Document Detail

Repair of a strip perforation with calcium-enriched mixture cement: a case report.
Jump to Full Text
MedLine Citation:
PMID:  25031599     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
The present report reviews the diagnostic and treatment challenges of a mandibular molar with previous root canal treatment and signs of a procedural mishap, i.e. furcal radiolucency and localized swelling of the gingival margin in which a sinus tract was present. By tracing the sinus tract, it became evident that the lesion originated from the furcation area, not the root apices. This case was treated by cleaning/filling the coronal half of the canals and leaving the rest of obturating material untouched. The strip perforation zone in the mesial root was sealed off with calcium-enriched mixture cement. One week after treatment, the patient's symptoms had faded away and one year later, the lesion completely healed with bone replacement.
Authors:
Mohammad Jafar Eghbal; Mahta Fazlyab; Saeed Asgary
Related Documents :
8742999 - Sporadic leber hereditary optic neuropathy in australia and new zealand.
10348469 - Validity of family history data on essential tremor.
3616749 - Hereditary occurrence of anterior sacral meningocele: report of ten cases.
9450889 - Syndromal and nonsyndromal primary trigonocephaly: analysis of a series of 237 patients.
23964159 - Isolated splenic metastases from gastric carcinoma: a case report and literature review.
12081099 - Decrease in human fascioliasis in gipuzkoa (spain).
22036829 - Rituximab - shadow, illusion or light?
24627619 - Poor outcome of bilateral lower extremity morel-lavallee lesions: a case report.
17403889 - Pneumosinus dilatans of the ethmoid sinus presenting with exophthalmus: a case report a...
Publication Detail:
Type:  Journal Article     Date:  2014-07-05
Journal Detail:
Title:  Iranian endodontic journal     Volume:  9     ISSN:  1735-7497     ISO Abbreviation:  Iran Endod J     Publication Date:  2014  
Date Detail:
Created Date:  2014-07-17     Completed Date:  2014-07-17     Revised Date:  2014-07-21    
Medline Journal Info:
Nlm Unique ID:  101497347     Medline TA:  Iran Endod J     Country:  Iran    
Other Details:
Languages:  eng     Pagination:  225-8     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Iran Endod J
Journal ID (iso-abbrev): Iran Endod J
Journal ID (publisher-id): IEJ
ISSN: 1735-7497
ISSN: 2008-2746
Publisher: Iranian Center for Endodontic Research, Tehran, Iran
Article Information
Download PDF
© 2014, Iranian Center for Endodontic Research
License:
Received Day: 6 Month: 1 Year: 2014
Revision Received Day: 19 Month: 4 Year: 2014
Accepted Day: 2 Month: 5 Year: 2014
Print publication date: Season: Summer Year: 2014
Electronic publication date: Day: 5 Month: 7 Year: 2014
Volume: 9 Issue: 3
First Page: 225 Last Page: 228
PubMed Id: 25031599
ID: 4099957
Publisher Id: iej-9-225

Repair of a Strip Perforation with Calcium-Enriched Mixture Cement: A Case Report
Mohammad Jafar Eghbala
Mahta Fazlyaba
Saeed Asgaryb*
aDental Research Center, Research Institute of Dental sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
bIranian Center for Endodontic Research, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
*Corresponding author: Saeed Asgary, Iranian Center for Endodontic Research, Research Institute of Dental Sciences, Evin, Tehran, Iran. Tel:+98-21 22413897, Fax: +98-21 22427753, E-mail: saasgary@yahoo.com

Introduction

Even though a root canal filling might conform to the state-of-the-art in science and technology, the possibility of failure cannot be excluded as microbial leakage can compromise the success of nonsurgical root canal therapy, and the quality of the coronal seal is just as important as the technical quality of the root canal filling for periapical health after root canal therapy (RCT) [1].

Apart from microbial debridement of the root canal system, the success of root canal therapy is based on achieving seal. The basis for this belief came from Hunter’s focal infection theory [2], Rosenow’s concept of elective localization [3], and the hollow-tube theory by Rickert and Dixon [4] stating that those bacteria which have survived the chemo-mechanical debridement of the root canal system or that persisted within the remaining filling materials, are capable of inducing endodontic failure. The presence of bacteria is known as the main reason for failure of endodontic treatment [5].

Accidental root perforation may also complicate the endodontic treatment per se [6-9]. Perforation can be defined as a pathologic/artificial communication between the root canal system and the external tooth surface [9, 10]. Mesiobuccal roots of maxillary molars and the mesial roots of mandibular molars are highly susceptible to strip perforation because of thin dentinal walls. Inappropriate instrumentation not avoiding the danger zone and over preparation of these thin root canals can cause strip perforation [8]. Extended defects and longtime elapse before repair, are accompanied by poorer prognosis due to down-growth of gingival epithelium just below the perforation site, especially when accidental perforations occur in the crestal area of two- and multi-rooted teeth [6, 11]. Bacterial infection originating from the root canal and/or periodontal tissues, results in inflammatory processes accompanied by pain and tenderness, suppuration, abscesses, and sinus tracts [7, 11]. For diagnostic purposes, it is essential for the clinician to trace the lesion by inserting a gutta-percha cone into the sinus tract and to take one or more radiographs to determine the origin of the lesion [12].

Successful management of root perforation depends on early diagnosis of the defect, choice of treatment and materials, host response, and the experience of the practitioner [10]. The orthograde treatment of root perforation follows the same rational of conservative endodontic therapy, i.e. prevention and treatment of periradicular inflammation [11]. This may be achieved by controlling the infection of the perforation site, or if already infected, by using procedures that can disinfect the area and provide the best possible seal against penetration of bacteria and their byproducts [6, 11].

The ideal material for perforation repair should be antibacterial, radiopaque, non-cytotoxic, non-absorbable, biocompatible and able to induce formation of hard tissue, particularly cementum, over the material and provide a three-dimensional seal [13-15]. Calcium-enriched mixture (CEM) cement was introduced as a hydrophilic tooth-colored biomaterial with favorable sealing ability. CEM is biocompatible, nontoxic for the pulp, and antibacterial. It is also proved to be hard tissue inductive; dentinogenic, cementogenic and osteogenic [16]. All these properties make CEM a valid biomaterial for cases of perforation repair.

This case report has focused on the diagnostic and treatment challenges of a furcation perforation in a mandibular molar; also, the one-year post-operative successful treatment outcomes are represented.


Case Report

A healthy 35-year-old male with no medical complication resorted, complaining of a dull pain in the mandibular first molar area on the left side. He stated that RCT of the aforementioned tooth was done by a general practitioner one year earlier. Upon clinical examination the tooth contour showed that it had been prepared for prosthetic crown which according to the patient was later removed to help in eliminating the tooth abscess. The tooth had a defective discolored composite build-up and was not mobile or tender to percussion. Visual scanning revealed a local tender inflammation overlying the buccal mucosa in the furcal region. A draining sinus tract was evident ~2 mm from the gingival margin within the keratinized mucosa. Careful periodontal probing of the tooth showed that pocket depth was within the normal range (<3mm). On a parallel radiography, previous RCT had a moderate quality. A large inter-radicular lesion was evident (Figure 1A). The sinus tract was traced with a #30 gutta-percha point (Ariadent, Tehran, Iran) and according to the second radiograph, its path did not lead to the root apices indicating that the lesion was not related to the apical and middle zones of the root canals (Figure 1B). On both cliché, an opaque bulk of material was evident on the coronal section of the mesial root filling that suggested the existence of an unusual event (i.e. strip perforation) and dentist’s effort to seal off that area which could potentially be the source of lesion (Figure 1A and 1B).

The possible treatment options including tooth extraction with/without replacement and perforation repair with orthograde re-accession and coronal restoration were explained for the patient. In accordance with the patient preferences, the option of saving the tooth via strip perforation repair with CEM cement was chosen. The patient signed an informed consent.

After administering 0.2% chlorhexidine rinse (Behsa Co., Tehran, Iran), the tooth was isolated. The restorative material was removed and all canal orifices were located. The coronal ~4-5 mm of the root filling material was extirpated and 5.25% NaOCl was left in the canals for ~5 minutes. Meanwhile CEM cement (BioniqueDent, Tehran, Iran) was prepared according to manufacturer's instruction. After drying the canals with paper points (Ariadent, Tehran, Iran), CEM cement was placed into the orifices. The biomaterial was gently packed with a dry cotton pellet and appropriate paper points to obtain a good adaptation. Then it was covered with a moistened cotton pellet and the tooth was temporarily restored (Coltosol; AsiaChemiTeb Co., Tehran, Iran). A control post-operative radiography showed the flow of CEM filling through the perforation site into the lesion that confirmed the pre-operative diagnosis (Figure 1C).

On a subsequent visit one week later, all sings/symptoms had subsided and the buccal swelling in the gingiva had faded away. The patient was referred for the prosthetic treatment of the tooth. One-year follow-up radiography revealed complete healing of the lesion and its replacement with bone (Figure 1D). The tooth was totally functional and symptomless.


Discussion

This article represented the diagnostic and treatment challenges of a previously perforated mandibular molar with periodontal abscess that was successfully treated with CEM cement.

Primary endodontic disease with secondary periodontal involvement, primary periodontal disease with secondary endodontic involvement, or true combined diseases are clinically and radiographically very similar [12, 17, 18]. In this case, the furcation abscess could have been mistakenly diagnosed as a primary periodontal lesion. As no sign of periodontitis or even gingivitis was present, this differential diagnosis was ruled out.

The disease associated with radiolucency around endodontically treated teeth is apical periodontitis which may have persisted despite treatment, reoccurred after initial healing, or emerged during the post-operative follow-up period, so it’s appropriate to characterize it as post-treatment disease (PTD) [19, 20]. PTD, like other disease processes, can be resolved only if the etiological factor is eliminated or effectively curtailed. As mentioned earlier, the cause of PTD in this current case was not the quality of previous apical seal; despite being unsuccessful, there was an attempt to seal off the strip perforation in the mesial root with an opaque cement (Figure 1A and 1B). It is obvious that not only the endodontic retreatment of the tooth wouldn’t eliminate the cause of the disease but also it could potentially worsen the situation by enlarging the perforation during the action of instruments and intensifying the obturation. In other words, endodontic retreatment would not change the outcome and repair of the perforation site remained essential. Complete healing of the furcation lesion after one year confirmed this decision (Figure 1D).

Another issue is the importance of coronal seal which appears to be of equal, if not greater, clinical relevance compared to apical leakage as a cause of endodontic failure [21]. Coronal leakage can occur along the restoration margins through the endodontic filling. According to Ray and Trope, defective restorations and adequate root canal fillings have a higher incidence of failures than teeth with inadequate root canal fillings and adequate restorations. In some studies the influence of coronal seal on periapical status is stated to be much more than that of a well qualified RCT [22]. From all these data, it can be assumed that co-existence of coronal leakage and accidental endodontic periodontal communication pathway had caused the problem and a hermetic seal could resolve it.

CEM cement was introduced as an endodontic filling material. This cement has favorable properties such as flow, film thickness, antimicrobial properties, and biocompatibility [10, 16, 23-26]. Creation of a three-dimensional seal is highly important in the success of perforation repair [11]. The sealing ability of CEM which improves in the presence of phosphate-buffered solution (PBS), is comparable to MTA [9], and ensures the perfect outcome of the treatment. In addition, the formation of bone in the healed lesion cannot be overlooked. Hard-tissue (bone, cementum and dentin) inducing ability of CEM is proved in many studies [14, 27]. This phenomenon can be due to its sealing ability, biocompatibility, high alkalinity, and antibacterial effect [27]. Moreover, CEM has the ability to promote hydroxyapatite formation which can be another reason for its hard tissue inducing property [16].


Conclusion

Smart combination of correctly chosen treatment and material and correct diagnosis of the etiology, is the key to successful treatment. As a biocompatible hard tissue inducing material, CEM cement may effectively be used for repair of procedural perforations.


Acknowledgment

The authors wish to thank the Iranian Center for Endodontic Research (ICER).

Conflict of Interest: ‘None declared’.


References
1. Tronstad L,Asbjornsen K,Doving L,Pedersen I,Eriksen HM. Influence of coronal restorations on the periapical health of endodontically treated teeth Endod Dent TraumatolYear: 20001652182111202885
2. Grossman LI. Endodontics: then and now Oral Surg Oral Med Oral PatholYear: 197132225494934772
3. Rosenow EC. Studies on elective localization. Focal infection with special reference to oral sepsisJ Dent ResYear: 19191320567
4. Rickert UG,Dixon C. The controlling of root surgeryTransactions of the Eighth International Dental CongressYear: 1931
5. Senges C,Wrbas KT,Altenburger M,Follo M,Spitzmuller B,Wittmer A,Hellwig E,Al-Ahmad A. Bacterial and Candida albicans adhesion on different root canal filling materials and sealers J EndodYear: 201137912475221846541
6. Fuss Z,Trope M. Root perforations: classification and treatment choices based on prognostic factors Endod Dent TraumatolYear: 1996126255649206372
7. Alves RA,Souza JB,Goncalves Alencar AH,Pecora JD,Estrela C. Detection of Procedural Errors with Stainless Steel and NiTi Instruments by Undergraduate Students Using Conventional Radiograph and Cone Beam Computed Tomography Iran Endod JYear: 201384160524171022
8. Froughreyhani M,Salem Milani A,Barakatein B,Shiezadeh V. Treatment of Strip Perforation Using Root MTA: A Case Report Iran Endod JYear: 20138280323717336
9. Haghgoo R,Abbasi F. Treatment of Furcal Perforation of Primary Molars with ProRoot MTA versus Root MTA: A Laboratory Study Iran Endod JYear: 20138252423717329
10. Asgary S,Eghbal MJ,Fazlyab M,Baghban AA,Ghoddusi J. Five-year results of vital pulp therapy in permanent molars with irreversible pulpitis: a non-inferiority multicenter randomized clinical trial Clin Oral InvestigYear: 2014
11. Tsesis I,Fuss Z. [Endodontal and periodontal aspects of root perforations] Refuat Hapeh VehashinayimYear: 20092633951, 7120162991
12. Zehnder M,Gold SI,Hasselgren G. Pathologic interactions in pulpal and periodontal tissues J Clin PeriodontolYear: 20022986637112390561
13. Noetzel J,Ozer K,Reisshauer BH,Anil A,Rossler R,Neumann K,Kielbassa AM. Tissue responses to an experimental calcium phosphate cement and mineral trioxide aggregate as materials for furcation perforation repair: a histological study in dogs Clin Oral InvestigYear: 20061017783
14. Samiee M,Eghbal MJ,Parirokh M,Abbas FM,Asgary S. Repair of furcal perforation using a new endodontic cement Clin Oral InvestigYear: 20101466538
15. Aggarwal V,Singla M,Miglani S,Kohli S. Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair J Conserv DentYear: 2013165462524082579
16. Asgary S,Ahmadyar M. Vital pulp therapy using calcium-enriched mixture: An evidence-based review J Conserv DentYear: 201316292823716958
17. Oved-Peleg E,Lin S. [Periodontal-endodontal interactions] Refuat Hapeh VehashinayimYear: 20052234351, 9116323408
18. Rotstein I,Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions PeriodontolYear: 200434165203
19. Farzaneh M,Abitbol S,Friedman S. Treatment outcome in endodontics: the Toronto study. Phases I and II: Orthograde retreatmentJ EndodYear: 20043096273315329565
20. de Chevigny C,Dao TT,Basrani BR,Marquis V,Farzaneh M,Abitbol S,Friedman S. Treatment outcome in endodontics: the Toronto study--phases 3 and 4: orthograde retreatment J EndodYear: 2008342131718215667
21. Aledrissy HI,Abubakr NH,Ahmed Yahia N,Eltayib Ibrahim Y. Coronal microleakage for readymade and hand mixed temporary filling materials Iran Endod JYear: 201164155923130071
22. Asgary S,Shadman B,Ghalamkarpour Z,Shahravan A,Ghoddusi J,Bagherpour A,Akbarzadeh Baghban A,Hashemipour M,Ghasemian Pour M. Periapical status and quality of root canal fillings and coronal restorations in iranian population Iran Endod JYear: 201052748223130031
23. Tavassoli-Hojjati S,Kameli S,Rahimian-Emam S,Ahmadyar M,Asgary S. Calcium enriched mixture cement for primary molars exhibiting root perforations and extensive root resorption: report of three cases Pediatr DentYear: 201436123E7E
24. Asgary S,Nazarian H,Khojasteh A,Shokouhinejad N. Gene expression and cytokine release during odontogenic differentiation of human dental pulp stem cells induced by 2 endodontic biomaterials J EndodYear: 20144033879224565658
25. Naghavi N,Ghoddusi J,Sadeghnia HR,Asadpour E,Asgary S. Genotoxicity and cytotoxicity of mineral trioxide aggregate and calcium enriched mixture cements on L929 mouse fibroblast cells Dent Mater JYear: 201433164924492114
26. Asgary S,Alim Marvasti L,Kolahdouzan A. Indications and case series of intentional replantation of teeth Iran Endod JYear: 20149171824396380
27. Asgary S,Eghbal MJ,Ehsani S. Periradicular regeneration after endodontic surgery with calcium-enriched mixture cement in dogs J EndodYear: 20103658374120416429

Figures

[Figure ID: F1]
Figure 1 

A) Pre-operative parallel radiography of the lower first molar with an extensive furcation lesion and defective coronal restoration. Note the opaque material in the mesial root (white arrow); B) Diagnostic radiography after tracing the sinus tract with a gutta-percha cone that ends up within the furcal lesion (white arrow head). Again, note the opaque cement in the mesial root (white arrow); C) Post-operative radiograph; note the flow of CEM cement into the furcation area. The apical 1/2 of all canals are left untouched; D) One year follow-up radiography shows complete healing of the furcal lesion and its replacement with bone



Article Categories:
  • Case Report

Keywords: Key Words Calcium-Enriched Mixture Cement, CEM Cement, Endodontics, Furcation Defects, Perforation Repair, Root Canal Therapy, Root Perforation.

Previous Document:  Effect of Mineral Trioxide Aggregate, Calcium-Enriched Mixture Cement and Mineral Trioxide Aggregate...
Next Document:  Presence of two distal and one mesial root canals in mandibular second molars: report of four cases.