkar. Tooth Hemisection and Restoration an Alternative to Extraction- A Case Report. International Journal of Dental Clinics 2011:3(3):67-8. 4. Shafiq K, Javaid A, Asaad S, : Hemisection: An option To Treat Apically Fracyured & Dislodged Part Of A Mesial Root of a Molar. JPDA Vol. 20 No. 03 July-Sep 2011: 183-186 5. Shah S et all : Hemisection – A Conservative approach for a periodontally compramised tooth – A Case Report. Journal of Advanced Oral Research, Vol 3; Issue 2: May-Aug 2012: 31-35 6. Vineet S. An innovative approach for treating vertically fractured mandibular molar hemisection with socket preservation. Journal of Interdisciplinary Dentistry. 2012;2(2):1423. 7. Weine FS. Endodontic therapy. 5th ed. St. Louis: Mosby; 1996
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Aesthetic improvement of discolored anterior maxillary teeth: A case report Mochamad Farid Diantara*.Ruslan Effendy**.Laksmiari Setyowati** *Resident Student of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. Airlangga University
ABSTRACT Background:Discolored anterior teeth are often perceived as an esthetic problem.Because of the growing need for beautiful and the establishment of esthetic treatment method. usually to solve that problem can be reached by restorative treatment. Purpose:To describe that even though there are many treatment alternatives and procedures, esthetic improvement of discolored anterior teeth using all ceramic crowns, can improve patient’s appearance. Case : This article presents a case report on esthetic improvement of discolored anterior maxillaryteeth. 12 was non vital tooth with periapical lesion and 11,21,22 were vital teeth after poor filling a few years ago. The patient requested esthetic improvement as an expectation for satisfy esthetic result. Case management:Endodontic treatment was done to the discolored non vital tooth 12 prior to the final restoration.Fiberposts and all ceramic crowns were used as final restoration to improve the discolored tooth. Discolored vital teeth 11,21 and 22 restored with all porcelain crowns. Conclusion:esthetic improvement can be done successfully on colored anterior maxillary teeth. Endodontic treatment, fiber posts, and all ceramic crowns were used to improve patient’s appearance where esthetic result could be achieved by this treatment. Keyword :aesthetic,discoloration, endodontic treatment, periapical lesion Korespondensi (Correspondence): Mochamad Farid Diantara, Resident of Conservative, Faculty of Dentistry, Airlangga University. Jl. Mayjend. Prof.Dr. Moestopo 47 Surabaya, Indonesia INTRODUCTION Appearance of anterior teeth have an important role in supporting the individual performance, thus the problem on the teeth will have an impact on a person's self confidence. Aesthetic problem on anterior teeth can be caused by several things such as a change in color, shape and number of abnormalities, attrition, caries, diastema and fractures.1 The patients‟ demand for treatment of unaesthetic anterior teeth is steadily growing. Accordingly, several treatment options have been proposed to restore the aesthetic appearance of the dentition. For many years, the most predictable and durable aesthetic correction of anterior teeth has been achieved by the preparation of full crowns.2 Advances in technology dentistry has developed several techniques for the treatment of dental esthetic problems with composite resin
restoration, direct composite or indirect ceramic veneers and all ceramic crowns.1,4 However, if the teeth are already compromised by the presence of extensive carious lesions, wear, old restorations or endodontic treatment, placement of a crown is the more prudent choice.3 The natural and harmonious appearance, furthermore, is one of aesthetic elements that all patients wish.4 In order to achieve optimal esthetic, dentists must really create natural appearance as natural dentition in the right arch, proper inclination and alignment to the adjacent teeth. Considering esthetic, the best material of choice for matching the natural state of a complex human dentition as in indirect anterior restoration is ceramic for the highly desirable properties in color stability, translucency, light transmission, and biocompatibility5 Aesthetic dentistry, using a combination of science and art, involves the use of colors to create a natural toothlike restoration. hence, 250
color and shading are absolutely necessary to make restoration look like a natural tooth.6 Color and shade are indicated for all restoration: direct and indirect restoration, both anterior and posterior.6 Vital bleaching also is often indicated before and after restorative treatments to harmonize the shade of the restorative materials with those of natural teeth. determining the correct shade and color material is the best approach for a good esthetic restoration.7 The purpose of this case report, is to describes the aesthetic improvement of the discolored anterior maxillary teeth that can be achieved with an all ceramic crown restoration and external bleaching procedures as intervention to get the natural color of teeth as a color guide of the all ceramic crown restoration.
discolored teeth 11,21, and 22 restored with all ceramic crown. Alginate impression was done to produce the study model, wax up model and temporary crowns as provisional restoration (Figure3).
Figure 1. clinical feature before treatment
CASE A 18 year old female patient, came with the chief complaint of discolored maxillary anterior teeth. Patients require aesthetic improvement of discolored maxillary anterior teeth. In the first appointment, anamnesis and clinical observation were done. From anamnesis, it was found that the patient had restorative treatment with composite filling a few years ago. On clinical examination, it was found poor composite restorations teeth #12,11,21, and 21 with discoloration.Teeth #11, 21, and 22 response to the EPT and thermal tests. While the teeth 12 do not respond to the EPT, thermal and cavity tests. percussion test no pain, normal periodontal tissues around the teeth and no mobility (Figure 1). On radiographic examination was found rounded radiolucent image with clear boundaries radiopaque on apical #12. Based on the examination of subjective, objective and radiographic then at 12 was diagnosed with dental pulp necrosis accompanied with periapical lesions. teeth 11, 21, and 22 reversible pulpitis accompanied by discoloration (Figure 2). After thorough explanations, the patient approved and consented about conservative esthetic improvement procedure through conventional endodontic treatment on tooth #12. The restoration planning was determined using fiber post and all ceramic crowns while the
Figure 2. Panoramic photo
A B
Fig. 3A.Study Model
B
Fig. 3B. Wax up model
CASE MANAGEMENT
B
After anamnesis, clinical examination, thorough explanation, and patient‟s consent about esthetic improvement treatment procedure, on the second visit, endodontic treatment was done on tooth #12. Acces opening using endo access bur. after the determination of the working length using apex locator, confirmed by radiographic and the working length of 23.5 mm obtained (Figure 4A). Endodontic treatment was performed in single length technique (M two, VDW) for the cleaning and shaping of #12 according to the manufacturer‟s sequence and working lengths. Irrigation was done with NaOCl2,5% between preparation sequences and lubricated by EDTA cream. Trial photo was 251
taken to confirm the preparation and sealing of gutta point obturation. Dressing of the root canal using CaOH paste and covered with temporary restoration. Patients were instructed to return one week later. On third visit. All under normal circumstances, good surrounding tissue, no pain on percussion test, the gingiva around normal, no tooth mobility. Temporary restoration was removed and cleaned. Root canal obturation was done according to working lengths using thermoplastic technique (Figure 4B).
A
Fig. 4A. DWP
B
Fig 4B. Obturation photo
On the fourth visit, external bleaching procedure in office was performed to determine the natural color of the teeth (as a guidance). Color mapping was first performed using the shade guide provided by the manufacturer, the initial color before bleaching was B3. External bleaching using carbamid peroxide base material (Opalescence Xtra boost) according to the manufacturer's instructions. After bleaching obtained final color A2 (Figure 5).
A
Fig. 5A. Initial color
C
Figure 5 C. Final color
B
Fig 5B. bleaching procedure
D
D. After bleaching
On the fifth visit, After the endodontic treatment was accomplished, teeth #12 was prepared for post and core using fiber posts (luxapost, DMG). Form mapping of fiber post using the template, removal of guttap used drill provided by the manufacturer. Fiber posts and cores was cemented permanently using resin cement. Thus teeth 12,11,21, and 22 were prepared for the manufacture of all ceramic crowns before being sent to a dental laboratory. Double impression and bite record were done as a guide to make the final all ceramic crowns. Remains of the impression materials were cleaned and the teeth were prepared for temporary provisional crowns cementation (Freegenol GC). The temporary provisional crowns (Tempron GC) were cemented, the impression result was sent to the dental laboratory for all ceramic crowns production along with a detailed laboratory prescription. For color mapping, a Vita 3D shade guide of 2L 1.5 was selected, as well as explicit details about what to be done regarding the anatomical morphology, normal anterior alignments, and occlusion.
A
B
Figure 6A.Preparation of all ceramic crowns Figure 6B. temporary provisional crowns
On the sixth visit, all ceramic crowns were available and were put on the model. These crowns were cemented one-by-one using resin cement (Relyx, 3M). The excess from cementation was cleaned before full set with hand instrument and contacts of each crown were checked using dental floss. Occlusion and contact showed a fit state. The final result showed better teeth colour compared to the initial condition prior to esthetic treatment hence changing the appearance and finally increase patient‟s self esteem (Figure 7). Patient follow up was done 6 months after treatment, there was no complaint and the patient was satisfied with the result (Figure 8). 252
Figure 7. Final esthetic result
B
A
Fig 8A. Initial Rӧ photo
Fig 8B. after 6 month
DISCUSSION Esthetic improvement need patient‟s objective and subjective considerations, because beside the high cost of treatment, it involves removal of natural tooth structures and vitality, moreover it also requires good cooperation and understanding between the patient and dentist as operator.5 in this case the choice of treatments for discolored anterior teeth can be achieved through restorative treatments with all ceramic crowns and interventions supported by external bleaching treatment to determine the natural color of teeth. This case showed that colored anterior maxillary teeth could be overcome with esthetic improvement using all ceramic crowns. Endodontic treatment performed on tooth #12 pulp necrosis with periapical lesion. Periapical lesions should be treated early with non-surgical endodontic procedures. Surgical intervention is recommended only after non-surgical endodontic treatment failure. Success of nonsurgical endodontic treatment of periapical lesions was 85%. The highest percentage of approximately 94.4% in the partial or complete healing of endodontic periapical lesions were treated non-surgically.8
Posts as intra canalretentions are needed.5 The use of fiber posts as an option because FRC posts offer a number of advantages over metal posts due to their modulus of elasticity being closer to that of dentin and superior esthetic quality. Teeth restored with FRC posts show better resistance to fracture propagation than teeth restored with prefabricated or cast metal posts. Endodontically treated teeth reinforced with a prefabricated fiber post have shown lower incidences of root fracture.9 All ceramic crowns were chosen for better esthetics. The use of all ceramic crowns has been increasing in strength and popularity. This is supported with the newly developed materials such as Zirconia and the invention of CAD/CAM technology.5,7 In this case, before the making of all porcelain restorations previously performed external bleaching. External bleaching in this case not as a definitive treatment only as an intervention to get the natural color of the teeth due to the color of existing teeth have changed color and varying degrees of coloring. In conclusion, esthetic improvement can be done successfully on colored anterior maxillary teeth. Endodontic treatment, fiber posts, and all ceramic crowns were used to improve patient‟s appearance where esthetic result could be achieved by this treatment. It is also supported by the fact that the external bleaching as an intervention to get the natural color of the teeth prior to the manufacture of all ceramic crowns. REFERENCES 1. Mount GJ, Hume WR. 1998. Preservation and restoration of tooth structure. Mosby international Ltd.p.218-23 2. Peumans M, Meerbeek BV, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J Dent, 28: 163-177, 2000. 3. El-Badrawy W , El-Mowafy O. Comparison of Porcelain Veneers and Crowns for Resolving Esthetic Problems: Two Case Reports. Journal of the Canadian Dental Association December 2009, Vol. 75, No. 10. p. 701-4
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4. Zubaidah Nanik. The aesthetic treatment for anterior teeth with lost crown by endorestoration. Dent. J. (Maj. Ked. Gigi), Vol. 42. No. 2 April–June 2009: 99−1035. 5. Lunardhi Cecilia, Prasetyo Eric. Esthetic rehabilitation of crowded and protruded anterior dentition. Dent. J. (Maj. Ked. Gigi), Vol. 42. No. 1 January–March 2009: 46-49 6. Freedman G. 2012. Contemporary esthetic dentistry. Elsevier Mosby. St Louis Missouri, USA. p. 161-7 7. Heyman HO, Swift EJ, Ritter AV. 2012. Sturdevant‟s art and science of operative dentistry.6th ed. Elsevier, Singapore.p. 282-5; 307-12 8. Roda RS, Gettleman BH. Non surgical retreatment. In: Cohen S, Hargreaves KM. Pathway of the pulp. 10th ed. Chapter 25. St Louis: Mosby Elsevier; 2011. Hal 175-84 9. Masayuki H, Shinji T, Masao Y, Eiji K and Yutaka . Durability of fiber-post and resin core build-up systems. Dental Materials Journal 2010; 29(2): 224–228
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Complex aesthetic treatment as a correction for maxillary protrussion and central diastema closure Putri Galuh Prawitasari *, Ari Subiyanto *, Setyabudi** * Residences of endodontic, Faculty of Dentistry, University of Airlangga ** Lecturer of Conservative Dentistry Faculty of Dentistry, University of Airlangga
ABSTRACT Background: protrussion in anterior teeth with great diastema can cause aesthetic problems, especially in female patients. Complex aesthetic treatments is an alternative treatment that can accommodate the needs of patients who do not want an aesthetic treatment with orthodontic appliances. Purpose: The aim of this article is to present an alternative treatment of dental protrusif problems with a large diastema. Case: Patient, a 62-year-old woman complained that she hardly close her lips because of her maxillary anterior teeth were protrusif accompanied with central diastema. This condition was getting worse each and every day. Patients demanded her teeth to have an aesthetic value. Case management: a complex aesthetic treatments was chosen to accommodate the aesthetic needs of the patient. Four maxillary anterior teeth was having its inclination repaired, of which two (teeth 11 and 12) performed root canal treatment prior to subsequently made fabricated posts. Treatment was continued with preparing the anterior teeth then to be installed of an all porcelain crown. Conclusion: complex aesthetic treatments able to give the aesthetic needs of the patient where treatment using orthodontic devices are not desired by the patient. Keywords:
protrusif,
diastema,
complex
aesthetic,
fabricated
post,
all
porceain
crown
Correspondence (correspondence): Putri Galuh Prawitasari, Resident of Conservative, Faculty of Dentistry, Airlangga University. Jl. Mayjend. Prof. Dr. Moestopo 47 Surabaya, Indonesia INTRODUCTION A protrusif teeth combined with a large central diastema certainly will cause an aesthetic problems for the patient. Especially if the patient feels this situation is severely getting worse, the patient consequently be difficult to pursed lips and it is becoming a constraint function. Aesthetic dentistry is a harmony integrity of some oral physiological functions with equal emphasis so obtained or produced through the ideal dental restoration with color, shape, structure and function to achieve health and optimum durability. Several factors that affects dental esthetics is the shape and proportions of teeth, color, size and position. Some other relevant factors include the position of smiles and lip lines and its relationship with the visibility of teeth, dentition aesthetics, symmetry dentition, and the relationship of dental midline with the midline of the face and lips.
From some of the factors above, tooth position and visibility are things that need to be underlined in the writing of this case report. And the report of this case is made with the aim to present an alternative treatment of dental problems: protrusif with a large diastema CASE Patient is a 62-year-old woman, came to the Conservation Department of the Airlangga University with complaints of her front teeth were deemed increasingly advanced and pushing the upper lip and the patient felt increasingly difficult to keep her mouth closed. Approximately less than a year before, the patient ever complained about this to an orthodontist, but the patient refused treatment performed using orthodontic appliances. Patients want treatments that quick and able to repair the anterior teeth accompanied by central diastema. Clinical examination obtained right and left 255
maxillary central and lateral incisors with a forward inclination, include the overbite: right central incisor was approximately 8 mm left central incisor approximately 5 mm right lateral incisor approximately 6 mm. left lateral incisor approximately 5 mm The second central incisor overjet less than 5 mm, while the lateral incisors approximately 3 mm. There is a central diastem width of approximately 3-4 mm. All of the central and lateral incisors are vital and periodontal status is healthy, there is superficial Class V caries in palatal right central incisor region. When the lips closed, there is a visibility of the central incisor incisal approximately 2-3 mm and lips that look forward.
From the study model and the wax-up, treatment will be concluded the fourth maxillary teeth in order to have harmony and improvement mesiodistal inclination. With a detailed treatment of central incisors and right lateral root canal treatment will be done in advance because it takes a fairly large inclination change and fear it would disrupt the pulp tissue. Root Canal Treatment Root canal treatment was done to the right central and lateral incisors. It starts by giving the local anesthetic. Furthermore, is to make the access opening and to open the roof of the pulp by using a round bur and endo access bur. Then do the retrieval of diagnostic wire photo (DWP) and the working length of 23.5 was obtained for the central incisors and 22 for the lateral incisor. The working length was later confirmed by using apex locator and obtained the same results with the DWP.
Figure 1. Clinical view
CASE MANAGEMENT At the beginning of the visit, informed consent was made and there is more detailed explanation of the treatment will be done for the patient. Then proceed with the making of the maxilla and mandible impression using alginate impression material. The impression model will be used as a study model and the wax-ups for temporary crowns. The wax-up model is used as a media to explain to the patient about the treatment plan and estimate treatment outcomes, as well as a reference to the provider in making the restoration.
Figure 3. Diagnostic Wire Photo
Glide path search is then performed using a the C-plus file
Figure 4. Glide path tracking
Figure 2. study model and wax-up
Then determine Reciproc file that will be used for the preparation: the central incisor was using number 40 while lateral incisor using 50. The preparation was carried out to tug back and found the dentin walls were clean and dry, 256
irrigation is done alternately with using 2.5% NaOCl and sterile distilled water, after the preparation completed, guttap percha trial is then performed according to the number of files used and adjusted length of the working premises. Then a root canal dried with sterile paperpoint. Then proceed with the application by using calcium hydroxide as a dressing materials (Metapaste) and closed with a temporary filling
the pulp chamber as the holder of the posts core. Seat is made with oval form to prevent rotational movement of the posts.
Figure 7. crown decapitations of 11 and 21 Posts procedure
Figure 5. Guttap try - in
On subsequent visits performed root canal filling using previous percha guttap used in the trial guttap stages with sealer application. After previously unloaded the temporary filling. Guttap percha then cut using a heated excavator. Then closed with temporary filling. Then the xrays to monitor the results.
This stage is performed after the guttap percha was cut. The Guttap percha was taken one-third of the length of the tooth that remains after the decaputation process. Guttap taken using Gates Glidden drill burs with a stopper installed in accordance with the predetermined length is 9 mm for the central and lateral incisors. After taking guttap considered complete, x-rays image was made to see the results.
Figure 8. Guttap percha Figure 6. root canal filling with guttap percha Crown Decaputations
At this stage tooth crown was prepared as a holder for the core of fabricated metal castings to be made later. This process carried out after temporary crown is prepared. First cut tooth crown to the extent of gingival crest using wheel bur, shape the roof using a fissure bur. Then do the cervical part of the tooth preparation below the gingival sulcus by using the round end tapered bur, check with the sonde to make sure no part of the discontinuous and sharp. Furthermore, the preparation is to make
After it was confirmed by x-rays, the next step is to make the impression of posts. Materials used is metal. The impression making is done by using uniclip. Size adjusted to the space within the root canal through x-rays and matched with templates. Uniclip selected the appropriate size and then inserted into the root canal, the making the impression of the entire jaw was done by using a plastic molding elastomeric material heavy body and light body. After setting, the impression material scoop removed from the patient's jaw. After casted with hard plaster
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material, working models were sent to the lab to made the posts. Posts insertion The posts can be inserted after the previous cast performed try in. Insertion is done by using lutting GIC cement type I
tooth color with shade guide, teeth be the benchmark adjustment is canines and the lower anterior teeth. Of matching with your shade of color is obtained 3M 3 with shade guide used is 3D vita. working model can then be sent to the lab with the instructions attached color. While re-inserted as the crown at each end of the patient visit.
Figure 11. Teeth colour match to shade guide Figure 9. Posts insertions Crown preparation
Preparation of 21 and 22 tooth crown done by adjusting the inclination of the posts that has been installed. This is done to maximize compatibility with the inclination of the teeth 11 and 12 Preparation begins by reducing the interdental using a fissure bur of approximately 2 mm on each tooth. Then the mixture of the labial and incisal tooth by using a round bur end tappered adjust inclination and length of the posts 11 and 12 Preparation of the cervical entrance into the gum pocket.
Crown Insertions Temporary crown removed and cleaned while the rest tumpatan. Liner is applied to the teeth 21 and 22 to prevent irritation of the pulp tissue. Then do the pairs try sheath on fourth crown of the maxillary incisor. Examined the marginal edges to ensure there are no exposed parts. Patients shown in the mirror. After the patient agrees with the results of pairs try, crown sheath inserted using resin cement Breeze.
Figure 12. Insersi mahkota selubung Figure 10. crown reparations of 21 dan 22 Working Model For Making All Porcelain Crown procedure
After preparation is complete, recheck the suitability of inclination and mesiodistal width of the fourth teeth. Furthermore, impression can be done using plastic elastomer material for the upper jaw and alginate to the lower jaw. After that, do the recording bite for occlusion conformance with patients. After this stage done, next is the adjustment of patients
DISCUSSION Protrusion is a condition that shows excessive inclination of the anterior teeth, this condition results in lips that do not close properly. Patients usually have difficulty closing the lips and having an aesthetic problem. Initial diagnose of the protrusions can be easily seen clinically. Clinically there are great distances on both lips when resting position of lip incompetence, that is the excessive effort to get the ideal lip closure and lip profiles are 258
prominent. Variation race determines the level of dental protrusion. In general, oriental and black people are more prominent than Caucasians. People with bad facial aesthetic generally have relatively more convex face based on the position of the anterior midline of the face, including teeth. Some literature also mentions that the protrusion associated with tooth size larger than normal. Various etiologies associated with the formation of the protrusions was multifactorial, several influential factors are genetic or hereditary factors, and environmental factors that nasty habit of sucking the thumb or finger and breathe through the mouth as well as genetic factors such as the volume of the tongue or skeletal factors. In these patients, ther are also central diastema. Diastema is a space that exists between two adjacent teeth. This diastema is a discrepancy between the dental arch and jaw arch. Maxillary central diastema, is a malocclusion that often appear to be a hallmark of the gap that exists between the maxillary central incisor. Many factors as the cause of a central diastema. Based on several studies that have been done that central diastema prevalence ranged from 1.6% - 25.4% in adults and more frequently in children, approximately 98% at age 6 years, 49% at age 11 years, and 7% at age 1118 years. More frequently in men than women. Based on more races in blacks compared with whites, Asian and Hispanic. Some causes of central diastema that occurs in the maxillary is that the lateral incisor size is small, the rotation of the incisor teeth, abnormal attachment of the frenulum, supernumerary teeth in the median line, congenital incisor teeth loss, diastema during normal growth, and imperfection closure of the median line. A complex aesthetic treatments involving more than one tooth with caries or tooth malformations shape and position. Complex aesthetic treatments today are not only needed by people in the productive age. In this case report, patients included in the geriatric age group, but patients have a high motivation to improve the aesthetic value of her teeth. Although the treatment can be quite invasive. In this case report root canal treatment performed
as a preliminary treatment of the tooth that needs large inclination repair is the teeth 11 and 12. This is done to avoid perforation of the pulp due to excessive grinding dentine tissue. While the two other teeth, the teeth 21 and 22 are not performed root canal treatment because tyhey do not needed a large inclination changes. Crown restoration was selected in this case because this restoration is able to accommodate the required correction as the correction of inclination and the diastema, the material is all porcelain restorations that are considered material to most meet the aesthetic needs for the moment, for that reason crown porcelain selected are selected from which all materials for maximize the aesthetic value without compromising its functional value.
Figure 13. Before and after treatment clinical view
Based on the above discussion it can be concluded that the complex aesthetic treatment is the right treatment to be used as a correction of inclination and a large diastema teeth. Final restoration using all porcelain crowns can maximize both the aesthetic and function of the patient. Patients feel satisfied after treatment in of both aesthetic and to function optimally. REFFERENCES 1. 2.
Brenna F. Restorative dentistry. St. Louis: Elsevier Mosby; 2009. p.251-73 Cohen S, Hargreaves KM. 2011. Cohen’s Pathways of the pulp. 10th ed. St. Louis : Mosby Inc. Pp. 490, 518, 626, 812 259
Craig RG. 2012. Craig’s Restorative Dental Materials. 13th ed. Philadelphia : Elsevier Mosby. p. 155 3. Dale BO, Asheim KW. Esthetic dentistry. Philadelphia: Lea and Febiger; 2005. P.136 4. European Society of Endodontology. 2006. Quality Guidelines For Endodontic Treatment : Consensus Report Of The European Society Of Endodontology. J Endod. Int. 39. Pp. 921-30 2.
5. 6.
7.
Goldstein RE. Esthetic in dentistry. 2nd ed. Hamilton: BC. Decker Inc; 1998. p.245-74 Grossman LI, Oliet S, Rio CED. 1996. Ilmu Endodontik Dalam Praktek. Edisi ke-11. Jakarta. EGC. Pp. 40-53 Walton RE, Torabinejad M. 2009. Endodontics principles and practice. 4th ed. Missouri. Saunders Elsevier. Pp 9-14
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Apexification in maxillary left incisor with mineral trioxide aggregate (MTA) Ahmad Riza Faruqi*. Nanik Zubaidah**. Febriastuti Cahyani** * Resident of Conservative Dentistry **Staff at Department of Conservative Dentistry Faculty of Dentistry Airlangga University
ABSTRACT Background: Cases of trauma to young permanent teeth patients often cause teeth to necrosis resulting in the formation of dentin and root growth stops. This resulted in a wide root canal and an open apex, sometimes the root is also shorter. Apexification is defined as a treatment to induce a calcific barrier in a root with an open apex or the continued apical closure of an incomplete root in teeth with necrotic pulp. Although different materials are used for the apexification procedure, Mineral Trioxide Aggregate (MTA) is the material of choice for apical barrier formation and healing. Purpose: to overview the successful closure of wide open apex using MTA. Case: A 15-years-old male reported complaining of pain in the upper front tooth since 1 weeks. There was a history of trauma to the same tooth about 5 years back. Clinical examination shows Elli’s class III fracture in permanent maxillary left incisor. Periapical radiograph revealed incomplete root formation with wide root canal and an open apex. Case management: Apexification with MTA was performed followed by post and core casting alloy with porcelain fused to metal crown. Conclusion: Apexification with MTA showed a good result in this case. Keyword : Trauma, open apex, apexification, mineral trioxide aggregate (MTA). Correspondence: Ahmad Riza Faruqi, Resident of Conservative Dentistry, Faculty of Dentistry Airlangga University. Jl. Mayjend.Prof. Dr. Moestopo No. 47 Surabaya 60132, Indonesia. Introduction Dental injuries are very common in children between six until nine years old. A serious complication of these trauma is the pulp necrosis.1 The completion of root development and closure of the apex occurs up to 3 years following eruption of the tooth.1,2 When teeth with incomplete root formation suffer pulp necrosis, the formation of dentine stops, and root development ceases. Consequently, the canal remains large, with thin and fragile walls, and the apex remains open. These features make instrumentation of the canal difficult and hinder the formation of an adequate apical stop. In such cases, in order to allow the condensation of the root filling material and to promote an apical seal, it is imperative to create an artificial apical barrier or induce the closure.3 Apexification is defined as a method to induce a calcified barrier in a root with an open apex or the continued apical development of an
incomplete root in teeth with necrotic pulp (American Association of Endodontists 2003). The goal of this treatment was to obtain an apical barrier to prevent the passage of toxins and bacteria into the periapical tissues from the root canal.2 Calcium hydroxide pastes have been considered as the material of choice to induce the formation of a hard tissue apical barrier.2 Despite its efficacy, this dressing has several disadvantages, such as variability of treatment time, number of appointments and radiographs, difficulty in patient follow-up, delayed treatment and possibility of increased tooth fracture after calcium hydroxide use for extended periods.3 Alternatives to calcium hydroxide have been proposed, the most promising being mineral trioxide aggregate (MTA). MTA introduced by the Loma Linda University has several advantages over Calcium hydroxide which includes superior biocompatibility, cementogenic properties, ability to set in the 261
presence of moisture and blood, superior sealing ability, high pH, radiopacity and its ability to aid in the release of bioactive dentin matrix proteins.4 The aim of this report is to describe the treatment of post traumatic maxillary left central incisor teeth with open apex using mineral trioxide aggregate (MTA). Case Figure 2. Preoperative radiograph showing open apex
A 14 year old male patient reported to the Department of Conservative Dentistry, RSGMP Airlangga University, Surabaya, with a chief complaint of fractured upper anterior tooth with a history of trauma five years ago. He wanted his tooth to be treated and kept, because he used to feel ashamed whenever he smiles. Clinical examination revealed Ellis class III fracture in #21 tooth (Fig.1). The tooth responded normally to percussion, palpation and had normal periodontal probing and mobility. Radiographic examination demonstrated the presence of an open apex and periapical lesion (Fig.2). The tooth did not respond to the pulp vitality tests. The diagnosis of the #21 tooth was pulp necrotic. The available treatment options were discussed with the patient and root canal therapy using MTA as an apical barrier was selected with cast post, and porcelain fused to metal crown restoration.
Case Management The treatment start with measurement the working length of #21 tooth, because the orifice was remains open. Working length was determined to be 14 mm by radiographs (Fig.3). The canal was gently debrided with large H-files (Kendo, VDW) and copious amounts of 2.5% sodium hypochlorite and sterile aquadest and the canal was dried with paper points. Calcium hydroxide (Metapaste, Meta-Biomed) intra canal medicament was placed for one week to disinfect the root canal.
Figure 3. Determination of working length.
Figure 1. Preoperative tooth
At the next appointment, calcium hydroxide was flushed with 2.5% sodium hypochlorite and rinsed with sterile quadest and the canal was dried with paper points. MTA (ProRoot MTA, Dentsply) was mixed according to the manufacturer‟s instructions and carried to the canal with a hand plugger (Machtou plugger, VDW). Apical plug of 4 mm of MTA was placed and confirmed radiographically (Fig.4). A sterile cotton pellet moistened with sterile water was placed over the canal orifice and the
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access cavity was sealed with temporary restoration (Cavit, 3M ESPE). On the next visit, there was neither patient complaint nor pain reported during two week after the apexification treatment was accomplished, teeth were decaputated and prepared for post and core. After decaputation and post preparation, double impression was done as a mould to fabricate the Ni-Cr post and core. Bite registration record was taken, and then the impression was sent to dental laboratory with a written detailed laboratory prescription. The acrylic provisional crown (Tempron GC) with post and core were cemented using temporary cement (Freegenol GC).
Figure 5. Cast post and core was cemented.
Figure 6. Cast post and core insertion
Figure 4. Apical plug of MTA
Figure 7. Provisional crown restoration.
After the cast posts and cores from dental laboratory were available, the temporary restoration was removed and cleaned. Cast posts and core from the lab was cemented permanently (Fig. 5,6) using luting cement (Fuji I GC). The tooth was preparated for porcelain fused to metal crown restoration. Double impression and bite registration record were done to make the final porcelain fused to metal crowns. The second temporary provisional crown (Tempron GC) was cemented (Fig.7), the impression result was sent back to the dental laboratory for crown production along with a detailed laboratory prescription. For color mapping, a Vita 3D shade guide of 2M2 was selected.
On the final stage, porcelain fused to metal crown was available. The crown was cemented using luting cement (Fuji I GC). The excess from cementation was cleaned before full set with hand instrument and contacts were checked using dental floss. Occlusion and contact showed a fit state. The final result showed good color and anatomical (Fig.8).
Figure 8. Final porcelain fused to metal crown restoration.
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Discussion An immature permanent incisor tooth is defined as one where the apex can be considered to be open. Root canal treatment of these teeth requires a root end closure technique to form a complete calcific barrier at the apex. The aim of root canal treatment is to eliminate the microbial cause of the infection. Hence the antimicrobial irrigant sodium hypochlorite were used and calcium hydroxide intra canal medicament for one week. The latter has been shown to eliminate bacteria in the root canal when applied for this period. H files were used because the aim is to clean the root canal walls of debris, not to shape the canal as the canals of immature non vital teeth are wide and have thin dentinal walls. MTA has been developed by Torabinejad and co-workers in 1990 at Loma Linda University. It is available as grey and white MTA. The material consists of tricalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, calcium sulphate dehydrate and silicate oxide. Presence of bismuth oxide makes it radiopaque.5 The analysis of in vitro and animal studies reveals different properties of MTA which seem interesting as regards apexification, offering good sealing ability, antimicrobial properties, a setting ability uninhibited by blood or water, biocompatibility, low cytotoxicity, non-resorbable nature and also an effect on the induction of odontoblasts and of a calcific barrier.1 pH of the material is 12.5 at three hours. MTA has a compressive strength comparable to IRM and Super EBA and reaches its maximum compressive strength in 72 hours.6 Felippe3 reported that the application of MTA immediately after root canal preparation favoured the establishment of a normal periodontal ligament and formation of new bone and cementum. The MTA behaved in a similar manner to the calcium hydroxide paste, even in the presence of exudate and contamination observed at the time of preparation, and promoted the disinfection of the canal and stimulated the formation of an apical barrier of hard tissue. Aminoshariae et al.7 evaluated placement of MTA using hand and ultrasonic condensation and suggested that hand condensation resulted in better adaptation and fewer voids than ultrasonic
condensation. Accordingly, in these cases hand condensation was used to compact MTA at the apex. In this case, the patient suffered trauma in the upper front teeth at a young age, resulting an open apex and wide root canal. The open apex will complicate the endodontic treatment. Therefore, it was required the formation of an apical calcific barrier. In this case, MTA acts as an apical plug that will induce apical calcific barrier formation and healing process. After getting the apical plug, root canal filling process can be done without waiting for the formation of calcific barrier, so that the definitive restoration can be completed. The selection of post and core design as a supporting in root canal must be appropriate with the size of the crown left concerning with the height of occlusal pressure (chewing power), diameter of root canal and tooth location as well as the health of periodontal tissue as supporting to post crown.8 The cast post have some advantages, the post and core not only become unity but also follow the shape of the root canal preparation, so it can be retentive and stable and doesn‟t need additional retention like pin.9 The principle of the tooth treatment after the endodontic treatment, moreover, is to carry out the restoration of root and crown with post crown and core which is retentive and stable so that it‟s not only easily removed but can also be used for long time in the mouth like the original teeth. However, it must be noticed that the teeth which have been treated by the endodontic treatment are relatively fragile and can easily fracture compared to the healthy teeth, since there is an organic and biological changes because of the death of pulp, the reduction of dental internal tissue, and the weakening linkage between enamel and dentin due to the scraping of dentin tissue during the root canal preparation causing the change of the tooth color. For those reasons, comprehensive protection is needed by using supporting post and core as well as by making restoration of porcelain jacket crown fused to metal in order to prevent the teeth from fracture.8,9 The aim of making an acrylic provisional crown was to protect posts and core inserted during the treatment and to describe the normal position of the anterior teeth appropriate with the 264
good dental curvature with normal overbite and overjet before the porcelain fused to metal crown delivered.10 The making of porcelain jacket crown fused to metal, thus, is a good treatment for reconstructing the esthetics, especially the anatomy construction and the color of the teeth which is appropriate with their original color and can function naturally.10 Similarly, Hume11 also states that porcelain jacket crown is the best solution to carry out the restoration of the tooth with optimal aesthetic. Conclusion MTA has numerous applications in endodontic therapy that range from apexification to pulpotomy. The primary advantages of this material as an apical barrier include reduction in the number of appointments, development of proper apical seal and excellent biocompatibility. This article demonstrated one of the indications of MTA as apexification material. Although additional research is necessary to determine additional indications for MTA, its use in endodontics certainly appears favourable and promising. The cast post and core was selected in this case, because of the less available crown structure. And the porcelain fused to metal crown restoration was chosen for better aesthetic result and good strength. References 1. Beslot-Neveu et al. Mineral trioxyde aggregate versus calcium hydroxide in apexification of non vital immature teeth: Study protocol for a randomized controlled trial.Trials 2011; 12:174 2. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-
visit apexification treatment: a prospective study. Int Endod J 2007; 40: 186–97. 3. Felippe WT, Felippe MCS, Rocha MJC. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J 2006; 39: 2–9. 4. Parirokh M, Torabinejad M,. Mineral Trioxide Aggregate: A Comprehensive Literature Review- Part I: Chemical physical and Antibacterial properties, J Endod 2010; 36: 16-27. 5. Matt G, Thorpe J, Strother J, McClanahan: Comparative study of white and gray Mineral Trioxide Aggregate (MTA) simulating a One or Two-Step apical barrier technique. J Endod 2004; 30: 876-9. 6. Sluyk, Moon, Hartwell: Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation repair material. J Endod 1998; 24: 768-71. 7. Aminoshariae A., Hartwell G.R., Moon P.C. Placement of mineral trioxide aggregate using two different techniques. J Endod 2003; 29(10): 679–82. 8. Chan DCN, Myers ML. Chipped, fractured, or endodontically treated teeth. In: Goldstein RE, editor. Esthetics in dentistry. 2nd ed. Hamilton, London: BC Decker Inc; 2002. p. 537–9. 9. Tohiroh DJ, Rahardo TBW. Retensi mahkota pasak berdasarkan desain pasak. Kumpulan Naskah Temu Ilmiah Nasional I (TIMNASI) 1998; 145–6. 10. Nanik Z. The aesthetic treatment for anterior teeth with lost crown by endorestoration. Dent J 2009; Vol 42(2): 99−103 11. Hume WR. Preservationand restoration of tooth structure. London:The CV Mosby Co; 1998. p. 185–90.
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Single Visit Endodontic Treatment Using Reciprocal Thermoplastic Obturation Technic : a case report
System
with
Srimelvina Riesky Murnidewi*. Nirawati Pribadi**. Achmad Sudirman** * Resident of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background : Single visit endodontic is root canal treatment completed in one visit appointment. One-appointment procedure is an endodontic therapy protocol that has been growing inpopularity among clinicians and patients. It definitely brings many advantages in clinical management and in relating to the patients’ needs. This gives the advantage to minimize the risk of contamination of microorganisms in root canal, no interappointment pain, and also save times. The reciprocating system uses a single-file technique with a reciprocating file and a proprietary engine for instrumentation. Purpose : To inform how to manage single visit root canal treatment using reciprocal system with thermoplastic obturation technic. Case Report : Departement of orthodonti counseled a male patient, 21 years old, with chief complaint was severe pain in in left maxillry second premolar. The pain began to arise about 3 days ago, and the patient was taking painkillers but the pain still persists. Clinical examination showed caries profunda, percussion test showed a positive reaction, and on the X-ray picture of the root canal looks normal without any narrowing. Case management : Irreversible Pulpitis were planned and treated with single visit endodontic treatment using reciprocal system. Thermoplastic obturation technique with downpack and backfill combination was chosen as the root canal treatment, is to obtain a hermetic root canal obturation. Control after 1 week, percussion is negative, patient have no pain. Conclusion : Single visit endodontic gives good result, risk contamination can be reduced, and saving time. Reciprocal system using single-use file, cut significant time and ensure maximal cutting efficiency. Thermoplastic obturation technique can make more good adaptation to the canal walls. Keyword : Single visit endodontic, reciprocal system, thermoplastic obturation. INTRODUCTION Root canal treatment is a step in order to maintain and preserve the tooth. It is universally accepted that a successful outcome in endodontic treatment depends on three factors : cleaning and shaping, desinfection and threedimensional obturation of the root canal system.1 During the past four decades there has been a tendency for choosing the oneappointment procedure instead of the multiappointment procedure for root canal treatment.2 In recent years, with the advent of rotary Ni-Ti, single visit endodontics has gained increased acceptance as the treatment of choice for most endodontic cases. Indications for single visit endodontics : vital teeth, physically and medically compromised patients, fractured
anteriors where esthetics is a concern, apprehensive but cooperative patient, patients who require sedation or operation room, non vital teeth with sinus tract. Contra indications for single visit Endodontics: acute alveolar abscess, acute apical periodontitis with severe pain on percussion, painful non vital tooth with no sinus tract, cases with procedural difficulties (calcified canals, curvatures, extra canals, etc), patients with TMJ disorders and inability to open the mouth, teeth with limited access, non surgical retreatment cases.3 Effective cleaning and shaping of the root canal system is essential for achieving the biological and mechanical objectives of root canal treatment. Traditionally, the shaping of root canal was achieved by the use of stainless steel hand files.4 Historically, carbon steel and 266
stainless steel instruments were used for root canal instrumentation. In 1988, Walia and colleagues introduced nickel-titanium (NiTi) files to endodontics. Since then, many NiTi file systems have been developed.5 The concept of reciprocating motion based on balanced force technique was introduced by Yared, who utilized the single F2 ProTaper instrument (Tulsa Dentsply, Tulsa, OK, USA) in reciprocating motion to shape root canals.6 In 2011, both WaveOne (DENTSPLY Tulsa Dental Specialties and DENTSPLY Maillefer) and Reciproc (VDW) were internationally launched as single-file shaping techniques.4 The instruments are made from an MWire nickel-titanium which offers greater flexibility and resistance to cyclic fatigue than traditional nickeltitanium. They have an Sshaped cross section (figure 1).4
Figure 1 : Reciproc cross-section
The Reciproc manufacturer suggests that only one of the three files is required to prepare a root canal: R25 (tip size 25 with a taper of 0.08 over the first apical millimeters), R40 (tip size 40 with a taper of 0.06 over the first apical millimeters), or R50 (tip size 50 with a taper of 0.05 over the first apical millimeters). Selection of the appropriate Reciproc instrument. A size 30 hand instrument is inserted passively (with a gentle watch winding movement but without filing action) to the working length. If it reaches the working length, the canal is considered large; the R50 is selected for the canal preparation. If the size 30 hand file does not go passively to working length, a size 20 hand file is inserted passively to the working length. If it reaches working length, the canal is considered medium; the R40 is then selected for the canal preparation. If the size 20 hand
instrument does not reach the working length passively, the R25 is selected (figure 2).4
Figure 2 : Reciproc files
The instrument rotates in counterclockwise (CCW) and clockwise (CW) directions, 150° CW rotation angle and 30° CCW rotation angle (angle of progression for each reciprocation cycle = 120°). To each 3 cycles, there is a whole rotation of instrument. Thus, the instruments are used at 10 cycles of reciprocation per second, the equivalent of 300 rpm (figure 3). When the instrument rotates in the cutting direction, it will advance in the canal and engage dentin to cut it. When it rotates in the opposite direction (smaller rotation), the instrument will be immediately disengaged. This action reduces the cyclic fatigue and subsequent file fracture and requires less working time during root canal preparation phase.4,7
Figure 3 : Reciprocation movement
CASE REPORT Departement of orthodonti counseled a male patient, 21 years old, with chief complaint was severe pain in left maxillary region. The pain began to arise about 3 days ago, and the 267
patient was taking painkillers but the pain still persists. Clinical examination showed patient with fixed bracket maxillary and mandibular, tooth no 25 was previously restored with temporary material filling and was tender on percussion (figure 4.A). Radiographic examination showed root canal looks normal without any narrowing (figure 4.B). Figure 6 : A. Working length measurement; Confirm working length with x-ray
Figure 4 : A. Clinical examination; B. Radiographic examination
B.
Root canal preparation using rotary one file reciprocal system R#40 (VDW) single length technique, with lubricant (RC-prep, VDW) (figure 7.A), and canal irrigation was done using continuous irrigation with 2% NaOCl and aquadest sterile (figure 7.B).
A clinical diagnosis of Irreversible pulpitis was made and single visit endodontic using reciprocal system was planned. CASE MANAGEMENT The tooth performed with anasthetic infiltration pehacain 2 %, using rubber dam (optradam plus size M, ivoclar, vivadent) during access opening (Endo access bur, Denstply Maillefer) and treatment to prevent bacterial contamination (figure 5). One orifices were located, then glide path was achieved with pathfiles (Dentsply, Maillefer) in rotary motion. Working length measurement (20 mm) by electronic apex locator (VDW Gold Reciproc) and confirm with radiograph (figure 6.A and 6.B).
Figure 7 : A. Root canal preparation using reciprocal system (VDW); B. Irrigation root canal
The fit of the gutta-percha cone is the last step in successful cleaning and shaping of the root canal. Master cone (gutta percha R#40) get initial fit, confirm with radiograph (figure 8).
Figure 8 : Radiograph of trial master gutta-percha cone Figure 5 : Using rubber dam
Dry the apical extent of the root canal with absorbent paper points. Thermoplastic obturation technique with downpack and backfill combination (warm vertical condensation technique) was chosen as the root canal 268
treatment, is to obtain a hermetic root canal obturation. (Beefill 2in1, VDW). Sealer (topseal, dentsply) was applied to the canal walls with a lentulo spiral filler. A R#40 master gutta-percha was fitted 0.5 mm short of the working length with a tug-back. The BeeFill down-packing device was used for the obturation of the apical part of the root canal system. A plugger (Dentsply Maillefer, Ballaigues, Switzerland) was introduced, searing the points off approximately 3 to 4 mm from the apex (figure 9.A). The coronal part of the root canal was filled with a backfilling device. The heated gutta-percha was vertically compacted with pluggers until the gutta-percha hardened (figure 9.B).
Figure 9 : A. down pack; C. backfill
Temporary filling material (cavit, 3M) used for coronal sealing after endodontic treatment. X-ray radiograph of the root canal after thermoplastic obturation (figure 10).
Figure 10 : X-ray after thermoplastic obturation
Patient control 1 week later, percussion is negative, patient have no pain. The temporary filling material was removed, then inserted a metal pre-fabricated post (Unimetric, Dentsply, Maillefer) with luting cement (GC Fuji type 1) (figure 11.A). Then, composite restoration (figure 11.B). Subsequent treatment plan is porcelain fused to metal crown (or PFM crown)
when fixed orthodontic treatment has been finished.
Figure 11 : A. insertion pre-fabricated post; B. composite restoration
DISCUSSION Advantages of single visit endodontics : patient comfort, no interappointment pain, saves time, minimizes fear and anxiety, minimizes incomplete treatment, familiarity of the canal anatomy, constant working length, esthetics (with fractured anteriors). A practitioner who is used to single visit endodontics would see no disadvantages in single visit endodontics. However, from an impartial view the following could be classified as disadvantages : tiring for the patient, flare-ups (if a flare-up occurs, it is easier to establish drainage in a tooth which is not obturated), not possible in all cases (difficult cases like calcified canals, severe curvatures, weeping canal, etc).3 The basis of successful single visit Endodontics is thorough cleaning and shaping.3 Advantages of rotary reciprocal system : centring ability, single file preparation, simplicity, less work steps, time-saving, less risk of contamination, easy to learn or less likelihood of procedural errors, the risk of instrument fracture is minimized.6 Irrigation is a key part of successful root canal treatment. It has several important functions, which may vary according to the irrigant used: it reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves tissue, cools the file and tooth, and furthermore, it has a washing effect and an antimicrobial /antibiofilm effect. Irrigation is also the only way to impact those areas of the root canal wall not touched by mechanical instrumentation.8 One advantage to paste lubricant (EDTA) is that they can suspend dentinal debris and prevent apical compaction. 269
EDTA to the lubricants has not proved to be effective. In general, files remove dentin faster than chelators can soften the canal walls. Aqueous solution, such as NaOCl, should be used instead of paste lubricants when using nickel-titanium rotary techniques to reduce torque.9 Sodium hypochlorite is the main irrigating solution used to dissolve organic matter and kill microbes effectively. High concentration sodium hypochlorite (NaOCl) has a better effect than 1 and 2% solutions. The major disadvantages of NaOCl are its cytotoxicity when injected into periradicular tissues, foul smell and taste, ability to bleach clothes and ability to cause corrosion of metal objects.8 Root canal obturation involvesthe threedimensional filling of the entire root canal system and its critical step in endodontic therapy. There are two purpose to obturation : the eliminate of all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system; and the sealing within the root canal system of any irritansts that remain after appropriate shaping and cleaning of the canals, thereby isolating these irritants. The advantage of warm techniques is that wide or even irregularly shaped root canals (such as in the case of internal resorption) and C-shaped canals found under the lower molars can be homogeneously filled. Thermoplasticized guttapercha techniques could be the material of choice to achieve a 3-dimensionsal.11 CONCLUSION Single visit endodontic gives good result, risk contamination can be reduced, and saving time. Reciprocal system using single-use file, cut significant time and ensure maximal cutting efficiency. Thermoplastic obturation technique can make more good adaptation to the canal walls.
REFERENCES
1. Gheorghiţă L, Ţuculina M, Diaconu O, Andrei V, Moraru I, Bătăiosu M, 2009. Access Cavity- the First Step in a Successful Endodontic Treatment. Curret helath sciences journal; 35:1. 2. Martins, Jorge N.R., Saura, Marina, Pagona, Athanasia, 2011. One appointment endodontic procedure on teeth with apical periodontitis: Is this a criterion for success? – A literature review. Med Dent Cir Maxilofac;52:181-6. 3. Jacob S, 2006. Single visit andodontics. Famdent Practical Dentistry Handbook. Vol.6. Issue 4. 4. Yared G, 2007. Canal preparation using one reciprocating instrument without prior hand filing: A new concept. International Dentistry – African Edition;2:2. 5. Lieutenant Commander Evan Whitbeck, Colonel Kathleen McNally, 2013. New Developments in Rotary Nickel-Titanium Instruments. Naval Postgraduate Dental School;35:5. 6. Young-Sil Yoo, Yong-Bum Cho, 2012. A comparison of the shaping ability of reciprocating NiTi instruments in simulated curved canals. Restorative Dentistry and Endodontics. Restor Dent Endod.; 37(4): 220–227. 7. Gavini G., Caldeira C.L., Akisue E., Candeiro M, Kawakami DAS., 2012. Resistance to Flexural Fatigue of Reciproc R25 Files under Continuous Rotation and Reciprocating Movement. J Endod;1:1–4. 8. M. Haapasalo, Y. Shen, Z. Wang, Y. Gao, 2014. Irrigation in endodontics. British Dental Journal. 216: 299 – 303. 9. Torabinejad M, Walton RE, 2009. Principles and practice of endodontics. 4th ed. Philadelphia, Pennsylvania: W.B. Saunders Company. 10. Gutmann J, Kuttler S and Niemczyk S, 2010, Root Canal Obturation: An Update, Academy of Dental Therapeutics and Stomatology, a division of PennWel.
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Management of Peg Shaped Maxillary Lateral Incisor during orthodontic treatment by esthetical approach: a case report Camelia Ariesdyanata*, Adioro Soetojo**,Dian Agustin Wahjuningrum** * Resident Student of Conservative Dentistry **Lecture at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background: Peg shaped is one of dental anomalies, in which the tooth has smaller size from the normal one. This mostly found on maxillary lateral incisor and this condition raises aesthetic problems for the patient. Veneer Indirect is one of the treatment solutions for lateral peg shaped teeth. Purpose : Veener Indirect management treatment for the patient with peg shaped on maxillary lateral incisor . Case Management: 20 years old female patient came to the Dental Hospital Faculty of Dentistry Airlangga University on the reference from PPDGS Orthodontic Clinic of Airlangga University to repair her tooth which is smaller than her other teeth. The patient had been doing orthodontic for 1.5 years and her treatment had reached retention phase. The patient was referred to get her tooth better in shape and size. Conclusion : Indirect porcelen veneer can be used to repair non caries damage like peg shaped. It can be one of solutions because it is better from the aesthetic point of view, more resistant to the abrasion, and the color changing. Moreover, it has good biocompability to the gum. Keyword : Aesthetic treatment, Indirect Porcelain Veneer, Peg Shaped. Introduction Teeth are a part of body which give more aesthetic value for someone‟s performance. The good color, shape, and composition of the teeth will increase someone‟s confidence. It also plays an important role in someone‟s success in this competitive environment nowadays. Peg shaped is one of the tooth anatomy disorders, in which the tooth has smaller size than the normal one and its shape is sharp. Peg shaped tooth mainly found on maxillary lateral incisor and the third molar. Peg shaped on lateral incisor frequently raises aesthetic problem because it is anterior. 2 Veneer is one of tooth treatments which aim to repair the disorder or tooth damage which is related to aesthetic. Composite resin or porcelain is the material used to make veneer. Porcelain veneer is better than others because it has good aesthetic, stabile color, and good resistant to high abration. Veneer means to cover ( anything) with a layer of something else to give an
appearance of superior quality1. Porcelain Veneer is a thin layer with the preparation depth ranging from 0.5 to 0.7 mm. it covers the labial of anterior and posterior surfaces. 2 The materials used to make veneer are composite resin and porcelain. Porcelain veneer has more advantages than composite veneer such as good aesthetic, stabile color, and resistance to the high abrasion, to biology, chemical, and mechanic effects. Moreover, the color of the porcelain veneer can be made to match your natural teeth very closely. 4 According to Touti (1999), veneer‟s advantages are resistant to plaques and can protect the dental structure because of limited preparation on the tooth enamel. 5 The indication of the porcelain Veneer according to Victor (1995) is 1. To restore the diastema, 2. To repair the tooth discoloration because of fluorosis, or tetracycline 3. To close the defects on the tooth enamel 4. To restore peg-shaped tooth 5. To Repair the tooth damage which endure tooth fracturer.3 while the contraindication from the porcelain veneer are parafunctional habits (clenching, bruxism), the 271
teeth with insufficient enamel for bonding, severe tooth fractures, excessive interdental spacing, moderate to severe malposition or crowding.3 In this case report explains about indirect porcelain veneer treatment on Peg shaped laterals. Peg shaped is one of dental anomalies, in which the tooth has smaller size and more conical shape from the normal ones. This happens mostly on the maxillary incisor both lateral unilateral and the third molar. Most of peg shaped lateral incisor patients have aesthetic problem since its position is in the anterior and is easily seen when the patient do his or her activities. Indirect Porcelain Veneer is chosen in this case because of some reasons, such as veneer has better aesthetic value, it is durable to the high abrasion an color changing. Besides, according to Roberson and Heymann, the porcelain veneer is proven having better biocompability to the gum tissues than the composite veneer.3 Case Report 20 years old female patient came to the Dental Hospital Faculty of Dentistry Airlangga University on the reference from PPDGS Orthodontic Clinic of Airlangga University to repair her tooth which was smaller and sharper than her other teeth. She previously had got orthodontic treatment for 1.5 years. Her treatment had reached retention phase. Based on the reference letter, the lateral incisor tooth ( 12 ) needed to treat in order to repair her small tooth shape so that it would be as normal and good as other teeth The clinical condition of the tooth 12 is smaller and more conical than the 22 tooth. The patient wanted the best treatment to get good aesthetic value for her tooth. ( Picture 1 ). Based on The objective examination on the tooth 12 Both percussion and the pressure were negative. An on the vitality examination using etil chlor, the tooth reacted to the cold water. The operator had given some choices of treatment to the patient. She also advised patient to indirect porcelain veneer because it has some advantages such as it has natural looking result,
it was very to the high abrasion and color changing, it also required the removal of less tooth structure than a full crown so its resistance was stronger. The patient finally agreed with the operator‟s advice.
Picture 1: Peg shaped on tooth 12
Case Management After conducting a complete anamnesis about the patient‟s complaint and need, also about the needed treatment, the next step was planning the treatment steps and explaining as clearly as possible to the patient about the steps. Inform consent, the clinical photo, and matching the color with the real one was done after the patient agreed with the treatment steps. The first step of preparation began with reducing labial around 0.5-0.7 mm using deep cutting or marking bur as the mark to control the preparation depth. Then, the labial was polished using long fissure flat end to get shoulder ending on the tooth cervical. Preparation on the tooth interproximal used long fissure on the contact point and formed the window to the tooth proximal. The incisor was cut around 1 mm up to the tip of incisor (Picture 2).
Picture 2 Preparation indirect porcelain veneer on tooth 12
To get the best result, the prepared tooth was polished using fine finishing bur so there was no undercut part. Then, the tooth was cleaned by pumice powder and water using rotary brush ( picture 3 ). 272
Picture 3 the clinical condition of the tooth after being prepared and polished.
After the preparation finished, the next step was molding. On this step was rather difficult because patient wore bracket. Therefore, on the 11th and 13th teeth were put the red dental wax to get a precise molding result. It was done by cutting the red dental wax in square about 5 mm then it was stuck on the bracket of the 11th and 13th teeth. (Picture 4).
Picture 6 : the molding result using double impression
After the molding step finished, the prepared tooth was covered with light curing composite, which used a temporary filling. The tooth cavity was dried then etsa was applied to a point of labial in order to cast the temporary veneer easily when the real veneer fitted. (picture 7 ).
Picture 7 : Etsa application on a point of labial.
Picture 4 : The fitting of red dental wax on the bracket of the 11th and 13th teeth
However, before the red dental wax stuck on the bracket, it was heated first. Then, it was shaped and polished (Picture 5 ).
Etsa material was rinsed with water and dried sterile cotton pellet. Then the composite was applied based on the real tooth crown of tooth 12. After that it was lighted cured for 20 second. ( Picture 8A and 8B ). Patient was instructed not to bite solid food and brush her teeth too hard.
A
B
Picture 5 : the step before the molding process
Then the tooth was dried using cotton pellet. After the tooth had been retracted using the retraction thread on tooth 12 gingival sulcus, the molding was done using elastomer. The molding process used half mouth guard and double impression with one step technique ( Picture 6 ). The antagonist tooth was molded using alginate and the half mouth guard.
Picture 8 A. the teeth after bonding and being dried. B. the teeth after light-curing composite was applied as the temporary veneer.
The next step was the determination of bite using two pieces of red dental wax which had been heated. Previously the patient was given the explanation to bite based on normal occlusion. Then the red dental wax was heated 273
and patient was instructed to bite as the previous instruction. Then the molding result was planted in the oxcludator before sending to laboratory for making the porcelain veneer. (picture 10).
Picture 12 the teeth condition after two weeks.
Discussion
Picture 10 the tooth model after planting in the oxcludator
On the next meeting, the temporary filling was removed then the tooth was cleaned by pumice dan brush. Then the dressing trial on the Porcelain veneer tooth 12, to match the anatomy, proximal edge, the curvature of the tooth, and color. Venner which had dressed trial shown to the patient before it was fitted permanently. Then tooth 21 was etsa using phosporic acid 37 % for 15 second, then washed, and dried. After that, dentin bonding was applied and light curing was done for 20 second. Porcelain veneer was cleaned from the trial material using cotton pellet then resin dual cured was applied onto the veneer. Veneer was applied to the tooth with light pressure then was lighted-curing for 4 second. . the residue of resin dual cured was cleaned using sonde ( Gambar 11A dan 11B ). The patient was instructed to keep her oral hygine and she returned two weeks later for checking up. On the check up, veneer was in a good condition, percussion was negative, the tooth was vital, the gingiva tissue was normal, and the color didn‟t change. The patient felt satisfied with her new tooth shape and and color.
A
B
Picture 11 the clinical condition on tooth 12 after being inserted veneer porcelain ( a) labial view (b) palatal view
Porcelain veneer was chosen on the tooth 12 because it had more advantages than composite veneer such as good aesthetic, stabile color, and resistance to the high abrasion, to biology, chemical, and mechanic effects. Moreover, the color of the porcelain veneer can be made to match your natural teeth very closely. 4 Besides, veneer preparation was more conservative than crown because it sacrificed less tissue than the crown. On this case, the anatomy of tooth 12 was peg shaped, and this condition really influence the patient‟s aesthetic and confidence. Therefore, the patient wanted the best treatment to reshape her tooth. Porcelain veneer was indicated to repair her tooth shape. It was also indicated to repair her tooth anatomy, discoloration, mall position, and malformation at once. The usage of indirect porcelen veneer on tooth 22 was given to solve the patient‟s aesthetic problem. Technique and the material used in porcelain veneer were proven could give the satisfaction and long lasting result to the patient 5. Moreover, the most important advantage of veneer preparation was it was really conservative in reducing the tooth. The minimal reduction of the tooth could less the pulp exposure. The porcelain shiny surface could avoid plaque accumulation and it had good respond to periodontic tissues. The good aesthetic would support the patient‟s performance.6 In this case, patient still got an orthodontic treatment. Therefore, there was difficulty especially in the molding, fitting, and removing the bracket on the veneer surface. To solve this problem, before molding tooth 12, the neighbor teeth were covered by red dental wax. 274
It was done to get the precise molding result. The bracket on tooth 13 and 11 can cause an undercut when the molding material was removed from the tooth. It was because the bracket surface was not flat so that it would be difficult when the molding result was removed. The red dental wax which was applied to cover the bracket on tooth 11 and 13 functioned to get the best result of molding. The other difficulty was the process of fitting and removing the orthodontic bracket on the veneer surface. To fit the orthodontic bracket a certain glue was used to bond the bracket onto the porcelain RMO ( picture 13 ). When bracket was removed, it must be done carefully so that the veneer surface was not broken or released. The dentist whose specialization was conservation should accompany when the bracket was removed. Therefore, when the veneer was accidentally released it could be fitted soon
Picture 13: orthodontic bond for bonding orthodontic bracet in porcelain surface
Indirect veneer on the patient who was on the orthodontic treatment could be done as long as she had been in the retention phase. The purpose was to avoid the color changing and the damage of veneer. Using composite to replace veneer temporarily was better than using the acrylic because it needed less money and time. This material was also easy to apply and could be used directly after the cavity preparation. 7 The resin dual-cured usage on the 12th veneer 12 could give a good unification limit as porcelain crown when the veneer was pressed. Self-adesive cementing agent could reach adhesive dentin well although only happened
superficially contact. This material caused less hybrid or resin tag. Conclusion From the case review above, it could be concluded that veneer restoration with porcelain material on the 12th tooth which had peg shaped anatomy gave a better result both aesthetically and functionally. The chosen of veneer restoration was based on the case indication. The use of Porcelain veneer was also beneficial because it was better in aesthetic and Porcelain veneers were stronger and more durable than composite veneers. It had more minimal intervention than crown References 1. Kilian : Imformation for Preparation Cerec Conect Bite X- Rite Quality. USA., diakses pada tanggal 30-12-2010 2. Ching Chiat Lim : Case Selection for Porcelain Veneer, Quintessence International l995; 26 : 311-315 3. Victor O.A : Porcelain Veneer for incisor lateral case report, Quintessence International 1995 ; 26 4. Rosenstiel,S.F Contemporary Fixed Prosthodontics, 3 rd ed. St Mosby 2001; 609612 5. 5. Eni I : Restorasi Keramik secara Indirect. Majalah I Kedokteran Gigi .Bagian Prosttodontia Fakultas Kedokteran gigi Universitas Airlangga.2008;Vol 23 no 1 6. Kontorowics .G : Veneer, Inlay, Crown & Bridge Clinical hand book. 5 th ed Butterworth- Heinemann Ltd 1993 h 73- 76 7. 7. Hhtp // www.dentalfind.com/ Porcelain Veneer. Diakses 15 -8-2010 8. Roberson.,T.M., Heymann,E.J. Swift, Jr : Sturdevant S Art and Science of Operative Dentistry.5 th Ed. St.Louis;Mosby ,124-147
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Splint-crown for post hemisection tooth Bagoes W. Pribadi *.Cecilia G.J Lunardhi**.Setyabudi** *Resident student of conservative Dentistry ** Staff at Departement of Conservative Dentistry Faculty of Dentistry, University of Airlangga
Abstract Background :Hemisection denotes removal or separation of root with its accompanying crown partial of madibular molar.Purpose :To retain as much of the original tooth structure as possible Case : 17 years old male patient came to RSGM(P) FKG UA for treatment of mandibular left first and second molar both tooth was pulp necrosis Case management : the first molar however was badly damage and distal root canal was resorpstion. The second molar was balance force endodontic treatment. The treatment choosen were hemisection of the distal part of the tooth and endodontic treatment for the mesial root canal. The restoration was splint-crown between tooth 36 and 37.Conclusion :hemisection may be a suitable alternative to extraction and should be discussed with patients during consideration of treatment options. Key words :hemisection, splint-crown, endodontic treatment. Background Latest dental care is growing in line with the wishes of patient for maintaining their teeth as long as possible. Generally speaking, molar often experiencing revocation as a result from caries and periodontal disease. Under some circumtances, severe damage on molar's bifurcation or one of its root can be maintained by either bikuspidisasi or hemisection Hemisection is considered as one of endo surgery which involved separating a part of the root and crown , especially the mandibular molar , the teeth with more than one root. Hemisection is perfomed by cutting furcation in buccal - lingual direction so that one of the root and crown can be lifted. The main objective is to maintain the decent part of the teeth to perform restorative action for being functional. Hemisection is performed when severe bone damage to one of the root or tooth furcation that can not be cured by non surgical treatment. Root canal treatment is out of question when it comes to broken instrument, perforation , caries , resorbtion , vertical fracture or calcified root canal. Only when root and crown are remaining in fairlygood condition and restorative action can be performed.
The contraindications are the support of surrounding bone of the root to be maintaned is inadequate. The two roots fused or the distance is too close to be separated as well as root canal treatment can not be weel performed on the roots that will be maintaned. This case report is describing hemisection on the left first molar mandibular tooth which the mesial root was maintained while lifting the distal. Case management Male ; aged 19 ; came to endodontistAirlangga University with a serious pain on the lower back left part of the tooth. On the first visit cilinical examination is established and found that the first and second molar teeth had an extensive caries and pain is indicated when percussion test established. On dental radiograph shown ; 36, radioluscent on the distal of the crown, round radioluscent distal root, the periodontal ligament is widen, resorption of distal root and bifurcation seem thin. 37, radioluscent on the root and periodontal ligament widen, 38, impaction
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figure 1 : 36 teeth clinical
figure 2 : radiograph showing 36, 37 teeth
The initial treatment is root canal treatment and post and restoration sheath, also consulted to oral surgery for impacted tooth extraction 38. After informed consent signing, the treatmen begins with cleaning the cavity. Treatment began on 36 , root canal treatment performed on the mesial with crown down pressureless technique with the help of EDTA preparation gel and irrigation with NaOCl 2% , H2O2, aquadest CaOH2 dressing. It should be decided to do hemisection on the distal root. On second visitation after there are no complain, mesial root canal obturation on 36 with a single cone technique with top seal sealer is carried. Visit 3, 36 teeth filling control. Root canal preparation on 37 is carried after 38 odontektomi treatment. Preparation of 37 was done by using force balance method on the mesial root because of slightly bent root with crown down pressureless technique and the help of EDTA preparation gel and irrigation with NaOCl 2% , H2O2, aquadest. The 4 visit , no complain on root canal treatment , therefore single cone obturation technique on 37 is conducted. Fifth visit ,hemisection performed on the distal root 36. 2cc block mandibular anasthesia, then cutting bifurcation with buccal lingual directionusing carbide bur. After furcation is splited distal portion and thr rest of the root is lifted using bein and lower jaw pliers. Distal side
of the tooth is smoothed by fine finishing bur. Because of the fact that the rest of the crown is too short that occlusal grinding is not done. Former revocation socket is irrigated with saline, filled with bone graft and sewn 3.0 silk thread by two stiches. The remaining 36 made of fiber composite splinted around the mesial for fixation. Visit 6 taking the stitches due to closed wound. Visit 7 performed 3 month later due to patient control absence as preparation for final exam and SNMPTN. The wound has perfectly closed and preparation for both the mesial root fiber and fiber post insertion on 36. Preparation pegs on the distal root of 37and post insertion as well as making use of composite core with core build up. Visit 8 , dental ctown preparation on 36 and 37 using diamond bur. Make preparation to deliver to dental lab ( double impression technique using elastomeric molding material ) . Temporary crown installation. Visit 9 , trial insertion, articulation and occlusion check, splint crown mounting with GIC cement.
Figure 3 : RO post mesial root canal obturation on 36
Figure 4 : RO Post hemisection on the distal root
figure 5 : DWP photo 37 mesial root
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Figure 6 : trial gutta percha
figure 7 : RO 36, 37 post splint crown mounting with GIC cement.
occlusion. Another things to consider is restorative materials can cause periodontal disorder if there is a margin tha does not fit or contour crown adverse effect on occlusion, and causing a load too large will cause the failure of hemisection. In this case hemisection is more profitable because the patient refuses extraction given the fairly young age. Distal root is selected due too sizeable resorbtion. Post hemisection restoration must consider a few things, namely the determination of the occlusal surface area narrower,sufficientembrasureform and good marginal crown adaptation can increase the succes of hemisection. Prognosis of hemisection has been published in various journals, such as, Saad (et.al) concluded hemisection as good alternative to the teeth with extensive caries which one of the root can still be maintained and can serve as a buffer. While Park(et.al) also concluded molar hemisection have a good prognosis without any bone loss provided the patient has a good oral hygiene. Conclusion
Figure 8 : splint crown mounting with GIC cement.
Discussion Hemisection is an alternative procedure, especially to maintain the teeth with multiple roots that have been indicated for extraction. Some things to consider before doing hemisection include oral hygiene, caries index and patient medical status. In addition , furcation access also need to be considered to get easy access for separation as well as the rest of the bones were sufficient to support the roots of the tooth. Hemisection going to be tooth conducted three stages : first is endodontic treatment, this stage is very important because failure of root canal treatment will resulted hemisection contraindication, second stage of periodontal aspect. Factors that affect the distance between root, root shape, furcation location and root form. Third stage will be stabilitazion of restoration at the time of
Based on the discussion above, it can be conclude that the hemisection is an alternative that is betterbthan retraction and an alternatives that need to be discussed and considered among the treatment selection plan in patient with abnormalities in buffer tissues. References 1. Park J. Hemisection of teeth with questionable prognosis. Report of a case with seven-year result. Journal of the international Academy of Periodontology 2009;11(3): 214-9 2. Saad MN; Jorge M, Cameron C. Hemisection as an alternative treatment for decayed multirooted terminal abutment : A Case Report. JCDA www.cda-acd.ca/jcda June 2009, 75(5):387-90 3. SchmithMS,Brown HF. The hemisection mandibular molar. A strategic abutment. J of Prosthetic Dentistry 1987; 58(2): 140-44
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4. Walton, Richard E, Torabinejad M. Prinsipdanpraktekilmuendodonsia. Ed 3. Narlan S, Lilian J, editor.2008.Jakarta:EGC. 5. Parman G, VashiP.Hemisection: a case report and review. Endodontology 2003;15:26-29
6. Radke,usha, Rajesh Kupde, AditiPaldiwal. Hemisection: A window of hope for freezing toth.case report in dentistry. 2012. Aricle ID390874.4 pages.
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MODULATION OF ENDOGENOUS STEM CELLS, STRO-1, CD44, CD105 AND CD146 IN LIGAMENT PERIODONTAL OF WISTAR RATS POST AVULSION TEETH WITH INDUCING ALOEVERA Yuli Nugraeni *, Edi Widjajanto **, Wibi Riawan *** * Student Doctoral Program in Biomedical Sciences Graduate Program Medical Interests UB School of Medicine Malang1 **Lecturer Doctoral Program in Medical Science Graduate Program Faculty of Medicine, University of Brawijaya 2 *** Student Interests Megister Program in Biomedical Sciences Graduate Program Medical Faculty of Medicine, University of Brawijaya 3
ABSTRACT Heterogeneity and the ability of continuous remodeling of periodontal ligament tissue (PDL) indicates that there are progenitor cells (stem cells) that produce specialized cell types. namely PDL stem cells (PDLSCs). Periodontal ligament tissue is comprised primarily of connective tissue fibroblasts. The setting and the presence of fibroblast cells is unclear, thought to originate from stem cell system that can continuously update the cell. The purpose of this study was to determine the distribution of endogenous stem cells Stro-1, CD44, CD105 and CD146 in the periodontal ligament tissue of Wistar rats post tooth extraction. This research is true experimental laboratory that uses randomized approach posttest controlled group design in animal model of Wistar rats which may be lifted on incisive maxillary teeth. There are two groups, after the revocation, as the control group, and the group after the revocation of the exposure aloevera. In the post-extraction groups were divided into four treatment groups, respectively treated with antibodies specific Stro-1, CD44, CD105 and CD146, which is then carried by immunohistochemistry staining. Analysis of research data analysis using statistical analysis of research data by Oneway ANOVA, Tukey HSD, Pearson Correlation and Regression Testing. The results of this study showed no significant differences between the control group to the treatment group. The conclusion of this study showed a distribution of endogenous stem cells to specific antibody Stro-1, CD44, CD105 and CD146 showed the most significant PDLSC distribution and used as a marker or markers. Key words: jaringan ligamen periodontal, sel fibroblas, PDL stem cells INTRODUCTION Periodontal ligament (PDL) is not only for anchoring the teeth, but also contribute to maintain nutrition, homeostasis and repair. PDL consists of various types of cells, including cells that can differentiate into cementoblast and osteoblasts. Heterogeneity and the ability of continuous remodeling in PDL, indicating that there are progenitor cells (stem cells) that produce specialized cell types. In 2004, these allegations led to the discovery of three types of stem cells, one of which is derived from the periodontal ligament tissue that PDL stem cells (PDLSCs) (Jamal, 2011).
Periodontal ligament (PDL) is a connective tissue (connective tissue) that is located between the root and alveolar bone with a thickness of 0.25 mm. There are a lot of connective tissue fibroblasts inside (Gersdorff et al, 2008). Fibroblasts in the periodontal ligament is the dominant cell and is capable of producing components of extra cellular matrix (ECM) and responsible for the tissue to repair itself and regenerate. The group of fibroblast PDL plays a role in regulating and regeneration periodontal tissue in the wound healing process (Saito et al, 2002). Fibroblasts are the major cell type found in the periodontal ligament and contributes about 25 percent of all cells of the periodontal 280
ligament. The presence and configuration of fibroblasts which until now has not been clear, thought to originate from stem cell system that can continuously update it self. Various systems of this stem cells are also known as progenitor cells, it produce different types of fibroblasts. Stem cells are expected to be near blood vessels in the periodontal ligament or inside of blood vessels in the adjacent alveolar bone (Kenny and Barrett, 2001).
determine the proliferation and differentiation of MSCs in PDLSCs so as to maintain the viability of PDL tissue which may further suppress posttraumatic ankylosis avulsed teeth. The purpose of this study was to determine the distribution of endogenous stem cells CD44, CD105 and CD146 in the periodontal ligament of wistar rats after traumatic tooth avulsion with aloevera exposure. MATERIALS AND METHODS
Periodontal ligament stem cells (PDLSCs) shows the characteristics of mesenchymal stem cells (MSCs) that express cell surface markers, STRO-1 (putative stem cell marker) and CD-146 antibody (perivascular cell markers) in a population of PDL cells are heterogeneous. Another characteristic of PDLSCs been reported by Kim et al (2010) and Wada et al (2009) which has the potency to suppress the immune response and inflammatory reactions. Other studies have also indicate that PDLSCs not only have the characteristics of stem cells but also a unique cell to produce a three-dimensional network PDL (Maeda et al., 2011). Indonesia is a tropical country with diverse flora and fauna. Many of the natural resources that have been used by our ancestors as a healer or traditional medicine for a variety of health problems. One natural ingredient that has long been known and cultivated is aloe vera (aloe vera). This plant is widely available in all parts of Indonesia and has a variety of benefits, (Syukur, 2007). Aloe vera gel has been used as a traditional medicine of many cultures. Acemannan is the main polysaccharide fractions isolated from the gel aloe vera (aloe vera), it can improve the various stages of wound healing processes such as recruitment of macrophages, collagen synthesis, and wound contraction (Jittapiromsak et al., 2007; Lardungdee, Asvanit and Thunyakitpisal, 2008).
This study is true experimental laboratory design with randomized post test controlled group design, performed in the Laboratory of Biochemistry, Faculty of Medicine, University of Brawijaya. Sample of this study is animal of wistar rats which will be extration on incisive maxillary teeth. Then the upper jaw cut transversely to the slides made with paraffin method. Furthermore, the staining by immunohistochemical methods using specific antibodies against CD44 group, CD105 and CD146. Extraction Aloevera. Each 100 mg of crude powder Aloe chinensis Baker put in a 25 ml bottle. Then each sample was added 10 ml technical ethanol and mixed in maserator with slow stirring for 30 minutes at the start of immersion. Mix in maserator kept for 4 days with frequent stirring. After the maceration process, the filtrate was filtered with filter paper and the solvent was evaporated with a rotary evaporator (temperature 800C) (George et. Al., 2009). RESULTS Microscopic picture CD 44
A
B
Based on the concept of some previous studies, it was possible that the induction aloevera applied, can be understood and studied to 281
Figure 1. After the observation of the photomicrograph, the results of smear immunohistochemistry using specific antibodies was observed using Olympus CX21 microscope magnification of 400x. Figure 1A. Observations prior to revocation, arrows indicate positive expression. Figure 1B. Observations after a given exposure aloevera, arrows show increased expression in brown.
RESULTS
CD 105
A
B
Figure 2. After the observation of the photomicrograph, the results of smear immunohistochemistry using specific antibodies was observed using Olympus CX21 microscope magnification of 400x. Figure 2A. Observations prior to revocation, arrows indicate positive expression. Figure 2B. Observations after a given exposure aloevera, arrows show increased expression in brown.
CD 146
A
B
Figure 3. After the observation of the photomicrograph, the results of smear immunohistochemistry using specific antibodies was observed using Olympus CX21 microscope magnification of 400x. Figure 3A. Observations prior to revocation, arrows indicate positive expression. Figure 3B. Observations after a given exposure aloevera, arrows show increased expression in brown.
Stro-1
A
Figure 4. After the observation of the photomicrograph, the results of smear immunohistochemistry using specific antibodies was observed using Olympus CX21 microscope magnification of 400x. Figure 4A. Observations prior to revocation, arrows indicate positive expression. Figure 4B. Observations after a given exposure aloevera, arrows show increased expression in brown.
B
This study shows that by using the CD 44 antibody, positive expression seen in the cytoplasm or mebran periodontal ligament cells (PDLSc) (Figure 1A). In the post-extraction PDLSc cell that is exposed to aloevera showed increased expression, which looks at the picture of a brown color (Figure 1B). In studies using antibody CD 105, showed positive expression (Figure 2A). In the postextraction PDLScSc cell that is exposed to aloevera also showed increased expression, looks picture brown color (Figure 2B). Further observations using CD 146 antibody, showed positive expression PDLSc cell cytoplasm (Figure 3A). While the postextraction also showed increased expression, which looks at the picture of a brown color (picture 3B). In observation using STRO-1 antibody showed positive expression in the cell cytoplasm and its tendency PDLSc increased (Figure 4A). In the post-extraction, observations using antibody STRO-1 shows the results of a more increased expression (Figure 4B). DISCUSSION The periodontal ligament membran (PDL), is a dynamic connective tissue undergo continuous adaptation to maintain the size and width of the tissue membran, as well as structural integrity, including fiber and bone remodeling. The main role of the PDL is for anchoring the tooth root to the alveolar bone socket, as a mechanical load bearing which takes place in the process of mastication. PDL cells have the potential to maintain or reconstruct periodontal tissue in 282
response to environmental changes, have also been reported that the PDL tissue plays an important role in the regeneration (Ishikawa et al., 2009). The population of MSCs in the PDL tissue has the potential to differentiate into fibroblasts, osteoblasts, and cementoblas, which is an important cell population to maintain and overhaul the periodontal tissues. PDLSCs shows the characteristics of MSCs that also express cell surface markers, that is STRO-1 (putative stem cell marker) and CD 146 antibody (perivascular cell markers) in a population of PDL cells are heterogeneous (Maeda et al., 2011). In this study it appears that for some antibodies such as CD 46, CD 105, CD 146 and Stro-1 showed increased expression in the cell cytoplasm PDLSc. While the observation post extraction with aloevera exposure showed an increasing trend of expression, it is because aloevera exposure can stimulate an increase in the number of cells PDLSc. Aloevera gel has been used in traditional medicine of many cultures. Acemannan is the main polysaccharide fractions isolated from the gel aloe vera (aloe vera), can improve the various stages of wound healing processes such as recruitment of macrophages, collagen synthesis, and wound contraction. A previous study reported that acemannan can induce the expression of BMP-2 on pulp cells and human periodontal ligament cells (Langdurdee, Asvanit, and Thuyankitpisal, 2008). Molecular mechanisms that regulate the effects of acemannan on cellular activity continues investigated. Based on the structure, composition and molecular weight sugars, acemannan can bind to specific cell surface receptors and intracellular signaling pathways then start it downstream to stimulate the proliferation and differentiation. Acemannan activates mitogen-activated phosphorylation 38 protein kinase (p38 MAPK) in the cells of the
dental pulp. periodontal ligament cell proliferation, gen expression, osteogenic differentiation, and mineralization. Therefore acemannan can induce the proliferation and differentiation of periodontal ligament cells via the MAPK pathway (Chantarawaratit et al., 2013). Acemannan is ß (1,4) polymannosepolisakarida acetate extracted from Aloevera gel, has been investigated can stimulate the expression of proteins involved in the formation of hard tissue such as osteopontin (OPN), alkaline phosphatase, bone sialoprotein (BSP) and BMP2. Additionally, acemannan has been reported to induce mineralization in vitro by cementoblas, bone marrow stromal cells and dental pulp fibroblasts. (Chantarawaratit, Sangvanich and Thunyakitpisal, 2013). Bone morphogenetic proteins (BMPs) and Growth and differentiation factors (GDFS) together to form a cytokine family -sistein in TGF-β superfamily. BMP has demonstrated its ability to induce bone formation and regulate morphogenetic in the development of various tissues. Many studies have shown an increase in alveolar bone and cementum regeneration by induction of BMP-2 in some periodontal breakdown. However, BMP-2 treatment did not induce the formation of a functional structure of the PDL, such as Sharpey fibers, which sometimes can lead to ankylosis. On the other hand, BMP also showed that induction by forming a functional-oriented PDL, linking between bone and cementum, it is a rare observation of regenerative therapy by BMP-2 (Kim et al., 2009). BMP signaling pathway initiated when the cell surface bind and unite the type I and type II serine-threonine kinase transmembrane receptor. Constitutively active type II receptor, and phosphorylate Ser-Gly domain in type I receptor kinase. This leads to the recruitment of signaling pathways Smads (R-Smads, Smad 1, 5 or 8). After phosphorylation, R-Smads are released from the receptor and recruit common mediator Smad complex (Co-Smad or Smad-4). This will migrate into the nucleus and activate transcription of specific target genes. BMP 283
signaling is modulated by many proteins at various points that contain negative feedback circuit (Capra and Conti, 2009). Further signaling molecules will be transduced by Smad family, which consists of intracellular proteins. This signaling pathway is essential for TGF-b signal transmission from the cell surface to the nucleus. Smads are a special role in the signaling pathway, namely in the form of Smad1, 5, and 8 of which are targeted by bone morphogenetic protein receptor (BMP) whereas Smad 2 and 3 are targeted by TGF-b and activin receptors. SARA (Smad Anchoring Receptor Activator) a protein domain that appears to play an important role in recruiting Smad 2 to TGF-b receptor complex, and this indicates that the corresponding protein may serve the same function in the BMP signaling pathway. Mediator Smads general, consists of Smad phosphorylation of R-Smads 4. induced heteromeric complex with Smad 4, and R-Smad / Smad 4 this complex translocate to the nucleus to target specific gene responses (Letamendia, Labbe and Attisiano, 2001). Differentation Growth Factor 5 (GDF-5), also known as cartilage-derived morphogenetic protein-1 (CDMP-1), is a member of the BMP family, which includes superfamily of transforming growth factor beta (TGF-β). Mutations of GDF-5 have been identified in relation to bone growth and development in mice and humans. GDF-5 has also been shown to have a specific induction capacity of the tendons and ligaments in animal tissues such as ectopic (Foreland, Rueger and Aspenberg, 2003). GDF-5, also known as BMP-14, reported significantly to induce the formation of new bone, cementum and root surface along the fiber (fiber sharphey) on infraboni without causing damage to the walls of root resorption and ankylosis (Kim et al., 2009). Ankylosis or resorption turnover is common in post-traumatic avulsed tooth is a pathological fusion between the tooth root and alveolar bone. Ankylosis has been known as the imbalance between new alveolar bone and periodontal
tissue formation that disrupt or impede periodontal regeneration. In vivo, ankylosis associated with the application of recombinant BMP-2, which explains that BMP-2 is highly osteoinductive with low activity of periodontal regeneration, while acemannan can stimulate the regeneration of both the soft and hard tissue (Chantarawaratit, Sangvanich and Thunyakitpisal, 2013). In this study proved that exposure to aloevera containing the active substance acemannan may affect the distribution of cells PDLSc. Acemannan can stimulate an increase in the expression of GDF 5 (BMP14) PDLSc by inducing p38 MAPK signaling pathways that may affect the proliferation and differentiation PDLSc through signaling pathways GDF5 (BMP14). In this study indicated that Stro-1 is an immuno-reactive antibodies, which showed positive expression to an increased tendency PDLSc cells after exposure given aloevera. The results of these observations can be used as a baseline for future studies of Stro-1 is used as a marker of cells PDLSc. REFERENCES Chantarawaratit P, Sangvanich P, Banlunara W, Soontornvipart K, Thunyakitpisal P. 2013. Acemannan sponges stimulate alveolar bone, cementum and periodontal ligament regeneration in a canine class II furcation defect model. Thailand: Chulalongkorn University Foreland C, Rueger D, Aspenberg P. 2013. A comparative dose-response study of cartilage-derived morphogenetic protein (CDMP)-1, -2 and -3 for tendon healing in rats. J Orthop Res. 2003;21(4):617–21 Forslund C, Rueger D, Aspenberg P. 2003. A comparative dose-response study of cartilage-derived morphogenetic protein (CDMP)-1, -2 and -3 for tendon healing in rats. J Orthop Res. 2003;21(4):617– 21. Gersdoff n., Miro x., Rodriguesm., Geffers R., Toepfer T., Huels A. 2008. Gene Expression analysis of Cronically 284
Inflamed and Healthy Human Periodontal Ligament cells in vivo. Dental Research Journal.5(1); 5-6
pathways. Lhe Journal of Bone and Joint surgery 83:1; 31-39
Ishikawa I, Iwata T, Washio K, Okano T, Nagasawa T, Iwasaki K, et al. 2009. Cell Sheet engineering and Oter Novel Cellbased Approaches to Periodontal Regeneration. Periodontal 2000 : 51: 220-38.
Saito Y, Yoshizawa T, Takizawa F et al., 2002. A Cell Line with Characteristic of the Periodontal Ligament Fibroblast is Negatively Regulated for Mineralization and Runx2/Cbfa/Osf Activity, Part of Which Can be Overcome by Done Morphogenetic Protein-2. Journal of Cell Sciences 115, 4191-4200.
Jamal, Mohammed, Sami Choyle, Harold Goodis, and Sherif M K. 2011. Dental Stem Cells and Their Potential Role in Regenerative Medicine: Journal of Medical Science. 4(2): 53-61
Syukur C, Hernani. 2007. Budi Daya Tanaman Obat Indonesia. Jakarta: PT Penebar Swadaya.
Nawaporn Jittapimrosak, Suwimon Jettacheawchankit, Peechanika Langdurdee, Polkit Sangvanich and Parutha Din Thunyakitpisal. 2007. Effect of acemannan on BMP-2 Expression in Primary Pulpal Fiobroblast and Periodontal fibroblast in vitro study. Journal Oral Tissue engine 4(3): 149-154. Kenny dan Barrett. 2001. Pre-replantation Storage of Avulsed Teeth: Fact and Fiction. Journal of the California Dental Association. P.1-11. Kim H S, Kim K H, Kim S H, et al., 2010. J Periodontal Implant Sci, 40; 265-270. Letamendia A, Labbe E, Attisiano L. 2011. Transcriptional Regulation by Smads: Crosstalk between lhe TGF- and Wnt
Maeda H, Wada N, Fujii S, Tomokiyo S, and Akamine A, 2011. Periodontal Ligament Stem Cells. Department of Endodontology and Operative Dentistry, Kyushu University, Japan. www.intechopen.com. 25: 619-638. Pechanika Lardungdee D.D.S, M.S., pornpun Asvanit D.D.S., M.S, Pasutha Thunyakitpisal D.D.S,. M.S. 2012. Effect of acemannan on the dentinsialophosphoprotein and dentin matrix protein 1 mRNA expressions in primary human pulpal cells. Thailand: Chulalongkorn University Priscilla Capra and Bice Conti. 2009. The role of Bone Morphogenetic Proteins (BMPs) in bone tissue engineering: a mini review. Italy: Scientifica Acta 3, No. 1, 25 – 32
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Root Apex Resection in Patient With periapical lesion and traumatic history (Case Report) Joshua Sutedjo*, Sri Kunarti**, Febriastuti Cahyani** * Resident Student of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Surgical procedures in the field of conservation dentistry drawn when conventional endodontic procedure gives a bad prognosis. Apex resection treatment aims to dispose of infected and damaged tissue at the tip of an infected tooth root as well as providing an opportunity for the body to do the healing. The case report describes the treatment of apex resection in patients with a history of trauma and periapical lesions. Endo surgical treatment performed preceded by opening a flap on the labial teeth 21 and 22. Curettage procedure was then performed on the apical. Root canal treatment is then performed one visit in conjunction with the apical curettage procedure. Keyword : Endodontic surgery, periapikal lesion, apexresection Introduction
Material and Methods
Apical resection is the action by performing root resection on the apical region of teeth. indication of treatment of fracture of the root apical resection is the third apikal of root of the trauma, perforation of the apical third, the presence of a difficult root canal ramifications filled, fracture of endodontic instruments, lesions and complaints are settled even after root canal treatment.1-2 In this case report, the patient had experienced trauma that causes abnormalities in the dental pulp. In general, trauma cases occur in the maxillary anterior teeth because of its location in front. In addition, in patients with trauma cases, the problems that arise are usually not only in the pulp tissue, but also involves the periodontal tissues. Inadequate management of patients with trauma cases may cause problems in the future. The problem that arises is usually the presence of persistent pain in the teeth and tooth discoloration and tooth mobility. The case report describes the management of apical resection in patients with a history of trauma and inadequate endodontic treatment.
40-year-old female patient came to the clinic of Airlangga University specialist with complaints on her anterior teeth. The patient had an accident 8 years ago that led to mobility on her anterior teeth. Patients went to the dentist shortly after the accident, but after the completion of treatment, the pain still exists until today. The patient also complained about the discoloration of the teeth. Patient wants the teeth treated. On the examination, teeth 21 and 22 got discoloration and from the clinical examination percussion and palpation in the apical area of the teeth are positive, there is no mobility of both teeth and the gingival tissue is normal. Radiographic examination shows periapical lesions on the roots of teeth 22 with no clear boundaries. While the 21 teeth , the lesions is not found. In the periodontal tissues, laminadura thickened. In the teeth 21 and 22 appear to have been treated with an underfilling a root canal filling treatment. (Figure 1)
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Irrigation is carried out again and followed by dressing of calcium hydroxide (metapex) along the root canal until the cavity is full then covered with cotton and temporary filling. A Gambar 1 A. clinical photo B. rontgen photo
First Visit In first visit, retreatment process was done by releasing guttap in the root canals of teeth 21 and 22. Wire Photo Diagnostic performed using a size 12 K-file and then be confirmed by using apex B locator and radiographic picture. (Figure 2)
Gambar 2 : Foto Diagnostic Wire Photo ( DWP )
Having obtained the proper working length, 22mm on both teeth and then re-do the root canal preparation with ProTaper rotary (densply) to F4. Irigation done during root canal preparation using 2.5% NaOCl and rinsed with sterile distilled water. After the root canals were dried with sterile paper points, the trial guttap was done with radiographic confirmation. (Figure 3)
Second Visit Patients were given a description of the surgical procedure and is willing to sign a maintenance agreement (informed consent) to undergo a surgical procedure. Preparations were done and patient attempts as comfortable as possible. Sterilization of the operation area. Then local anesthetic in the labial and palatal teeth 22. Surgery started after 5 minutes under local anesthesia. The semilunar flap incision made just above the estimated 22 teeth lesions, starting from the distal portion 21 and extends toward the distal opening 22. The periosteum opening is done carefully using raspatorium until bones clearly visible. The tip of the flap then retracted so that the apical lesions can be seen clearly. On the labial alveolar bone of teeth 22 are seen having periapical abnormalities, this making it easier to determine the location of the bone. Then do the drilling using bone bur to obtain a clear visualization. Then the whole periapical soft tissue excavated using an excavator. Overall lesion tissue was then appointed to be cleaned. The area around the apex cleaned using H2O2. Then cutting the root tip approximately 3 mm using a fissure bur that leads to the labial bevelshaped 45-degree angle for easy visualization of the operator. Smoothed the root using extra fine diamond bur. Then do the filling of the root canal on the teeth within the work length minus 3mm, before that the cavity was cleaned with H2O2 and sterile distilled water. (Figure 4) Then the cavity at the root tip cleaned using EDTA gel and then irrigated with sterile distilled water to clean the smear layer. The cavity that has been dried covered with mta and the lost tissue have been filled with bone grafting.
Gambar 3 guttap trial F4
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Discussion
Gambar 4 : Pengisian dengan guttap
Mucoperiosteal flap is returned to the original position after pressure is applied carefully with a cotton swab and tampon for a few minutes and do sewing as much as 4 stitches. Patients were given postoperative instructions, patients are prescribed antibiotics clindamycin and analgesics. Patients were scheduled for control 1 week later. (Photo)
Photo : after suturing process
Third Visit One week after the apex resection the patients complained the teeth are still ache. On clinical examination, percussion was negative and there is no tooth mobility. Postoperative area still looks red because it is still in the stage of wound healing but already recover. Operator decides to lift 4 stitches with bent edges scissors Fourth Visit A month after surgery, tissue looks normal again, the patient did not complain of pain, percussion and palpation negative and normal tooth mobility. The radiographic examination shows the apical alveol regions are already condensed and formed a new tissue.
Surgical endodontic treatment performed when conventional endodontic treatment have a poor prognosis. The case above showed posttraumatic teeth which had been through a failed root canal treatment. Treatment failure was indicated by the occurrence of persistent pain,discoloration of the teeth and periapical abnormalities.3-4 In this case report, there are several factors to be considered to perform endo surgical procedures, including: The presence of a fairly large lesion in the apical treated teeth earlier, large canals resulting from the earlier treatment which increase the risk of fracture when preparation performed, large size of the apical lesion about 5mm which caused difficulty in cleaning.5 The apex resection is defined by the American Association of Endodontic (AAE) as dissection in the root apical tooth in which root canal treatment has been done with a failure, as a result of several factors such as lack of control of infection, poor design in cavity access, inadequate instrumentation and filling, undetected channel roots and coronal leakage.6 But keep in mind, before surgery operators must understand the contraindications of surgical endodontic treatment include the patient's general condition,the presence of severe damage to the supporting bone and periodontal tissues, teeth with very short root, root apical position which is near to the anatomical structures. In this case report the patient has no contraindications to surgery.7 At the surgical procedure the operator found difficulties in the process of flap creation and disposal of alveolar bone tissue because of the position precision required so that the flap is not too big but not too small. Flap using trapezoidal technique to get a good and clear field of view. Disposal of alveolar bone tissue around the apical teeth should not be too much because the healing will take longer. Disposal of alveolar bone tissue follows the pattern in the radiolucent radiographic picture.
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References 1. Boucher, Sobel, Saveur. 2000. Persistent pain related to root canal filing and apical fenestration. American Association of Endodontists. 26 (1): Pp. 242-244 2. Grossman, L.I. 2010. Ilmu Endodontik Dalam Praktek. Edisi ke 12. EGC. Jakarta 3. Hideki, Martins, Mancini. 2005. Evaluation of apical sealing in root apex treated with demineralization agents and retrofiled with mineral trioxide aggregate through marginal dye leakage. Braz Dent J. 16(3): Pp. 22-27 4. Hui, T P. 2006. The root resection of an endodontic periodontal lession. International dentistry SA. 8(6): Pp. 8-12 5. Maria,Isabel,Alvaro.Sergio,dkk. 2011 Endodontic treatment of dental formation anomalies Stricto Sensu Program. Departerment Endodontic University of Cuiaba Brazil. Brazil dental Journal. 26(1): Pp. 27-32 6. Subiwahjudi, A. 2001. Bedah Endodontik. Departemen Konservasi Gigi Universitas Airlangga. Pp. 29-39 7. Walton, Torabinejad. 2009. Principles and Practice of Endodontic. 3th ed. Philadelphia. W.B. Saunders Corp. Pp. 341-357
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INTERNAL BLEACHING OF DISCOLORED TOOTH WITH CALCIFIC METAMORPHOSIS ABNORMALITY Rendhy Popyandra1, Latief Mooduto2, Eric Priyo Prasetyo3 *Resident of Spesialist Program of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background : Tooth discoloration can be caused by extrinsic causes, intrinsic causes or combination of both. One local cause of tooth discoloration thus intrinsic factor is calcific metamorphosis within the root canal space. Calcific metamorphosis with different levels of severity can be found at approx]imately 4-24 % of traumatized teeth.Purpose : the aim of this case report is to discuss the treatment of discolored tooth due to intrinsic factor. Case : A female patient (35 years old) presented to Conservative Departement, Airlangga University complaining discoloration of the maxilla left and right central incisor. A radiograph discloses dispositin of hard tissue. Case management : the treatment is make a cavity for internal bleaching treatment. Conclusion : tooth color improvemebt as a result of the treatment. Keyword : Internal Bleaching, calcific methamorphosis, discoloration Introduction Tooth discoloration or anterior tooth discoloration is a common problem that mostly happens in estetic term, thats the patients problem to be solved. There are several treatment choices that can be done, for example with restoration treatment which veneer crown or bleaching treatment. There are many advantages using bleaching technique in management case of d discoloration, that easier and cheaper. Tooth discoloration can be caused by extrinsic and intrinsic factor. Extrinsic discoloration happened in outer surface of the tooth, loccally the stain of tea or tobacco this type of discoloraion will be usually removed by toot polishing intrinsic factor caused the stain on enamel or dentine like the useof tetrasicline in long period that penetrated dentine. Tooth discoloration caused by untrinsic factor usually hard to be removed. Calcific metamorphosis or root canal obliteration is the deffect from traumatic tooth such as luxation and tooth accident. Clinical overview of Calcific metamorphosis by Petterson and Mitchel is the tooth with darker
collor due to transluensi decreasing caused by thicker dentin. The mechanism of Calcific metamorphosis has not been known for sure, but it has a relation with pulp neurovascullar damage when the traumatic accident happened. Tooth discoloration with Calcific metamorphosis caused by degradation product or secunder or tersier dentin development after trauma. Hard tissue development mechanism on tooth with Calcific metamorphosis is availability of osteoid tissue that produced by odontoblast in perifer pulp chamber or pulp cells that not differenciated which caused by trauma. This situation causes simultan tissue depotition that similiar to dentin along the perifer and inside the pulp chamber. These tissue will be fussion with the others, and create radiographic features that shows calcified roor canal. There are several types of internal bleaching technique, there are walking bleach, termokaltalitik and intrakoronal whitening with carbamide peroxide 10%. Walking bleach tehnique most often used because its easier, take a shortime, safe and comfortable for the patients. This technique is basically placing mixed superoxol paste on pulp chamber.
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There are several indication of internal bleaching which are tooth discoloration caused by trauma, consumption tetrasicline, mild fluorosis. The contraindication are opened root canal, enalme erosion, wide caries, peroxide alergic, damage restoration, sensitivity that felt before. The complication and further effect that can be happen on the bleaching procedureare external root resorbtion, chemical burn, damaged restoration. CASE REPORT A female, 35 years old went to Conservation Departement Clinic Universitas Airlangga Surabaya. She had problem with different colour of her anterior tooth. She had motorcycle accident when she was 12 years old. At that time, there is a mobillity on those teeth but she didn‟t felt any pain so she left the teeth untreated for along time and there is no mobility on those teeth anymore. In the objective axamination, 11 and 21 have darker colour than the teeth beside them. Thermal examination, percussion and palpation are false, there is no anomamally on the surounding tissue and occlussion is normal. Radiographic examination shows only on the coronal part of the tooth. The diagnosis for 11 and 21 are non vital. The treatment plan for this case is endointacanal treatment and then internal bleaching to repair the colour until similiar with the teeth beside and restoration for the cavity wth compite resine. On the first visit, oral subjective, objective, radiographyc examination had been doneon 11 and 21 to stand the diagnosis, treatment plan and informed concent. After that opening of pulp chamber had been done by using a round bur, seeking of orifice with Glyde and senseus profinder. Because of the orifice had not been found , so Glyde had been placed on pulp chamber and closed by temporary cement (Caviton) and the treatment had been postponed . On the second visit, seeking of orifice had been done by using senseus profinder and glyde but the orifice hadn‟t been found yet. Due to internal bleaching treatment plan so cement barrier and bleaching agent placement had been needed. Therefore, making of root canalwith
round bur, 2mm depth had been done, continued by internal bleaching proscedure with walking bleach tehnique. First, the tissue around the teeth that would be treated had been protected by using vaseline. Second step is the base cavity had been close by GIC with 1mm depth, the pulp chamber had been cleanedby naCl 2,5% then had been dried by threway syringe. Third, Hidogen peroxide 35% (opalescence endo,Ultradent) had been placed in the pulp chamber pressed with cotton pellet to the labial wall and closed wih Zinc Phospat Cement (Ellite Cement 100, GC). Fourth, using the shade guide to measure the colour,and the colour is 5M2. Fifth, patients control a week later.
The third visit, checking had been done on the third visit, the patient had no complaint of the treated teeth, and clinical examination showed the teeth colours has not been close to the desire result. So the procedure had been repeated and control a week later.
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There is no complain from the patients on the fourth visit, clinical examination showed the teeth colour 2L 2,5 were similliar to the teeth beside, after that continued with removing internal bleachig agent and cavity restoration by composite resine.
controled. Follow up radiographically examination on the treated teeth is recomended for one year after treatment to diagnostis the possobility of servical resorbtion. Base on the discussion above it can be concluded that teeth discoloration caused by intrisic factor like calcific mertamormophis treated by internal bleaching, with sattisfy result. internal bleaching with walking bleach tehnique take a shorter time, safe and comfortable for patient. REFFERENCE
DISCUSSION Histopatologis experiment that had been done by Patterson and Mitchel (1965), examine teeth pulp status with calcific metamorphosis failed to show patologic proscess. Lundberg and Cvek (1980) who did histologic experiment with permanent incisivus pulp with narrowing pulp chamber conclude that in those teeth there were no microorganism and moderate inflamation respons was found on one of the pulp. West (2007), conclude that there are several choices to the treat the tooth discoloration caused by calcific metamorphosis which are external bleaching, intensional endodontic treatment followed by internal bleaching, internal bleaching external bleaching without endodontic treatment, extracoronal restoration, apical tooth resection. The success of the internal bleaching treatement showed after 2-4 times visit and depends on the severnes of discoloration and some researches mentioned that the teeth that had been discolored for years are not responding as well as the teeth that had just been discolorated. Besides, there are also some experiments that report discoloration on younger patient are easier to be treated by bleaching treatment than the elder patients. This case might be caused by dentinal tubuly that still widely opened on the ounger teeth make it possible for bleaching agent to better diffuse. One of the complication that might be happened after internal bleaching treatment is external resorbtion, especially caused by oxidation agent, specifically hidrogen peroxide 30-35% so the case report still need to be
1. Rotstein I, Walton RE. Bleaching discolored teeth: Internal and external. In: Walton RE, Torabinejad M,eds. Principle and practice of endoontics. 4th. Philadelphia: WB Saunders Company; 2009.p.31. 2. Plotino G, Buono L, grande NM, Pameijer CH, Somma F. Nonvital tooth bleaching : a review of the literatures and clinical procedures. J Endod 2008;34(4):394-407. 3. Munley CPJ, Goodel l CGG. Calcific metamorphosis. Clinical update 2005;27(4). 4. Greenwall L. single vital tooth whitening.International Dentistry SA;10(1):48-52. 5. Rotstein I. Tooth discoloration and bleaching. In: ingle JI,Backland LK, eds.Endodontics.5th ed.London:BC DeckerInc;2002.p.850-3s
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Management of traumatic immature teeth in maxillary incisor by aesthetic approach Yusuf Bagus Pamungkas1, Dian Agustin Wahjuningrum2, Laksmiari Setyowati3 1 Resident of Conservative 2,3 Staff Department of Conservative Faculty of Dentistry, Airlangga University Surabaya-Indonesia
ABSTRACT Background: Traumatic in immature teeth can lead to injury of the pulp and peri apical. Traumatic injury may disturb maturity process and stopping closure apex. Open apex results hermetic seal which became difficult reach it. The closure of root apex is very essential for success of the endodontic treatment. On the other side, traumatic induce bleeding and decomposition products can penetrate the dentinal tubules and stain the surrounding dentin and enamel. That condition may lead teeth discoloration and make an aesthetic problem. Until now the apical barrier formation and healing still challenging in root canal treatment. Purpose: The aim of this case reports is to overview the closure of root apex in permanent incisor using MTA and to inform the result of internal bleaching treatment with walking bleach technique on the anterior permanent tooth due to trauma. Case: 21 years old female patient went to the Dental Hospital Faculty of Dentistry Airlangga University. The patient wanted to remove the discoloration on her anterior maxillary tooth. This tooth has traumatic history 17 years ago. On radiographic examination showed incomplete root formation with wide open apices and root canal at the same tooth. Case management: Apexification with MTA was performed followed by thermoplasticized gutta percha obturation and internal bleaching procedure with walking bleach technique. The final restoration is composite resin restoration. Conclusion: MTA can be a valid option for apexification rather than calcium hydroxide and intrinsic discoloration due to traumatic injury can be treated with walking bleach technique. Key words: Apexification, MTA, trauma, discoloration, internal bleaching Korespondensi (correspondence) : Yusuf Bagus Pamungkas, Resident of Conservative, Faculty of Dentistry, Airlangga University. Jl. Mayjend Prof. Dr. Moestopo 47 Surabaya, Indonesia. INTRODUCTION Tooth Aesthetic is an important thing for patient, one of it is the tooth color. The discoloration especially on the anterior can raise an aesthetic problem which psychologically influences the patient‟s confidence. One of the main causes of the discoloration is trauma. Traumatic injury happens to immature teeth. It may disturb maturity process and stopping closure apex. If it happens, apexification is needed. Apexification is a procedure to trigger the formation of apical calcific barrier to close the opened apex on the immature teeth with non
vital pulp. Therefore, the filling material can fill the root canal. 1 One of the best apexification materials nowadays is mineral trioxide aggregate (MTA). The usage of MTA for apexification will shorten the treatment time and the result is more satisfying.2, 3 One way to solve the traumatic teeth which have the discoloration is by bleaching. Bleaching is a way to restore the color to match the natural color closely through the chemical process in order to restore the patient‟s aesthetic. To overcome the discoloration caused by pulp necrosis, bleaching intracoronal using walking bleach which happens in the pulp can be done. 4 this technique is chosen because it 293
needs less time, less cost, but gives more comfort and safety for the patient.5 The purpose of this case report is to view the closure of permanent incisor root apex using MTA and to inform the treatment result of bleaching internal treatment using walking bleach technique on the permanent anterior because of trauma. CASE REPORT 21 years old female patient, a private company employee went to the Dental Hospital Faculty of Dentistry Airlangga University. The patient wanted to remove the discoloration on her anterior maxillary tooth. She felt unconfident every time she smiled. This tooth has traumatic history 17 years ago when she was in elementary school. Once she fell and hit the wall; she didn‟t feel hurt but one of her anterior a little bit broken. She wanted her tooth to be treated so that its color the same as its surrounding teeth. (Picture 1). On the intraoral examination was seen blackish discoloration around the crown of tooth 11. Based on shade guide Vita 3D, tooth discoloration 5M 2 occurred on tooth 11. The occlusion examination shown normal occlusion with 2mm and overbite 2mm. The percussion and palpation were negative, there was no mobility, and the tissues around the tooth showed no abnormalities. According to vitality test, tooth 11 was non vital. There was no caries or fracture either on the crown or the root. On the dental periapical on tooth 11 was seen radiolucency and also unclosed the tip of apical (Picture 2). The clinical diagnosis for 11 tooth was discoloration which was caused by pulp necrosis and was accompanied by an open apex. Dental care plan for 11 in this case was root canal treatment and apexcification with MTA, after that internal bleaching treatment was performed using the walking bleach technique. For the final restoration was used composite resin restoration on the palate.
Picture 1. Clinical Features tooth 11 before the treatment.
Picture 2. Radiographic initial overview of tooth 11
THE CASE MANAGEMENT On the first visit, it was done subjective and objective examinations, intraoral clinical photos and radiographic photos to support the diagnosis and treatment plan. Then the patient was explained about the cause of the discoloration of the teeth, stage of treatments which would be carried out, the results which could be achieved, the possibility of rediscoloration and side effects which could occur, as well as the costs involved. After the patient understood and agreed on the treatment plan procedures, the patient was asked to sign a letter of medical consent (informed consent). The tooth which would be bleached, was photographed to record the initial state of the tooth. In clinical photos were seen blackish discoloration around the crown of the tooth 11. Then it matched with the Vita 3D shade guide, and it was obtained that the initial color of tooth 11 was 5M2 and the color of adjacent teeth was 1M1. The next step was the opening of the pulp chamber and disposal of the dental pulp chamber roof on tooth 11 using endo access bur to make the access cavity in the tooth. Then its 294
length was measured using an apex locator with file no 70. In the photo Diagnostic Wire Photo (DWP) was obtained the working length of tooth 11 = 20mm (Picture 3).
Picture 4. The overview of radiographic applications MTA on third apical of tooth 11
Picture 3. The Overview of Diagnostic radiographic Wire Photo (DWP)
The preparation of root canals on tooth 11 using k-file needle up to number 110 with a pull stroke technique. Each turn of the files was done the irrigation of 2.5% NaOCl and sterile aquades to remove necrotic tissue and dentin powder that was in the root canal using a syringe and irrigation needle 30G side vended. After the the root canal was dried with sterile paper points and dressing was done using Ca (OH) 2 with the brand Metapaste, then the cavity was given cotton and filled temporarily with Cavit. At the second visit (1 week after the first visit), the check up was done. At the check up, patient didn't have any complaints, temporary filling was still good, no exudate and blood in the root canal, and percussion was negative. Then, dressing materials Ca (OH) 2 was cleaned using irrigation materials 2.5% NaOCl until clean and dried by sterile paper point. To prevent the filling of root canal in the tip of apical was out, then the closure of the tip of apical was done with Mineral Trioxide Aggregate provision (MTA) brand ProRoot MTA (Dentsply) with the consistency of wet sand at a ratio of 1: 1 (mixed with sterile aquades). Application of MTA into the channel with the help of the plugger, with the thickness of MTA ± 2mm on apical of tooth 11. Then it was closed with sterile cotton which was moistened with sterile aquades and placed in the orifice of filled temporarily with Cavit. After that photo radiographic applications MTA on tooth 11 was taken (Picture 4).
On the third visit (2 weeks later), apical dental examination on tooth 11 to make sure the MTA had hardened. Then the remaining root canal was filled using gutta percha thermoplastis back-gill (VDW, Beefill 2 in 1, USA) with a resin sealer (Top Seal), then the cavity was given cotton and filled temporarily with Cavit. This was followed by radiographic photo to ensure that the root canal was filled perfectly and looks hermetic (Picture 5).
Picture 5. The radiographic overview of gutta-percha backfill obturation thermoplastis.
On the fourth visit, the root canal obturation post control was done and there were no complaints. Then, it was followed by internal bleaching procedures with the walking bleach technique. the next treatment step was the reduction of gutta-percha on tooth 11 along 2mm under servical tooth then it was closed with a GIC at least 2mm above the gutta percha to prevent penetration of the bleaching material to the apical or out to the CEJ because it could lead to external resorption. After that entered the Opalescence Endo bleaching ingredient (Hydrogen Peroxide 35%), and then pressed toward ding = ding labial and closed cavity with GIC (Picture 6). The maximum bleaching effect was obtained approximately 24 hours after treatment, then the patient was instructed to return after 3-7 days to evaluate the results. 295
Picture 7. post-treatment of internal bleaching control (2 months)
DISCUSSION
Picture 6. application Opalescence Endo
of
bleaching
materials
After giving endo opalescence 35% hydrogen peroxide for 4 times (for 4 weeks), it was obtained the tooth color which matched with the teeth next to it; that was based on the Vita 3D shade guide color 1M1. Then the bleaching material was taken, the pulp chamber was cleaned and irrigated with saline then cavity on the palate was prepared for a permanent restoration. After that, the 35% phosphoric etching asthma (3M, ESPE) on the tooth cavity 11 for 15 seconds was given. Then it was rinsed, applied bonding material (XP Bond) and irradiated for 20 seconds. For the final restoration on tooth 11, composite resin restorations (3M Z350XT) was used because Then it was rinsed, applied bonding material (XP Bond) and irradiated for 20 seconds. For the final restoration on tooth 11, composite resin restorations (3M Z350XT) was used because after root canal treatment, the rest of tooth tissues was still quite a lot of , then resin composite irradiated for 20 seconds.Next, the finishing and polishing were done. On the next visit, after 2 months, post-treatment for control of internal bleaching was administered. On the subjective examination, was obtained the results that no complaints from the patient and she was very satisfied with the treatment results. While the objective examination was obtained that the color of tooth 11 did not change and matched the color of the 3D Vita shade guide 1M1. Composite filling was in good condition and gingiva around the tooth was normal (Picture 7).
Trauma or injury collision could cause discoloration on one or several teeth that could lead to the breaking down of the blood vessels in the tooth crown, bleeding as well as the lysis of erythrocytes. Iron product in hemoglobin joined with hydrogen sulfide which was a product of the bacteria to form iron sulfide, entered into the tubules and colored the dentin. When a tooth became necrotic, the discoloration would be more severe.6 Bleaching or tooth whitening was a way to return the tooth color change, until it was closed to the color of natural teeth through the chemical process. Bleaching could be done on vital or non-vital teeth which was discolored. Discoloration of teeth due to trauma or necrosis could be belached with 95% success rate compared to the effect of the use of drugs or restoration.7 Intrakorona Bleaching was done by walking technique bleach.4 This techniques was chosen because visiting time was shorter, more efficient, more comfortable and safer for patient.5 Mechanism of peroxide bleach and nonperoxide was by entering through the intermediary of the enamel to the dentin tubules and oxidized the pigment in dentin, causing the color of the teeth become whiter. The process of teeth whitening was done based on the mechanism of the oxidation reaction. The stains found on enamel and dentine would be oxidized by the teeth whitening gel (hydrogen peroxide) which acted as a strong oxidator. This oxidator material had the ability to damage the color molecules, through its reaction with free oxygen which was released. This situation made the color became neutral and cause the bleaching effects.8 From the results of the vitality of the tooth 11 showed that non-vital tooth that need root canal treatment was carried out beforehand. In this case, it appeared that radiographic of the apical tio which was wide open so that it was necessary apexification used Mineral Trioxide Aggregate (MTA) to prevent overfilling of obturation material. Teeth with open apex could 296
be caused by trauma, caries or other pulp diseases. The absence of a natural constriction at the apical tip would make it difficult to control the obturation material, where the purpose of filling root canals on tooth with open apex was closing the channel which was big enough between the root canal system and periradicular tissues. this would provide a barrier so that the obturation material could be solidified.9 After obturation, obturation materials was reduced to the depth of 2 mm to apical direction of the orifice then on it was given the base by using GIC as thick as 2 mm to prevent leakage of bleaching material to the periodontium. it also minimized the inflammation in the periodontium tissue and prevented the occurrence of cervical external resorption. 5.10 In this case, opalescence 35% hydrogen peroxide endo was used because the gel was indicated for teeth which had discoloration, its easy application and its longer contact time with the tooth tissue which was longer so that the effects of bleaching teeth was better. In addition, the effectiveness of this material could be seen only in one visit because this material diffused into the enamel and dentin tubules due to its small molecular weight, ie 30g / mol.7,11,12 On the anterior teeth which had pulp necrosis due to intrinsic discoloration, walking bleach method using 35% hydrogen peroxide gel gave satisfactory results due to its easy application and shorter time of visit as well as safety and comfort for the patient. Buttke said that 2 of 3 patient with internal bleaching treatment, having stable color for nearly 16 years and without any internal or eksternal resorption .13 CONCLUSION Based on the above discussion it coud be concluded that root canal treatment followed by apexification on the tooth with open apical and internal bleaching using walking bleach method in the case of intrinsic discoloration due to pulp necrosis could give good results for patient satisfaction in terms of aesthetic. Prognosis in this case was good because the patient was cooperative and the tooth condition was possible to be treated.
REFERENCES 1. Rafter M. Apexification: a review. Dentsl Traumatology 2005; 21 : 1-8 2. Maroto M, Barberia E, Planells P, Vera V. Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA). Dental Traumatology 2003; 19: 165-9 3. El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatric Dentistry 2006; 28: 248-53 4. Greenwall L. Bleaching techniques in restorative dentistry. New York: MartinDunitz Ltd; 2002. 5. Retnowati E. Perawatan walking bleach pada gigi incisivus sentralis kiri maksila disklorasi intrinsik akibat nekrosis pulpa. Maj Ked gigi Juni 2009; 16(1): 91. 6. Abbott P, Heah SY. Internal bleaching of teeth: an analysis of 255 teeth. Australia Dental journal 2009; 54: 326-33. 7. Deliperi S. Clinical evaluation of non-vital tooth whitening and composite resin restorations: Five-year results. The European J of Esthetic Dentistry 2008; 3: 14-25 8. Tarigan R. Perawatan pulpa gigi (Endodonti). Cetakan I. Jakarta: Widya MEdika; 1994. 9. Fellippe WT, Felippe MC, Rocha MJ. The effect of MTA on the apexification and periapical healing of teeth with incomplete root formation. Int End J 2006; 39: 2-9. 10. Plotino G, Buono L, Grande NM, Pameijer CH, Somma F. Non vital tooth bleaching: A review of the literature and clinical procedures. JOE 2008; 34Z(4): 394-407. 11. Dietschi D. Non vital bleaching: General considerations and report of two failure cases. The European J of Esthetic Dentistry 2006; 1 : 52-61. 12. Brosur produk Opalescence Endo, Ultradent product,inc. 13. Buttke TM. Internal bleaching of non vital teeth. Int Journal of Endodontics 2009; 32: 376-78.
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Internal Bleaching Treatment For the Patient With Traumatic History a Case Report Irwan Lazuardi*. Ira Widjiastuti; Eric Priyo Prasetyo * Resident of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Introduction : Internal bleaching is one treatment that aims to improve the color of the non-vital teeth. Common causes of tooth discoloration is due to trauma which causes the tooth has changes in circulation after the death of pulp tissue. Purpose : Explaining the internal bleaching treatment in patients with a history of trauma. Case Report : 23 years old female patient came to the clinic PPDGS RSGMP Conservative Dentistry of Airlangga University with a complaint her right anterior discolored and sore. Patient experienced a trauma when she was a teenager and she had never done a root canal treatment on her teeth. One of her anterior tooth had begun to change its color since two years ago and for the last one month it had been hurt. On the clinical features seem composite filling on palatal tooth 11 and discoloration. On the radiological description, it was seen that tooth 11 had experienced the root canal treatment but the preparation and filling did not reach the working length should be.Treatment : Re root canal treatment first was done on 11 teeth which was sore and discolored, then internal bleaching treatment to restore the color of teeth was performed.Conclusion : Internal bleaching treatment could restore the aesthetics on non-vital teeth which experienced discolored because of trauma. Keyword : Traumatic history, root canal treatment, Bleaching Internal Discoloration of the teeth is one of aesthetic problems that encourages patients to find improvement to solve it. Although the restoration methods to mitigate it have been available, whitening procedures is clearly more conservative, simpler and cheaper.1 The tooth whitening procedure known as dental bleaching is divided into two according to the procedure of applications namely internal and external bleaching procedures.2 The goal of treatment is to improve the color on the non-vital teeth. The most common causes of discoloration is the trauma on the tooth. (2d) Grossman correlates this discoloration with iron sulfide where the red blood cells can undergo hemolysis and release hemoglobin which reacts with hydrogen sulfide, a metabolic by product of bacteria, to form iron sulfide. It causes the gray staining of the tooth.4 The indication of internal bleaching treatment is discoloration is from the dentin because there is change in circulation from the
pulp chamber and it cannot be overcome by external bleaching .5 While the contraindications of internal bleaching is the discoloration occurs on the superficial enamel, discoloration due to imperfect formation of enamel, loss of tooth tissue which is severe enough, discoloration of teeth due to caries and discoloration of composite.5 Non-vital teeth first must be treated using root canal (endodontic treatment) first, then bleaching treatment can be done. The materials commonly used in bleaching are superoksol (30-35% hydrogen peroxide) and sodium perborate. The dentist will incorporate this bleaching material into the crown, then it will be covered by temporary fillings. There are several kinds of bleaching techniques in internal bleaching procedures. The techniques which are frequently used are walkin and termokatalitik bleaching. 6.7 Termokatalitik technique is the technique of separation by putting the oxidator material in the pulp chamber and heat it. This 298
heat is obtained from lamps, heated tool, or electric heater which is specifically made for tooth bleaching. The disadvantage of this technique is the external resorption of the roots in the cervical region because of irritation of the cementum and periodontal ligament. Irritation may be derived from oxidator materials combined with the heat. Therefore, the application of heat during this bleaching should be limited.6.7 The next technique is the walking bleach technique. This technique aims to restore the tooth color by putting bleaching material to the pulp chamber in which previously the tooth had been undergone the root canal treatment; its gutta percha had been discharged to the extent below the gingival margin. Then, the horns of the pulp is cleaned with a round bur. A protective cement base was placed on gutta percha and it does not go beyond the gingival margin. It aims to protect the roots of the bleaching material.6.7 Application of etching with phosphoric acid needs to be done before the application of bleaching materials with the aim to form porosity which facilitate the entry of bleaching matetial to the dentin. A periodic control was carried out until the desired color was gotten. 8 Periodical control was performed at least 1 week if the color change is not too large, then the time control can be carried out more frequently as needed. the common restoration after internal bleaching procedure is composite filling. 8
so that its color was darker than the adjacent teeth. (Figure 1) After checking by vita 3d shade guide, the tooth had 4R 2.5 and the next tooth was 2M 1 color. The neighbor teeth became the standard of the target color to be achieved. She also complained that her tooth frequently got aches and painful when it used to eat and drink cold beverage. On percussion and pressure examinations, she felt pain. The tooth mobility was negative and there was no fistula or swelling on the tooth. On the X-ray images, it was known that the teeth 11 and 12 had been treated endodontically. However, the endodontic treatment on tooth 11 was less than perfect where the preparation and filling were under the working length should be. (Figure 2) On the patient first visit, the demolition of composite filling using a round bur on the lingual tooth 11 was done. Then, the opening access using the endo access bur was performed to navigate the orifice. For the preparation of root canal, the file used was file for root canal retreatment namely rotary proTaper retreatment file D1, D2 and D3 of densply.
Case Report
Figure 1: The discoloration of tooth 11was seen on the clinical feature.
23 years old female patient, came to the clinic PPDGS RSGMP Conservative Dentistry of Airlangga University with complaint that her right anterior tooth color had changed since one year ago. She had suffered traumatic injury on her tooth because of motorcycle accident when she was a teenager. Dental root canal treatment had been performed. However, since one year ago the patient was aware that her tooth became darker. The patient was embarrassed by her appearance and wanted her tooth to be treated. The general condition of the patient was she experienced a discoloration of on her tooth
Figure 2: On the X-ray of tooth 11 was obtained that the filling of root canal was under filling
During the procedure, the cavity preparation was irrigated by 2% NaOCl, and 299
rinsed by sterile aquades water and dried by cotton pellets. The determination of the working length using a K-file # 25 and the apex locater; it was obtained that root canal working length was 23.5 mm and it was confirmed by x-rays. The next procedure was done using D1 retreatment file with the half (1/2) of the working length or 11.5 mm and then D2 file with two third (2/3) of working length or the 17 mm. Then D3 file was prepared in accordance with the working length that was 23.5 mm. Irrigation was being done during the procedure of root canal preparation using NaOCl and sterile aquades water. Then the preparation was continued using F4 file using ProTaper rotary files and lubricant EDTA. Next, the preparation was continued until it reached the desired working length. After that, the trial photo of gutta-percha was done and it was obtained that the gutta-percha was hermetic in the root canal. On the next step, the dressing was applied to the tooth using calcium hydroxide paste (Metapaste) and filled temporarily. Patient was instructed to return for control a week later On the second visit, one week later, the patient didn't feel pain and the ache in the tooth didn't recur. Moreover, the patient never consumed analgesic anymore. the condition of temporary filling was good, the surrounding tissues were also good, percussion test was negative, and the mobility test was negative. Then temporary filling was opened, dressing material was cleaned by irrigatig sterile NaOCl 2% and rinsed by sterile aquades. Next, the root canal was dried by sterile paper point. The root canal filling with single cone technique using gutta-percha point F4 corresponding to the size of the last file was done. Then, it was added sealer top seal densply, gutta percha was cut as long as the orifice using excavator which was heated and condensed by plugger. After that, it was filled temporarily and was taken picture of the root canal filling. (Figure 3)
Figure 3: X-rays of root canal filling. On the third visit, patient did not feel any pain on her tooth. Then the gutta percha was taken as long as 2 mm from the gingival margin and then x-ray photo was carried out for the confirmation. The checking was done by plugger that was measured from the crown length plus 2mm. Then over the gutta-percha was closed using GIC with the thickness 2 mm or as long as the gingival margin The next stage was the application of bleaching materials superoksol (30-35% hydrogen peroxide) in the pulp chamber where previously in the pulp chamber had been applied etching for 20 seconds. Then the rinsing and drying with sterile cotton pellets were done. Bleaching material was applied sufficiently to the pulp chamber then it was covered with cotton and the cavity was covered with GIC Fuji 9 to prevent the bleaching material out . Patient was instructed to control 1 week later. in the control, it was obtained that the GIC filling was still good and the patient had no complaint such as ache and pain on the tooth. from the aesthetic point of view, the patient's tooth color had reached satisfactory aesthetic result. (Figure 4)
Figure 4: The tooth condition after 1 week control The patient's tooth underwent a color change from 4R 2.5 to 2 M 1 when it was 300
viewed using the comparison of vita lumunar 3d (Figure 5). Aesthetically, she felt satisfied with the treatment result.
Figure 5: Clinical description of the teeth before and after bleaching treatment After the patient agreed with the result obtained, then the GIC filling on lingual tooth was discharged and then the composite filling procedure with 3M was done. After the composite filling procedure, occlusion check using articulating paper was carried out. Then, the reduction was done using the fine finishing bur. After that, it was polished using astropol rubber to get the maximum aesthetic result. Discussion Discoloration of teeth is one of aesthetic problems which are frequently complained by patients. Tooth discoloration usually involves one or more teeth. The discoloration of the teeth can happen due to intrinsic and extrinsic factors.8 The trauma on one or more teeth causes capillaries in the pulp chamber rupture, causing bleeding intra pulp. the blood or blood components which is flooding the pulp chamber will go into the dentinal tubules by diffusion, then the red blood cells undergo a hemolysis process by releasing the hemoglobin. Hemoglobin will undergo a process of degeneration and release iron components. the iron components will react with hydrogen sulfide, a product of the bacteria, which produce sulfuric feric compound whose color is black. This compound then penetrates into the dentinal tubules, causing discoloration on the tooth crown. The discoloration is associated with how
long the pulp has become necrotic, the longer the colored compounds are in the pulp chamber, the greater the degree of the discoloration.789 In this case the patient was given internal bleaching treatment using walking bleaching technique. This technique was chosen because it required shorter treatment time, more convenient more economical and safe for patient. Walking bleach was a technique which insert an oxidizing material into the pulp chamber. It was given repeatedly for 3- 7 days until obtained the desired results.8,9 Bleaching process was based on oxidation-reduction reactions. On the redox reaction, oxidizing agent would release free radicals that do not have pair of electrons. These electrons would bind to organic molecules to achieve stability, the districts which had double bonds would be disconnected into simpler bond which gave a lighter color. 10,11 The use of ionomer glass with the thickness 2 mm could prevent the penetration of hydrogen peroxide into the root canal and it also could serve as a basis for the final restoration after the treatment finished. The selection of ionomer glass cement as a cervical seal because it had adhesive properties which could chemically bind to dentin so it could prevent the coronal leakage. it was also biocompatibility, anticaries, compressive strength which was similar to dentin and easy to use.3,6,7 In this case, 35% hydrogen peroxide opalescence gel endo was used because it was indicated for post-treatment dental endodontic which experienced discoloration. The easy application and the contact time of the dental tissues may take longer so that the effects of bleaching could be better. Moreover, gel dosage form was insoluble and it did not easily penetrate like liquid form.12 Conclusion In the case above, discoloration of the tooth due to intrinsic factor that was trauma. Therefore, the treatment which was carried out was internal bleaching using walking bleaching. This technique was chosen because the operator could control periodically the result of the treatment. Moreover, the applied technique of walking bleach is simpler. 10 301
Before doing the bleaching treatment, the operator must know the cause of discoloration because it decides the result of the treatment. The routine control must be done to evaluate the radiology and clinically after the internal bleaching treatment. 11
intraprifice barriers adn root filling material. Med oral patol oral cir bucal 2012jul 1;17(4):e710-5
REFERENCES 1.
Rotstein I,Walton RE. Bleching discolored teet; Internal and exernal. In: Walton RE, Torabinejab M, eds. Principple and practice of endodontics; 4 th. Philadelpi:W saunders Compny; 2009.p.31 2. Walton RE,Rotstein I. Pemutihan kembali (Bleaching) Gigi berubah warna: internal dan external. Dalam Wlton RE, Torabinejad M,eds. Eds.Prinsip dan praktek ilmu endodonsi.Ediai kedua. Jakarta;EGC;p. 510-11. 3. Grag N,Grag A.Textbook of endodontics 2nd ed. New Delhi: jaypee Brother Medical Publisher;2007.p.8-56 4. Grossman LI,Oliet S,Del Rio C. Ilmu endodontik dalam prktek.Ed.ke-11.Rafiah A (penerjemah).Jakarta: EGC:1995. 5. Grenwall L. Single vital tooth whitening. Vol 10.London : International Dentistry SA;2008.p49-50 6. Brenna F. Restorative dentistry.St.Louis:Elsvier Mosby;2009.p.251-73 7. Walton RE, Torabinejad M. Prinsip & praktik ilmu endodonsia. Ed.3.Jakarta:EGC;2003.p.453-63. 8. Plotino G,Buono L,Grande NM.Nonvital tooth bleaching: A review of the lierature and clinical procdures. Journal of endodontics 2008 april ;34(4): 394-404. 9. Sulieman MAM .An overview of toothbleaching tchniques: chemistry,safty and efficacy. Periodontology 2008; 48:148-69 10. Goldstein RE. Esthetics in dentistry 2nd ed.Hamilton:BC.decker inc;1998.p.254-74 11. Ascheim KW,Dal BG. Esthetics dentitry: a clinical appoach to techniques and material 2nd ed.St.louis:Mosby;2001.p.255-63 12. Canoglu E,Guldahi K. Sahin C,Altundasar E, Cehreli ZC. Effect of bleaching agents on sealing properties of different 302
Root canal retreatment challenge of abscess periapical in maxillary central incisors by aesthetic approach Aditya Syahputra*, Dian Agustin Wahjuningrum **, Ira Widjiastuti ** *Resident Student of Conservative Dentistry **Staff at Department of conservative Dentistry Faculty of Dentistry. University of Airlangga
ABSTRACT Background Endodontic retreatment commonly correlated with the failure in initial endodontic therapy. Many factors causes failures in endodontic therapy, these include incomplete cleaning and shaping root canal and inadequate obturation. If the obturation of the root canal under filled, the root canal system could have become re-infected. Purpose of this case report is to present the challenge of a root canal retreatment of maxillary central incisors with periapical abscess. Case management A male, 23 years old patient came with the problem of discomfort feeling associated tooth 11 and 21. Patient felt pain of his tooth and tooth was tenderness to percussion, but palpation and mobility were normal. Patient also reported a history of previous endodontic therapy approximately 1 year ago. The clinical examination showed there was a restoration acrylic crown on tooth 11 and 21. Radiological examination showed the root canal under filled with radiolucency in the periapical area. Root canal retreatment that followed by the post fiber and zirconia crown as the final restoration. Conclusion Root canal re-treatment can be successful through complete re-cleaning and re-shaping the canal. The result of the root canal retreatment is favorable and the patient feels comfortable. Key words : Root canal retreatment, under filling, aesthetic approach INTRODUCTION Most of the root canal treatment failures are caused by the diagnose mistake, case selection, and the treatment procedures. 1 These three steps are related each other; the mistake on one step can cause failure. However, this failure can be handled by retreatment, apex surgery, or pull out the tooth.1,2 In some countries including in United States, the periodontal abnormalities such as chronic apical and apical abscess are found on more than 30% teeth which have been experienced the root canal treatment. The abnormality found is mainly caused by the infection on the root canal system. The infection happens because there are microorganisms which are persistent or enter the obturated root canal because of restoration leakage. Therefore, it can be concluded that the success of the root canal treatment depends on the quality of the root canal obturation and the final restoration. Persistent Microorganism is the main
cause of infection on the post root canal treatment. On the root canal treatment which is under filled, the part of unprepared root canal can be suitable place for microorganism to multiply. Some species of microorganism can survive in the bad environment with the lack of nutrition.3. Some species such as Streptococci, Lactobacilli, Actinomyces Sp., Peptostreptococci has ability to multiply with or without oxygen and they can survive in the environment with extreme alkali acidity. 3. This case report will discuss about conventional endodontic retreatment on maxillary central incisors with periapical lession because of underfilling obturation and inadequate restoration CASE REPORT A twenty three year old male patient came to the PPDGS Clinic RSGMP dental conservation of Airlangga University with a 303
problem his two incisors ere frequently painful while eating and getting pressure. He also complained his crown was yellowish and he was not esthetically satisfied. On the thorough anamnesis was found that the patient had endodontic treatment on his incisors 1, 5 year ago. Moreover, he told that he got root canal treatment and crowned by the previous dentist. However, one year later his incisors were painful every time he ate. The patient also complained that his gum was frequently abscess. He wanted his two incisors got retreatment. (Picture 1) On the subjective examination, it was found percussion on the 21st and 12th teeth. However, the tooth palpation and mobility were normal. Visually, there was redness on the 11th tooth and the patient felt discomfort when it pressed too hard. The acrylic crown on the patient‘s tooth had been yellowish and uncover on the cervical lingual. (Picture 2)
Picture 3: X-ray picture of 11th and 21th teeth Clinical diagnose of 21st and 12th teeth were pulp necrosis with endodontic post treatment periapical lesion. The Prognosis was good because of the patient‘s oral hygiene is good. Moreover, the patient was really cooperative and he didn‘t have systemic abnormality. THE CASE MANAGEMENT THE FIRST VISIT
Picture 1: the clinical view of the 11th and 12th teeth, seen from Labial.
On the first visit, the acrylic crown was holed on the palatal side, then lining cement was also opened using ultrasonic tip until the gutta percha exposed. The tip of seen gutta percha was tendered by DMS IV and waited for a while. The gutta percha was thrown away using certain rotary instrument for retreatment (Protaper, Densply), based on its sequence, that was DX, then continued by D1. For D2 and D3 files were not used because the obturation only one third of root.
Picture 2: the clinical view of the 11th and 12th teeth, seen from Palatal. On the radiology examination was seen that the root canal was under filled with clear bordered radiolucency in the periapical area
Picture 3: Opening Acces of 11th and 22nd teeth
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After the gutta percha was removed from the root, the next step was radiology confirmation to see whether there was remain of the gutta percha. The next step was re-preparation on the root canal conventionally. Begin with the measurement of the length working using apex locator (Raypex 6, VDW). It was got the length working 21 mm and it was confirmed by radiology. After that the preparation of root canal was done using file rotary instrument reciprocal file R50 with lubricant (MD ChelCream) and irrigation used NaOCl 2,5% and sterile aquades.
Picture 4: X-Ray of obturation THE THIRD VISIT
After the irrigation was dried using sterile paper point, the root canal obturated by a syringe using calcium hydroxide as dressing material ( metapaste ). After that, the teeth were temporarily filled. The patient was asked to return a week later. THE SECOND VISIT On the second visit, a week later, the patient didn‘t feel hurt. The temporary filling was good and the cotton pellet was still clean; there was no exudates percussion and the pressure was negative. Moreover, there was no fistula on the soft tissues. Then the teeth were irrigated using NaOCL 2,5 % and sterile aquades. After that, the root canal was cleaned for the filling preparation. The picture trial was done using gutta percha R50 before the obturation step was done. Then, the result was confirmed by radiology. The working length which was suitable with the root canal was gotten. Then it was dried and isolated as the first step of obturation. The obturation using lateral condensation with master cone gutta percha R50 and 2 gutta percha no 25 ( red) using calcium hydroxide sealer ( top seal, Densply ). After that the cavity was temporarily filled before the radiology examination was done. On the radiology examination was seen hermetic filling. Patient instructed to return one week later.
On the third visit, the root canal check up was done. There was no complaint from the patient so the pin preparation could be fitted. The prefabricated pin ( Fiber post, Densply ). was used, then gutta percha was thrown away according to the length of pin using Gidden Drill ( Maillefer, Densply ). Then preparation was done using peso reamer ( Maillefer, Densply ), continued by precision drill for pin fiber. After that, the dressing trial was done and continued by the radiology confirmation to know whether the length of the pin was suitable or not. After the suitable length of the pin was gotten, the resin cement was put. After that, core built up to form the pin core using multi core. The fiber cutting was done after the core making using diamond bur was finished
Picture 5 : insertion of post fiber pin on the 21st and 12th teeth. Then the formation of pin core based on the crown jacket preparation. The Insisal was lessening using wheel diamond bur with the height 2/3 of the clinical crown. The axial then was rounded using long fissure flat end to get 305
shoulder finishing on the cervical line. Afterward it was furnished using fine finishing to avoid undercut. Next, the teeth was dried using cotton pellet and the teeth retraction using retraction thread on sulcus gingival teeth 21 and 12 before molded using elastomeric. After the teeth were ready, the molding was done using the half jaw molding spoon with double impression technique. Antagonist teeth were molded using alginate. Then, the biting decision using two pieces of dental waxes which had been heated before was done. Previously, the patient had been instructed to bite based on normal occlusion. Then, the color calibration was done. The patient involved in taking the decision in this step.
A
B Picture 10 the zirconian crown before it was fitted on patient, A. labial view B. Palatal view Then the patient were asked whether the crown was suitable with what he wanted, in term of color and the form. After the patient agreed, the crown was fixed using resin cement. He was asked for check up one week later (Picture 13).
Picture 9: The process of color choice. After that, the temporary crown was fitted using luthing cement (Picture 10). The tooth besides it was casted using red gips and then planted on the oxcludator before sending for making the zirconian crown.
Picture 11 the fitting of Zirconian Crown on the 21st and 12th teeth
THE FOURTH VISIT On the fourth visit, the dressing trial of the zirconian crown was done (picture 12 ). The occlusion check up using articulating paper was held to know whether there was premature contact or not. The tooth anatomy and the color were adjusted. Then, the cervical area was checked up to see whether there was opened part or not. Picture 12 X-ray picture after 1 year evaluation
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THE FIFTH VISIT A follow up evaluation was done a week after the fitting of zirconian crown. Based on anamnesis, the patient felt satisfied with the crown and he didn‘t complain about aesthetic or subjective. On the clinical examination, gingival area was normal, the color was stabile, and there were not occlusion contact and the tooth mobility. DISCUSSION In this case report, the patient complained about his painful teeth and the bad aesthetic after the root canal treatment. Therefore, the treatment for this case was retreatment the root canal on the 11th and 12th teeth and restoration using zirconian crown. The root canal treatment failures in this case because the underfilling oburation. It was proven by the radiography picture; there were the teeth which were under filed so that the unfulfilled root canal became the breeding place of the persistent microorganism. It made the patient complained subjectively. Besides, the patient felt not satisfied with the existing restoration because the previous restoration used acrylic whose color easily changed. Moreover, there was cervical adaptation which was not strong enough on the lingual so that it was supposed to be the cause of the entrance of microorganism or bacteria on the root canal. Retreatment on this root canal purposed to vanish the number of microorganisms and inadequate of the previous root canal filling material. With an appropriate conventional retreatment was hoped could fix the failures on the previous treatment. The main principle was reshaping and recleaning the root canal and filling which was hermetic based on the working length and the strong restoration.1. The pin was fitted on the 21st and 11th teeth after the endodontic retreatment was done. This step was done to give additional retention on the teeth after the endodontic treatment. 3. The main purpose of the restoration on the teeth which were got endodontic treatment
was to return the function and aesthetic. Moreover, it divided the chew burden so that both the teeth and the crown jacket could stay longer on the mouth cavity. The teeth which had got endodontic treatment were likely to snap and easily broken than the healthy teeth. It was because of the organic and biology processes, the death of the pulp and the weak joining dentin emailbecause of the root canal preparation. 4.5. After endodontic retreatment zirconia crown was chosen because it was better in term of the aesthetic than the porcelain. The Zirconia crown has better in color, anatomical, and at the same time it looked more natural, considering the teeth in this case were anterior which needed beautiful aesthetic. CONCLUSION From the case above, could be concluded that the patient felt satisfied with the result of the treatment given. There was no following complain both esthetically, subjectively, or functionally. REFERENCES 1. Friedman S. Orthograde Retreatment. Dalam: Walton RE, Torabinejad M (ed). 2. Principles and Practice of Endodontics 3rd ed, Philadelphia: WB Saunders. 2002: 346-356. 3. Dumsha TC, Gutmann JL; Clinician’s Endodontic Handbook.2000 .LexiComp.Ohio.P 140-3, 213-9. 4. Asgeir Sugurdsson.Evaluation of Success and Failure.Dalam: Walton RE,Torabinejad M (ed).Principles and Practice of Endodontics 3rd, Philadelphia:WB Saunders.2002:331344. 5. Healing I,Gorfil C,et al:Endodontic Failure caused by inadequate restorative procedure: Review and treatment recommendations.J Prosthet Dent 2002:87:674- 8. 6. Gutmann JL, Dumsha TC; Problem Solving in Endodontic.Ed 3th.1997.Mosby ST Louis .p 5-8.
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ENDODONTIC RE-TREATMENT ON RIGHT MAXILLARY INCISIVE CENTRAL TOOTH USING RECIPROC SYSTEM Oktari Paramita 1, Mandojo Rukmo 2, Edhie Arief Prasetyo3 1 Resident of Departement of Conservative Dentistry 2 Lecturer of Postgraduate Program of Conservative Dentistry 3 Lecturer of Postgraduate Program of Conservative Dentistry
ABSTRACT Endodontic retreatment commonly correlated with the failure in previous endodontic therapy. Important factors that could be related with this condition were the quality of the root canal fillings and the coronal restoration. If the obturation of the root canal under filled, the root canal system may not have been effectively cleaned and shaped or could have become reinfected. Endodontic retreatment was purposed to restore this condition with its ability to eliminate the infection. The aim of this case report was to describe the endodontic retreatment on the upper central right incisor using reciproc system. Case report: A female, 46 years old patien came with the problem of discomfort feeling and there is a discolored tooth 11. She also reported history of previous endodontic therapy approximately 4 years ago. The clinical examination showed there was a discolored tooth , percussion test showes a positive reaction, palpation test negative and no mobility. Radiological examination showed the root canal under filled. Case management: endodontic retreatment using reciproc system followed by the fiber post and porcelain fused to metal as the fnal restoration. Conclusion: endodontic retratment can make a good result on case failure initial endodontic therapy caused under filled and unadequate restoration. Keywords: endodontic retreatment, underfilling, reciproc system, fiber post Correspondes : Oktari Paramita, Resident of Conservative Faculty of Dentistry, Airlangga University. Jl. Mayjend. Prof. Dr. Moestopo 47 Surabaya 60132, Indonesia. Introduction Endodotic treatment is needed when pulpal tissue become infected and inflamed through various ways such as caries or trauma, making the pulpal tissue necrotic. The main goal of endodontic treatment is the correct diagnosis, optimal mechanical and chemical preparation and three-dimensional obturation of the root canal. Traditional endodontic treatment aims to eliminate bacteria from root canal system and establish effective barriers againts root recontamination. To achieve success, cleaning, shaping and filling of the entire root canal system are considered essential steps in endodontic therapy.1 Failure factors in root canal conventional treatment are frequently related to presence of residual bacteria (persistent infection) or reinfection in a previously
disinfected canal (secondary infection). Root canal treatment usually fails when treatment falls short of acceptable standarts. The reason many teeth do not respond to root canal tratment is because of procedural errors that prevent the control and prevention of intracanal endodontic infection. The major factors associated with endodontic failure are the persistens of microbial infection in the root canal system and/or the periradicular area. The clinician is often misled by the notion that procedural errors, such as broken instrument, perforations, overfilling, underfilling, ledges and so on are the direct cause endodontic failure.2 Endodontic therapy has reached high success rates thanks to the development of equipment and instrumentation techniques that allow professionals to solve a large number of clinical cases in a shorter period of time. A new concept was introduced for root canal biomechanichal preparation using only one 308
motor-driven NiTi instrument, with no previous instrumentation. The new single file system with reciprocating motion includes three instruments called Reciproc ( R25, R40 and R50). These files are made of M-wire NiTi alloy that offers greater flexibility and greater resistance to cyclic fatigue than traditional NiTi system. The main advantage is that the working time is four times faster than the traditional NiTi systems 3. The reciprocating movement aims to minimize the risk of instrument fracture caused by torsional stress as the angle of counterclockwise rotation (cutting direction) was designed to be smaller than the elastic limit of the instrument. Case report A female patient, 46 years old came to dental clinic University of Airlangga complaining of discomfort feeling and discoloured tooth on maxillary incisivus. The patient did not have any systemic disease and were not under any type of medication or drugs. Intraoral examination showed discoloured tooth, percussion test showes a positive reaction, palpation test negative and no mobility. Radiological examination showed the root canal under filled. The previous endodontic treatment was 4 years ago. The tooth diagnosed was pulp necrosis. Treatment planning for this situation was retreatment endodontic, fiber post and crown porcelain.
Figure 2 At the first visit, the opening access to the root canal orifice used endoaccess diamond bur. The gutta percha were removed from root canal. the cavity was irrigated by NaOCl 2% , rinsed by aquades and dried by cotton pellet. The determination of the working length used Kfile #15 and apex locaater. The working length was confirmed by x-ray. (figure3)
Figure 3
Figure 1
Afterward the preparation of the root canal by using blance force techniques used reciproc files. On the preparation process used EDTA lubricant, canal irrigation used NaOCl 2% and rinsed by aquades. After the preparation reach the working length, the trial gutta percha photography is done, and the result was hermetic guttapercha in the root canal. After that the tooth was dressed used calcium hydroxide paste and temporarily filled. The patient was asked to return next week
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Figure 4 The second visit, a week later, the patient still feel pain. The temporary filling was opened, the dresing substance was cleaned by irrigating with NaOCl 2% and rinsed by using sterile aquaes. Then the root canal was dried by sterile paper point and then dressed using cresophen and temporary filling. The third appoinment, the patient did not have any complain. The temporary filling condition was good, percussion test wa also negative. Then the temporary filling were removed, the root canal cleaned by irrigating NaOCl 2% and rinsed by sterile aquades. Then the root canal was dried by sterile paper point. The filling of root canal was done with the single cone technique using guttapercha point which has appropriate file size. Sealer was added and gutta percha was cutalong orifice using excavator which was heated and condensed by plugger. Then the root canal was filled temporarily and take the x-ray photo. (fig. 5)
The fourth visit, there was no tenderness on percussion and palpation. Next step was fixing of post fiber pin, calibrating the pin size with the template, picking up gutta percha with penetration drill and calibrating the root canal calibration drill. After that, the pin cut in trial (fig. 6), core built up, gingival management and crown preparation (fig.7). The die used elastomers material with double impression technique and antagonist mould used irreversible hydrocolloid. Next step was masking the dental record, calibrating color (fig.8), and fixing temporary crown on prepared tooth. The patient demanded to check up one week later.
Figure 6
Figure 7
Figure 8 The fifth visit, ceramic crown was fixed and trial, articulation was examined, anatomy and the color was calibrated. Ceramic crown was inserted using resin cement (fig.9) Figure 5
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Conclusion
Figure 9 Discussion Endodontic retreatment was needed in this case because there was reinfected pulp. The previous endodontic treatment was failed because there is incomplete obturation (underfilled). There is an exudate when the gutta percha removed from the canal. Bacterial, mechanical, or chemical irritation to the pulp may result in tissue necrosis and release of disintegration by products that may penetrate tubules and discolor the surrounding dentin. To achieve success, cleaning, shaping and filling of the entire root canal system are considered essential steps in endodontic therapy. Reciproc showed the best results concerning smear layer removal, and obtaining the same results for debris elimination 5. Reciproc was also able to maintain the original shape of the apical third of the root canal. The irrigant used in this case was NaOCl 2%. It is an antiseptic and inexpensive lubricant and also most commonly used root canal irrigant. Free chlorine in NaOCl dissolves vital and necrotic tissue by breaking down protein into amino acids. It has also bactericidal effect. Advantages of NaOCl include its ability to dissolve organic substance present in the root canal system and its affordability. The fiber post was used on this case because the remaining root wall is still good enough. The fiber has many advantages, such as fiber post has modulus of elasticity similar to dentin which allow the post to flex slightly with the tooth and dissipate stress, thereby reducing the damage to the root. Fiber post are not susceptible to galvanic or corrosion activity..4
Endodontic retreatment was needed when there was reinfected root canal because of incomplete the previous root canal treatment. This case were using reciproc files because its use by single file so it has shorter working time . By using reciproc files, this methode could achieve effective cleaning and shaping of the root canal system. Reference 1. Mohamed, R.A, Gueorgieva, T.G, 2013, Endodontic Treatment of lower lateral incisor with three root canals-case report., J of IMAB,vol 19, issue 2 2. Siqueira Jr, 2001, Aetiology of root canal treatment failure: why well-trated teeth can fail, International Endodontic Journal, 34, 110. 3. Meireles, S.A, et al, 2013, Endodontic treatment of mandibular molar with rot dilaceration using Reciproc single file system, Restore Dent Endod, 38(3): 167-171. 4. Boksman, L, et al, 2012, Fiber post techniques for anatomical root variations, The Journal of the Greater Houston Dental Society. 5. Amaral P, et al, 2013, Smear layer removal in canals shaped with reciprocating rotary system. Journal of clinical and experimental dentistry. 5(5): 227-230.
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AESTHETIC ODONTOPLASTY WITH A NANOHYBRID COMPOSITE Laksmiari Setyowati Staff Department of Conservative Faculty of Dentistry, Airlangga University Surabaya-Indonesia
ABSTRACT Background: An attractive smile has always been the focal point of a person’s attention. Currently, more people attempt to improve their aesthetic appearance and thus their self-esteem, because they know it might lead to better social acceptance. To solve that problem can be reached by restorative treatment. Purpose: To describe treatment alternatives that improve the maxillary canine position in the arch and the associated gingival architecture in that region. Case: This article presents a case report on esthetic improvement of an ectopic localization of the maxillary canine teeth, and a gingival retraction associated to the dislocated positions in the arches of these teeth. The diagnosis revealed caries lesions in the mesial and distal surface teeth 21 and in the mesial surface teeth 11 and 12. In addition, the tooth 2.2 was diagnosed agenesis. Case management: Restoration with nano-hybrid composite was done on teeth 21, 11, and 12. Odontoplasty was done on teeth 13 and 23. to mask the gingival tissue morphology from the canine cervical area with compomer. Conclusion: Aesthetic improvement describes an on invasive restorative dental procedure that masks the gingival morphology, allows the dental professional to restore the upper canines shape, position and relative crown length, and harmonize it with the adjacent soft tissue. The selection of a nano-hybrid composite in this restoration contributes to aesthetic, mechanical advantages leading to a more aesthetic smile. The simple principles of visualization perceptions with the dental environment and restoration treatment options can be successfully applied in restorative dentistry to achieve optimal tooth aesthetics and enhance the smile of any patient. Keyword: aesthetic, odontoplasty, nano-hybrid composite INTRODUCTION The importance of dentofacial attractiveness for the psychosocial well-being of an individualis well established. An attractive smile has always been the focal point of a person‘s attention. Currently, more people attempt to improve their aesthetic appearance and thus their self-esteem, because they know it might lead to better social acceptance. To understand why a smile with dentition inharmony is considered beautiful, it is necessary a visual perception to the dental [1] environment. The six anterior superior teeth play an important role in this specific issue. It is the contrast of shape, colour, line and texture that enable us to differentiate one tooth from another, the teeth from the gingival tissues, and the smile from the face.
When facing ectopic maxillary canines, for example, an orthodontic treatment should be considered. Although the orthodontist is able to place the canines in the most aesthetic and functional location, generally at least 2 years and 10 months are required for an orthodontic treatment. Sometimes, due to the restorative dentistry development, an alternative option can be considered. In order to recreate normal canines shape, position and colour, porcelain veneers or crowns are the solution, but a [2,3] composite resin restoration is also possible. The delivery of functional, aesthetic restorations has been simplified by the introduction of contemporary composite materials. The new nanocomposite materials offer better aesthetics, strength and durability, combining scientific principles for increased [4,5] longevity. 312
The aesthetic influence of gingival architecture on symmetry and tooth length as it relates to the ―smile line‖ can be altered through periodontal surgical techniques. The practitioner can influence the appearance of the smile by correcting tooth length problems as they relate to upperlip line and correction of [6] right-to- left asymmetries. In addition, proper evaluation and diagnosis of the gingival architecture and lip lengthening lead to a reliable treatment plan that provides a more [7] aesthetic perception to view the oral space. The purpose of this article is to present an alternative solution to orthodontic treatment and periodontal surgical procedures in a clinical case of ectopic maxillary canines. A conservative aesthetic restoration technique with a nanohybrid resin composite is presented to restore maxillary canines morphology and position. In addition, to repair the soft tissue, the gingival tissue, morphology from the exposed cervical area, we used a light-curing gingival-shaded compomer or composite. CASE Clinical case of ectopic maxillary canines direct aesthetic restoration A 30 years old female patient appeared in the dental office, not pleased with her smile (Fig.1), related to the position of the anterior teeth. The diagnosis revealed caries lesions in the mesial and distal surface teeth 21and in the mesial surface teeth 11 and 12. In addition, the tooth 2.2 was diagnosed agenesis, an ectopic localization of the maxillary canine teeth, and a gingival retraction associated to the dislocated positions in the arches of these teeth. CASE MANAGEMENT After the study of the smile line and occlusion, the patient was presented with the treatment options: the possibility of orthodontic and periodontal rehabilitations with the purpose of re-establishing the maxillary canine position in the arch and the associated gingival architecture in that region.
Figure 1 Due to time and economic limitations, various alternative solutions were proposed to the patient. A conservative aesthetic composite direct restoration to rebuild the canine morphology and position was the patient‘s choice. The nano-hybrid composite was used for the tooth and a compomer was used to mask the gingival tissue morphology from the canine cervical area. Nano-hybrid composite was selected because it combines good physical, mechanical and aesthetic properties. It has a significantly lower polymerization shrinkage than conventional composites, related with the high particle incorporation ceramics. Also has good consistency and very good handling characteristics, is smooth and does not slip, it stands in place and almost never sticks to the instrument. This nano-hybrid composite provides good options for the restoration shade selection, dentine and/or enamel, since it is available in 16 shades (including one incisal and two opaque shades). The current trend toward minimizing filler size in order to achieve great optical qualities, and toward maximizing filler loading is an attempt to satisfy all of the requirements for dental composites.[8] Advantages named within the context of high filler loading of RBCs are improved mechanical properties [8–10], high wear resistance [11], and reduced polymerization shrinkage [8]. Nano-hybrid RBCs contain a range of different filler sizes, also large filler particles besides the eponymous nano scale sized fillers. The varying particle sizes provide for a homogenous filler distribution within the matrix, since the small nano fillers are able to occupy the spaces between the larger particles perfectly and therefore help to generate RBCs with filler loadings that are comparable with the 313
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conventional hybrid composites. Nano-hybrid RBCs are claimed to combine both the positive characteristics of macro-filled composites (such as excellent physical and mechanical properties) and of micro-filled ones (e.g. excellent finishing and polishing qualities) and thus can be recommended as universal filling materials for anterior and posterior restorations.[12] The matrix of most of these new types of composites still consists of the conventional BisGMA monomer developed by Bowen, yet new types of monomers have recently been introduced in the matrices of nano-hybrid composites, like the dimer acid based dimethacrylate monomer (N‘Durance, Septodont), and a special urethane monomer, namely TCD-urethane (Venus Diamond, Heraeus Kulzer). Restorative compomer indicated to mask exposed, discolored or hypersensitive cervical areas, especially in long teeth of the visible anterior area, a where the gingivo-incisal width is excessive. The patient selected this treatment plan because it consists of a technique that demands only one office session, it was a good conservative rehabilitation alternative (not limiting the possibility of other kinds of solution in the future) and also because it was economically accessible. After the signature of the inform consent, casts and wax-up preparations were done to visualize the ideal canine size and shape and the aesthetic commitment involved in order to evaluate its feasibility. The upper incisive (colourA2) and the upper canine (A3 and A2) shades were selected in natural daylight using the shade scale. The gingival shade of the upper canine region (opaque white and nature) was selected.
Figure 2
Figure 3 Then a spherical tungsten rotary instrument with medium rotation and cooling was used to remove the carious tissue and finish the cavity preparations in the mesial and distal surfaces of the tooth 21 and in the mesial surfaces of 11 and 12. The cavosurface angle is rounded, and a long bevel is placed to facilitate an invisible transition from resin to tooth. (Fig. 4 and 5)
Figure 4
Caries restorative treatment After isolating the operating area with cotton rolls, a spherical diamond rotary instrument with high rotation and cooling was used to prepare and shape the cavities in teeth 21, 11 and 12 (Fig.2 and 3).
Figure 5 Purpose of acid etch are removing the smear layer, dentin demineralized, include dentin peritubules and intertubules, and allowing the formation of resin tags within the dentin structure.[13]
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will be bound and some will be release with the possibility of an allergic responses (Fig. 7).
Figure 6
Figure 7 Conventional finishing and polishing techniques were performed with laminated carbon tungsten burs, rubber cups and discshaped felt instruments. Aesthetic canine odontoplasty Restorative dentistry can change the position and morphology of teeth to restore a functional and aesthetic occlusion. The periodontium was more visible in the forced smile than in the natural smile. Age and gender influenced the position of the smile line for only the natural smile. A patient‘s smile expresses a feeling of joy, success, sensuality, affection and courtesy, and reveals self-confidence and kindness. The harmony of the smile is determined not only by the shape., the position and the color of teeth but also by the gingival tissues. First, the mandibular incisal edge position should be considered. Afterwards, the relationship of the maxillary anterior teeth to the lips, mandibular incisors, canines and the whole dental arches is examined. When the three major determinants of incisal edge position (occlusion, phonetics and aesthetics) are used to place the anterior teeth where they will work better, all clinical cases have the potential form or [15] aesthetic success. When maxillary canines are displayed, the patient‘s primary concern is 315
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There is considerable evidence that acidetching of dentine, in itself, is not a cause of pulpal inflammation because the acids are buffered by dentine and do not reach the pulp tissue. However, etching the dentine removes the smear layer and opens the tubules, allowing a positive dentinal fluid flow and this leads to an increase in the wetness of the dentine surface. Also, should marginal leakage occur subsequently, the pathway to the pulp will be more open and the pulp will be more susceptible to irritation. It also decreases bond strength. [14] Used phosphoric acid increase saliva flow, in order to solve the problem by placing the high volume suction over the tooth and leave it in place for 20 seconds. The other challenge of rinsing the gel comes from its acidity and ability to cause the patient to salivate during a time when isolation is critical. We use a disposable surgical suction to remove as much of the blue gel as possible prior to rinsing. Then rinse with the high volume suction directly over the tooth to minimize the amount of phosphoric acid that gets on the patient's tongue. In my total-etch technique, I utilize a rewetting/desensitizing agent after rinsing and prior to placing the primer to overcome both the risk of postop sensitivity and over-drying. An acetate matrix band was applied in the proximal spaces on each prepared cavity, one at a time, with two layers of a 6th generation (type II) self-etching adhesive system, nanoparticle , to achieve uniform and brilliant cavity surfaces. The application of this adhesive system consisted of mixing an acid-based primer and adhesive (2 bottle system) for 5 seconds, the application on the cavities surfaces, drying with soft airjet for 5 seconds and subsequent light curing, with a blue light emitting diode (LED) for 20 seconds. The left sphere represents the volume of light-cured composite prior to polymerization. The right sphere represents the volume and shrinkage pattern of the material after polymerization when not attached to any surface. Note how the material moves toward the light of the curing tip at the right (Fig. 6). All cavities had been restored, according to layer technique with the nano-hybrid composite and light-cured for 20 seconds for both vestibular and lingual aspects. Incompletely cured resin causes not all HEMA
usually aesthetics. In restorative dentistry, attention is first paid to the tooth (translucency, opalescence, and transparency) and shade characteristics to clearly identify the value. Moreover, the position of the lower lip line as well as the symmetry of the smile should be considered. In addition to these fundamental objective criteria, subjective criteria such as tooth arrangement and position, variation in tooth form, relative crown length, and the aesthetic principles of proportion, play a part in the successful occlusion and phonetic integration of an aesthetic resin composite [16,5] restoration. Before all the aesthetic restorative proceedings, a try-in restoration with selected resin composite shades and no adhesive technique was performed considering the previous wax up. At this time the patient still had a chance to discuss some size, shape and shade alterations she wanted to have. After patient consent was received, the aesthetic proceedings were started. First, a cylindrical diamond rotary instrument was used with high rotation and cooling to obtain a rough enamel surface, without removing a significant amount. Afterward, an aesthetic non invasive restoration of the vestibular gingival tooth area was performed. By means of a pre-etch technique, the phosphoric acid 37%gel (Fig.8) was applied for 30 seconds on the 23 tooth enamel surfaces (vestibular and lingual), and then removed with water.
[17]
strength. After these procedures, the enamel surfaces of the 23 tooth exhibited a uniform and brilliant feature. One layer of the Compomer was applied on the cervical third surfaces of the 23 tooth and light cured for 20 seconds. The compomer shade was used to simulate the gingival tissue in shape and contour. With this material, the gingival architecture and contour could be masked in accordance with the upper anterior teeth gingival line. Later, the same procedure was done in tooth 13 (Fig. 9)
Figure 9 Then, in the vestibular and palatine surfaces of the 23 cervical and medium third tooth, one layer of the nano-hybrid composite A3 shade was applied and adapted. The A2 shade was used for the cusp restoration of the same tooth. After good adaptation and sculpture, this single layer was light cured for 20 seconds on the vestibular and palatal surfaces. The same protocol was applied for the restoration of the 13tooth. The tooth characterization regarding position and morphology was done, and then occlusion verified with precision to deliver a functional and aesthetic occlusion to improve the smile line. The application of the dental loss in the proximal surfaces of both 13 and 23 teeth confirmed good contact points with the adjacent tooth. Conventional finishing and polishing techniques with laminated carbon tungsten burs, rubber cups and disc-shaped felt devices were performed on all of the restorations (Fig. 10)
Figure 8 The dental surfaces with an opaque white aspect for the application of the adhesive system. This technique allows the reduction of bacterial plaque of the uncut enamel surfaces, before applying two layers of the self-etch adhesive system, to improve the bond
Figure 10 316
CONCLUSION Because of the aesthetic and functional importance of the maxillary canines in the oral balance, therapeutic orthodontic alignment and periodontal rehabilitation should be indicated in ectopic maxillary canines. The evaluation of aesthetics needs is different from one person to another and from one dental professional to another. Clinicians should evaluate specific patient needs and conditions ,presenting all different alternative viable techniques. This paper describes an on invasive restorative dental procedure that masks the gingival morphology, allows the dental professional to restore the upper canines shape, position and relative crown length, and harmonize it with the adjacent soft tissue. These lection of a nano-hybrid composite in this restoration contributes to aesthetic, mechanical advantages leading to a more aesthetic smile. The simple principles of visualization perceptions with the dental environment and restoration treatment options can be successfully applied in restorative dentistry to achieve optimal tooth aesthetics and enhance the smile of any patient. REFERENCES 1. Moskowitz ME. Determinant soft dental esthetics: a rational for smile analysis and treatment. Compend Contin Educ Dent. 2005 Dec; 16(12): 1164,1166. 2. Grande T, Stolze A, Goldbecher H. Management of an extremely displaced maxillary canine. J Orofac Orthop. 2005 Jul; 66(4): 319-25. 3. Kokich VO Jr, Kinzer GA. Managing congenitally missing lateral incisors. Part I: Canine substitution. J Esthet Restor Dent. 2005; 17(1): 5-10. 4. Wilson KS, Antonucci JM. Interphase structure-property relationships in thermo set dimethacrylate nano-composites. Dent Mater. 2005 Dec17; [E pubahead of print] 5. Terry DA. Direct applications of a nanocomposite resin system: Part1-The evolution of contemporary composite materials. Pract
Proced Aesthet Dent. 2004 Jul; 16(6): 41722. 6. Townsend CL. Resective surgery: anesthetic application.: Quintessence Int. 2006 Aug; 24(8): 535-42. 7. Perenack J. Treatment options to optimize display of anterior dental esthetics in the patient with the agedlip. J Oral Maxillofac Surg. 2005 Nov; 63(11): 1634-41 8. Ferracane JL. Current trends in dental composites. Crit Rev Oral Biol Med 2005;6:302–18. 9. Mayworm CD, Camargo Jr SS, Bastian FL. Influence of artificial saliva on abrasive wear and microhardness of dental composites filled with nanoparticles. J Dent 2008;36:703–10. 10. Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization of nanofilled compared to universal and microfilled composites. Dent Mater 2007;23:51–9. 11. Turssi CP, Ferracane JL, Serra MC. Abrasive wear of resin composites as related to finishing and polishing procedures. Dent Mater 2005;21:641–8. 12. Mitra SB, Dong Wu, Holmes B. An application of nanotechnology in advanced dental materials. J Am Dent Assoc 2010;134:1382–90. 13. http://www.dentistryiq.com/articles/2011/08 /total-etch-or-self-etch-the-debatecontinues.html 14. Mclntyre JM. Dental Caries – the major cause of tooth damage. In: Preservation and Restoration of Tooth Structure. 2nd Ed. Eds Mount & Hume, Knowledge Books and Software, Brisbane, 2005, Chapt 3. 15. Small BW. Location of incisal edge position for esthetic restorative dentistry. Gen Dent. 2010 Jul-Aug; 48(4): 396-7. 16. Blitz N. Anterior crowns in re-establishing vertical dimension of occlusion: overcoming fear of heights. Oral Health. 2007 Feb; 87(2): 23-4,27-9. Update: 6th-and7th-generation Bonding Agents. Dental Advisor 2005, Nov; 22(9): 1-5.
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Componeer as a direct veneer restoration on maxillary anterior teeth Hanny Ilanda1, Tien Suwartini2 , Wiena Widyastuti 2 1 PPDGS, Bagian Konservasi, Fakultas Kedokteran Gigi, Universitas Trisakti 2 Bagian Konservasi, Fakultas Kedokteran Gigi, Universitas Trisakti
ABSTRACT Background: People always wants to have a brighter and beautiful smile in a single visit which cause esthetic dentistry care have to keep improving over time. One of the esthetic restorative available is Componeer veneer. Direct veneer system using Componeer are available for six upper anterior teeth with different applicable sizes and colors and in accordance with the wishes of each individual. Case: 30 years old female patient complained of upper front teeth front has diastema and discolored. Patient wants their teeth in order to perform better patched. Case management: direct veneer composite restoration and diastema closure using Componeer on six upper anterior teeth. Conclusion: The use of Componeer manage to aesthetically achive diastema closure, color uniformity and contour correction, fast, easy, and economical. Key Words : class III dan IV cavity, composite restoration, veneer, Componeer Correspondence : Hanny Ilanda, c/o Bagian PPDGS Konservasi Gigi Fakultas Kedokteran Gigi Usakti. Jl. Kyai Tapa Grogol Jakarta, Indonesia INTRODUCTION Nowadays, aesthetic in various fields not only obtained with the visual beauty but involves all the senses. Humans are not satisfied only by appearance, but should be comfortable, improve health and happiness. Aesthetic has evolved into a multi-dimensional concept with broader aspects of the functional (1). Satisfactory appearance is not only important in social life, but also work life. A survey has shown that attractive people will have better jobs (2). Great knowledge in all aspects of aesthetic / cosmetic dentistry and integration of the triad philosophy of "health, function and beauty" will assist the dentist in performing optimal dental care (3). Esthetic restoration of anterior teeth can be done with composite resin restoration, veneer and crown (4). Anterior tooth veneer was first discovered by Dr. Pincus (5) in 1937 and then became more popular in the mid-seventies using three different ways: Direct veneer composite, indirect composite and indirect veneer custommade porcelain veneer (6) (7) (8).
Recently, some manufacturers of dental restorative materials introduced direct prefabricated composite resin veneer system (including Edelweiss and Componeer) which become the latest alternative veneer treatment in one visit. The system is available for the six upper anterior teeth with a variety of sizes and colors so that the manufacture of composite veneer direct become faster and easier. This technique has been claimed to be more economical, faster and simpler than the ceramic veneer restorations because it does not need provisional restoration and no lab fees. This system also proved to be quick and simple and can be repaired. When compared with direct composite veneer technique without prefabricated dissertation, this technique is also faster and produces a more refined veneer surface, not porous, and shiny (9). The purpose of this case report is to improve the esthetics of anterior teeth on a patient who has a old veneer with secondary caries using prefabricated composite direct veneer system (Componeer) (10).
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CASE A 30-year-old woman came to the Rumah Sakit Gigi dan Mulut Bagian Spesialis Konservasi Gigi FKG Usakti to fix the damaged and discolored anterior maxilla tooth with a short time and affordable cost. From the anamnesis,endodontic patients had been treated with direct composite veneer restorations 5 years ago. From the results of intra-oral examination there are six direct veneer restoration on anterior teeth with secondary caries. Veneer on tooth 13 previously released by the physician for orthodontic treatment. Examination results percussion, negative pressure, cold test positive with ethyl chlorine 13,21,22,23 teeth; negative on teeth 11 and 12, no pains and no abnormalities in the soft tissue around the maxillary front teeth (Figure 1). In the panoramic x-ray examination of visible teeth 12 and 11 had been root canal treated (Figure 2).
Figure 1. Direct veneer on 12,11,21,22, and 23
Figure 2. Panoramic X-ray with ndodontically treated tooth on 11 and 12 Treatment plan for this case will be using prefabricated composite resin veneer restorations which is explained to the patient and the patient agreed to the treatment plan.
CASE MANAGEMENT
Figure 3. (A) Caries and old restoration removal (B) After composite restoration (C) Veneer preparation (D) Proximal edge smoothed using polishing strip Scaling and intraoral x-ray and panoramic were done on the first visit. The patient was explained about the procedure as well as the maintenance costs required then they signed informed consent. Prepared teeth will be cleaned of plaque. Veneer restorations and secondary caries previously removed using high speed diamond bur tapered fissure (Comet). Carious teeth were restored using resin composite beforehand (Ceram-X, Dentsply) first. Then proceed with the veneer preparation that begins on the labial incisal up above the top of the gum shaped chamfer. Preparation extended into the proximal part while maintaining contact point (Figure 3). Proximal composite restoration were smoothed using a polishing strip (Shofu). Minimum preparation were examined using a contour guide. The whole procedure is using Optragate (Ivoclar) for ease of vision and protect the oral mucosa. A
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Figure 4 Shade selection on 12,11, and 21 (A) light units (B) room light
Figure 6 retraction cord and celluloid strips were applied before bonding application
Shade selection is done on the teeth 11,13, and 21 on the 2 lighting conditions using dental chair unit and room natural light (Figure 4). Determination of the size of the veneer is done using contour guide to get the precision size and shape (Figure 7).
Color modifier (Color + Plus) mixture of yellow and white to get the dentin color and covered the dark color on non-vital 22 tooth (Figure A 7A and 7B). A layer of composite was distributed using a modeling instrument MB5 (Coltene)on the prepared surface and the Componeer‘s surface evenly to prevent air trap. Componeer placed on teeth that have been given composite and positioned with light pressure using a placer. Installation is done on both the first central incisor (Figure 8A). Then the rest of the composite which came out from the edge of Componeer cleaned using a modeling instrument (Figure 8B). After all Componeer installed properly, light cure performed initially on the palatal side during the first 40 seconds of each B section and followed the labial. B
C
D
Figure 5. contour guide After all the tooth is cleaned and dried, the entire surface of the prepared tooth and inside Componeer etched using 37% phosphoric acid for 15 seconds, then rinsed with water spray and dried with a light air spray using two-way syringe (Figure 6). Retraction cord is applied on the gingival sulcus (Ultrapak, Ultradent). Bonding is applied to the tooth surface separated using celluloid strip and light cured. Bonding layer is also applied to the inside Componeer and light air spray was applied.
A
Figure 7 (A) yellow and white color modifier mixed agents (B) Color modifier application on 22 tooth
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D
Figure 11. Result DISCUSSION Figure 8 (A) Componeer is applied using placer (B) Remaining Componeer cleaned with modeling instrument Before polishing, the alignment of the incisal edge first checked using a ruler (Figure 9). Excessive part marked with a pencil and removed using flame-shaped diamond bur. Marginal part was smoothed using a superfine diamond bur and flexible disc (Shofu) ranging from the most coarse to fine. Completion and polishing on proximal part is done by using finishing and polishing strips as well as the incisal part using flexible disc. Final polish using Astrobrush (Ivoclar) (Figure 10) without water which will create a clean and shiny surface to prevent accumulation of plaque (Figure 11).
Figure 9 incisal alignment measurement
In this case the chosen restoration was direct prefabricated composite resin veneer on anterior teeth because patients want to get satisfactory results in a short time, minimal reduction of tooth tissue, and more economical. Full veneer was selected for consideration of aesthetic factors and better retention than partial veneer. The advantages of prefabricated composite resin veneer technique is minimal preparation which will not destroy the integrity of the normal hard tissue on the tooth, reducing the time of the visit as prefabricated veneer is available in various sizes according to each individual, as well as more economical because it requires A no additional for the laboratory. Direct prefabricated veneer restoration offers an alternative for the use of composite veneer direct (free hand) which is more difficult and time consuming, operator skill is required and precision in the application of composite materials. Indication of the prefabricated composite veneer restoration on the tooth for large / damaged tissue loss or the uneven color on the buccal, non-vital teeth are experiencing discoloration, tooth discoloration due to trauma, extensive fractures, and teeth that had dysplasia B or hypoplasia enamel. While in some dental veneer aims to improve moderate to severe discoloration (tetracycline and fluorosis), hypoplasia / dysplasia enamel (amelogenesis imperfecta IIIA), restoration / damage to several teeth with extensive tissue loss, attrition of the incisal tooth, financial limitations, and immature tooth which have a different gingival profile (4).
Figure 10 Astrobrush polishing 321
In this case, the preparation is done with retaining contact points to protect the enamel on the proximal attachment so the bonding and resin could bond better (11). Chamfer-shaped edge preparation is done to obtain the contours of natural teeth and prevent damage the contour of original tooth, minimizing pressure to higher fracture resistant and provide room for veneer attachment (12). Restoration with secondary caries on the proximal part were removed and restored first to get a better contact position to obtain a good edge density during veneer placement and obtain good occlusion. In conclusion, prefabricated veneer restoration using Componeer preceded by a conventional composite restorations could restore function to aesthetic dental caries experience extensive defects, diastema, and discoloration on non-vital teeth. For the advice, the range selection of appropriate treatment with dental conditions that want to be treated, can improve the aesthetic function. Long-term clinical observation needs to be done to determine the overall success of the dental treatment. Reference 1. Patil R. Esthetics and its Role in Dentistry. In Patil R. Esthetic Dentistry : An Artist Science. India: PR Publications; 2002. p. 16. 2. Goleman D, Goleman T. Beauty's hidden equation. Am Health. 1987 March. 3. WH O. Resolve to recommit to excellence.
AACD J. 1997;(2). 4. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservtive procedures. Eur J Esthet Dent. 2008; 3: p. 14-29. 5. Pincus C. Building mouth personality. In California state dental association; 1937; California. 6. FR F, DR M. Laminate veneer restoration of permanent incisors. JADA. 1976; 93: p. 790792. 7. LM H, JE F. Laboratory technique for the laminate veneer restoration. Pediatric Dentistry. 1982; 4: p. 48-50. 8. Haas B. Mastique veneers: a cosmetic and financial alternative in post-periodontal care. J N J Dent Assoc. 1982; 53: p. 25-27. 9. Beolchi R, Forti W. Prefabricated veneers: A hybrid technique for easier (and more afforable) asthetic result. Dental Tribune. . 10. DT J, M V, J S. Aesthetic treatment of severely fluorosed teeth with prefabricated composite veneers : a case report2. Int Dent African Edition. ; 2(6). 11. McLaren E. Porcelain veneer preparation: to prep or not to prep. inside dentistry. 2006 may. 12. Ho C, Grobler B. Porcelain veneers: treatment guidelines for optimal aesthetics. Australasian Dental Practice. 2011 March/April;: p. 154-164.
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Treatment Of Toothwear Nevi Yanti, Trimurni Abidin Department of Conservative Dentistry, Faculty of Dentistry University of Sumatera Utara Medan-Indonesia
Abstract Background: Toothwear is the loss of tooth structure by means other than decay due to daily use. This condition can be caused physiologically related to the masticatory function, pathologically toothwear caused by parafungsional factors. The impact from toothwear will cause the crown to look shorter and loss of vertical dimension. Objective: This article will explain about the treatments of toothwear according to the dental abnormalities experienced by patient, such as toothwear on the palatal surface of the upper incisors, toothwear on anterior teeth accompanied by overclosure, and toothwear which resulted in loss of space in the anterior teeth. Conclusion: Tooth Wear can be caused by several things and found in different cases. Therefore, the treatment for different cases of toothwear require different handling is also in accordance with dental abnormalities that experienced by patient. Treatment for toothwear on the palatal surface of the upper incisors can be done with a composite resin restoration on the palatal part of the incisor. In the case of toothwear on the anterior teeth accompanied by loss of teeth that causes the overclosure can be treated with composite resin restorations on the mandibular anterior teeth, the using of long span bridge to the maxillary, and the use of removable partial denture for the mandibular posterior teeth. Toothwear treatment resulted in loss of space of the anterior teeth , can be done by using a combination of Dahl concept and direct composite build up technique. Keywords: toothwear, treatment INTRODUCTION Tooth is the hardest tissue in human body; however, due to daily use, this tissue can be injured because of attrition process or commonly called toothwear.2 Toothwear is the loss of tooth structure that occur mechanically or chemically. Toothwear can be found in the form of attrition, erosion, abrasion and abfraction. The toothwear process can be cause by physiological and pathological processes. Physiologically, it is related with the mastication function while pathologically is caused by parafunction.1-3 The impact from toothwear will cause the crown to look shorter and loss of vertical dimension.1,3-5 Toothwear can be caused by a combination of erosion and attrition due to the habit of letting the acidic beverage stays at palatal surface. Severe toothwear can be occur due to the regurgitation of gastric contents into the mouth secondary to gastroesophageal reflux
disease. In that case found that the combination toothwear happen mechanically and chemically.4 Toothwear in the form of attrition and abrasion can also happened with patient dentition who does not have teeth substitution for long time due to the loss of their posterior teeth.1,2 In this condition, the patient tends to move the mandibular forward and use their anterior teeth for mastication. This may cause the patient to lose their vertical dimension of occlusion and becomes overclosure.1 Overclosure is an occluding vertical dimension that results in excessive inter occlusal distance when the mandibular is in the rest position. It results in reduced interidge distance when the teeth are in contact. Overclosure is signed by a deep fold at the corner of the mouth. In this condition the patients normally get tired easily while masticating food, having problem with clicking of the temporomandibular joint, and their faces look shorter.1
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There are two kinds of vertical relation. The first is when the teeth contact during centric occlusion whilst the second one is when during rest position. The rest position is the neutral position of mandibular when the muscles of the mouth are opening and closing in balance. The difference between the two vertical dimensions is called free way space which is usually about 2-4 mm. If the free way space is more than 2-4 mm, it indicates there has been overclosure. The loss of the vertical dimension in a long term may influence the appearance of the face, which will look older, and in severe condition it may cause angular cheilitis.1,3 When the occlusal vertical dimension is lost, a treatment should be carried out to improve the vertical dimension. Some treatment can be conducted, for example by lengthening the crown, repositioning the teeth by orthodontic procedure, or replace the teeth with removable dentures. In this article will explain some treatment for toothwear according to the dental abnornalities experienced by patient, that is toothwear on the palatal surface of maxillary incisors, toothwear on anterior teeth accompanied by overclosure, and tooth wear resulting in loss of space in the anterior. REVIEWS 1. TREATMENT FOR TOOTHWEAR ON PALATAL SURFACE OF MAXILLARY INCISORS In this case, the cause of toothwear is the combination of erosion and attrition ( Figure 1a and 1b). This is due to the patients often allow acidic beverage stays on the palatal surface. In this case the composite resin restoration is use to applied to the palatal surface of the tooth to restore those teeth who have toothwear case (Figure 1c). This restoration increases the vertical dimension and the separation of posterior teeth between the maxillary and the mandibular. After 3 months later, the occlusion will stablilize and intercuspal position of the anterior teeth will back to normal (Figure 1d).4
Figure 1a. Translucent incisal edges Figure 1b. Toothwear that cause by combination of erosion and attrition
Figure 1c. Composite resin applied at improved the appearance of the anterior teeth. Figure 1d. Composite resin have the palatal surface.
Severe toothwear can be occur at the maxillary anterior teeth due to the regurgitation of gastric contents into the mouth secondary to gastroesophageal reflux disease. In patients with this condition, the gastric juices which have a pH about 1 may cause severe erosive wear of the palatal surfaces of the upper anterior teeth. Composite resins were added to the buccal and palatal surfaces of these teeth to increase the vertical dimension (Figure 2b and 2c).4
Figure 2a. Severe toothwear; Figure 2b. Microhybrid Figure 2c. Palatal view on the maxillary anterior teeth composite resin applied on shows that microhybrid the buccal and palatal surfaces composite resin improve the erosion condition of the anterior teeth.
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The following are tips for restoring teeth with toothwear condition due to a combination of erosion and attrition: • Using the dentin bonding agent carefully. Remember to always follow the instruction of the fabrication in order to maximize the strength of the bond. Because toothwear that happens involving dentin, which bonding is important in the restoration procedure • Increasing the occlusal vertical dimension according to the number of missing tooth structure. 2. TREATMENT FOR TOOTHWEAR ON ANTERIOR TEETH WITH OVERCLOSURE CONDITION A seventy six years old woman patient came to restore the maxillary and mandibular anterior teeth due to attrition on the posterior teeth. The patient have used the acrylic removable partial denture for ten years but she experienced the discomfort of the removable partial denture so she does not wear it since five years ago. Clinical examination shows that there is clicking on the temporomandibular joint that cause the discomfort to the patient. Intraoral examination shows that 12, 14, 15, 23, 26, 27, 34, 35, 36, 37, 46 and 47 missing; 11, 13, 21, 22, 31, 32, 41, 42, 43 and 44 affected by attrition and deep bite in anterior relation (overclosure). Radiographic examination shows that there is loss of tooth and 11, 21 and 22 have been treated with endodontic treatment before. In this case, the patient has experienced a very complex condition. Treatment planning will begin with using composite resin to restore the mandibular anterior teeth, the making of long span bridge for maxillary and the use of removable partial denture for mandibular posterior teeth.
• Before performing the treatment, remind the patients that there may be a change on the occlusion. This is important when restoring the anterior teeth of the patient. • When adjusting the occlusion, make sure there is a recovery of new occlusion contact. • If the remaining tooth structure is below 50%, it is recommended to use crowns instead of composite resin restorations.
Figure 4. Panoramic radiograph shows that severe attrition on the anterior teeth and loss of posterior teeth.
Figure 5. Diagnostic model of maxillary and mandibular
The examination of occlusal vertical dimension with the Niswonger and Willis technique were conducted by concerning with the appearance of the patient. The measuring result of vertical dimension of occlusion was 61mm, and the rest position was 69mm, which means that there is loss or reduce of occlusal vertical dimension. In conclusion, the rest position subtracted by the occlusion position, 69mm - 61mm = 8mm, and then was subtracted by free way space. The result of the lost vertical dimension of occlusion was 8mm - 4mm = 4mm. Then, the diagnostic wax up for maxillary model was taken by elevate the bite, about 2mm (Figure 6).1
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Figure 6. Diagnostic wax up model
Diagnostic wax up were a long span maxillary bridge and heightening crown of mandibular anterior teeth which was for her lower jaw. Both diagnostic waxed up were made by using wax material. The improving process of the lost occlusal vertical dimension was gradually conducted. The first stage is restoration of 33, 32, 31,41, 42 and 43 by lengthening the incisal edges 2mm with composite resin A3 and A1 to maintain the esthetic and increase the occlusal vertical dimension (Figure 7). Then the patient was evaluated for 2 weeks and results shows that she had no problems with her temporomandibular joint. The second stage was the preparation process of these teeth mention 11, 13, 21 and 22(Figure 8).
Figure 9. Temporary bridge for maxillary anterior teeth. To make the long span bridge with twelve units that make of porcelain fused metal materials, 16, 24 and 25 must be anesthetized. Therefore, the formation of the gingival margin after the final preparation was in ridge form, meanwhile the shape of the pontic facing the gingival anterior teeth are ridge lap, and for the posterior teeth are sanitary.1 The making of long span bridge for 11, 12, 13, 14, 15, 16, 21, 22, 23, 24, 25 and 26, and the design of the cantilever for 26 with porcelain fused metal (Figure 7-A). After the making of the long span bridge is finished, it was inserted into the patient.1 The next stage was the making of acrylic removable partial denture for the mandibular. The 34 was given two fingerwrought wire with rest on mesial, meanwhile 43 was given Gilet clamer (Figure 10 A&B).
Figure 7. Lengthening of mandibular anterior teeth using composite resin. Figure 8. Preparation of maxillary teeth.
The next process is the making of temporary long span bridge for 11, 12, 13, 21 and 22. Then increasing the occlusion by 2mm not only to maintain the esthetic and increase the occlusal vertical dimension, but also improve the overclosure of the patient. This temporary bridge is made of self curing acrylic ( Figure 9).1
Figure 10. A) Maxillary long span bridge; B) Acrylic removable partial denture for mandibular
Figure 11. Maxillary long span bridge and acrylic removable partial denture for mandibular after used.
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During the insertion of the mandibular acrylic removable partial denture, correction of the occlusion must be conducted by using the articulating paper in order to obtain a stable occlusion. After being polished, the acrylic removable partial denture was inserted into the mouth of the patient (Figure 11). Controls are conducted on the first and the seventh day after the insertion.
TREATMENT OF TOOTHWEAR USING THE COMBINATION OF DAHL CONCEPT AND DIRECT COMPOSITE FREE HAND TECHNIQUE In many cases, toothwear is localized to the upper incisor and canine region (Figures 13a, 13b,13c).
3. TREATMENT OF TOOTHWEAR USING THE COMBINATION OF DAHL CONCEPTS AND DIRECT COMPOSITE BUILD UP TECHNIQUES 3.1 DAHL CONCEPT Dahl et al introduced a concept to create space to restore worn anterior teeth where such space was absent. It involved the use of a cobaltchrome removable anterior bite plane that caused separation of the posterior teeth (Figures 12a and 12b).
Figure 12.Cobalt-chrome bite plane; a) palatal view, b) buccal view 3.2 DIRECT COMPOSITE BUILD UP TECHNIQUE Direct composite build up technique that can be conducted are using the ‗free hand‘ technique and an alternative matrix-guided method. While the techniques described apply to cases where dento-alveolar compensation has occurred, and there is insufficient space to place restorations at the current vertical dimension, these principles could be adapted to situations where sufficient space is available (eg wear has occurred recently and dento-alveolar compensation has not yet resulted). Typically, a patient with moderate/severe toothwear may require an increase in OVD of 2−3 mm anteriorly.5
After the space in the anterior have obtained and the posterior occlusion position is back in normal, in order to control the occlusion while building up the teeth, composite should be added to the cingulum region of both upper canines and the mandibular manipulated into the retruded axis. The patient should then be guided to close into the uncured resin until the desired anterior space is achieved. This is done carefully and quickly to avoid moisture contamination of the uncured composite. On opening, the composite is cured and the presence of even, bilateral cingulum contact at the new OVD should be checked.5
The next phase is to build up the incisors individually to the desired proportions. Following standard bonding procedures, an increment of dentine composite is placed on the cingulum area of one of the central incisors and, 327
again, the patient closes into the uncured resin and opens (Figure 13e). The resin is cured and an enamel shade is chosen to build the mesial and distal contacts with the aid of a matrix strip (Figure 13f).5
Finally, a single increment of enamel composite is applied to give a seamless labial surface, reducing the possibility of voids (Figure 13g). The restoration is now trimmed to the desired dimensions and finished with fine diamonds, discs and polishing points (Figure 13h).5
TREATMENT OF TOOTHWEAR USING THE COMBINATION OF DAHL CONCEPT AND DIRECT COMPOSITE MATRIX TECHNIQUE
With a free-hand technique it is important to be familiar with the average widths and relative proportions of teeth − a disposable ruler or periodontal probe are useful in this regard (Figure 13i). The occlusion is checked with thin articulating paper to ensure even contact and protective guidance in protrusive and lateral excursions. The posterior teeth will be out of occlusion and should be monitored over subsequent months until contact is reestablished (Figures 13 j, k). Patients should be warned that their occlusion will feel different at first but that they should become accustomed to it within a few weeks.5
After the space in the anterior have obtained and the posterior occlusion position is back in normal, an alternative technique involves the use of a silicone matrix to assist in the build-up process (Figure 14a). Impressions, along with inter-occlusal and face bow records, are taken allowing the laboratory to mount study casts on a semiadjustable articulator in the retruded axis. The clinician should decide on the required increase in vertical dimension and the technician produces a diagnostic wax-up to ideal contour. It is important that the wax is kept 1−2 mm clear of the gingival margins and that the embrasures are clearly defined to improve control of the composite when building up. Cingulum occlusal stops should be produced to ensure axial loading of the restored teeth (Figure 14b). An accurate palatal silicone matrix is made which should extend just beyond the incisal edges. A transparent silicone, such as Memosil (Heraeus-Kulzer, Hanau, Germany) may be advantageous as the composite can be cured through the matrix. The matrix should be of sufficient thickness to be fairly rigid and stabilization is provided by extension on to adjacent teeth and the palatal (or lingual) mucosa.5 At the chairside, the patient‘s acceptance of the wax-up should be confirmed. If the patient has difficulty visualizing the final result, a vacuum form stent can be made of the wax-up. 328
This can be filled with provisional crown material and seated over the teeth and allowed to set, thus providing the patient (and dentist) with an aesthetic preview.5 Having checked that the silicone matrix can be seated accurately, the enamel margins of the teeth are bevelled, the surfaces cleaned with pumice and standard bonding procedures carried out. A thin increment (0.5−1 mm) of enamel composite is placed in the matrix corresponding to the palatal/incisal aspect of the tooth. The matrix is seated and the composite gently manipulated such that it is kept just clear of the proximal contact areas but forms the proposed incisal edge (Figure 14c). The composite is cured and the matrix removed. The palatal contour and incisal length are thus determined and the build-up is continued without the matrix. Dentine shades can be applied and sculpted to produce the body of the tooth incorporating mamelons and other subtleties. Layering the composite in this manner optimizes the aesthetic result.
Figure 14. Worn anterior teeth Proximal areas are built up with a thin layer of enamel shade aided by a matrix strip (Figure 14d). The labial surface is restored with a single increment of enamel composite and finishing is completed as described earlier (Figure 14e). The occlusion is finally checked and modified as necessary to create even contact on the restorations at the new vertical dimension, with canine guidance (if possible) in excursive movements (Figure 14f). Follow up is as previously described, as time is allowed for posterior teeth to move back into contact (Figures 14g, h).5
DISCUSSION Toothwear is a problem that is relatively complex and requires time and considerable expense from patient. The main impact by toothwear is the shortening of the crown resulting in a decrease in vertical dimension. In this case, it is necessary to increase the vertical dimension by doing restoration. Some composite restoration technique can be an option to restore the toothwear teeth accordance with the dental problems that experienced by patients. In the case of tooth wear on the palatal surface of the upper incisors, composite resin restorations applied on the palatal of the tooth. Restoration of the occlusal surfaces of posterior teeth is not necessary because toothwear more localized on the surface of palatal itself. The initial increase in the occlusal vertical dimension will cause the separation of the posterior teeth, subsequently causing the dentoalveolar compensation, and then the occlusion will be stable. In the case of tooth wear with overclosure condition, the treatment is performed by addition of composite resin on the mandibular anterior teeth, the making of long span bridge for the maxillary teeth, and a removable partial denture for the mandibular posterior teeth. The increase in the vertical dimension in this treatment should be done gradually so that the muscles of mastication can adapt to the new occlusal vertical dimension. 329
In the early stages, the elevation of the bite on the 31, 32, 33, 41, 42, 43, and 44 at the incisal teeth with composite resin restorations must be conducted. This is to increase the occlusal vertical dimension. Next is the making of long span bridge for the maxillary teeth. The reason of using the long span bridge in this treatment is due to the rigid character of the bridge so as to prevent the occurrence of fractures during restoration and can distribute the load so to assure more balanced on opposing teeth. The final stage, the making of removable partial dentures on mandibular posterior teeth. This treatment is conducted because the patient experienced a considerable tooth loss, that is 34, 35, 36, 37, 45, 46, and 47. In addition to correct the occlusal vertical dimension in order to be better, the making of denture can also improve the function of mastication and enhance the functional comfort of the patient. The ‗Dahl technique‘ has been used to obtain space for anterior restorations and has been modified such that direct composite restorations are placed at increased occlusal vertical dimension. These restorations have proved durable and aesthetic, protect tooth structure and posterior occlusal contact is predictably re-established.5 Over a period of several weeks or months, via a combination of eruption of posterior teeth, intrusion of anterior teeth and possibly mandibular repositioning, the posterior occlusion was re-established. This technique has proved successful, with posterior occlusion being re-established, partially or completely, in 94−100% of patients over a 4−9 month period.5 The treatment that can be conducted for toothwear located on the anterior inter-occlusal space which is inadequate are direct and indirect restorations4. This indirect restoration techniques can be done, but the crown preparations are destructive of the already compromised teeth and may negatively impact pulpal health. In contrast, direct composite restorations have several distinct advantages to the indirect technique for anterior toothwear which is more minimally invasive, and can restore aesthetics and function, making the clinician to control the final aesthetic, reduce the cost and time of
treatment for patients and clinicians by making several shorter sessions, as well as to show better outcomes for patients. In this case, after the inadequate of space problem has been corrected, then the next restoration will be done by using the direct composite technique, either free hand or using a matrix. Both of these techniques are able to provide good results if used carefully. Free hand technique can avoid repeated visits and performed in a single treatment session. However, the use of matrix techniques shows more benefits due to an aspect change of the restoration, that is the making of anatomical palatal and incisal side position directed by the matrix.5 CONCLUSION AND SUGGESTION Toothwear is an increasing problem and restoring worn teeth with composite resin is a viable and relatively straightforward option in a general practice setting.1,4,5 A variety of treatment have been proposed to restore worn teeth such as application of composite resin at the palatal part of the incisors. Then, toothwear on the anterior teeth accompanied by loss of teeth that causes the overclosure can be treated with composite resin restorations on the mandibular anterior teeth, the using of long span bridge to the maxillary, and the use of removable partial denture for the mandibular posterior teeth. Besides, toothwear occur in the maxillary anterior teeth, can be done by using a combination of Dahl concept and direct composite ‗free hand‘ technique as well as matrix.5 REFERENCES 1. Djulaeha E, Sukaedi. The management of over closured anterior teethdue to attrition. Dent J 2009; 42;4: 194-8. 2. Lussi A. Dental Erosion. Switzerland: Karger, 2006: 17-22. 3. Rostiny. The correction of occlusal vertical dimention of tooth wear. Denj J 2007; 40;4: 161-4. 4. Bartlett D. Using composites to restore worn teeth. JCDA 2006; 72(4): 301-4. 330
5. Robinson S, Nixon PJ, Gahan MJ, Chan MFWY. Techniques for restoring worn anterior teeth with direct composite resin. Dent Update 2008; 35: 551-8.
6. Turner KA, Missirlian DM. Restoration of extremely worn dentition. J Prosthet Dent. 1984; 52: 467-74.
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The Difference In Root Canal Surface Smoothness At The Apical Third Between Instruments With Continuous Rotation And Reciprocating Movement Wahyuni Suci Dwiandhany.* Munyati Usman.** Endang Suprastiwi.** *Lecturer in The Departement of Conservative Dentistry and Endodontics, Hasanuddin University ** Lecturer in The Departement of Conservative Dentistry and Endodontics, University of Indonesia
Abstract Background: Smooth root canal wall is one of the indicator to assess the cleanliness of root canal preparation. It indicated that the file has been in contact with root canal wall so the debridement will be more optimal. The instruments with continuous rotation motion has many disadvantages. Therefore root canal preparation system with reciprocal motion have been developed. The aim of this study is to compare the root canal wall smoothness at the apical third after preparation with continuous rotation and reciprocal instruments. Methods: Thirty two human mandibular first premolars were divided into 2 groups. Group 1: root canal preparation using Mtwo (VDW, Germany) continuous rotation instrument. Group 2: root canal preparation using Reciproc (VDW, Germany) reciprocal instrument. After preparation, root canal smoothness at the apical third was measured using surface roughness tester. The data was analyzed using independent T-test. Result: The difference between groups were not statistically significant with p value = 0,739 (p > 0,05). Conclusion: Instruments with continuous rotation and reciprocating movement have no difference in the root canal surface smoothness at the apical third. Keywords: Root canal wall smoothness, apical third, continuous rotation, reciprocal. Introduction The main principle of the root canal treatment include endodontic triad, consists of access preparation, root canal preparation (cleaning and shaping), and obturation.1 The success of root canal treatment is highly influenced by the cleanliness of the root canal from microorganisms and necrotic tissue which gained through chemomechanical preparation. Mechanical preparation of root canal consists of cleaning and shaping the root canal.2 The purpose of root canal preparation is to prepare the root canal taper continuously to coronal direction. This condition will facilitate irrigation and instrumentation, retaining the original shape of the root canal, maintaining the position of the apical foramen, keeping the apical surface as small as possible, and create the smooth root canal walls.1-7 The root canals prepared in order to facilitate disinfection by irrigant and medicaments followed by root canal filling in three dimensions in order to obtain a hermetic apical seal.1,2
There are several methods to assess the cleanliness of the root canal, such as the dentinal shaving, the cleanliness of irrigant, and the enlargement of the file size to three size above the initial file size. However, these indicators are not associated with debridement. The smoothness of the root canal walls was more preferred indicator. This indicates that the file has been in contact and smoothen the entire surface of the canal wall that can be accessed so debridement can be more effective.4 In order to assess the smoothness, a subtle tactile sensation at the time emphasized the file across the surface of the canal walls was used.8 To overcome the disadvantages of NiTi instruments with continuous rotation, Yared (2008) creates a new perspective of NiTi files which is a single file with reciprocal motion.9 The advantage of reciprocal movement with a single NiTi files is a chairtime may be shortened due to fewer sequences. This was supported by De-Deus et al. (2010) which states that the use of NiTi techniques with single reciprocating files bring many advantages as a single file technique 332
works faster.10 You et al. (2011) concluded that the working length can be accomplished within 21 + 7 seconds in human molars. These result indicates that the time needed for the preparation of the root canal is shorter because it only uses one file, in other words the taper preparation can be obtained faster.11 Franco et al. (2011) showed that the reciprocal movement will prepared the root canal wall more evenly because of a good centering ability. Reciprocal movement produces a larger contact area between the root canal walls and the instruments, so the quality of debridement can be as effective as continuous rotation.4 In a reciprocal motion stated by Yared (2008), the instrument cut the dentin while moving counter-clockwise with the counterclockwise rotation angle greater than clockwise rotation. When the instrument rotates clockwise, the linkage between instruments and dentin immediately disengaged (happened in filing / scraping motion). Scraping action occurs when the instrument rotates to the direction of the negative rake angle, so the smooth sensation can be achieved. The application of apical pressure to the instrument is very light because the insertion of the instrument into the channel occurs automatically.9 ATR Vision Motor used in the research of Yared (2008) was no longer produced, so he developed a new system for single file reciprocating technique without the use of hand files called Reciproc system. There was only one Reciproc instruments used for root canal preparation, depending on the size of the initial file of the root canal. Instruments made of NiTi M-Wire which is more flexible than traditional NiTi. The instrument has an S-shaped cross-sectional design and progressive tapered.12 Both Mtwo and Reciproc instruments can be used with endomotor, have S-shaped crosssectional design, taper-shaped, non-cutting tip, radial land was absent and positive rake angle. 13. (Figure 1 & 2). The differences between the two was in the movements and preparation techniques. The preparation movement of Mtwo is continuous clockwise rotation with a rotation angle of 360° and a single length technique, while Reciproc moving reciprocally with the counter clockwise cutting direction and the crown down techniques.9
Figure 1. Mtwo cross-sectional design is S-shape with non-cutting tip. (Reference: Mtwo, The Efficient NiTi System: User Information. Available at: http://www.vdw-dental.com. Accesed July 25, 2012.)
Figure 2. Reciproc cross-sectional design (Reference: Yared G. Canal preparation with only one Reciprocating instrument without prior filing: a new concept. Available at:
http://www.vdwReciproc.de/images/stories/pdf/GY_Artikel_en_ WEB.pdf. Accesed July 25, 2012.) Although the preparation techniques with a single reciprocal NiTi files have many advantages, but several clinical and laboratory studies regarding its cleaning and shaping ability towards the root canal wall and the root canal surface smoothness still needs to be done. Therefore, the author wants to do a study comparing the instruments with continuous rotation (Mtwo) and reciprocal movement (Reciproc) in terms of smoothness of the surface area of the root canal in the apical third. The purpose of this study was to compare the level of surface smoothness at the apical third of the root canal walls after prepared using instruments with continuous rotation motion and reciprocal motion.
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Materials and Methods Samples was cleaned and soaked in saline before used for the study. The patency of the apical foramen standardized by inserting C-Pilot file #15, until the tip is visible. Then the working length of each sample was measured up to 0.5 mm shorter than the working length of the CPilot file #15 at this position. The working length of each sample was measured and recorded . Next step is to create the endodontic access using access burs. Samples were prepared using Mtwo and Reciproc files (VDW, Munich, Germany) applying the single length technique for Mtwo and crown down technique for Reciproc, using 5 files (Mtwo files size 10/.04 to 25/.06 and Reciproc file size R25) with endomotor. A set of Mtwo files can only be used for 8 teeth while R25 files can be used for 4 teeth. To avoid operator fatigue then in one day operator can only prepare 16 samples at once. Root canal preparation using Mtwo system were done according to the working length with brushing motion without pressure and rotation speed of 280 rpm and a torque of 120 gcm (11,772 Nmm) that were adjusted to the manufacturer's instructions with irrigation at each replacement of the next sequence instrument. After preparation, the root canals were rinsed with a chelating agent (MD Cleanser, Meta Biomed Co. Ltd., Korea), and finally rinsed again with NaOCl. Root canal preparation using Reciproc system begins with the placement of irrigant within the cavity access of the root canal. Root canal preparation was performed with 3 mm deep pecking movements according to manufacturer's instructions. After three times of the pecking motion with an amplitude of + 3 mm, the instrument was cleaned with an interim stand and irrigated with NaOCl. There was approximately 3 mm clearance below the root canal that has been prepared, then the preparation was continued until 2/3 of the working length. The working length was confirmed with C-Pilot #15 file and continue until working length was reached. After preparation, the root canals were rinsed with chelating agents (EDTA 17 %, MD Cleanser,
Meta Biomed Co. Ltd., Korea), and then finally rinsed again with NaOCl. Sample grouping were randomized, and divided into two groups with the same number of samples in each group : • Group 1 (n = 16): Root canal preparation with MTwo basic sequence (10/.04, 15/.05, 20/.06, up to 25/.06) • Group 2 (n = 16): Root canal preparation with Reciproc file size R25 All of the root canal samples were dried with paper points and the orifice were covered with a cotton pellet and sealed coronally with glass ionomer cement. Two longitudinal grooves were made on the buccal and lingual surfaces of each sample by using a carborundum disc and water cooled high speed handpiece to facilitate vertical cuts using chisel after instrumentation and irrigation. Then the samples were numbered and divided randomly into two groups (Figure 3). Each splitted sample was randomly selected and then embedded in the silicon with the exposed root canal walls surface facing outward. Measurement with the surface roughness tester was made in the apical third area. After the measurement was done, the measuring tip generates an analog signal which was then stored as digital data and can be seen on the screen or printed paper. The values that appear on the screen were recorded and the SEM examination of samples representing each group was performed (Figure 4).
Figure 3. A. The prepared samples were splitted with carborundum disc and ready to be measured with surface roughness tester; B. MTwo and Reciproc samples.
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the prepared samples there were more homogenous dentine tubules and less ireegular surface. (Figure 5).
A
B
Figure 4. Surface roughness measurement using surface roughness tester device (Surfcorder SE-1200, Kosaka Laboratory, Japan).
The data of the assessment were included in the numerical measurement scale with two unpaired groups. To see the smoothness of the root canal walls surface after preparation, the statistic unpaired T-test with a level of significance p < 0.05 was performed . Result The data was obtained by evaluating the surface roughness on the root canal walls at the apical third by recording the roughness as measured by surface roughness tester . Data normality were tested with ShapiroWilk test (sample ≤ 50) with p > 0.05, then the surface smoothness of root canal walls at the apical third of the two groups were analyzed with an unpaired T-test using SPSS 17. Based on the result of normality test, it can be concluded that the distribution of troughness value was normal (p = 0.413 for continuous rotation and p = 0.143 for the reciprocal), therefore it will be continued with unpaired T-test. Normality of the data was presented in Table 1. Group Continuous rotation (Mtwo) Reciprocal (Reciproc)
Shapiro-Wilk Test p = 0,413 p = 0,143
Table 1. Normality test of Mtwo dan Reciproc groups with Shapiro-Wilk test
SEM examination on unprepared samples showed the irregular surface and dentine tubules were covered with pulp debris layer, while on
Figure 5. SEM images: (A) before preparation; (B) after preparation with continuous rotation instrument; (C) after preparation with reciprocal instruments. Red arrow shows the unprepared area of the root canal wall surface at the apical third.
Root canal wall surface roughness was measured with surface rougness tester. The mean value of the root canal surface roughness in a continuous rotation group is of 1.24 μm and 1.29 μm in the reciprocal group. Table 2. The difference between continuous rotation group and reciprocal group in term of root canal wall Group Continuous rotation (Mtwo) Reciprocal (Reciproc)
N
Mean + SD
16 16
1,241563 + 0,3301226 1,292156 + 0,5043164
CI 95% Lower
Upper
1,065653 1,023425
1,417472 1,560888
surface smoothness. *Unpaired T-test with p value < 0,05
The mean value shows that the mean roughness in reciprocal preparation group was slightly higher than the continuous rotation preparation group. Statistical test using an unpaired T-test for two groups revealed that the p value was 0.739 (p > 0.05) (Table 2). The statistical test indicated that there was no significant difference between continuous rotation group and reciprocal group in term of root canal wall surface smoothness.
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P Value
*p = 0,739 p > 0,05
Discussion The extracted mandibular first premolars were used in this study because it has a single root, and enable the uniformity of the sample. Teeth were stored in saline solution to maintain it‘s moisture and resembling the condition in the mouth like a biological state. Root canal preparation was done while maintaining the crown that resembles the clinical oral condition. Other criteria used were standardized apical diameter by C-Pilot file #15 and the working length was 0.5 mm from the apical foramen. Kuttler (1955) stated that the CDJ can be seen microscopically in 96 % of cases and were located in between 0.524 to 0.659 mm from the apical foramen. CDJ is the ideal point of the boundary of the preparation because it was the meeting point between the pulp and periodontal tissue.14 Gulabivala et al. (2005) states that root canal treatment procedure will affect the shape of the root canal wall surfaces depends on the anatomy of the root canal, the instrument used, the strategy and how to use the instrument as well as chemicals used for debridement of the root canal.15 Canals were prepared using the Mtwo instruments with single length technique, and the Reciproc instruments with crowndown technique. Both of these techniques can maintain the shape of the root canals because of it‘s tapered shape. On the other hand, some disadvantages of continuous rotation NiTi files include the possibility of cross contamination due to the number of files that are used and the fracture tool unexpectedly due to excessive wear. The use of disposable rotary files with reciprocal movement has been recommended to reduce fatigue on the instrument and prevent cross contamination.16 The advantage of reciprocal movement with a single NiTi files is a chairtime may be shortened due to fewer stages. Reciprocal movement produces a larger contact area between the root canal wall and the instruments, thus the quality of debridement can be as effective as continuous rotation.4 Therefore, in this study the author use the continuous rotation NiTi instruments (Mtwo) compared with reciprocal NiTi instruments (Reciproc) which has the same cross-sectional design.
SEM images of the surface profile of the root canal walls that have been prepared with continuous rotation and reciprocal movement showed almost homogeneous surface, but there are also a number of irregular surface. The presence of an irregular surface in the apical third area indicates that there were unprepared root canal surface due to the use of both continuous rotation and reciprocal instruments that tends to create the rounded shape preparation in oval shaped root canal. According to the study of Foschi et al. (2004), the presence of an irregular surface was the result of predentin, groove, and depression in the root canal wall.17 Therefore, irrigation and administration of medicaments plays important role for root canal debridement that was unable to reached by mechanical preparation. In this study, it can be seen that the degree of the continuous rotation samples smoothness is higher than the reciprocal samples, but the results showed no statistically significant difference. Measurement of surface roughness by a tester device was to produce numbers that describe the surface roughness of the sample, so the higher the number indicates the more rough surface and also vice versa. Non-significant difference between these two samples might be due to the same cross-sectional design of these two instruments (S shape). The final shape of the root canal relies on the preparation techniques and cross-sectional design of the instruments.18 The difference between both instruments lies in the direction of rake angle, where the Mtwo instrument cuts clockwise, and the Reciproc instrument cuts in counter-clockwise direction. As for the movement and preparation techniques, Mtwo rotates continuously at a single length technique, while Reciproc move reciprocally with a 120o angle difference and will reaches one full rotation in three cycles with crown down techniques.12 The use of surface roughness tester to measure the smoothness of the root canal wall has the advantage that it is quite accurate in measurement and has simple procedure. However, some difficulties were encountered during the study such as the difficulties in tooth splitting (to get the two halves are symmetrical), where there was an uneven section on the edges of the sample. The existence of the uneven edges 336
of the sample complicates the research, because a flat surface was needed so it will not interrupt the stylus/needle gauge. The stylus/needle gauge was unable to touch the over concave surface because the size of the stylus is quite short, therefore the samples needs to be flattened without disturbing the surface that will be measured. The narrowness of the root canal also limit the measurement, so it can only be done two measurements on different trajectories In this study, the difference in preparation motion has no influence on the smoothness surface of the root canal walls. Therefore, both of these instruments do not have different root canal wall surface smoothness at the apical third area.
6.
7.
8.
9.
10. Conclusion From this study, it can be concluded that the apical third of the root canal walls that have been prepared by a continuous and reciprocal instruments have the same degree of smoothness. Therefore the authors suggest to do further research using other methods that are easier and simpler and the instrument with the reciprocal motion can be used as an alternative to prepare the root canal easier and faster.
11.
12. References 1.
2.
3.
4.
5.
Friedman S, Mor C. The success of endodontic therapy healing and functionality. J Calif Dent Assoc 2004;32(6):493-503. Schilder H. Cleaning and shaping the root canal. Dental Clinics of North America 18(2):269-96, 1974. Calberson FLG, Deroose CAJG, Hommez GMG, Raes H, De Moor RJG. Shaping ability of GTTM rotary files in simulated resin root canals. Int Endod J 2002;35:60714. Franco V, Fabian C, Taschieri S, Malentaca A, Bortolin M, Del Fabbro M. Investigation on the shaping ability of nickel-titanium files when used with a Reciprocating motion. J Endod 2011;37:1398-1401. Bonaccorso A, Cantatore G, Condorelli GG, Schäfer E, Tripi TR. Shaping ability of four nickel-titanium rotary instruments in
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simulated s-shaped canals. J Endod 2009;35:883-6). Rangel S, Cremonese R, Bryant S, Dummer P. Shaping ability of RaCe rotary nickeltitanium instruments in simulated root canals. J Endod 2005;31(6):460-3. Yoshimine Y, Ono M, Akamine A. The shaping effects of three nickel-titanium rotary instruments un simulated s-shaped canals. J Endod 2005;31(5):373-5. Walton RE. Current concepts of canal preparation. Dental Clinics of North America 1992:36(2);309-26. Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observations. Int Endod J 2008;41:339-44. De Deus G, Brandão MC, Barino B, Di Giorgi K, Fidel RAS, Luna ASL. Assessment of apically extruded debris produced by singlefile ProTaper F2 technique under Reciprocating movement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:390-4. You SY, Kim HC, Bae KS, Baek SH, Kum KY, Lee WC. Shaping ability of Reciprocating motion in curved root canals: a comparative study with micro-computed tomography. J Endod 2011;37:1296-1300) Yared G. Canal preparation with only one Reciprocating instrument without prior filing: a new concept. Available at: http://www.vdwReciproc.de/images/stories/pdf/GY_Artikel _en_WEB.pdf. Accesed July 25 Bergmans L, Cleynenbreugel JV, Wevers M, Lambrechts P. Mechanical root canal preparation with NiTi rotary instruments: rationale, performance and safety. Am J Dent 2001;14(5):324-33. Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc 1955; 50: 544552. Gulabivala K, Patel B, Evans G, Ng YL. Effects of mechanical and chemical procedures on root canal surfaces. Endodontic Topics 2005;10:103-22. Bier CAS, Shemesh H, Tanomaru-Filho MT, Wesselink PR, Wu MK. The ability of different nickel titanium rotary instruments to induce dentinal damage during canal preparation. J Endod 2009 2009;35:236-8). 337
17. Foschi F, Nucci C, Montebugnoli L, Marchionni S, Breschi L, Malagnino VA, Prati C. SEM evaluation of canal wall dentine following use of Mtwo and ProTaper NiTi rotary instruments. Int Endod J 2004;37:832-39.
18. Turpin YL, Chagneau F, Vulcain JM.Impact of two theoretical cross-sections on torsional and bending stresses of nickeltittanium root canal instrument model. J Endod 2000;26:414-417.
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MTA APPLICATION IN INTERNAL MANAGEMENTCASE REPORT
RESORPTION
CASE
Diana Soesilo, Fani Pangabdian Staff Department of Endodontics, Faculty of Dentistry, Hang Tuah University Surabaya - Indonesia
Abstract Background. Internal resorption is an unusual condition where the dentin and pulpal walls begin to resorb centrally within the root canal. If the condition is discovered before perforation of the crown or root has occurred, root canal therapy may be carried out with the expectation of a fairly high success rate. ProRoot® MTA (Mineral Trioxide Aggregate) is used for creating an apical plug during apexification, repairing root perforations during root canal therapy and treating internal root resorption and can be used as both a root-end filling material and pulp-capping material. Case. A female patient, 15 years old with pulp necrosis in right upper first incisive with heavy discoloration at the tooth came to get orthodontic treatment. At radiographic view, there is radiolucency in the root canal. Case Management. Patient was treated with root canal therapy using MTA to fill the internal resorption in root canal. After one year examination, patient can be treated with orthodontics treatment and indicated repair at periapical bone lesion. Conclusion. In conclusion, MTA is an appropriate material to manage perforating internal root resorption Key Words : Internal Resorption, MTA Correspondence: Diana Soesilo, Staff Department of Conservative Hang Tuah University. e-mail :
[email protected]; Phone : +628165458101 INTRODUCTION Internal root resorption is a rare condition in permanent teeth, characterized by progressive lost of tooth substance starting from the root canal wall. Internal root resorption is usually asymptomatic, slowly progressing, and detectable upon routine radiographic examination or by the clinical sign of a ―pink spot‖ discoloration visible through the crown of the tooth as a result of internal root resorption in the coronal third of root canal1. Internal root resorption is a resorptive defect of the internal aspect of the root following necrosis of odontoblasts as a result of chronic inflammation. Resorption has been associated with multinucleated giant cells adjacent to a pulpal granulation tissue2. When this pathology has been diagnosed, if tooth is considered restorable and has a reasonable prognosis, endodontic treatment is the treatment of choice, and must
begin as quickly as possible to limit the progression of internal resorption3. Selection of suitable restorative material for cases of root perforation continues to be a challenge, especially if there is extensive tooth loss. Various biomaterials have been used to seal root perforations, among them MTA has gained popularity due to its biocompatibility, potential to induce osteogenesis and cementogenesis, sealing capacity superior to that of other materials, mechanical strength, capacity to promote healing of periradicular tissue, bacterial activity, capacity for adhesion in the presence of blood, radiopacity, resistence to humidity, in addition to being well tolerated by the tissue3,4. Mineral Trioxide Aggregate (MTA) is based on Portland cement, which primarily consists of tricalcium silicate, dicalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite. The particles of MTA are smaller than in Portland cement and bismuth oxide is added to increase radiopacity. MTA are two 339
types – grey and white. The white and grey MTA differs mainly in their content of iron, aluminium and magnesium oxides5. The compressive strength of MTA is about 40 Mpa after 24 hours. The sealing efficiacy against penetration of bacteria in microscopes between cement and tooth substance has shown better adaptation and less leakage of MTA, compared to amalgam, IRM, and SuperEBA6. CASE
Figure 2. Radiographic examination
The patient, a 15 year old young woman was came to get an orthodontic treatment, and was consulted from Orthodontics Department to Endodontic Department. In the clinical examination, there was discolored tooth of her first right upper incisive but asymptomatic. The patient was in good health, with no significant past or present illness, but she had dental trauma history at the anterior teeth. Posterior occlusion was normal, overjet 10 mm, overbite 3 mm. The tooth did not respond to vitality test. In the radiographic exam, the presence of an oval shaped bone rarefaction was verified in the central of the root canal, which characterized internal root resorption (Fig.1). Based on the clinical and radiographic findings the diagnosis was pulp necrosis with internal root resorption. The treatment plan was endodontic intracanal continued with orthodontic treatment (Fig 2).
CASE MANAGEMENT The tooth was isolated and opened the coronal access to the root canal. Necrotic pulp tissue was removed from the canal and working length was established with Diagnostic Wire Photo (DWP), it was 21 mm (Fig 3). Irrigation with Hydrogen Peroxide (H2O2) 3% and aquadest sterile. Calcium Hydroxide (Ca(OH)2) paste was placed in the canal to alkalinize the environment (Fig 4). After this a new appointment was made to change the Calcium Hydroxide dressing for every 30 days, all performed with canal instrumentation, irrigation with Hydrogen Peroxide 3% and final irrigation with distilled water and dressing with Calcium Hydroxide. From radiographic examination, had seen that calcium Hydroxide paste was always been resorbed after 30 days (Fig 5). After the period of 6 months from the beginning of treatment, and finding that the tooth was asymptomatic, without bleeding and the internal resorption radiographically stable, the internal pulp cavity was filled with white MTA (Fig 6). One month later, the patient was controlled and by the radiographic appearance the MTA didn‘t resorbed. Clinical and radiographic control was continued for seven month after beginning with the clinical treatment. The patient had already got her orthodontic treatment. The tooth was shown stable, without signs and symptoms and with absence of apical rarefaction (Fig 7).
Figure 1. Clinical examination
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Fig 3. DWP; Fig 4. Ca(OH)2 application; Fig 5. Ca(OH)2 resorbtion
Fig 6. MTA application; Fig 7. Control after 7 months
DISCUSSION Internal inflammatory root resorption is an insidious pathological process, initiated within the pulp space and associated with loss of dentine. It is often described as oval shaped, symetrically distributed over the root canal space, and is usually asymptomatic and detecable by radiographs. When diagnosed, immediate removal of the causative agent must be considered, aiming to arrest the cellular activity responsible for the resorptive activity4,7. The process of tooth resorption involves an elaborate interaction among inflammatory cells, resorbing cells, and hard tissue structures. However the process of tooth resorption is believed to be very similar to that bone
resorption. Injuries to and irritation of bone, dentin, and cementum lead to chemical changes within these tissues. The result is the formation of multi-nucleated giant cells, which are referred to as clasts. The clastic cell is the key cell type which is responsible for all hard tissue resorptive processes, which are accompanied by cells such as macrophages and monocytes in resorptive activities. Collectively, the cells orchestrate a complex interplay of molecular biologic events which involve cytokines, enzymes, and hormones which influence the progression of resorption8. After the diagnosis of internal root resorption, the treatment must be started rapidly, with the objective of removing necrotic portion of the pulp. The irregularities present in root canal system, especially in internal root resorption defects, make it difficult to clean and fill the root canal. The persistence of organic rests and bacteria in these irregularities may interfere in the success of endodontic treatment in the long term3. The use of root canal dressing with a material based on Calcium Hydroxide between sessions was aimed at dissolving remaining pulpal debris and alkalinizing the environment9. Calcium Hydroxide is antibacterial and has been shown to effectively eradicate bacteria that persist after chemo mechanical instrumentation. Calcium Hydroxide has also been shown to have synergistic effect when used in conjunction with sodium hypochlorite to remove organic debris from the root canal. Nevertheless, some case reports demonstrated the inability of Calcium Hydroxide to eliminate bacteria in ramifications because of its low solubility and inactivation by dentin, tissue fluids, and organic matter. Despite these limitations, the use of multiple Calcium Hydroxide dressings has been advocated to enhance chemo mechanical debridement of the internal root resorption defect7. Mineral Trioxide Aggregate (MTA) is known as a biocompatible material that may induce cementum formation around the furcal perforation in animal study. The clinical applications to human subjects also have proved that MTA is good for solving the problem derived from perforation. It is not interfered the presence of moisture and inhibits the activity of bacteria. A good success rate can be achieved 341
with MTA usage for repair of root perforations is recommended10. MTA seals vey superiorly and no gaps were found in any of experimental specimen. By virtues of providing good seal and preventing microleakage, it can be proclaimed as antibacterial agent. MTA just like Calcium Hydroxide induces dentine bridge formation. Hard tissue bridge deposited next to MTA is because of sealing property, biocompatibility, alkalinity. Tricalcium oxide in MTA reacts with tissue fluids to form Calcium Hydroxide, resulting in har tissue formation. MTA is capable of activation of cementoblasts and production of cementum. It consistently allows for the overgrowth of cementum and also facilities regeneration of the periodontal ligament. MTA allows bone healing and eliminates clinical symptoms in many cases5. In this case, MTA was selected because of its known abilities for repairing, sealing and mechanically strengthening the weak lateral walls. MTA has many favourable properties, which include good sealing properties, biocompatibility, bactericidal effects and radiopacity. White MTA was used because it was a low iron and nonstaining formula11. CONCLUSION Internal root resorption is often difficult to distinguish since resorptive defect is often asymptomatic, usually recognized by routine radiographs. In this case, the diagnosis of internal resorption was based on the patient‘s radiographic examination and clinical features. In this case, Calcium Hydroxide plus instrumentation was effective in dissolving and flushing granulation tissue. But radiographic examination showed there was Calcium Hydroxide paste resorbtion. The use of MTA sealed the defect well. The patient returned after seven months with no signs or symptoms. The tooth was in function with no discomfort or pain during that time. Finally, the treatment of the defect with MTA was considered successful as evidenced by clinical and radiographic finding.
REFERENCES 1.
Patel S, Ricucci D, Durak C, Tay F. Internal Root Resorption : A Review. J Endod 2010;36:1107-21. 2. Arjun Das KP. Mineral Trioxide Aggregate for Management of internal Resorptive Defect. JIADS vol. 2 Issue 1 JanuanyMarch. 2011:46-7. 3. Morais C.A.H., Candido A.G., Pires L.C, Pascotto R.C. The Use of White MTA in the Treatment of Internal Root Resorption : Case Report. Dental Press Endodontic. 2012 Oct-Dec; 2(4):51-6. 4. Jacobovitz M, de Lima RKP. Treatment of Inflammatory Internal Root Resorption with Mineral Trioxide Aggregate : A Case Report. International Endodontic Journal 2008;41:905-12. 5. Rao Arathi, Rao Ashwini, Shenoy R. Mineral Troxide Aggregate – A Review. The Journal of Clinical Pediatric Dentistry Vol. 34 No. 1. 2009:1-6. 6. Bergenholtz G, Horsted-Bindsleu P, Reit C. Textbook of Endodontology. 2nd Ed. Blackwell Publishing Ltd. West Sussex. 2010;212-16. 7. Sierra-Lorenzo A, Herrera-Garcia A, Alonso-Ezpeleta LO, Segura-Egea JJ. Management of Perforating Internal Root Resorption with Periodontal Surgery and Mineral Trioxide Aggregate:A Case Report with 5 Years Follow Up. International Journal Periodontics Restorative Dent 2013;33:3-9. 8. Yadav P, Rao Y, Jain A, Relhan N, Gupta S. Treatment of Internal Resorption with Mineral Trioxide Aggregates: a Case Report. Journal of Clinical and Diagnostic Research. 2013:1-2. 9. Siqueira JF Jr, Lopes HP. Endodontia : Biologia e Tecnica. 2nd Ed. Guanabara Koogan. Rio de Janeiro. 2004:581-618. 10. Upadhyay Y. Mineral Trioxide Aggregate Repair of Perforated Internal Resorption : A Case Report. Journal of Oral Health and Community Dentistry 2012;6(3):149-50. 11. Meire M, Moor RD. Mineral Trioxide Aggregate Repair of A Perforating Internal Resorption in A Mandibular Molar. J Endod 2008;34:220-23. 342
Retreatment on inadequate root canal filling of lower left premolar using NiTi file rotary instrument Fairuza Afada*, Ketut Suardita**, Cecilia Gerda Juliani Lunardhi** * Resident of Conservative Dentistry, Faculty of Dentistry, Airlangga University, Surabaya – Indonesia ** Staf of Department of Conservative Dentistry, Faculty of Dentistry, Airlangga University, Surabaya – Indonesia
ABSTRACT Background: The success of root canal treatment was influenced by three main factors, cleaning, reshaping, and obturating. Endodontic failure may occur if one or more of those factors were failed to be established. Case: A 69 years old male patient complained on lower left premolar had been painful since 2 weeks ago. The tooth had done RCT (Root Canal Treatment) 2 years ago. On radiographic there was a diffuse radiolucency at periapical and 3mm gutta percha underfilling. Clinically there was restoration that had been separated. A procedure to remove root canal filling materials from the tooth using rotary retreatment file instrument (ProTaper, Dentsply) was done according to the sequence (D1, D2, D3). These instrument made the procedure became less difficult and faster. Reshaping was also held on finishing rotary file (F3). Antimicrobial therapy was using calcium hydroxide (Metapex, Meta Biomed). After 3 periodic intracanal medicament visits, obturation was performed and PFM (Porcelain Fused to Metal) crown as final restoration. Long term prognosis should be evaluated periodically. Keywords: Retreatment, underfilling, untreated canal, rotary instrument. INTRODUCTION Endodontic treatment failures can be caused by a number of factors namely cleaning and shaping procedures which were deficient, inadequate obturation, and corona restoration leakage. The presence of untreated root canals (both main and additional root canal) is the second common cause of endodontik treatment failures .1 Obturation of the root canal which is not strong is one cause of the common endodontic treatment failures. underfill is the filling which is not hermetic because it doesn't reach the working length.2 Endodontic treatment failures due to inadequate obturation can be overcomed by endodontic retreatment.3 many literatures explain that the premolars have one root canal. But according to the anatomical variability of Boehne, premolar root which tends to be more flat is more difficult to find than on the molar. some cases which
were resolved by Boehn showed faily large variability on the premolar root anatomy .4 Premolar in general has sapikal bifurcation and even trifurcations. Contemporary endodontic techniques and many other supporting examinations allow the retreatment success without surgery on apical region.4 In this case report will be discussed about the re-treatment of endodontic treatment in endodontic treatment failure due to inadequate root canal obturation and the existence of the root canal which has not been treated. CASE REPORT A 69 years old male patients came with complaints of lower left molar felt uncomfortable if chewed and the food was frequently tucked. Dental root canal treatment was done 2 years ago and its filling was off two weeks ago. Based on the clinical examination of the teeth 35 was seen a cavity on the distal, on 343
the teeth 36 and 37 there was a crown porcelain fused to metal which began to damage at the occlusal. At radiographic examination, it was known that on the tooth 35 en done the root canal treatment but the obturation result was inadequate (underfilling) and there was radiolucent on periapical region (Figure 1).
using 2% NaOCl and sterile Aquades, and the preparation of root canal using lubricant that was RC-Prep (Premier).
Gambar 3. The trial of Guttapercha.
Figure 1: The result of previous RCT.
From the examination above it was obtained that there was a chronic apical abscess on the tooth 35 due to endodontic treatment failure (inadequate obturation). CASE MANAGEMENT On the first visit after the determination of dental diagnosis, the guttapercha was taken from the root canal using ProTaperrotary retreatment instrument. After the gutta percha was drawn, the working length was measured using K-file 17 with the help of apex locator (VDW), which was later confirmed by radiographic picture and it was obtained the working length 21 mm (Figure 2).
Dressing was performed using calcium hydroxide (Metapaste, Biomed) and the tooth was filled temporarily. Patients was instructed to control one week later. The next day, the patient came complaining his tooth was still aching. Therefore, the temporary filling was removed and the search of orifice was done due to the posiibilty of root canal undiscovered. The additional root canal had been found using Kfiles 10 and apex locator (VDW). Later it was confirmed by radiographic picture and obtained 19 mm working length. The root canals was prepared with ProTaper Universal Rotary (Dentsply) until it was obtained tug back on the file F3, then the radiographic picture was done for gutta percha trial. Dressing was performed using calcium hydroxide (Metapaste, Biomed) and the tooth was filled temporarily. Patient was asked to control one week later and was given analgesics prescription when needed. One week later the patient returned, he didn't feel any pain. Then the temporary filling was disassembled and the root canal was irrigated to clean the calcium hydroxide paste. After that the root canal was dried with paper points and filled with single cone technique using ProTaper F3 guttap as long as 21mm and 19 mm with sealer (Top Seal, Dentsply) and filled temporarily. Then, the radiographic picture of the root canal obturation was done. (Figure 4).
Figure 2. The Diagnose using Wire Photo
Then the root canals was prepared using ProTaper Universal rotary (Dentsply) in sequence to obtain the tag back to the file F3. Each turn of the file number is always irrigated 344
Figure 4. After obturation.
A week later the patient came back to control his post root canal obturation. It was not obtained any complaints so the guttap was taken off for placing prefabricated post (Unimetrik, Dentsply). Then the radiographic picture was done to confirm the diameter and length of the peg whether they were proportional with the root canal circumstances. Then the peg was inserted using luting cement Fuji I (GC). Furthermore, the manufacture of core build-up with dual cure composite resin core build-up (Multicore) (Figure 5).
. Figure 6. The temporary crown on teeth 35, 36 dan 37.
Patient was asked to return one week later. On that visit, there was subjectively no complaints and no clinical abnormalities in the oral cavity of patient. Temporary crown was removed and then the trial of crowns porcelain fused to metal (PFM) was done. It was seen that the crown had a contact area, adaptation edge, check occlusion and articulation. Anatomy and the teeth color were in line with the expectations. The installation PFM crowns used Fuji I Glass ionomer luting cement (GC). On the next visit was done control then subjective and objective examinations were done and no. abnormalities were found (Figure7)
Figure 5. After the formation of core.
Teeth 35, 36, 37 were molded using materials rubber-based (Aquasil, Dentsply) with double impression technique and antagonist teeth molded with alginate molding material. Then the bite record was done. Determination of tooth color was done with the help of Vita Classical Shade Guide (Vident) and the color of the teeth porcelain fused metal crown would use A3. The molding result in the form of a working model in occlusion and the assistance of bite records were sent to the laboratory for processing. Tooth color and design of the crown was informed to the dental laboratory. Then, it was made a temporary crown with self cured acrylic resin and temporary cementing was done. (Figure 6)
Figure 7. Insertion of PFM.crown
DISCUSSION The failure of endodontic treatment of the tooth 35 due to the root canal obturation which was not adequate and the untreated root canal. From these circumstances, the microorganisms and toxins can penetrate through the network periapeks.5
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Premolar had a strange pulp anatomical variation. On one root canal often had two or even three branches. The description of accurate radiography was an important part of the evaluation of endodontic treatment. Conventional radiography was still the most widely used in endodontic treatment. Many literatures discussed the limitations of conventional radiography, one of the result was misinterpretation or missdiagnose. The evaluation of the cone beam computed tomography (CBCT) showed radiographic results which were accurate as three-dimensional images. The current literature had shown that the CBCT results could explain the existance of lesiperiapika which were more accurate than conventional radiography. It showed the location and extension of the perforation, and clear the root canal anatomy. Despite the many benefits of CBCT compared to conventional radiography, in its use had to consider the basis of radiation accepted by the patient.6 On the re-endodontic treatment was required to take the entire root canal obturation material available, handle root canal obstruction and overcome the hindrance of reaching the working length. If all of these steps could be done well, then cleaning and shaping procedures could be done well too, so that adequate obturation could be done.7 To remove the guttap, ProTaper Retreatment instrument was used because it was easy, efficient and effective. D1 ProTaper file was used for the first time because it had a cutting tip that could make a way through guttap. Because the previous obturation length was more than 2/3 the length of the root canal, so the process of taking guttap followed by ProTaper file D2 and D3.8 The root canal irrigation must be done in order to clean the root canal from microorganisms, debris and necrotic tissue and lubricate the instruments and root canal walls. 2% NaOCl was chosen as one of the ingredients of irrigation because it was one of irrigation materials with the highest antibacterial. To prevent entrainment of NaOCl in the root canal, then rinsing with aquades steril was done.9 Preparation was done with the crown down pressureless technique to maintain the shape of the tappered root canal.10 Calcium
hydroxide was chosen as a dressing material because it was alkaline so it was antibacterial, non-toxic to the tissue, could be resorbed by the body and could stimulate the formation of the tooth hard tissue.11 Obturation of the root canal was performed with single cone technique because the diameter of the root canal after preparation was not too wide and apical seal was obtained by using ProTaper guttap F3. In addition, the single cone technique was the most convenient filling technique, it had the good quality of obturation and apical marginal infiltration, as well as able to reduce bacterial penetration optimally.12 While waiting for the manufacture of the final restoration, the temporary crown was made to maintain occlusion, prevent the occurrence of fractures in the teeth which had been prepared and keep the teeth to work well.13 Post Prefabricated was required to provide retention to the core and final restoration.14 The Jacket of porcelen crown fused to metal was chosen because its aesthetic was good and strong enough to endure the pressure and load chew. 15 CONCLUSION Evaluation using CBCT before endodontic treatment can prevent the failures in the treatment and also can help endodontic retreatment without surgery. Root canal treatment will give a satisfactory result and a good prognosis if the determination of diagnose is accurate and the techniques, materials and technologies used are also in accordance with the indication. REFERENCES 1. Khan M, Rehman K, Saleem M. 2010. Causes of Endodontic Treatment Failure - A Study. Pakistan Oral & Dental Journal 30(1): 232-236. 2. Chugal NM, Clive JM, Spangberg LS. 2003. Endodontic Infection: Some Biologic and Treatment Factors Associated with Outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 96: 81-90.
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3. Rosenberg DB. 2009. Endodontic Retreatment versus Tooth Extraction Endodontic Practice :24-30. USA. 4. Boehne Daniel J. 2012. Premolars: often more anatomic variability than molars. California 5. Cohen S, Hargreaves KM. 2011. Pathways of The Pulp. 10th Edition. St. Louis: Mosby. 6. Randy L. Ball 7. Ruddle CJ. 2004. Nonsurgical Endodontic Retreatment. Journal of Endodontics 30(12): 827-845. 8. Gu LS, Ling JQ, Wei X, Huang XY. 2008. Efficacy of Protaper Universal Rotary Retreatment System for Gutta-Percha Removal from Root Canals. International Endodontic Journal Vol. 41: 288–295. 9. Schafer E. 2007. Irrigation of The Root Canal. Quintessenz Journal 1(1): 11-27. 10. Riitano F. 2005. Anatomic Endodontic Technology (AET) – ACrown Down Root Canal PreparationTechnique: Basic Concepts, Operative Procedure and
Instruments. International Endodontic Journal 38: 575–587. 11. Mustafa M, Saujanya KP, Jain D, Sajjanshetty S, Arun A, Uppin L, Kadri M. 2012. Role of Calcium Hydroxide in Endodontics: A Review. Global Journal of Medicine and Public Health 1(1): 66-70. 12. Pereira AC, Nishiyama CK, Pinto LC. 2012. Single-Cone Technique: A Literature Review. RSBORevista Sul-Brasileira de Odontologia 9(4): 442 – 447. 13. Beckman T. 2005. Temporary Crown Restorations Second Edition : 8-9. California: Quercus Corporation. 14. Peroz I, Blankenstein F, Lange KP, Naumann M. 2005. Restoring Endodontically Treated Teeth with Posts and Cores –A Review. Quintessence International 36 (9): 737 – 746 15. Cheung W. 2005. A review of The Management of Endodontically Treated Teeth: Post, Core and The Final Restoration. Journal of American Dentist Association Vol. 136: 611 -619.
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Internal bleaching treatment in geriatric patient: review and case report Fani Pangabdian, Diana Soesilo Staff Department of Endodontics Faculty of Dentistry, Hang Tuah University Surabaya - Indonesia Abstract Background. Internal bleaching is a common treatment for non-vital discolored teeth due to dental trauma. Internal bleaching ingredient is a strong oxidizing agent because it has power to penetrate the organic material on the dentinal tubules so it can push the dye out. This case report aim is to show that the internal bleaching treatment as an alternative for non-vital discolored teeth caused by trauma and repair is done with composite resin restorations. Case. A female patient, 65 years old who had previous endodontic treatment performed by both clinical and radiographic, and treated internal bleaching using opalescence endo containing 35% hydrogen peroxide. Case management. Cleaning pulp chamber of the previous dental fillings , removal gutta point 2-3 mm below the orifice using a round bur with an angle of 45o to the direction of the labial, zinc phosphate cement applications on gutta point, etching with 37% phosphoric acid, applications opalescence endo containing hydrogen peroxide 35 % , giving temporary restoration with cavit on the cavity. Then patient being controlled after 1 week and repeated 3 times until the patient reaches the desired color. At evaluation after three applications of bleaching materials, the tooth‘s color has changed according to the color of adjacent teeth. Composite resin restorations performed one week later to wait the stable color and restore the tooth‘s shape. Conclusion. The conclusion of this report is non-vital discolored tooth not only can be treated with veneers or crowns treatment, but also internal bleaching treatment.
Key Words : Non-vital discolored teeth, internal bleaching Correspondence: Fani Pangabdian, Staff Department of Conservative Hang Tuah University. e-mail :
[email protected]; Phone : 0817386917 INTRODUCTION Anterior tooth discoloration is a cosmetic problem that is significant enough to encourage patients and dentists seeking improvement efforts. Although it has been available restoration methods to overcome them, such as crown and veneer treatments, this discoloration can be corrected totally or partially with teeth whitening or bleaching treatment. Bleaching is a process that will make teeth look whiter. The process of teeth whitening was first described in 1864 and has developed to the present. There are several options of teeth whitening treatments which are adapted to the type of color change that happened1. Discoloration of the teeth can be caused by several factors, such as external and internal factors2,3. Discoloration from external factors
can be classified either derived from nonmetallic materials and metallic materials. External metallic discoloration is: a nonenzymatic browns coloring (natural degradation process of glicocylatate protein), the formation of metal sulfide pigments, and exposure to metallic salts. External non-metallic discoloration is a chromogen which is released by the food into the oral cavity during the process of digestion of food components, beverages (especially tea and coffee), mouthwash, medications, or cigarettes2,3. Internal factors discoloration caused by dental restorative materials (amalgam), caries, trauma, infections, drugs (tetracycline and fluoride use in large doses over several years), disturbance during pregnancy (e.q: nutritional deficiencies, pregnancy complications, anemia and bleeding disorders), genetic factors and 348
hereditary disease that affects the development and maturation of the enamel and dentin, systemic disease during the period of tooth formation.2,3 Bleaching materials a. Hydrogen Peroxide Hydrogen peroxide is a powerful oxidizer available in varying degrees of concentration, though commonly used is a stabilized solution with levels of 30 to 35 percent. This high content of solution should be used with caution because it is unstable, rapidly losing oxygen, and can explode if not kept refrigerated or kept in the dark. Hydrogen peroxide is a caustic material and can cause tissues burning on contact with it. b. Sodium perborate This material can be obtained in powder form or in various combinations of commercial mixtures. At the initial form, this material contains approximately 95% perborate, which can result in 9.9% oxygen. Sodium perborate is stable when in a dry state, but if there is an acid, warm water, or water, will turn into sodium metaborate, hydrogen peroxide, and nasen form oxygen. Mixtures of sodium perborate monohydrate that available are trihydrate and tetrahydrate. The differences are in oxygen content, which determine the effectiveness of the material. Mixture of sodium perborate that used to is alkaline and pH depend on the amount of H2O2 released and the remaining Na-metaborate. Sodium perborate is easier to control and safer than high concentrated solution of hydrogen peroxide. Therefore, this material is the material of choice for internal bleaching. c. Carbamide Peroxide Carbamide peroxide, also known as urea hydrogen peroxide, can be obtained in a variety of concentrations between 3 and 15%. Well known commercial preparations contain approximately 10% carbamide peroxide with an average pH of 5 to 6.5. Usually also contains glycerin or propylene glycol, sodium stanate, phosphoric acid or citric acid, and aroma. In some preparations, added Carbopol, a watersoluble resin, to prolong the release of active peroxide and increase the storage period.
Carbamide peroxide 10% will break down into urea, ammonia, carbon dioxide, and about 3.5% hydrogen peroxide. Carbamide peroxide system that used in external bleaching is associated with a variety level of damage to the tooth and surrounding soft tissue. This material may affect the retention of composite resin and marginal seal. Therefore, these materials should be used with extreme caution, usually under the strict supervision of a dentist.1,3 Case A female patient aged 65 years old came to the Dental Hospital School of Dentistry, University of Hang Tuah with discoloration at left upper front teeth. The anamnesis obtained the information that patients experiencing trauma 20 years ago, but just checked and conducted promptly to the dentist about 2 years ago when the tooth has already experiencing a change in color. After 2 years patients were never control again to the dentist because there was no symptom but the tooth color getting darker. Clinical examination showed that discolored teeth 21.22 (darker than 5M), percussion is negative, normal gingiva around the tooth. To help enforce the diagnosis, periapical radiographic photo has done on teeth 21 and 22.
Fig.1. Showing discoloration teeth 21,22
The result of periapical radiographic photo showed that post root canal treatment was good, with marked by root canal filled hermetically with gutta-percha points.
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Fig 2. Radiograph periapical teeth 21,22
CASE MANAGEMENT Based on anamnesis, clinical and radiographic examination can be known the clinical symptom of the tooth is discoloration because of trauma and post root canal treatment. Based on diagnose then the dentist prepared a treatment plan that is conducted internal bleaching and permanent restoration using composite resin filling. First visit: - Diagnose - Initial tooth color adjustment 5M1 (Vita 3D master) - Cleaning pulp chamber from the previous dental fillings - Removal gutta point 2-3 mm below the orifice using calibration drill - Zinc phosphate cement applications on gutta point - Etching with 37% phosphoric acid. - Applications of bleaching materials ―Opalescence Endo (35% H2O2) - Giving temporary restoration with cavit on the cavity.
Fig.4 Applications etching Fig.5 Applications ―Opalescence Endo‖
Control I : • Subjective examination: Anamnesis: no symptom • Objective examination: EO : no abnormalities IO : Cavit is still good. gingiva normal, percussion is negative, tooth color 4M1 (Vita 3D master) - Cleaning pulp chamber of the previous dental fillings and bleaching materials - Etching with 37% phosphoric acid - Applications of bleaching materials ―Opalescence Endo (35% H2O2) - Giving temporary restoration with cavit on the cavity.
Fig.6 Shade was recorded again (4M1 vita 3D master)
Fig.3 Removal gutta point 2-3 mm below the orifice
Control II : • Subjective examination: Anamnesis: no symptom • Objective examination: EO : no abnormalities IO : cavit is still good. gingiva normal, percussion is negative, tooth color 3M1 (Vita 3D master) 350
-
Cleaning pulp chamber of the previous dental fillings and bleaching materials Etching with 37% phosphoric acid Applications of bleaching materials ―Opalescence Endo (35% H2O2) Temporary restoration with cavit on the cavity.
Fig.7 Shade was recorded again (3M1 vita 3D master)
Control III : • Subjective examination: Anamnesis: no symptom • Objective examination: EO : no abnormalities IO : Cavit is still good. gingiva around normal, percussion is negative, tooth color 2M1 (Vita 3D master) - Cleaning pulp chamber of the previous dental fillings and bleaching materials - Permanent restoration using composite resin filling
Fig.8 After 3 visits, the shade (2M1 vita 3D master) as desired was obtained
DISCUSSION Bleaching is a process that will make teeth look whiter. There are several options of teeth whitening treatments that are adjusted to the type of teeth discoloration.4 Discoloration of
the teeth can be caused by several factors, that are external and internal factors.2,3 Intrinsic discoloration caused by unification chromogenic material in the enamel and dentin, during odontogenesis or post tooth eruption. Intrinsic discoloration post eruption usually occurs as a result of trauma that leading to hemorrhage which causing the tooth pulp becomes necrotic. Hemolytic releases hemoglobin, which get degraded to release iron. Iron combines with hydrogen sulfide become iron sulfide that spreads into the dentinal tubules and produces bluish / black color. Failure to take all the remnants of the pulp during endodontic therapy also can cause discoloration. Pulp fragments that remains in the crown, usually in the pulp horn, can cause discoloration gradually. Pulp horn must be opened and exposed during cavity entrance opening procedure to ensure that the entire pulp tissue has been lifted and avoid root canal cement retention at a later stage. Dirty or brown color on the teeth are the characteristics of the pulp degradation without hemorrhage which cause protein degradation or pulp necrotic.3 In addition intrinsic discoloration can also be caused by endodontic treatment, i.e obturation materials and intracanal medicaments. Unclean obturation material from the pulp chamber when completing root canal treatment can cause blackish color of the teeth. Meanwhile, discoloration fom intracanal medicaments can be caused by iodoform or phenols medication which commonly inserted in the root canal, in direct contact with the dentin. Sometimes in a long term, thus allowing drug penetration and oxidize. These materials tend to color dentine gradually darker than before.5 In this case the material chosen is Hydrogen Peroxide. Hydrogen peroxide is a powerful oxidizer available in varying degrees of concentration though commonly used is a stabilized solution with levels of 30 to 35 percent. This high concentration solution should be used carefully because it is unstable, rapidly losing oxygen can lead to explode if not kept refrigerated or kept in the dark. In addition this material is caustic and can burn the material when in contact with tissue. The mechanism of tooth whitening is the oxidation reaction of the peroxide. The process of bleaching will occur when the material is 351
done converting peroxide pH, temperature and light to get free oxygen.6 Hydrogen peroxide has a low molecular weight and is able to penetrate into the enamel and dentin. Fundamental process of teeth whitening is the oxidation and reduction reactions. Hydrogen peroxide release oxygen which can terminate protein bond that joined with stain in single bond.7 Hydrogen peroxide (H2O2) as an oxidizing agent having free radicals that do not have a pair of electrons to be separated and then received by email so that the oxidation reaction occurs. Free radicals of peroxide are perhydroxil (HO2) and oxygenize (O+). Perhydroxil is a powerful and free radicals play a role in the process of teeth whitening, while the oxygenize as a weak free radicals.8 In its natural form, hydrogen peroxide is a weak acid and produce a weaker oxygen as free radicals. At under neutral pH conditions, the process of decomposition of hydrogen peroxide will not form active oxygen as expected, thus changing the pH becomes more alkaline will produce active oxygen free radicals more powerful beneficial effects of teeth whitening.6,9 Because the pH solution affects its effect, so buffer solution of pH change from 9.5 to -10.8 in order to generate more free radicals HO2.8 These free radicals will react with unsaturated bonds and cause electron conjugation and the change in the energy absorption of organic molecules in the structure of the tooth (email, dentin). Teeth molecules changed its chemical structure with the addition of oxygen and will form organic molecules email smaller with color that is brighter so as to produce effect bleaching and teeth become more luminous.10,11,12 CONCLUSION The conclusion of this report is non-vital discolored tooth not only can be treated with veneers or crowns treatment, but also internal bleaching treatment.
Filipov, I., Vladimirov, S., 2007, ―Method for Professional Whitening of FluorColoured Teeth‖, J. IMAB -Annual Proceeding (Scientific Papers), book 2, 4345 3. Ross Kerr, A., Jonathan A Ship, ―Tooth Discoloration‖, eMedicine-Article Last Updated:Mar16, 2007 www.clevelandclinic.org/health/healthinfo/docs/3100/3147asp index= 10958, diakses tanggal 25 Maret 2008 4. Gursoy, U. K., Eren, D. I., Bektas, O. O., Hurmuzlu, F., Bostanci, V,, Ozdemir, H., 2008, ―Effect of external tooth bleaching on dental plaque accumulation and tooth discoloration‖, J. Med Oral Patol Oral Cir Buccal, 1,13(4), E266-9 5. Cohen, Stephen dan Richard C.Burns. Pathways of The Pulp. Mosby Co. St. Loius. 2002. P. 585-8 6. Rismanto, D.Y, Damayanti, I. M, Dharmo, R. H., 2005, ―Dental Whitening‖, PT Dental Limas Mediatama, Jakarta, 9-14 7. Boksman, L., 2006, ―Current Status of Tooth Whitening‖, Literature Review, September, 76-79 8. Wagner, B. J., 1999, ―Whiter TeethBrighter Smiler‖, Special Supplemental issue-Access, September-Oktober,.1-12 9. Nakamura, T., Saito, O., Ko, T., Maruyama, T., 2001, ―The Effect of Polishing and Bleaching on The Colour oh Discoloured Teeth in Vivo‖, J. Oral Rehab., 28, 10801084 10. Bernie, K. M., 2003, ―Maintaining ToothWhitening Results‖, J. Pract. Hygiene, 3436 11. Vanable , E. D dan LoPresti, L. R, 2004, ―Using Dental Material‖, Pearson Prentice Hall, New Jersey, 80-85 12. Suprastiwi, E., 2005, ―Penggunaan Karbamid Peroksida sebagai Bahan Pemutih Gigi‖, Ind. J. Dentistry, 12(3): 139-145 2.
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Walton, Richard E. Torabinejad, M. Prinsip dan Praktik Ilmu Endodonsia. Edisi 3. Jaksarta: EGC. 2008. P. 60-9, 455-8, 458-9, 459-71
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Cytoxicity Test of Diadema Setosum Shell Extract Againts Fibroblast Culture Cell ( Uji Sitotoksisitas Ekstrak Cangkang Landak Laut (Diadema Setosum) Terhadap Kultur Sel Fibroblas ) Novi Virina Irawati*, Aprilia**, Meinar Nur Ashrin*** * Students of the Faculty of Dentistry, University of Hang Tuah ** Department of Conservative Dentistry Faculty of Dentistry, University of Hang Tuah *** Department of Prosthodontics Faculty of Dentistry, University of Hang Tuah
ABSTRACT Background: Calcium is one of the basic ingredients of calcium hydroxide which is used in the field of dentistry as pulp capping material. Utilization of shells to be used as biomaterials Diadema setosum new to the field of dentistry, because one of the ingredients in Diadema setosum shells is calcium. Purpose: To find out the cytotoxicity of Diadema setosum shell extract against fibroblast cell cultures. Material and Methods: This research was carried out by using post test only control group design. Fibroblasts cultured in 96 wells were divided into a control group of cells (n=6), media control (n=6) and treatment (n=6). Treatment groups were given various doses extract with concentration of shells Diadema setosum 125 µg, 250 µg, 500 µg, 1000 µg, 2000 µg. Optical density was read with an ELISA reader and calculated the percentage of viability. The cell viability data were analyzed by One-way ANOVA statistical test and LSD. Result: Data indicate decreased cell viability in all treatment groups, level of concentration of the extract by Diadema setosum shell, that is 125 µg(83.7%), 250 µg(81.9%), 500 µg(66.25%), 1000 µg(57.08%), 2000 µg(42.95%). There is a significant difference (p=0.000) in all treatment groups after analyzed by using One-way ANOVA. Conclusion: Diadema setosum shell extract do not have toxic effects on cultured fibroblast cells at concentrations 125 µg, 250 µg, 500 µg, 1000 µg and has toxic effects on cultured fibroblast cells at the highest concentration, that is 2000 µg. Keywords : Diadema setosum, fibroblast cell culture, cytotoxicity Correspondence: Aprilia, Departemen Konservasi Gigi, Fakultas Kedokteran Gigi Universitas Hang Tuah. Jl. Arif Rahman Hakim 150 Surabaya. Telp. (031) 5912191. E-mail:
[email protected] INTRODUCTION Pulp as one of the formative organs of tooth reacts to hot and cold stimuli which are referred as pain. That pain sensation acts as a warning sign of unusual situation in pulp as well as a protective reaction. Stimuli that induce protective reactions and are capable of damaging the pulp are bacteria (in the event of caries), mechanical stimuli (traumas, fractures,
cavity preparations and attritions), and chemical stimuli, such as acidic food and toxic dental materials. While mild pulp injury does not cause significant change, a severe one will result in local inflammation called pulpitis. Pulp capping is one of the methods used to alleviate inflammation in exposed pulp, with calcium hydroxide as the material of choice. This is because calcium hydroxide has excellent biocompatibility with high pH and
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bacteriostatic property. In addition, this material is also believed to stimulate new odontoblast cells differentiation which then form the reparative dentin. One of the sea creatures whose potential has not really been tapped into is sea urchin/echinoid (or ‗landak laut/bulu babi‘ as it is usually called in Indonesia) . Its shell is coated by stable black liquid pigment. The shells be included as endoskeleton because their bodies are covered by epitelial layers. The skeleton is called as test that structured by calcium carbonat which are produced on the oral area. In dentistry, the high level of calcium inside the shell of sea urchin might be used as a pulp capping material. The pulp capping in the market are all synthetics. Nowadays, there are many researches that use natural materials as dental materials substitude. For that reason, a further experiment is needed to test the calcium inside the sea creatures as pulp capping materials. However, we have to test the cytoxicity test to fullfilled the material biocompatibility‘s requirement before we apply it on human being. Based on that explanation, writer wants to do a research about cytoxicity test of diadema setosum shell extract againts fibroblast culture cell. This research is done by using a spesific type of sea urchin called Diadema setosum because they are easily obtained and they are animals under supervision. MATERIALS DAN METHODS This is an analitic experimental laboratorium research. 2 Kilos of spineless Diadema setosum were cleaned using ice water and the organs were taken out. After it was cleaned, we dried out the shells using freeze dry method. Next, we extract 250mg of diadema setosum using ethanol solvent with macetarion method. The result was paste and devided into 7 groups, which are the control cell group, media control, concentration of 125 µg, 250 µg, 500 µg, 1000 µg, 2000 µg. Diadema setosum extract was diluted into α-MEM medium solvent to get the treatment group. After that, we did cytoxicity
test on fibroblast cell cultures and read the optical density in spectophotometry using the ELISA Reader with 620nm wavelength. Count the cells viability percentage mean of optical density sampel on each sample with various concentration againts cell control. RESULTS Cell viability results based on the cytoxicity experimental test of Diadema setosum shell against fibroblast cell cultures are presents on Table 1 bellow. Sampe l
Contro l cells
125
250
500
1000
2000
I
0
40.3
60.6
III
0
42.5
55.1
IV
0
38.1
50.9
V
0
52
52.7
VI
0
34. 6 33. 2 38. 3 23. 1 33. 7 39. 6
62.9
0
13. 1 15. 9 20. 5 12. 5 21. 2 25. 4
42
II
10. 6 12
42.6
60.2
18. 4 12. 7 22. 3 21. 4
Tabel 1. Cell viability results
Based on the cell viability calculation results, we can calculate the mean and standard deviation score. Next, we tested the normality test (Shapiro-Wilk test) to find the data distribution. On this research, the data distribution is normal (p>0.05). After that, we do the homogenity test (Levene‘s test) and get 0.035 as the results which shows that the data is not homogen and we need to transform the data. We get a homogen data (p>0.05) after the data was being transformed and next we do ANOVA test and get F=116.946 as the result. P=0.000 (p<0.05) means there was a significant cell viability difference between the treatment groups. For that reason we need to find the cell viability significant comparison using the LSD test. The LSD test result show that there was a significant cell viability between the control group and all of the treatment groups (p>0.05). There were no significant difference on the 125 µg and 250 µg (p>0.05) which is p=0.522. 354
DISCUSSION Calculation is then done on the optical density results from the ELISA Reader to measure fibroblast cell viability in varying concentrations of Diadema setosum shell extract. The results were as follow: there occurred 57.05% cell death in 2000 µg concentration as compared to cell control (100%), whereas it was 42.92% in 1000 µg concentration, 33.75% in 500 µg concentration, 18.05% in 250 µg concentration, and finally 16.3% in 125 µg concentration. These results show that Diadema setosum shell extract concentration of 1000 µg, 500 µg, 250 µg, and 125 µg do not exhibit cytotoxicity since the fibroblast cell death caused was still below 50%. On the other hand, there was more than 50% cell death in 2000 µg concentration (57.05%) and hence this particular shell extract concentration is considered cytotoxic to fibroblast cells. Sea urchin shells and spikes contain toxic active substances like polyhydroxy and apelastroside A and B and the increase of these substances dissolved in the cell media results in its increasing cytotoxicity property. Polyhydroxy compound contains highly polar phenol groups which form polar bonds with cells‘ lipoprotein, resulting in the substance accumulation and followed with cell membrane lipid disintegration. This disintegration disrupts cell permeability and causes fibroblast cells to swell and finally burst, resulting in the eventual cell death. Therefore high phenol concentration is more cytotoxic than substituted lower ones and this explains the cell death that exceeds 50% in shell extract concentration of 2000 µg. On the other hand, Diadema setosum shell also contains advantageous phenol compound like polyhydroxyl naphtoquinone which has the same composition as echinochrome A. Phenol compound acts as antioxidant that scavenges ROS (Reactive Oxygen Species), which are pathogenesis causing endogenous and/or exogenous free radicals. These free radicals oxidise cell membrane lipoprotein and cause tissue damage, eventually leading to cell death.
Whereas antioxidant is needed by the body to stabilise and stop the formation of free radicals as well as preventing damage caused by the oxidative stresses on protein, lipid, and normal cells. Diadema setosum shell extract also contains calcium and magnesium minerals. In this study, we found 0.048% b/b calcium ions in the shell extract as compared to the 21.6% b/b measured in shell without the extraction process where the use of the ethanol containing substance may possibly cause the decrease in the calcium ions composition. The human body contains as much calcium as 2% of its total body weight and calcium itself has an important role in the organism‘s physiological and biochemical processes. Calcium ions are involved in the basic processes in the body like regulation of the cell membrane electric potential, DNA synthesis, enzyme activities, photosensory and chemosensory transductions, neurotransmitters release, membrane permeability, and intercellular communication. Calcium ion is one of the various second messengers that mediate cellular responses for a variety of stimuly like proliferation, movement, secretion, and cell neurotransmission. It enters the cell by diffusing through calcium channels on the plasma membrane, where the calcium ions move from the region with high concentration to the low concentration. Beside intracellularly, calcium ions are also found in the tooth enamel and dentine in the form of big and compact hydroxyapatite crystals (Ca10(PO4)6(OH)2) which together with carbonate, magnesium, sodium, potassium, and other ions are embedded in strong, almost insoluble protein fibers and constitutes enamel. These crystallized salts make enamel even harder than dentine, but dentine contains calcium salts which makes it very resistant to compression and collagen fibers which contributes to dentine‘s higher tensile strength. CONCLUSION From this study, we found variable cytotoxicity results with MTT assay using Diadema setosum in differing concentrations, 355
where concentrations of 125 µg, 250 µg, 500 µg, and 1000 µg do not show cytotoxicity as evident in cell death below 50% as compared to 2000 µg which therefore translates to this concentration being cytotoxic. The percentages of the cell death with respect to the concentrations are 125 µg (16.3%), 250 µg (18.05%), 500 µg (33.75%), 1000 µg (42.917%), and 2000 µg (57.05%). REFERENCES 1) Grossman.1995. Ilmu Endodontik dalam Praktek. Edisi 11. EGC : Jakarta, p.65. 2) Kidd Edwina A.M., Bechal S.J. 1991. Dasar-dasar Karies. EGC : Jakarta, p.33, 36. 3) Walton and Torabinejad. 2008. Prinsip & Praktek Ilmu Endodonsia. Edisi 3. EGC : Jakarta, p. 10-11, 36, 430. 4) Bence R. 2005. Buku Pedoman Endodontik Klinik. Penerbit Universitas Indonesia, p.11. 5) Melissa, et al.2011.Trioxide Aggregrate (MTA). Majalah Ilmu Kedokteran Gigi 2011. Available from http://ilib.ugm.ac.id/jurnal/detail.php?dataId=11 880. 6) Vimono IB. 2007. Sekilas Mengenai Landak Laut. Available from http://www.oseanografi.lipi.go.id/sites/de fault/files/oseana_xxxii(3)37-46.pdf. 7) Aprilia HA. 2012. Uji Toksisitas Ekstrak Kloroform Cangkang dan Duri Landak Laut (Diadema setosum) Terhadap Mortalitas Nauplius Artemia sp. Available from http://ejournals1.undip.ac.id/index.php/jmr/article/view/ 890. 8) Rovani CA., et al. 2008. Perbandingan Sitotoksisitas Endhomethasone, AH Plus dan Apexit Plus. Dentofasial Vol. 7 No. 2 : 71-72. 9) Dewi Indah K. 2006. Pengaruh Dosis dan Lama Pemberian Pulperyl Terhadap Kematian Sel Fibroblas. Fakultas Kedokteran Gigi Universitas Airlangga, Surabaya. JBP Vol. 8 No. 2.
10) Camandola S, et al. 2005. Suppresion of Calcium Release from Inositol 1,4,5Triphosphatesensitive Stores Mediates the Anti-apoptotic Function of Nuclear Factor-kB. The Journal of Biological Chemistry Vol. 280 No. 23. 11) Fadhilah D. 2012. Efek Minuman Terhadap Kekerasan Mikro Email Gigi Manusia (Penelitian In Vitro). Skripsi. Fakultas Kedokteran Gigi Universitas Hasanuddin, Makassar. 12) Shankarlal S, Prabu K, Natarajan E. 2011. Antimicrobial and Antioxidant Activity of Purple Sea Urchin Shell (Salmacis virgulata). American-Eurasian Journal of Scientific Research 6 (3):178181. 13) Mariyanti A. 2009. Aktivitas antioksidan Jus Tomat Pada Pencegahan Kerusakan Jaringan Paru-Paru Mencit yang Dipapar Asap Rokok. Jurusan Biologi Fakultas MIPA Universitas Semarang. Biosaintifika Vol. 1 No. 1.
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The Inhibition of Rhizophora mucronata Bark Extract Against The Growth of Enterococcus faecalis Bacteria Muhammad Baraja*, Twi Agnita Cevanti**, Kristanti Parisihni*** *Student of Faculty of Dentistry Hang Tuah University **Department of Conservation Faculty of Dentistry Hang Tuah University ***Department of Oral Biologic Faculty of Dentistry Hang Tuah University
ABSTRACT Backgrounds : Enterococcus faecalis is a gram positive facultative anaerobic bacteria which commonly found in failed endodontic treatment. ChKM is a root canal sterilization agents that commonly used. The extract from Rhizophora mucronata bark has a broad spectrum antibacterial effect against gram positive and gram negative bacteria, therefore it could be potentially developed as a root canal sterilization agents. Purpose : To determine the ability of Rhizophora mucronata bark extract in inhibiting the growth of Enterococcus faecalis bacteria. Methods : This study is an experimental study with post test only control group design, consisted of 8 groups: one positive control group (ChKM), one negative control group (DMSO 1%), and six treatment groups of Rhizophora mucronata bark extract with different concentrations of 2.5 mg/ml, 5 mg/ml, 10 mg/ml, 20 mg/ml, 40 mg/ml, and 80 mg/ml where each group consisted of 16 samples. Inhibitory effect was examined by measuring the clear zone around the filter paper. Data were analyzed by Kruskall-Wallis test and followed with Mann-Whitney test. Results : Results of this study indicate the presence of Rhizophora mucronata bark extract inhibition. In this study, the higher concentrations used, the greater the inhibitory effect. Average inhibition zone of each groups: 2.5mg/ml (6.56mm), 5mg/ml (6.83mm), 10mg/ml (7.27mm), 20mg/ml (7.77mm), 40mg/ml (8.29mm), 80mg/ml (9.23mm), ChKM (20.55mm), DMSO 1% (6.01mm). Conclusion : Rhizophora mucronata bark extract could inhibit the growth of Enterococcus faecalis. Key words : Enterococcus faecalis, endodontic treatment, Rhizophora mucronata bark Correspondence: Twi Agnita Cevanti, Departement of Conservation Faculty of Dentistry Hang Tuah University, Jl. Arif Rahman Hakim 150 Surabaya. Phone: (031) 5912191. E-mail:
[email protected] INTRODUCTION Bacteria play a major role in the development and process of pulp and periapical diseases.1 It can penetrate to the pulp and root canal through the exposed of dentin tubules due to caries process. Interactions and the production of toxin that produced by the bacteria can cause an endodontic infection.2 The main purpose of endodontic treatment is to eliminate all bacteria from the teeth and to keep it in sterile conditions by preventing the entry of bacteria during and after endodontic treatment. If these conditions can be achieved,
then the teeth can be maintained and restored to the normal function.3 In general, root canal treatment failure occurred due to an error at the time of diagnosis and treatment planning, restoration leakage, lack of knowledge about the anatomy of the pulp, inadequate root canal debridement and disinfection, human errors, underfilled or overfilled root canals, and vertically root fractured. But the major cause of endodontic treatment failure is because there are persistent bacteria and shown by the presence of periapical lesions on teeth that have been treated.2,4
357
Several studies have shown that anaerobes obligate were the dominant species in infected root canals, especially Enterococcus faecalis.5 The resistance of Enterococcus faecalis was caused by the ability of this bacteria to form a biofilm layer that can allow these bacteria to a thousand times more resistant to phagocytosis, antibody, and antimicrobial than organisms that do not produce biofilms.6 Enterococcus faecalis has cytolisin, AS-48 and bacteriosin that play a role in inhibiting the growth of other bacteria. This explains the low number of other bacteria in persistent endodontic infections and cause Enterococcus faecalis as the dominant microorganisms in root canals.7 Root canal sterilization is an integral part in root canal treatment and considered as an essential in root canal treatment success.2 Root canal medicines was used in order to eliminate bacteria that can not be eliminated by chemomechanical processes such as Enterococcus faecalis bacteria.8 One of the root canal sterilization agent that is often used was the phenolic group, such as ChKM and Cresophene. ChKM has some weaknesses such as strong odors, bad taste, can be absorbed by temporary restoration and can spread to the oral cavity, so that the patient will complain of bad taste and can cause allergic that can harm the pulp.2,9 Cresophene has cytotoxic content and has carcinogenic, mutagenic, and teratogenic possibilities.1 Mangrove as a coastal floral has some content that can be used in alternative medicine such as Rhizophora mucronata. Rhizophora mucronata could be easily found because the life span of this species extends from the outer coastal waters of the flooded area to sandy area.10 Rhizophora mucronata has greater antibacterial activity than the other types of mangroves and the bark of Rhizophora mucronata have greater antibacterial activity when it compared with other parts.11,12 Rhizophora mucronata bark extract can inhibit the growth of Staphylococcus aureus and Pseudomonas aeruginosa which is resistant to a number of antibiotics.11 Rhizophora mucronata bark extract inhibitory power at a concentration of 2.5 mg / ml to 80 mg / ml were tested against
mixed periodontopathogen bacterial growth and 80 mg / ml concentration was the most effective concentration to inhibit the growth of mixed periodontopathogen bacteria.13 Mangrove trunk and bark has a high content of active chemicals including tanin, because the skin has phloem which serves to distribute the results of tree photosynthesis to all parts. Beside tanin, there are some other content in the bark of Rhizophora mucronata that potentially could be used as an antibacteria such as alkaloid, saponin, flavonoid, and terpenoid.12,14 MATERIALS AND METHODS This study consists of 8 groups: one positive control group (ChKM), one negative control group (DMSO 1%), and six treatment groups with different concentrations of Rhizophora mucronata bark extracts, start from 2.5 mg / ml, 5 mg / ml, 10 mg / ml, 20 mg / ml, 40 mg / ml, and 80 mg / ml where each group consists of 16 samples. To make Rhizophora mucronata bark extract, 0.5 kilogram Rhizophora mucronata bark was dried out without being exposed to direct sunlight for ± 7 days, then cut and mash it using food processor. Rhizophora mucronata bark will shrink to 150 gram. Rhizophora mucronata bark extracts was produced using percolation method. Percolation method was performed by using 95% ethanol as the solvent. Percolation is done with simple laboratory scale equipment with capacity of 300 ml at room temperature (25-35°C). Rhizophora mucronata bark and ethanol soaked within three to six hour, after that filter it and collect the filtrate. The next step is evaporate the ethanol that contained along using an evaporator at 50°C. The extract was dissolved in DMSO 1% to obtain the desired concentration. Then Rhizophora mucronata bark extract mixed with the solvent using a vortex for 10 seconds. After that, sterilize and filter it with a micropore membrane syringe (0,45μm) to maintain purity and contamination from other microorganisms in the extract.13 Enterococcus faecalis bacteria colony was taken from a blood agar culture as much as 2 inoculation loop, then incubated it in brain heart 358
infusion liquid for 2x24 hours at 37°C in an anaerobic condition. Then the cloudiness of the bacterial suspension is equated to 0.5 Mc Farland standard to obtain a bacterial suspension containing 1.5x108 CFU / ml (Colony Forming Units) with the striped black and white background.. Prepare for sterile brain heart infusion agar for eight group, two control groups and six treatment groups. Take Enterococcus faecalis culture from brain heart infusion liquid which has been equated with the solution of Mc Farland (bacterial suspension containing 1.5x108 CFU / ml), and then wipe the bacterial culture on the entire surface of brain heart infusion agar using sterile cotton-tipped applicator. Put filter paper on an agar medium of Enterococcus faecalis using sterile tweezers. Drops 1% DMSO for 10 µm on filter paper that has been placed on an agar medium of Enterococcus faecalis to the negative control group. For the positive control group, drops the filter paper with ChKM for 10 µm, meanwhile for the treatment group, filter paper dripped with Rhizophora mucronata bark extract as much as 10 µm for each consentration.. Place the petri dish into the incubator for 2x24 hours at 37°C in an anaerobic condition. Measures the inhibition zone of extracts of Rhizophora mucronata using digital calipers (in mm). Inhibition zone of Rhizophora mucronata extract is a clear area around the filter paper. Clear zone was measured in the horizontal plane, vertical, and diagonal by using digital calipers (in mm), and then divided by 3 to obtain the average.15 RESULT Result of this study described as follows: Table 1 Average inhibition zone diameter and standard deviation of Rhizophora mucronata bark extracts against Enterococcus faecalis bacteria growth.
Groups K1 K2 K3 K4 K5 K6 K7 K8 Total
Replication 16 16 16 16 16 16 16 16 128
Average 6,0163 20,5469 6,5594 6,8294 7,2750 7,7700 8,2875 9,2313
Standard Deviations 0,00885 1,85829 0,54054 0,52884 0,62370 0,80118 0,81192 0,74478
Y
X
(-)
(+)
2,5
5
10
20
40
80
Graphic 1 Average inhibition zone graphic (Y=mm)
The graphic above shows the presence of inhibition of Rhizophora mucronata bark extracts. Followed by an increase of the inhibition from 2.5 mg / ml to 80 mg / ml. Largest inhibition from this experiment is the positive control group (ChKM). Largest inhibition from the treatment group is 80 mg / ml. DISCUSSION Inhibition of Rhizophora mucronata bark extracts increased according to the concentration used in this study. This happened because the greater the concentration of the extract, the greater the content of the active substances. In Rhizophora mucronata bark extract contains active compounds that were able to used as an antibacterial such as flavonoid, alkaloid, terpenoid, saponin and tanin.16 Alkaloid, flavonoid, tanin, and terpenoid content from Rhizophora mucronata bark extract is higher when compared with the other antibacterial contents from this mangrove.12 Antibacterial mechanism of tanin is due to the alcohol cluster of polyphenolics chain react with 359
lipids that compose bacterial cell walls. Because of these reactions, bacteriolysis will happen.17 Biological activity of flavonoid against bacteria was done by destroying the bacterial cell wall that consist lipids and amino acids and will react with the alcohol group of flavonoid compounds, so that the cell walls will be damaged and the compound can penetrate into the nucleus. Furthermore, this compound will have a contact with the DNA in the nucleus and through the polarity difference between the lipid constituent of the DNA with alcohol groups on the flavonoid compounds, there will be able to occur a reaction that will damage the lipid structure from DNA of bacteria so that bacteriolysis will be happened and the bacteria will also be dead.17 Alkaloid have an alkali cluster that contains nitrogen. The existence of these cluster when it contact with the bacteria will react with amino acids compounds that form the bacterial cell walls and DNA. The effect of this reaction could change the composition of amino acids in the DNA chain, and will change the genetical balance of the bacterial DNA, so that the DNA will be damaged. With the damage to the DNA, the nucleus will be damaged too. Damage to DNA in the nucleus is also going to intiate a lysis in the nucleus..17 Terpenoid is able to bind with lipid and carbohydrate that will interfere the permeability of the bacterial cell wall, so that bacteriolysis will be happened.18 Saponin compounds could inhibit the bacterial growth by forming a complex compounds with the cell membrane through the hydrogen bonds, so that will destroy the permeability of the cell wall and that will lead to a cell death.19 Brain heart infusion was selected as the growth medium because this media is effective for Enterococcus faecalis bacteria.20 Diffusion method was used as an antibacterial test methods in this study because the purpose of this study was to determine the inhibition of Rhizophora mucronata bark extracts against Enterococcus faecalis bacteria growth. This method is quite simple and effective way to determine the antibacterial activity of a sample and to determine the
inhibition of Rhizophora mucronata bark extracts.21 ChKM used as a control in this study because it is one of the root canal sterilization material from phenolic group which is oftenly used besides calcium hydroxide and cresophene.2 Cresophene not be used as a control in this study because it contains a steroid, where the antibacterial effects against bacteria Enterococcus faecalis is not known and also it's not yet known whether it works in accordance with the bark extract of Rhizophora mucronata. Calcium hydroxide proved not effective in inhibiting the growth of bacteria Enterococcus faecalis, due to the high pH which is the impact of the calcium hydroxide can not be maintained, this is happened due to the buffering capacity of dentin.2,9,22 ChKM consist of 60% chlorophenol , 40% camphor, and 6% menthol. ChKM has the ability to denaturate protein, inhibits the synthesis of nucleic acids, and destroy the bacterial cell membrane, so that the bacterial growth would be inhibited.23,24 Camphor works as a dilution and reduce irritation characteristic of pure chlorophenol. The camphor that contained in ChKM can prolong antimicrobial effects. Menthol can reduce irritant characteristic from chlorophenol too and can be used as a pain reducer. ChKM is able to destroy a variety of root canal microorganisms and could be used in root canal treatment with an apical lesion.2 ChKM work just like saponin that contained in the extract of Rhizophora mucronata that destroy the permeability cell wall and that will lead to cell death by forming complex compounds with the cell membrane through hydrogen bonds.19 The results from this research is 80 mg / ml is the concentration that has the biggest inhibition compared with the other concentrations. However, this concentration is smaller when it compared with the inhibition ChKM as a control. This is caused by the amount of saponin compounds in Rhizophora mucronata bark extract that has the same antibacterial mechanism as ChKM is not as high as the other active compounds such as alkaloid, flavonoid, tanin, and terpenoid. And because ChKM have a large enough phenol content (60%), when it compared with the extract Rhizophora 360
mucronata at the most effective concentration at 80 mg / ml is equal to 8%. Therefore ChKM has a greater inhibition when it compared with Rhizophora mucronata bark extract. However, ChKM have some weakness such as strong odors, bad taste, can be absorbed by temporary restoration material and can spread to the oral cavity, so that the patient will complain of bad taste and can cause an immune reaction that can harm the pulp, therefore extract Rhizophora mucronata bark can be developed as an alternative sterilization material in root canal treatment. Although it does not have strong odors, but Rhizophora mucronata bark extract has a disadvantage that the color is quite dark, so it can be a constraint to use this mangrove.. Because this study only shows the difference in the inhibition of Rhizophora mucronata bark extracts against Enterococcus faecalis bacteria growth at a concentration of 2.5 mg / ml, 5 mg / ml, 10 mg / ml, 20 mg / ml, 40 mg / ml and 80 mg / ml, further research needs to be done which might be expected to support the use of Rhizophora mucronata bark extract as an alternative sterilization materials in root canal treatment.
an antibacterial agents, especially for Enterococcus faecalis, and a research to find the inhibition of Rhizophora mucronata bark extracts against the growth of other bacteria in root canals.
CONCLUSION AND SUGGESTIONS
1.
Based on the results of this research, it is known that Rhizophora mucronata bark extracts have inhibitory effect against the growth of Enterococcus faecalis bacteria. Rhizophora mucronata bark extract at a concentration of 80 mg / ml was the most effective concentration to inhibit the growth of bacteria Enterococcus faecalis, but the inhibitory effect is smaller than the ChKM as a positive control. However before this extract is used as an alternative materials in root canal sterilization, there's some several test that needs to be done. Such as toxicity test of Rhizophora mucronata bark extracts against periapical tissues when compared with ChKM, tooth discoloration test after using Rhizophora mucronata bark extracts, dilution test to determine the minimum bactericidal concentration (MBC) of the extracts from the bark of Rhizophora mucronata against bacteria Enterococcus faecalis, a research to find a single extract from the Rhizophora mucronata bark active compound which can represent it as
ACKNOWLEDGEMENT This research is made possible through the help and support from everyone, including my parents, teachers, family, and friends. Please allow me to dedicate my acknowledgment of gratitude towards the following significant advisors and contributors. First, I would like to thank Twi Agnita Cevanti drg., Sp. KG for her advice, support, encouragement, and the theme of the research. Second, I would like to thank Kristanti Parisihni drg., M. Kes for her advice, support, and encouragement. Finally, I sincerely thank to my parents, family, friends, and to all those that I can't mention who provide the love, advice and moral support. The product of this research would not be possible without all of them. REFERENCES
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Stuart CH, Schwartz SA, Beeson TJ, Owatz CB, 2006. Enterococcus faecalis: Its Role In Root Canal Treatment Failure and Current Concepts in Retreatment. Journal of Endodontics, 32(2): 93-98 Kayaoglu G, dan Ørstavik D, 2004. Virulence Factors of Enterococcus faecalis: Relationship to Endodontic Disease. International and American Associations for Dental Research, 15(5):308-320 Johnson WT, Noblet WC, 2006. Endodontics Colleagues for Exellence. United States: American Association of Endodontics. Available from http://www.aae.org/uploadedFiles/Publicati ons_and_Research/Endodontics_Colleague s_for_Excellence_Newsletter/Cleaning%20 and%20Shaping%202006%20Final.doc. Accessed. April 1, 2013 Grossman LI, Oliet S, Del Rio CE, 1995. Ilmu Endodontik Dalam Praktik. Penerbit buku kedokteran EGC : Jakarta, h 236 Yanti LA, 2012. Pertumbuhan Bibit Rhizophora mucronata Lamk, pada Berbagai Intensitas Naungan, Skripsi, Universitas Sumatera Utara Medan. Ravikumar S, 2010. Antibacterial Potential of Chosen Mangrove Plants Against Isolated Urinary Tract Infectious Bacterial Pathogens. World Applied Science Journal, 14(8):1198-1202 Nurdiani R, Firdaus M, Prihanto AA, 2012. Phytochemical Screening and Antibacterial Activity of Methanol Extract of Mangrove Plant (Rhizophora mucronata) from Porong River Estuary, Journal Basic and Technology 1(2): 27-29 Firdianto G, 2013. Daya Hambat Ekstrak Kulit Batang bakau Besar (Rhizophora mucronata) Terhadap Pertumbuhan Bakteri mixed periodontopathogen. Skripsi Fakultas Kedokteran Gigi Universitas Hang Tuah Surabaya, h 52 Kariem, Ichwan Doel, 2002. Distribusi Kandungan Zat Ekstraktif Tanin Terkondensasi Pada Tegakan Rhizophora mucronata Pada Ekosistem Tambak Tumpangsari di Blanakan Purwakarta Charyadie FL, 2013. Daya Hambat Ekstrak Daun Alpukat (Persea Americana Mill.) Terhadap Pertumbuhan Bakteri
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Enterococcus faecalis. Skripsi Fakultas Kedokteran Gigi Universitas Hang Tuah Surabaya, h 28 Bandaranayake, 2002. Bioactivities, Bioactive Compounds and Chemical Constituents of Mangrove Plants. Australian Institute of Marine Science. Journal of Wetlands Ecology and Management, 10: 421-452 Gunawan, 2009. Potensi Buah Pare (Momordica charantia l) Sebagai Antibakteri Salmonella typhimurium. Program Studi Pendidikan Bioligi Fakultas Keguruan dan Ilmu Pendidikan, Universitas Mahasaraswati, Denpasar. Puspitasari dkk, 2012. Uji Daya Antibakteri Perasan Buah Mengkudu Matang (Morinda citrifolia) Terhadap Bakteri Methicillin Resistan Staphylococcus aureus (MRSA) M.2036.T Secara In Vitro. Noer IS, Nurhayati L, 2006. Bioaktivitas Ulva reticulate Forsskal Asal Gili Kondo Lombok Timur Terhadap Bakteri. Jurnal Biotika, 5(1): 45-60 Uttley AHC, George RC, Naidoo J, Woodford N, Johnson AP, Collins CH et al, 1989. High-level Vancomycin-resistant Enterococci Causing Hospital Infections. Epidem. Inf, Great Britain, 103:173-181 Nufailah D, Wibawa PJ, Winarko, 2008. Uji Antibakteri Produk Reduksi Asam Palmitat Dalam Sistem NaBH4/BF3.Et2O Terhadap Escherichia coli dan Staphylococcus aureus. Skripsi, Universitas Diponegoro Semarang. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB, 2006. Enterococcus faecalis: Its Role In Root Canal Treatment Failure and Current Concepts in Retreatment. Journal of Endodontics, 32(2): 93-98 Bachtiar SY, Tjahjaningsih W, Sianita N, 2012. Pengaruh Ekstrak Alga Cokelat (Sargassum sp.) Terhadap Pertumbuhan Bakteri Escherichia coli. Journal of Marine and Coastal Science, 1(1): 53-60 Osswald R, 2005. The Problem of Endodontis and Managing it Trough Conservative Dentistry, p 134-144
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Repair Of Furcation Perforation With Mineral Trioxide Aggregate (MTA) Rista Eka Aprilianti Sugiono*, Ratna Meidyawati** * Postgraduate student, Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia **Lecturer, Departement of Conservative Dentistry, Faculty of Dentistry Universitas Indonesia
ABSTRACT Introduction: Perforation is a communications between root canal system and periodontal tissues. Objective: The treatment of furcation perforation with MTA. Case report : A 51 year-old female patient complaints of pain on the right maxillary first molars. Two weeks ago the tooth replace with new filling. Radiographic examination showed the pulp chamber has filled with filling. The diagnosis was apical periodontitis et causa pulp necrose. During the opening access occur iatrogenic furcation perforation. MTA was used to repair the furcation perforation. After 1 months and 6 months showed a healing. Discussion: The use of MTA to seal furcation perforation is a good choice because the MTA has a good sealing ability and can be induce healing. Conclusion: MTA in this case successfully repair furcation perforation Key word: furcation perforation, MTA INTRODUCTION Perforation is a pathogenic communications between root canal and periodontal tissue through the floor of pulp chamber or root canal walls. The formation of perforations may caused by caries process which extends toward the furcation or caused by iatrogenic. Iatrogenic perforation may caused by several situations, such as lack of dental anatomy knowledge and operator skill, lower position of the pulp roof which is very close to the floor of pulp chamber or on the retreatment cases where the entire the pulp chamber has been filled by restorative materials. A sign of perforation is the presence of the sense of pain while the working length measurement, spontaneous bleeding and burning pain or discomfort during the irrigation performed with Sodium Hypochlorite 2.5% . The opening procedure to obtain the entrance straight at the apical foramen often experience failure and one of a furcation perforation happen as a result. An iatrogenic furcation perforation many due to operator errors for searching an orifice. A perforation should be identified as early as possible to avoid further damage to the tissues periodonsium. If the perforation is not
immediately corrected then the prognosis is being worse.3,8 Mineral trioxide aggregate (MTA) is a material used to repair a perforation. MTA is a derivate of Portland cement made of fine hydrophilic particles with a high component is calcium phosphate and calcium oxide. Mineral Trioxide Aggregate was developed first by Dr. Torbinejad at Loma Linda University in 1993, the MTA can release calcium hydroxide which can lead to cementogenesis, have a marginal adaptation and have a good sealing ability.5,6 Arens and Torabinejad reported the presence of bone repair on furcation perforation after MTA application, the results showed a good interaction with the bone-forming cells. Koh et al, said that the MTA has a biologically active substrate for bone cells and stimulates the production of interleukin. MTA also can stimulate the production of cytokines in osteoblasts and has the effect of calcium hydroxide as well as induce ie formation of dentinal bridge.2 Arens and Torabinejad reported two cases of large furcation perforation that were repaired by MTA. Pace, et al conducted a clinical examination and radiographs 6 months, 1 year, 2 years and 5 years after using MTA to repair perforation in 9 363
of 10 teeth Oliveira, et al also repair perforations in the furcation area with MTA on molars and follow up for 20 months with clinical examination and radiographs. Silveira, et al reported 2 cases use the MTA to repair furcation perforations. 3 This paper will be presented regarding the case of furcation perforations repairs iatrogenic fault caused by using the MTA.
Fig.1 Preoperative radiograph on #16 tooth
CASE REPORTS A 51-year-old female patient with complaints of pain on right maxillary first molar since 2 weeks ago and disturbed night's sleep. She informed that 2 months ago she replace new filling. Objective examination of the tooth #16 there is composite filling, vitality test negative and percussion positive. A radiographic examination showed the pulp chamber filled by filling material, there is a thickened periodontal ligament, lamina dura was interrupted on the apical of mesial root and a radiolucent on the apical. The diagnosis was apical periodontitis et causa pulp necrose (fig.1). The treatment is root canal treatment and finally the tooth was restored with fiber post and metal porcelain crown. After diagnosis is established then do the access opening using of the endo access bur (Dentsply Maillefer,Switzerland). Because the pulp chamber has been filled by filling, the operator does not have a reference when conducting access opening so that the results in a furcation perforation. Furcation perforation occurred with a diameter of 2 mm (fig.2) and can be identified, then the first exploration conducted on all three root canal orifice using a K-file # 15 (Dentsply Maillefer, Switzerland) up to reach the working length that was confirmed by electronic apex locator. Directly performed root canal preparation using Universal ProTaper hand use (Dentsply Maillefer, Switzerland) with lubricant by RC-Prep (Premier® Dental Products Company) up to the size of F2 on mesio buccal and palatal roots and F3 on the disto buccal roots. Root canals were irrigated using 2.5%. Sodium Hypochlorite After the root canal was prepared later perforation repair with MTA then placed above the moist cotton pellet and closed with temporary filling (GC Caviton).
Fig.2 Radiograph showed a furcation perforation lesion
On the second visit radiograph performed using the master cone to confirm the working length (fig.3). Then after the all three root canal irrigated with sodium hypochlorite 2.5% , dried and root canal filling performed with gutta-percha (Protaper® Universal Gutta Percha,Dentsply Tulsa Dental, Switzerland) and sealer (Endometasone N, Septodont UK) (fig.4.1 and fig.4.2). After the root canal filling, MTA performed to application again to close the perforation that are still not completely covered (fig.5.1 and fig.5.2). The palatal roots cleaned from the MTA for installation of fiber post.
Fig. 3 Radiograph showed master apical cone trial
Fig.4.1 Radiograph showed root canal filling.
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Fig.4.2 Clinical photograph of root canal filling
Fig.5.1 Clinical photograph of MTA application
Fig.5.2 Radiograph after placement of MTA Odontocem at the furcation region and root canal filling
On the third visit, 2 weeks after roots canal filling, there was no subjective complaints and on objective examination the percussion was negative. The palatal root canals were prepared for the installation of fiber posts (Fiber Kleer) using duel cure resin cement ( Breeze® ) (fig.6) and the entire cavity is filled with resin composite (3M ESPE).
On the fourth visit after 1 week then performed preparation for the manufacture of metal porcelain crown (fig.7). Metal porcelain crown inserted a week later and simultaneously with radiographic analysis after root canal filling 4 weeks and showed no improvement in the area of perforation but there was no subjective and objective complaints. (fig.8) After 6 months later on the radiographic analysis showed an improvement in the area of perforation (fig.9)
Fig.7 Clinical photograph of crown preparation
Fig.8 Radiography after 1 months after post operative showing the lesion has been close
Fig.9 Radiography after 6 months after post operative showing normal architecture adjacent and at the repair site.
DISCUSSION
Fig.6 Radiograph showed the fiber post trial
The causes of pain on the #16 tooth due to pulp necrosis. Initiated due to the leaks in filling where the composite was shrinkage during polymerization which led to a gap between the cavity and filling it is that 365
encourage inflammation of the pulp through pulp necrosis. So that in this case the pain occur due to necrosis of the pulp which has resulted in inflammation of the periodontal tissues. Perforation at the time of opening the access frequency when not observed the degree of inclination tooth toward the neighboring tooth and alveolar bone resulting in tooth structure too much decision which resulted in perforation of the crown or root of the tooth. The direction of bur were not aligned with the long axis of the tooth, making the preparation of access based on the shadow in the dental mouth mirror causing tendencies to direct away from the long axis of the tooth burs and re-check the orientation of the access opening negligent during preparation can lead to perforation..1 Perforation may occur in lateral roots and furcations. This location is very influence on the prognosis. If the defect is located at or above the height of the cresta bone, hence the prognosis is good. However, if the perforations in the bottom third of the cresya bone on the corona roots generally have the worst prognosis.3 Furcation perforation area there are two types ie direct types and stripping type, respectively occurs with different causes and also handled in a way that does not as well as the prognosis varied. Direct perforation occurred during search of the root canal orifice. It is usually accessible, small, and walled. This perforation can be immediately repaired with MTA, or when the conditions are dry can be applied with glass ionomer cement and the prognosis is good. While stripping perforation is furcation perforations on the side of the root surface toward the corona caused by excessive preparation in order to achieve the cone-shaped root canals using a bur. If the direct perforation can be performed non-surgical, stripping perforation in general, not accessible, and require more complicated measures. General result of the stripping perforation is followed by the formation of inflammatory periodontal pocket. Perforation in this case due to by the time access preparation ignore of the pulp chamber anatomy that has been filled by filling material, so there is no guidance and preparation is too deep thus causing the perforation in the furcation area. Type of perforation in this case is direct perforated. 1
There are several types of materials that have been used to repair the perforation. One of the important requirements for a material that has the sealing ability to close the perforation well and do not lead damage to the surrounding tissue. The use of MTA as a cover perforations have been carried out and the MTA meets the requirements as an ideal material because it has properties of biocompatibility and a good seal. 3 MTA has initial pH value 10.2 and pH 12.5 sets similar to Ca(OH)2 and it can not resorption.7 Microscopic examination of periodontal tissues after application of MTA on furcation perforation in the periodontium showed improvement and formation of new cementum material above. MTA extrusion did not show any side effects, and showed good biocompatibility. Furcation perforation after MTA application, the results showed a good interaction with the bone-forming cells. In addition, the MTA is which biocompatible endodontic cement, antibacterial, adaptable to marginal, good sealing, hydrophilic, non-toxic, is not easily absorbed and radiopaque.3,4 Another study showed a growth of cementum, bone and ligament periodontium when MTA is used to close the perforation. MTA application conducted after completion of the root canal treatment until the obturation. The use of MTA in this case refers to the case report presented by Arens and Torabinejad. This case uses the MTA OdontocemTM because free eugenol and turpene. The pH of Odontocem is high for a while, but after set will be reduced to a more neutral pH. This will provide of antibacterial effect at the beginning, followed by improvements in biocompatibility, the material will set over time so that continue healing. MTA application in this case conducted in two steps because first step of the MTA have not been up close the perforation area. The use of Universal ProTaper hand use ( Dentsply, Tulsa Switzerland) in this case because it is easy, fast and use the crown-down technique. Crown-down technique has several advantages, ie: eliminate the constriction in the cervical area so it can get straight access to the apical and the apical instrumentation can be done more efficiently, more accurately assessment of root length as well as the simplify and improve the efficiency of irrigation, can be 366
more easily remove of debris, to prevent debris encouraged to periapical thus reduce the risk of post-treatment pain and, the use of fewer instruments, shorter preparation time and preparation result in the larger cone form. Root canal Preparation conducted until the the walls is smooth and obtained the healthy dentin powder on the root canal and, there is a tug back and apical stop on the main cone. Canals filling by using siller (Endometasone N, Septodont) because it has antiseptic activity and antiinflammatory which lasted for several hours and after being placed in the root canal.8 Irigant of 2.5% Sodium Hypochlorite selected because it has antimicrobial effect in dissolving pulp tissue from the remaining organic components, as a lubricant of root canals, are an inexpensive, easily available, and easy to use.5 RC-Prep (Premier® Dental Products Company ) containing 10% peroxide urea, 15% glycol and 15% EDTA. EDTA (Ethylene diamine tetraacetic acid) works removes smear layer (Meryon et al.1987), cleaning and help to disinfecting dentine (Yoshida et al., 1995). Therefore, RC-Prep (Premier® Dental Products Company) used in this case to lubricate the root canal so that the instrument can be easily enter into the root canal work along.9 Cavit selected as temporary filling because it has good adhesion to dentin, little expansion when hardened, radiopaque and hardening when it contact with saliva The success of the treatment in this case seen on radiographs improvement, no subjective complaints, and clinical examination found no abnormality. So that made of fiber posts and post-endodontic restorations metal porcelain crown to protect the tooth from the remnant of tissue and the possibility of fracture to restore of the tooth function.
endodontic therapy to avoid procedural accidents. In this case furcation perforation occurred in the absence of a guidance to the access preparation because the pulp has been filled by filling. MTA in this case successfully repair furcation perforation. REFERENCES 1.
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5.
6.
7.
8.
CONCLUSION Neverthless an excellent initial radiographic examination,careful consideration of the anatomy and position of the tooth should be the first factor to be considered before
9.
Walton, RE. Prinsip dan Praktek Ilmu Endodonsi. Alih Bahasa: Narlan S, Winiarti S, Bambang N.ed ke-3. Jakarta: EGC, 2008. P.353-354 Arens DE, Torabinejad M. Repair of Furcal Perforations with Mineral Trioxide Aggregate: Two Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996:82-8A Unal G, Maden M, Isidan T. Repair of Furcal Iatrogenic Perforation with Mineral Trioxide Aggregate: Two Years Follow-up of Two Cases. European Journal of Dentistry. October 2010;4:475,479. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and Chemical Properties of A New Root-end filling Material. J Endod 1995;21:349-53 Pitt Ford TR, Torabinejad M, Mc Kendry DJ, Hong CU, Kariyawasam SP. Use of Mineral Trioxide Aggregate for Repair of Furcal Perforations. Oral Surg Oral Med Opathol Oral Radiol Endod 1995;79:756-63 Seltzer S, Sinai I, August D. Periodontal Effects of Root Perforation Before and During Endodontic Procedures. J Dent res 1970;49:332-9. Arathi R, Ashwini R. Ramya S. Mineral Trioxide Aggregate- A Review. J Clin Pediatr Dent. 2009 34(1):1-8 Keles A, Mustafa K, Dissolution of Root Canal Sealers in EDTA and NaOCl solurions. The Journal of The American Dental Association. January 2009;140,74-7 Steinberg D, Abid-El-Raziq D, Healing In vitro Antibacterial Effect of RC-Prep Components on Streptococcus sobrinus. Endod Dent Traumatol 1999;15:171-174
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Root canal retreatment of maxillary first molar (case report) Sonny1, Ratna Meidyawati2 1 Postgraduate Student of Conservative Dentistry, Faculty of Dentistry,Universitas Indonesia, Jakarta 2 Lecturer at Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta
ABSTRACT Introduction: Failure of root canal treatment is generally attributed to either residual or resistant intraradicular microorganisms surviving or resistance after cleaning and shaping procedures. Clinician incapability to preparation root canal with correct working length resulted the remain of anaerob bacteria that can evolved inside root canal and effected infection on periradicular area. Aim: To report a case of root canal retreatment of maxillary first molar. Case: A 23-year-old male patient came with his upper right posterior tooth which had root canal treatment 6 months ago and expected to receive a permanent restoration. Inadequate root canal obturation was recognized radiographically. Sinus tract was observed on soft tissue palatal side. Gutta percha was previously softened with eucalyptus oil and removed using Hedstroem File. Root canal was prepared using ProTaper Universal Files. Medicament interappointment using calcium hidroxide and obturation was completed using lateral condensation method. Conclusion: Failed of root canal treatment in this case caused by inadequate root canal preparation, and successful of retreatment depending on cleaning and shaping, hermetic obturation, and adequate coronal restoration. Key words: root canal retreatment, failed root canal treatment, cleaning and shaping BACKGROUND The main purpose of root canal treatment are cleaning and shaping according to the working length. In some cases the failure of root canal treatment showing a persistent lesion like a sinus tract caused by intraradicular infection. In several cases, the number of strains and species of facultative anaerobes Gram positive microorganisms which predominate is Enterococcus faecalis. The choice of antibacterial medication during retreatment is very important.(1) Before the clinician performs root canal retreatment, it is important to know the failure causes of previous root canal treatment. Several factors affecting failure of the root canal treatment, such as preparation of root canal cannot reach the working length, missed root canal, inadequate irrigation, non hermetic root canal obturation, coronal microleakage, fracture, and periradicular infection.(2) The success of root canal treatment can be evaluated from the radiography, subjective
and objective examination. Patient may consider success as relief from acute symptoms, perhaps the resolution of swelling or absence of tenderness. Success has been determined by lack of any symptoms and a normal radiological presentation.(2) Follow up radiographic after a period 6, 12, 24 month is necessary to evaluate the successful of treatment. Normal and continues lamina dura, normal periodontal ligament, bone, and tooth can be using normally without any symptoms from the patient indicated the successful of root canal treatment.(3) The tooth which had root canal treatment need an adequate coronal restoration to preserve long lasting prognosis such onlay or full crown. Coronal microleakage can cause failure of root canal treatment.(3) The purpose of this case report is to present the root canal retreatment which caused by preparation of root canal previously cannot reach the correct working length.
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CASES A 23-year-old male patient came to Klinik Spesialis Konservasi Gigi RSGMPFKGUI with his upper right posterior tooth which had root canal treatment 6 months ago and expected to receive a permanent restoration. Extra oral examination normal.Intra oral examination of tooth 16 had a temporary filling and a sinus tract was present at the palatal side (Figure 1). Percussion and palpation test was negative. Tooth 17, 27, 28, 37, 47 caries D3. Enamel fracture on tooth 16,26,11,21. Radiography examination (Figure 2) revealed that a root canal treatment had been previously performed with non-hermetic obturation and could not reach working length, widen periodontal ligament space, and discontinued lamina dura. Radiolucent lesion seen on palatal root about 2mm diameter. No calculus in all regio, and the oral hygiene index was 0,78. The clinical diagnosis of tooth 16 was asymptomatic abscess apical chronic e.c pulp necrotic.
solvent eucalyptus oil. Hedstroem file was inserted around gutta percha and was gently screwed in 360° clockwise direction. Gutta percha was removed by withdrawing the file by hand. After all gutta percha was removed (Figure 3), initial files were determined, palatal 25/19mm, mesiobuccal 15/17mm, and distobucal 15/14mm. The root canals were irrigated by 2,5% sodium hypochlorite solution. The root canals were negotiated by using no 10 C+ file (DENTSPLY). Working length were determined using an electronic apex locator (Root ZX, Morita) and then confirmed radiographically. The working length at mesiobuccal and distobuccal were negotiated using no 15 K-file. The canals were cleaned and shaped with ProTaper Universal rotary files (DENTSPLY), the palatal canal was shaped until F4/20mm, mesiobuccal was shaped until F3/18mm, and distobuccal was shaped until F2/17mm. RC Prep (Premier) was used as the lubricant. Apical patency was achieved in all canals and was maintained with no 10 K-file (DENTSPLY). Master gutta percha points were fit within canals and were confirmed by radiograph (Figure 4). Calcium hydroxide was used as the interappointment medication (Calcipex II, Nishika) and the cavity was filled with temporary filling.
Figure 1. 16 pre operative clinical condition. Sinus tract was seen at palatal side.
Figure 3. All gutta percha were successfully removed
Figure 2. Radiograph of tooth 16.
CASE MANAGEMENT At first appointment temporary filling was removed, and three canal orifices were located: palatal, mesiobuccal and distobuccal. The existing gutta percha was removed with
Figure 4. Master cones were confirmed using radiograph
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At the following visit, 1 week later, the patient came without subjective and objective complaints. Calcium hydroxide was removed using 2,5% sodium hypochlorite irrigation. Final irrigation were used EDTA 17% and chlorhexidine 2%. The canals were dried with paper points and obturated with ProTaper gutta percha and resin based sealer (AH26, DENTSPLY) using lateral condensation technique. The access cavity was filled with GIC type 2 (Fuji 9, GC). Radiograph was taken after the obturation (Figure 5).
Metal onlay was inserted at the following appointment. The radiograph was taken. Onlay was fit, retention, marginal and proximal adaptation was good (Figure 8a). The occlusion was checked using articulating paper (Figure 8b). Onlay was cemented using type 1 GIC (Fuji 1, GC) (Figure 8c).
Figure 8a
Figure 5. Radiographic image post obturation
On the follow up visit, there was no subjective complaints. Palpation and percussion tests were negative. Sinus tract at palatal side was disappear (Figure 6). The root canal treatment was followed by onlay preparation (Figure 7).
Figure 8b
Figure 8c
Figure 8a. Radiographic image of metal onlay Figure 8b. Clinical view of metal onlay Figure 8c. Clinical view of cemented metal onlay
At 1 month follow up evaluation, the patient was showed no subjective and objective complaints. Percussion and palpation tests were negative. Sinus tract had disappeared (Figure 9).
Figure 6.One week follow-up after obturation. Sinus tract was disappear.
Figure 9. One month follow up evaluation. No sinus tract was found.
Figure 7. Metal onlay preparation 370
DISCUSSION This case report discusses about root canal retreatment in poorly obturated tooth. The diagnosis of this case is chronic apical abscess et causa pulp necrotic. Although the patient had no subjective complaints but there was sinus tract on objective examination. There was radiolucency lesion at palatal apex at radiograph examination, thickened lamina dura and disconnected and widened periodontal ligament space which is a sign of failure of root canal treatment. Before performing the root canal retreatment procedure, it is important to know the factors that cause the failure of previous root canal treatment. The cause of treatment failure at 16 is because the obturation are not hermetic and not reached the working length. The final restoration which was still used temporary restoration allowing microleakage from the coronal. Root canal retreatment procedure on tooth 16 includes access preparation, removing existing gutta percha, confirming the proper working length, preparing the root canals biomechanically, confirming apical patency, obturating hermetically according working length, and placing an adequate final restoration to prevent coronal leakage. The access orifice 16 were done by removing the temporary restoration. Good visibility to the orifice are important in order to have good access to the root canals. If the final restoration was leaked or infected by secondary caries, it must be removed entirely, because it can lead to bacterial contamination during root canal treatment. Eucalyptus oil were used to softened gutta percha because it is safer than chloroform and it can dissolve zinc oxide-eugenol based sealer.(5) Chloroform is carcinogenic and has a high toxicity if the material leak out into the periapical tissues.(6)Hedstroem file inserted through the gap around the softened gutta percha and the dentin wall, then rotated 360° in order to have the gutta percha engaged to the file, so when the hedstroem file pulled out the gutta percha can be lifted. The use of excessive gutta percha solvents may result in covered dentinal tubules by gutta percha.(2)
Working length was measured using apex locator combined with radiographic image. Apical patency was achieved using no 10 K-file. The purpose of confirming the apical patency of the root canal is to ensure that there is no debris on the apical foramen and to distribute the irrigation to the apex. (2) An adequate disinfection of the root canal system will increase the success of the root canal treatment. The irrigation that used in this case is a combination between 2,5% sodium hypochlorite as an organic solvent and antibacterial, and 17% EDTA as an inorganic solvent. Sodium hypochlorite was flooded during cleaning and shaping procedure. The irregular apical isthmus which is difficult to clean during mechanical instrumentation is expected to be cleaned with sodium hypochlorite.(7) Chlorhexidine 2% was also used in this case, in order to eliminate anaerobic bacteria Enterococcus faecalis, because these species are more resistant to sodium hypochlorite and calcium hydroxide.(1) Root canals were obturated using ProTaper gutta percha non-ISO according to the final file. The lateral condensation technique was used in obturating all canals. Resin based sealer AH26 was used, which have adhesive properties to the root canal dentin walls, minimal shrinkage while setting, and has a good long term stability.(8) Type 2 GIC was used as the base, because it has good marginal adaptation and easy to manipulation. (9) The final restoration for tooth 16 is metal onlay. Endodontically treated teeth are prone to fracture in bucco-palatal direction due to loss of tooth structure. Metal onlay can merge the walls that separate into a single unity. (10) CONCLUSION The success rate of this root canal retreatment is good, because the main cause of the previous root canal treatment failure has been corrected. Sinus tract is dissapear which is a good sign of healing process. No subjective and objective complaints were found in followup evaluation.
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Consideration In Choosing Provisional Restoration In Endodontically Treated Maxillary Incisor With Periapical Lesion: A Case Report Susi * Trimurni Abidin** * Resident of Spesialist Program of Conservative Dentistry ** Lecturer of Specialist of Conservative Dentistry Faculty of Dentistry, University of Sumatera Utara Jln. Alumni no. 2 Kampus USU Medan 20155
Abstract The treatment success of pulpal disease does not only depend on the quality of endodontic treatment, but also its final restoration. In endodontic treatment, provisional restoration is needed in cases with periapical lesion that has not resolved. The purpose of this paper is to report the consideration and selection of appropriate provisional restorations for endodontically treated anterior teeth with unresolved periapical lesions but the patient needs immediate aesthetic demand. A woman aged 16 year old with asymptomatic irreversible pulpitis on tooth 11 and pulp necrosis on tooth 21 presenting with chronic apical abscess. In the severely damaged clinical crown with extensive caries, after root canal treatment has been performed, post core with full crown is planned as final restoration. Teeth 11 and 21 with unresolved periapical lesion that has been endodontically treated are indicated for provisional restoration using a resin composites for esthetic consideration. Key words : provisional restoration , periapical lesions , composite resin INTRODUCTION The failure of endodontic treatment commonly occurred because of errors in pre operative, during operative and post operative endodontic treatment .The failure of treatment can occur because of wrong diagnose and case selection, cleaning ,shaping and obturation procedure , appropriate coronal sealing .The determination of proper final restoration after the endodontic treatment is very important. 2,3. Restoration performed after the endodontic treatment has special considerations depending on condition of periodontium , occlusion , aesthetic and etc. There are two considerations about restoration after endodontic treatment , they are provisional and final restoration . 3. Provisional restoration is the first step in achieving the success of the post endodontic treatment . There are three main functions of provisional restorations. First, it helps to stabilize the condition of infected surrounding periodontal of the tooth whose tissue treatment had been performed. Secondly, provisional
restoration gives a better aesthetic value and satisfaction to both the patient and dentist. The third it is to evaluate occlusion and as the technical reference during performing the final restoration . This article discusses about provisional restoration after endodontic treatment of maxillary central incisor with periapical lesion which have not bad progress using composite resin 3,5 . CASE REPORT A 16- years- old female patient came to the clinic of conservative Dentistry, Faculty of Dentistry USU with a chief complaint of toothache since six month ago which affected her physic and mental badly. (figure.1)
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Obturation was completed with lateral condensation technique and was used resin based sealer AHA 26( Dentsply, Switzerland). (Figure .3)
Figure 1 : Tooth # 11 with asymptomatic irreversible pulpitis #21 with necrosis caused due to chronic alveolar absess
Case Of Tooth #11 The dental clinical examination showed caries involving proximal mesial wall extending to the tooth palatal deep into pulp at the tooth 11. Subjective examination revealed cavities tooth pain on mastication since two months ago . Objective examination of teeth 11 was still in vital condition . The radiology examination showed discontinuation of lamina dura and no abnormality found in apical area .This tooth was diagnosed as asymptomatic irreversible pulpitis . The treatment plans were vital endodontic treatment with fiberglass reinforced composite post and composite crown as provisional restoration until healing of supporting tissue tooth place. The final restoration was porcelain crown.
Figure 3 : Obturation
After endodontic treatment was finished and waiting for the healing of periodontal tissues using diamond bur. cleaned and dried. ( figure. 4 ). Composite resin crown was made as provisional restoration and its preparation was done using tapered diamond bur gingival retraction was done using knitted gingival retraction cord (atrialpak ) and double Impression was apphid.
Figure. 4 : Preparation of provisional restoration.
Case Of Tooth #21.
Figure. 2 : Initial Apical File .
Access opening was done by endo access bur under local anesthesia Preparation of root canal was done using rotary protaper universal till File F3 and then irrigated using NaOCL 2,5% solution and EDTA gel 17% .
Clinical examination on tooth #21 showed caries involving proximal mesial wall extending to the tooth palatal deep into pulp and there was discoloration. Fistula was found at the labial mucous layer. The subjective examination revealed cavities. The patient felt the pain since one month a go while eating . Objective examination showed that tooth #21 had no response on vitality test and it was tender to 374
percussion. Radiographic examination showed there was radiolucent at the periapical tissue , widening of lamina dura and no treatment was given. This tooth was diagnosed as chronic alveolar abscess due to pulp necrosis. The treatment plan was non vital endodontic treatment . The provisional restoration was composite resin crown with fiber glass reinforced composite post , restoration while waiting the healing of periapical lesion final restoration was porcelain crown .Access opening was done using endo access bur (Edenta, Swedia). After Initial Apical File . The working length was determinate using apex locator and confirmed radiographically. (Figure .5).
Ficture 7 : Obturation
After endodontic treatment was done and waiting for healing of periapical lesion , fiber glass reinforced composite post with provisional restoration was performed with composite resin crown. ( Figure .8) Gingival retraction was done using retraction cord and double impression was taken cementation was done with resin self adhesive (3M ESPE, Germany) .Check occlusion . ( Figure .8)
Figure. 5 : Initial Apical file
Root canal preparation was done with rotary protaper universal (Dentsply,Switzerland) until file F3 and irrigation using. NaOCL 2,5 % and EDTA 17 % gel. Ledermix® was placed as intra canal medication for a week and the tooth was closed with temporary filling. After a week , Clinical exam showed no symptom on percussion and there was healing of lesion obturation using lateral condensation technique was done with resin based sealer AHA 26 sealer ( Dentsply, Switzerland) using lateral condensation technique. ( Figure .6)
Figure. 8 Figure.9 Figure 8 : Preparation of provisional restoration. Figure 9 : After provisional restoration.
DISCUSSION Provisional restoration is needed in un progressed periapical lesion, If flare up occurs, retreatment can be easily done . Besides that provisional restoration has many functions. Firstly, as occlusion and stabilization : preventing unwanted teeth movement and to provide inter cups and proximal tooth contact .Next , it is as an esthetic function as to give appearance, suitable colour for the anterior part of the teeth. Thirdly, contour and gingival health problem and periodontal tissue which is 375
unstable : to provide health oral hygiene, prevent gingival inflammation and ability to restore the gingival tissue to a normal condition and can be used to solve phonetic problem 2,4 . Provisional restoration materials that have been used already developed from time to time starting from cast metal where mixture used contains nickel chromium , silver and gold , cast metal is very good and it fulfills the mechanical , biological properties and last long but has unpleasant esthetic property due to unwanted colour especially on the anterior teeth .Steel cast provisional restoration is rarely used except for longer period of time 7,8. Provisional restoration material that are used are composite resin crown because the final restoration is made using porcelain crown .It is also as a reference technique in making final restoration as well as patients preference compared with direct composite build up . Also the direct composite build up may cause shrinkage in a long period of time 5,7 . Composite resin is a very popular material because it is easily used and fulfills the esthetic guidelines. Composite resin are very flexible , resembling the structure of the teeth which can be done directly by the dentist without having to send the model to laboratory process. Which can save time and colour can be easily adjusted. But composite resin has disadvantage which few types of resin can easily absorb the stain. causing unstable dimension . However composite resin appears to the acceptable option for provisional restoration compared with other materials 5,7,8. The requirement for provisional restoration at the most basic level needs a good marginal adaptation, physiological contour , embrasure and strength and longevity, provisional restoration must fulfill mechanical and biological criteria 1. Mechanical property The stress placed on provisional restoration during chewing , where patient cant avoid contact with provisional restoration when eating and chewing ,and the strength of material chosen .will affect the stability of the provisional restoration made. So materials chosen have to be taken into consideration and can lead to failure of the material. this is because patient may use this provisional restoration for 6 months or
more. Provisional restoration should last long and must provide sufficient longevity for a long period of time 3,5 . 2. Biological criteria. Provisional restoration can close and isolate each teeth from oral environment . It also protects until its protect the pulp from injury that cause by trauma, prevents dentin from secondary corners, closes the root to prevent the contamination of liquid and oral microorganisms. in order to facilitate oral hygiene, provisional restoration should provide margin adaptation, perfect contour and smooth surface. if the marginal restoration is inadequate or rough, it will affect plague control until gingival health will be disturbed. Provisional restoration will also protect the teeth in a stable condition from the periodontal aspect 3,5. Resin cement is used for the provisional restoration cementation dual cured resin cement is recommended as the luting cement in this case because this cement has retention and better resistention compare to other cements . Elasticity of the modulus approaching the dentin until this cement withstand fracture compare to other cement and is very good withstand thin root walls . Root canal of the dentin is etched before that to provide more adhesion because dentin tubulus and until the materials bond to proliferate with the tubulus dentin to from strong bond. CONCLUSION Provisional restoration is very important for the treatment and esthetic in dental restoration, waiting for final restoration until periapical lesions progress . The expectation of patient to words dental health is very high, provisional restoration will help the dentist to understand the patients need for esthetic and to restore the right function of the teeth. REFERENCES 1.
Asgeir Sugurdsson .Evaluation of Success and Failure. : Walton RE,Torabinejad M (ed).Principles and Practice of Endodontic 3rd,Philadelphia: WB Saunders. 2002: 331344.
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Lima af, spazzin ao, Glafasii, Corre Sobrinho, Carlini Junior Influence of Ferrule Preparation With or Whithout Glass Fiber Post on Fracture Resistance of Endodontically Treated Teeth. J Appl Oral Sci 2010; 18 (4) : 360-3. Lowe RA. Predictable Fixed Prosthodontic: Technique is The Key to Success. CompendContin Educ Dent. 2002;23(2 Suppl 1):4-12. Lowe RA. Tips for Successful Provisional Restorations—Every Time For Every Case.Dental Products Report. 2002;36(10):68-72. Lowe RA. Provisionalization: Mastering the Morphology. Dental Products Report. 2003;37(8):56-58. Goldstein, Ronald E. A Simple Technique to Create an Interim Provisional Restoration J INS DENT. 2008:17:95-98. Tjan A H, Castelnuovo J, Shiotsu G.Marginal Fidelity of Crowns Fabricated From Six Proprietary Provisional Materials. J Prosthet Dent 1997; 77:482485. Lang R, Rosentritt M, Leibrock A, Behr M, Handel G. Colour Stability of Provisional
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Crown and Bridge Restoration Materials. Br Dent J 1998;185: 468-471. Gulati A J. Physical Properties of Provisional Restorative Materials. University of Newcastle UponTyne, 1996. Nicholson J W, Chan D C. Two-Step Provisional Technique for Onlay Preparations. J Esthetic Dent 1992; 4:202207. Liebenberg W H. Improving interproximal access in directprovisional acrylic resin restorations.Quintessence Int 1994; 25: 697-703. Shillingburg H T, Hobo S, Whitsett L D.Provisional Restorations : Fundamentals of Fixed Prosthodontics.225-256. Chicago: Quintessence international,1998. Richard S. Schwratz, and James W robbins, Post Placement and restoration of Endodontically Treated Teeth : A Literature Review, Jourrnal of Endodontic, J:2004:30:5. Zivkovic S, Brkanic T, Dacic D, et all. Smear Layer In Endodontic. Serbian Dental J, 2005 ;52: 7-19.
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Endodontic Retreatment Of Left Mandibular First Molar Using Retreatment Files: A Case Report Novelin Y. Ompusunggu * TrimurniAbidin ** * Resident of Specialist Program of Conservative Dentistry **Lecturer of Specialist of Conservative Dentistry Faculty of Dentistry, University of North Sumatra Jln . Alumni No.2 Kampus USU Medan 20155
Abstract Endodontic treatment failure can occur due to errors in diagnosis, improper root canal procedures, poor obturation or failed restoration. Endodontic retreatment should be performed on failed endodontically treated tooth. It is a condition that needs further treatment in order to get a favorable result. The purpose of this case report is to describe an endodontic retreatment case performed on a female patient aged 40 years with #36 tooth that had been endodontically treated with poor obturation. The patient wanted to save her tooth. Retreatment files and solvents were used for complete removal of root canal filling material. Understanding the complete removal of root canal filling material is important in order to achieve higher treatment quality. Keywords: retreatment, removal of root canal filling material, retreatment files, solvents. Intruduction Endodontic treatment failure can be caused by various factors such as incorrect diagnosis (22.14%), iatrogenic errors at the time of treatment such as perforation, underfilled or overfilled, broken instruments, missing canal, broken restoration, inadequate root canal debridement (14.42%) and apical irritation by bacteria resulting in infection root canals (63.46%).1 Case of endodontic treatment failure can be carried out with retreatment.1 Removal of root canal filling can be done mechanically and chemically with hand and rotary instruments files and solvent to remove gutta-percha and sealer.2 Rotary files designed specifically for retreatment been evaluated, namely rotary file ProTaper retreatment (Dentsply Mailllefer, Ballaigues, Switzerland), and R-Endo (MicroMega, Bescanc, France).3,4 The use of solvent to soften the guttapercha is relatively more effective and faster than using heat. It is also safer, especially if used in the root canal.5 Some solvents that have been investigated such eucalyptol, xylene, metyl
chloroform, tetrahydrofuran, methylene chloride, halothane, rectified turpentine and orange solvent.6 Retreatment is aimed to eliminate the entire irritants / bacteria in the root canal system.7 Difficulty of retreatment depends on the opening access of the root canal. The greatest obstacle is the removal of old restorations such as onlay or post cores and the next process is a regular procedure of Triad principles Endodontic Treatment.1 The purpose of this case report is to describe the retreatment on tooth 36 which was previously treated with non hermetic obturation. Case Report A 40-year-old female patient came to the clinic of Conservative Dentistry, Faculty of Dentistry USU with complaints of discomfort in the left mandibular molar which has been endodontically treated. Subjective examination showed no abnormalities, objective examination showed the tooth 36 has composite resin filling, it should no sensitivity to explore test, cold test, percussion and palpation. There was no mobility and presence of calculus on maxillaris and 378
mandibular region. Radiographic examination should radiolucency looks at the apex of the tooth 36 and the widening of the periodontal ligament occurs, as well as poor root canal filling (Figure 1).
On the next visit clinical examination showed that patient had no complaint and radiography result showed healing of periapical radiolucency. The final irrigation with chlorhexidine 2% and fittings of Master Apical Cone was performed (MAC # 45/20 mm in the distal root and ISO # 35/19 mm in each mesiobuccal roots and mesiolingual ) (Figure 3) and obturation was performed with lateral and vertical condensation technique with resin based sealer (AH 26 (Dentsply, Switzerland)). Built was done with composite resin (3M, ESPE, Germany) (Figure 4).
Figure 1. Poor obturation on tooth 36.
Retreatment was performed on tooth 36 with rotary NiTi files on first visit, and root canal filling preparation was done to remove old restorations and root canal filling, 0.1 ml of chloroform was applied to the root canal to soften gutta-percha for 30 seconds then Protaper retreatment files(Dentsply Mailllefer, Ballaigues, Switzerland) were used to obturation material. This process was repeated and the solvent can be added if necessary until the guttapercha and sealer when remove completely. Treatment phase was followed by measuring the working length with apex locater and radiography was taken (figure 2), the size of IAF ISO # 20/20 mm at the distal root, IAF ISO # 20/19 mm respectively and mesiolingual mesiobuccal root of the tooth and the crown down technique was used with rotary instruments using ProTaper universal (X-smart, Dentsply, Switzerland) while the irrigation was done with NaOCl 2,5% and EDTA 17%, after the canals when dried, odontopaste (AM, Australian Dental) was applied for 2 weeks and temporized.
Figure 3. MAC on tooth 36.; Figure 4. Obturation on tooth 36.
On the next visit after 3 days for control, clinical examination showed that patient had no complaint, post space preparation was done by removing gutta-percha in the largest root is the root of all the distal two thirds the length of work or leave guttpercha at about 4 mm apical to Peezo reamer (Mani, Japan), cementation of fiber post was performed with self adhesive resin cement Rely X U100 (3M ESPE, Germany). Final restoration was completed by composite resin build up (Figure 5).
Figure 5. Final restoration on tooth 36. Discussion Figure 2. Determination of the working length of the tooth 36.
Endodontic treatment failure is most often caused by bacteria in the root canal, the other factors because of the failure such as root perforation. Initial failure can occur shortly after 379
endodontic treatment which may indicate the presence of bacteria in the root canal at the time of treatment.5 Endodontic treatment failure will cause periapical disease either acute or chronic inflammation such as abscesses, granulomas, radicular cysts.1 The fundamental difference between the initial treatment and retreatment is the need to remove root canal filling material that may exist. If access to the root canal system is achieved then entry to the root canal can be easily done as well.7 Gutta-percha removal can be done by mechanical and chemical technique, mechanical technique can be done using a hand or rotary instruments and chemical technique can be done using solvent.8 Combination of techniques used are often a problem and is determined by the clinical situation. Gutta-percha removal method also depends on the quality of root canal filling.9 In this case report using retreatment files rotary instruments ProTaper retreatment file ( Dentsply Mailllefer, Ballaigues, Switzerland ) because it is faster to remove obturation. ProTaper Universal retreatment combined with solvent takes a shorter time than hand instrument technique.3,4 The use of solvent gutta-percha is more effective and faster than just using mechanical technique retreatment files, especially if used in root canal. Solvent used in root canals do not have a detrimental effect on teeth or minimal risk and as long as it is confined to the root canal.11 Rotary NiTi files can be safely used throughout the root canal.6 Several studies have found that rotary NiTi instruments are more effective than hand instruments in removing obturation material but the majority of studies reported no significant difference between the effectiveness of rotary and hand instruments.10 Chloroform is used as a solvent for dissolving gutta-percha with limited toxicity when used clinically.11 This solvent has been used in most studies to evaluate the removal of gutta percha and sealer.12 Finally, although it has toxic properties, chloroform can reduce intracanal E. faecalis bacteria levels significantly, a property which may be useful when dealing with secondary endodontic infections. However, it should be noted that the gutta-percha is softened chemically to form a
smooth coating and attached to the walls of the root canal. It can also be due to the complex anatomy of the root canal (the existence of the isthmus, lateral canals and root canal shape irregularity). This makes release fillers become more difficult and takes time.10 Conclusion Removal of root canal filling is a key step in root canal retreatment. Retreatment treatment aims to eliminate the entire factor irritant / bacteria in the root canal system. Several techniques can be used in removing root canal filling material by mechanical and chemical technique. Mechanical technique using a hand or rotary instruments and assisted with the chemical which is solvent, but none of techniques is more effective, especially in the apical 1/3 of root canal. Reference 1.
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Mardewi, S,S,A. Perawatan endodontics. 2nd, Jakarta, Siti Mardewi KSA, 2009: 2932. Kumar,D, Gokul, P, Shivanna, V. A comparison of the relative efficacies of hand and rotary instruments in the removal of gutta-percha from the root canal during retreatment using stereomicroscope-An Invitro study. Journal of endodontology 2007:5-11. Gu, L, S, Ling, J,Q, Wei, X, Huang, X,Y. Efficacy of protaper Universal rotary retreatment system for gutta-percha removal from root canals. International Endodontic Journal 2008:41;288-295. Giuliani, V, Cocchetti, R, Pagavino, G. Efficacy of protaper universal retreatment files in removing filling materials during root canal retreatment. Journal endodontic 2008:34:1381-1384. Bergenholtz G., Horsted- Bindley P., Reit C. Textbook of Endodontology, 2nd ed., Iowa, Blackwell Publ. Ltd., 2010 Kosti, E, Lambrianidis, T, Economides, N, Neofitou, C. Ex vivo study of the efficacy of H-files and rotary NiTi instruments to remove gutta-percha and four types of
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sealer. International endodontic journal 2006:36:48-54. Duncan, H, F, Chong, Bun San. Removal of root filling materials. Endodontic topics 2011,19, 33-57. Tamse, A, Unger, U, Metzger, Z, Rosenberg, M. Guttapercha solvent-a comparative study. J Endodon 1986:12:337-339. Betti L,V, Bramante, C,M, Quantec, S,C. Rotary instruments versus hands files for gutta-percha removal in root canal treatment. International endodontic journal 2001:34:516-519.
10. Sae-lim, V, Rajamanickam, I, Lim, B,K, Lee, H,L. Effectiviness of profile 0,04 taper rotary instruments in endodontic retreatment. Journal endodontic 2000:26:100-104. 11. McDonald M,N, Vire, D,E,. Chloroform in the endodontic operatory. Journal endodntic 1992:18:301-303. 12. De Mello Junior, J, E, Cunha R, S, Bueno, C,E, Zuolo, M,L. Retreatment efficacy of gutta-percha removal using a clinical microscope and ultrasonic instruments:part 1- an ex vivo study. Oral surgery oral medicine oral pathology oral radiology endodntic journal 2009: 108: e59-e62.
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Proper Selection of Local Anesthetic in Case of “Hot” Tooth Tri Widiarni* Trimurni Abidin** * Resident of Spesialist Program of Conservative Dentistry ** Lecturer of Specialist of Conservative Dentistry Faculty of Dentistry, University of Sumatera Utara Jln. Alumni no. 2 Kampus USU Medan 20155
Abstract Achieving an adequate state of pulpal anesthesia is very important in endodontic treatment, especially in the case of the ―hot‖ tooth. In endodontic treatment local anesthesia failure occurs frequently, especially in the treatment of mandibular teeth that can be caused by several factors, among which the failure of an anesthetic agent to block Tetrodoxin-resistant sodium channels ( TTXr ) that are known to be elevated in cases of irreversible pulpitis. The use of 4% articaine with 1:100,000 epinephrine is an alternative anesthetic agent most often used in cases of failure of anesthesia using 2% lidocaine with 1:100,000 epineprine because it is sensitive Tetrodoxin ( TTXs). The purpose of this case report is to report two cases of patients with a diagnosis of symptomatic irreversible pulpitis on teeth 47 and 26, which require emergency endodontic treatment but they failed to achieve effective pulpal anesthesia using 2% lidocaine with 1:100,000 epinephrine. Selection and use of local anesthetic 4% articaine as one of materials of choice that can bind inflammatory and pain mediator in the dental pulp. It also needs comprehensive understanding of the clinical mechanism of action of anesthetic in order to choose the proper local anesthetic for the success of endodontic treatment. Keywords : “Hot” tooth, Tetrodoxin, Local anesthetic, Articaine. INTRODUCTION Profound pulpal anesthesia during the root canal procedure benefits not only for patient, but also for the dentist who will be less stressed worrying about patient reactions or sudden movement during therapy. Achieving adequate anesthesia in patients can be a challenge, especially in condition of a ―hot‖ tooth1. The term ―hot‖ tooth generally refers to a pulp that has been diagnosed with irreversible pulpitis, with spontaneous, moderate-to-severe pain1. This condition is most commonly seen in mandibular molars. Irreversibel pulpitis is the inflammatory condition of the pulp usually caused by any noxious stimuli, eg: dental caries, chemical, mechanical or thermal injuries to the pulp2. Sometimes after giving a proper anesthesia, patient still respond negatively to the treatment because of pain. This condition is often referred as ―hot‖ tooth2. Although local
anesthetics are highly effective in producing anesthesia in normal tissue, local anesthetics commonly fail in endodontic patients with inflamed tissue3. When a carious lesion approximates the pulp, inflammatory changes within the pulp progressively worsen. Chronic inflammation takes on an acute exacerbation with an influx of neutrophils and the release of inflammatory mediators (such as prostaglandins and interleukins) and proinflammatory neuropeptides (such as substance P, bradykinin, and calcitonin gene-related peptide)4. These mediators, in turn, sensitize the peripheral nociceptors within the pulp of the affected tooth, which increases pain production and neuronal excitability5. All of this leads to moderate- severe pain even after giving adequate anesthesia2. When the clinician is confronted with the case of a severe irreversible pulpitis in which the IANB and buccal infiltration using 2% lidocaine with 1:100,000 epinephrine achieves soft tissue and lip numbness but not pulpal 382
anesthesia, the question arises as to what is the best approach to achieve anesthesia for a ―hot‖ tooth?1,3. This article describes strategies that the endodontist can use when treating patients with teeth having moderate-to-severe pain. Selection and use of local anesthetic 4% articaine with 1:100,000 epinephrine as one of materials of choice that can bind inflammatory and pain mediator in the dental pulp. CASE REPORT Case report No. 1 A 38-year-old female patient came to the clinic of Conservative Dentistry, Faculty of Dentistry University of Sumatera Utara with her chief complaint was throbbing pain in the lower right molars and it had occured for 1 week. The pain was experienced especially in the middle of the night, causing the patient woke up and could not sleep. Patient already took painkillers but not much help. She was otherwise healthy with a non contributory medical history. There was no past dental history as this was her first dental visit. Intra oral clinical examination revealed tooth #47 carious. Vitality tests showed positive response to thermal test, this tooth was sensitive to percussion but not to palpation. The radiograph showed a deep carious lesion and no periapical pathology (Fig. 1A). Based on clinical findings and clinical examination, diagnosis of the tooth was symptomatic irreversible pulpitis. The root canal treatment was performed on tooth #47.
At the time of access opening preparation, patient still felt pain even though the lips and gingiva had felt numb. Patient was reanaesthesized with intraligamentary injection but after waiting a while the patient still felt pain when access opening preparation. The patient was given second anesthesia with 4% articaine with 1:100,000 epinephrine (Septanest, 4% articaine with 1:100,000 epinephrine). Having reached a state of pulpal anesthesia, access opening preparation was performed with endo access bur and irrigated with 2,5% NaOCl. After the pulp tissue was completely extirpated, working length determination using apex locator (DTER Apex Locator DPEX I) and confirmed with radiographic. Canals patency was established using an ISO file #8, #10 and # 15. Initial Apical File radiography was taken (Fig.1B). Root canal preparation was performed using i-RACE rotary instrument and was irrigated with 2,5% NaOCl. Root canals were dried and then ledermix was applied as intracanal medicament. Cavity is then closed with a temporary filling. Patients was prescribed ibuprofen to help relieve pain.
Fig.1B. Initial Apical File
Subsequent visits (3 days later), on clinical examination it showed that there was no subjective symptom, and patient did not feel pain any longer. Irrigation with 2,5% NaOCl and CHX 2% was applied as final irrigation. Root canals were dried and Master Apical Cone radiography was taken (Fig.1C). The root canals filling was done with sealer AH 26 and guttapercha points with lateral condensation technique (Fig. 1D).
Fig.1A. Tooth #47 with symptomatic irreversibel pulpitis.
On the first visit, periapical x-ray was taken. Patient was anesthesized with IANB using 2% lidocaine with 1:100,000 epinephrine. 383
Fig.1C. Master Apical Cone; Fig.1D. Obturation
This tooth was restored with onlay composite resin (Fig.1E). Follow-up period was performed after 3 months.
Fig.1E. Final restoration with onlay composite resin.
Case report No. 2 A 30-year-old female patient was referred to the clinic Department of Conservative Dentistry Faculty of Dentistry USU with her chief complaint was throbbing pain on the left side of her face that woke her up at night. It had accured for 4 days. Patient came to the dentist because of the severe pain. Clinical examination revealed tooth #26 with pulp exposure. Vitality tests showed positive response to thermal test, this tooth was sensitive to percussion but not to palpation. Radiograph was taken and no periradicular pathology was noted (fig.2A). Based on clinical findings and clinical examination, diagnosis was symptomatic irreversible pulpitis. The root canal treatment was performed on tooth #26.
Fig 2A. tooth #26 with symptomatic irreversibel pulpitis.
On the first visit, periapical x-ray was taken. The patient was given anesthesia with maxillary infiltration using 2% lidocaine with 1:100,000 epinephrine. At the time of access opening preparation, patient still felt pain even though gingiva had felt numb. The patient was re-anaesthesized with 4% articaine with 1:100,000 epinephrine (Septanest). After profound anesthesia was achieved, access opening preparation was done using endo access burs and irrigated with 2,5% NaOCl. After the pulp tissue was completely removed, working length was determined using apex locator (DTER Apex Locator DPEX I) and confirmed with radiographically. Canals patency using an ISO file #8, #10 and #15. Ro" Initial apical file (Fig.2B). Root canal preparation was performed using i-RACE rotary instrument and was irrigated with 2,5% NaOCl. Root canals were dried and ledermix was applied as intracanal medicament for 3 days. Cavity was close with a temporary filling. Patients was prescribed ibuprofen to help relieve pain.
Fig.2B. Initial Apical File
On second visit ( 3 days later ), clinical examination showed that patient was no longer felt pain. Irrigation with 2,5% NaOCl. Root canals were dried and MAC radiography was taken (Fig. 2C). Filling the root canal with sealer AH 26 and gutta-percha points with lateral condensation technique (Fig. 2D).
Fig.2C. Master Apical Cone.; Fig.2D. Obturation.
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This tooth was restored with onlay composite resin (Fig. 2E - 2F). Follow-up was performed after 1 month.
Fig.2E. Final restoration with onlay composite resin, 2F. Clinical image of final restoration and control after 1 month post treatment
DISCUSSION The term ―hot‖ tooth generally describes to a condition in which a pulp that has been diagnosed with irreversible pulpitis, with spontaneous, moderate-severe pain. In these case, clinician is confronted with the case of a severe irreversible pulpitis in which the conventional IANB and infiltration using 2% lidocaine with 1:100,000 epinephrine achieves gingiva and lip numbness but not pulpal anesthesia, so the question arises as to what strategies can be used to get the patient numb so that the root canal treatment can be done as comfortably as possible1. The first consideration could be to change the injection technique in attempting to block the inferior alveolar nerve, but controlled clinical studies have failed to prove its superiority. Hannan et al. (1999) used medical ultrasound to guide an anesthetic needle to its target for the IANB6. They found that although accurate injections could be attained by this method, it did not result in more successful pulpal anesthesia. Therefore, the accuracy of the injection technique (needle placement) was not the primary reason for anesthetic failure with the IANB1. Increasing the volume of the local anesthetic delivered during the IANB has also been found not to increase the incidence of pulpal anesthesia7. Increasing the concentration of epinephrine (1:50,000), with the hopes of keeping the anesthetic agent at the injection site longer, also showed no advantage in the IANB8. Patient with pain resulting from irreversible pulpitis has difficulty attaining
pulpal anesthesia. One theory to explain this is that the inflamed tissue has a lowered pH, which reduces the amount of the base form of the anesthetic needed to penetrate the nerve sheath and membrane. Therefore, there is less ionized form of the anesthetic within the nerve to produce anesthesia. This theory may explain only the local effects of inflammation on the nerve and not why an IANB injection is less successful when given at a distance from the area of inflammation (the ―hot‖ tooth)1. Other theories have looked at the presence of anesthetic-resistant sodium channels and the upregulation of sodium channels in pulps diagnosed with irreversible pulpitis1. It is confirmed that Tetrodoxin resistant channels (TTXr) class of sodium channels resist the action of local anesthesia. Increased expression of sodium channels in pulp are responsible for anesthetic failures in ―hot‖ tooth. TTXr channels are resistant to lidocaine, thereby causing incomplete anesthesia2. A lot of anesthetic solutions are available for aiming to achieve profound anesthesia to the patient, but all solutions are not advocating for managing a ―hot‖ tooth condition because of adverse effects such increased pain and trismus2. Recent research has looked at the use of a mandibular buccal infiltration injection of 4% articaine with 1:100,000 epinephrine as a supplemental injection to increase the success of the IANB injection1. Anesthetic efficiency of 4% articaine with 1:100.000 epinephrine shows higher anesthetic efficiency than using 2% lidocaine with 1:100.000 epinephrine when used as buccal infiltration. Mechanism of Action is that articaine contains a thiophene group, which increases its lipid solubility. Lipid solubility determines the extent of molecules penetration into nerve membranes. Therefore, articaine diffuses better through soft tissues than other anesthetics, thereby causing better anesthesia9,10. CONCLUSION Painful pulpitis remains the most common cause of endodontic emergencies. Complete pulp removal is the ideal choice of treatment to predictably relieve patient discomfort. However, the endodontic intervention cannot be performed unless the 385
treated tooth achieves profound pulpal anaesthesia. Because of the persistent pulpal inflammation, an increased amount of inflammatory mediators which can reduce the excitability threshold and to impede local anaesthetic efficacy11. In this case report, it can be concluded that IANB anaesthesia and maxillary infiltration using 4% articaine with 1:100,000 epinephrine in cases of symptomatic irreversibel pulpitis can achieve better pulpal anaesthesia so that the root canal treatment can be done as comfortable as possible. REFERENCES 1. Nusstein J, Reader A, Drum M. Local anesthesia strategies for the patient with a ―hot‖ tooth. Dent Clin N Am 54, 2010;237247. 2. Shabin S, Shetty A, Bhat G, Hedge M. Management of local anesthesia failures in endodontics with different anesthetic techniques and agents. Annual Research & review in biology, 2014;4(7): 1080-1091. 3. Minea L, Ricci D, Safaei M, Khan M, Dent M, Tjandra S. What is the best approach to achieve anesthesia of a hot tooth? An Evidence Based Report. Community Dentistry, Faculty of Dentistry, University of Toronto, Toronto, Canada, 2009.
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Byers MR, Narhi MV. Dental injury models: Experimental tools for understanding neuro inflammatory interactions and polymodal nociceptor functions. Crit Rev Oral Biol Med.,1999;10(1):4-39. 5. Dray A. Inflammatory mediators of pain. Br J Anaesth,1995;75(2):125-31. 6. Hannan L, Reader A, Nist R, et al. The use of ultrasound for guiding needle placement for inferior alveolar nerve blocks. Oral Surg Oral Med Pathol Oral Radiol Endod,1999;87(6):658-65. 7. Nusstein J, Reader A, Beck M. Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve block. Gen Dent, 2002;50(40):372-5. 8. Dagher F, Yared G, Machtou P. An evaluation of 2% lidocaine with different concentration of epinephrine for inferior alveolar nerve block. J Endod 1997;23(3):178-80. 9. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet.,1997;33:417-25. 10. Fragouli E, Dechouniotis G, Georgopoulou M. Anaesthesia in endodontics. ENDO (lond Engl) 2008;2(3):171-184. 11. Lin K. Local anaesthesia in the Management of painful pulpitis. New Zealand Endod J., 2010;41:5-12.
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