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Restrictive Access which had Led to Perforation

Terry Pannkuk, DDS, MScDComplications: Advanced Management, Perforations, Recall Observations, Sample Cases, All by Date

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Preoperative radiograph showing deep base and previous pulp chamber access

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Preoperative radiograph (horizontal angle)

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Microphoto showing initial access and caries control showing location of discovered canals and perforations

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Microphoto showing completed caries control

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Microphoto showing placement of Dycal barrier and preparation/cleaning of the perforation area

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Microphoto showing cleaned and shaped MB1 and MB2 canals

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Microphoto showing perforations repaired with MTA and the root canals filled with calcium hydroxide and sealed with Cavit

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Radiograph showing temporary resin build-up and calcium hydoxide placement

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Microphoto showing Dycal barrier seal and obturation at the second appointment

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Microphoto showing bonded amalgam core

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Immediate post-treatment radiograph

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Immediate post-treatment radiograph (additional angle)

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1 1/2 year recall radiograph showing the buccal roots of #14. Tooth #13 had been endodontically treated after the endodontic treatment of #14

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1 1/2 year recall radiograph showing the palatal root of #14

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1 1/2 year recall radiograph showing the challenging crown margins with questionable biologic width on the distal of #13

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Clinical microphoto showing the flat "col" in both the mesial and distal #14 interproximal areas. Periodontal pocket depths where within normal limits. The patient presented with heavy plaque accumulation.

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Decision Tree (#14)

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Patient: 66-year-old male with a history of heart attack and bypass surgery

Chief Complaint: Asymptomatic

Dental History: The patient reported a history of pain in the area of the maxillary left first molar. His dentist removed caries, which resulted in a pulp exposure. His dentist started the root canal treatment and referred the patient for completion.

Significant Findings: Slight percussion sensitivity, 4mm sulcular defect at the mid-buccal probing point, and a radiographic presentation showing a very deep base with calcified canals.

Diagnosis: Previous root canal access with acute periradicular periodontitis.

Prognosis: Fair (based upon questionable restorability)

Treatment Description and Special Considerations:
The preoperative radiograph revealed an extremely deep previous access filled with the temporary filling. The filling was removed and the tooth structure was stained with caries indicator dye. Caries was identified on the distal area covering the DB canal, and two pulp chamber floor perforations were revealed. The mesial wall is missing and the previous access was very deep at a subgingival level. After final caries removal the distobuccal canal orifice was found and the sites of perforation prepared and cleaned. The mesial margins were sealed off with a Dycal matrix. The distal of the tooth was judged to have adequate strength and integrity for restoration. The challenge was deemed to be the isolation and aseptic control of the case. Four root canal systems were cleaned and shaped. The MB2 was confluent with the MB1. Calcium hydoxide was placed followed by the packing of a deep Cavit temporary plug into each of the canal orifices. Both perforation sites were repaired with MTA. A Luxacore composite core bonded with Photobond was placed so that better aseptic isolation could be achieved with rubber dam on the following visit.

On the second visit, root canal treatment was routinely completed and a bonded amalgam core was placed after minor mesial crown lengthening.

The quality of the crown restoration was critical to the predictable success of treatment. A circumferential crown margin on sound dentin will best balance forces and provide fracture resistance. The perforations were likely due to poor access extension toward to distal, as the distobuccal canal had not been found. It was important to immediately repair the perforations before the furcation boned was affected and a perio defect was created. Dycal was used as a matrix and a temporary treatment seal. The Dycal was simply cut back after the seal of the perf sites and the canals were provided.

1 1/2 years after treatment the patient was recalled. Tooth #13 had been treated shortly after #14. Both teeth required challenging full coverage restorations. The biological width was a major consideration. Some gingival tissue reduction had been performed to get a circumferential margin on both teeth #'s 13 and 14. The interproximal "col" or saddle-form tissue between 13-14 and 14-15 had been flattened to improve cleansibility but the patient's oral hygiene behavior was relatively poor as heavy plaque accumulation was noted on the mesial surface of tooth #15. The gingival tissues remained relatively healthy with normal perio pocket probing depths. Both #13 and #14 teeth appear to be functioning well and without disease. The next planned recall examination is in 5 years at which time a CBCT scan will be performed to assess osseous regeneration as well as clinical health, stability, and function.

Key Learning Points:

  1. Access extension is important to avoid perforation and missing of canals.
  2. Meticulous placement of a barrer seal during treatment and creation of a hermetic interim temporary seal is extremely important in complicated cases with perforations and deep cervical caries because asepsis is important for a predictable successful outcome.
  3. Immediate MTA repair and sealing of a recent coronal root or furcation perforation is important to prevent abscess and periodontal breakdown.
  4. Dycal is a useful material which facilitates aseptic control during treatment of severely broken down teeth.
  5. Compromised biologic width is an ongoing consideration and it is important to periodically assess teeth treated with significant complications.

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