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This book is dedicated to the man

who has been a pioneer in the Specialty of Endodontics,

who was able to lift the Specialty to a whole different level
who first introduced the concept ofpredictability of the Lesion of Endodontic Origin
who changed the way Endodontics is performed world-wide
who has taught to the entire Endodontic world
who developed new revolutionary techniques which are still used world-wide and are still unsurpassed
who changed my life, trasmitting me all of his enthusiasm and love for this fascinating discipline,
my Mentor and my very good Friend

Prof Herbert Schilder

DTP: Studio Ciapetti - Florence, Italy

Printed by: ~ Arti Grafiche - Signa, Italy - 2009, April

Previous italian edition copyrighted 1993

ISBN 88-89411-01-5


Copyright © 2009 by WEdizioni Odontoiatriche II Tridente S.a.s.

All right reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in
writing from the publisher. Permission may be sought directly from Edizioni Odontoiatriche II Tridente s.a.s. in Florence,
Italy: phone +39 055 500 1312, fax +39 055 500 0232, email:, website:

Edizioni Odontoiatriche II Tridente s.a.s

Via degli Artisti, 6/ r
50132 Florence, Italy

Edited by


Visiting Professor of Clinical Endodontics, University of Florence Dental School, Italy
President, Warm Gutta-Percha Study Club
Founder and Director, Micro-Endodontic Training Center, Florence, Italy

Foreword by


Associate Professor, Department of Endodontics, University of Washington School of
Dentistry, Seattle, Washington
Clinical Instructor, Department of Endodontics,Boston University, Henry Goldman School of
Dental Medicine
Guest Faculty, Pacific Endodontic Research Foundation
Founder and Director, Center of Endodontics, Tacoma, Washington


Edizioni Odontoiatriche II Tridente - Firenze




Visiting Professor of Restorative Dentistry, Univeristy of Siena Dental School, Siena, Italy.


Professor and Chairman of Endodontics, Univeristy of Turin Dental School, Turin, Italy; Past President of the
Italian Society of Endodontics.


Private Practice limited to Endodontics, Washington, Washington DC, USA; Past President of the Venez uelan
Endodontic Society.


Founder, Dental Education Laboratories; Adjunct Clinical Professor, Department of Endodontics, University of
the Pacific School of Dentistry, San Francisco, California, USA; Diplomate, American Board of Endodontics.


Associate Professor, Department of Endodontics, University of Verona Dental School, Verona, Italy; Private
Practice limited to Endodontics, Rome, Italy.


Founder and Director, Pacific Endodontic Research Foundation, San Diego, California, USA; Lecturer,
University of California at Los Angeles; Consultant in Endodontics, VA Medical Center Long Beach, California;
Diplomate, American Board of Endodontics.


Visiting Professor of Clinical Endodontics, University of Florence Dental School, Florence, Italy; President, Warm
Gutta-Percha Study Club; Founder and Director, Micro-Endodontic Training Center, Florence. Past President
of the Italian Society of Endodontics; Past President of the International Federation of Endodontic Associations;
Editor of the "Italian Journal of Endodontics" and of "The Endodontic Informer".


Private Practice Limited to Endodontics, Amarilli, Texas, USA; Diplomate, American Board of Endodontics.


L.M.D. University of Geneva; Private Practice, Parma and Piacenza, Italy.


Fellow and Examiner for the Royal College of Dentist of Canada; Fellow of the Academy of Dentist1y
International; Fellow of the Academy of Dental-Facial Aesthetics; Endodontic Editor/or Oral Health; Past
President of the Gorge Hare Endodontic Study Club.


Clinical Professor Louisiana State University School of Dentistry, New Orleans, Louisiana; Clinical Associate
Professor Baylor College of Dentistry, Dallas, Texas; Fellow of the Pierre Fauchard Academy; Fellow
International College of Dentists; Private Practice limited to Endodontics, Tulsa, Oklahoma, USA .


Professor and Chairman, Department of Endodontics, LSUHSC School of Dentistry, New Orleans, Louisiana,
USA; Diplomate, American Board of Endodontics.



Private Practice, Turin, Italy.


Professor and Chairman of Endodontics, Univeristy of Chieti Dental School "G. D'Annunzio", Chieti, Italy; Past
President of the Italian Society of Endodontics; Past President of the Italian Society of Restorative Dentistry,
SID. O.C.; Editor of the Italian Journal of Endodontics; Co-Editor of the Italian Journal of Restorative Dentistry;
Honorary Member of the French Society of Endodontics.


International lecturer and researcher, Lookout Mountain, Georgia, USA.


Private Practice limited to Endodontics, Portland, Oregon, USA.

Visiting Professor of Endodontics, Univeristy of Chieti Dental Scoot "G. D'Annunzio ", Chieti, Italy; Private
Practice limited to Endodontics, Rome, Italy.


L.M.D. University of Geneva, Private Practice, Piacenza, Italy.


Assistant Professor, Deparment of Graduate Endodontics, Loma Linda University, Loma Linda, California,
USA; Adjunct Assistant Professor, Department of Endodontics University of the Pacific Sc/Joo! of Dentistry, San
Francisco, California; Consultant Department of Graduate Endodontics Long Beach Veterans Medical Center,
Long Beach, California, USA.


Associate Professor at the University of California, School of Dentistry, San Francisco; Fellow of the Harvard
School of Dental Medicine, USA .


Fellow of the Academy of Dentistry International; Fellow of the Pierre Fauchard Academy; Founder of ROOTS
-; Program Coordinator, Continuing Education Department, University of Toronto Faculty of
Dentistry, Toronto, Canada.


Private Practice of Endodontics, Scottsdale, Arizona, USA; Visiting Clinical Instructor, Pacific Endodontic
Research Foundation, San Diego, California; Adjunct Assistant Professor Graduate Endodontics Goldman
School of Dental Medicine, Boston, Massachusetts; Assistant Professor Graduate Clinical Endodontics Loma
Linda University School of Dentistry, Loma Linda, California; Instructor and Co-Founder Clinical Endodontic
Seminars, Scottsdale, Arizona.



CHAPTER 2 EMBRIOLOGY by Arnaldo Castellucci






CHAPTER 7 PULPAL PATHOLOGY by Arnaldo Castellucci


and Uziel Blumenkranz


and Kirk A. Coury





Giuseppe Cantatore
and Arnaldo Castellucci

and Elio Berutti




CHAPTER 17 CURVED CANALS by Arnaldo Castellucci


and Giuseppe Cantatore



CHAPTER 20 PROSYSTEM GT by Stephen L. Buchanan



Gary Glassman
and Kenneth S. Serota







CHAPTER 26 THE THERMAFIL SYSTEM by Giuseppe Cantatore _

and W Ben Johnson

CHAPTER 27 MICROSEAL TECHNIQUE by Vito Antonio Malagnino

and Paola Passariello



CHAPTER 30 ROOT RESORPTIONS by Arnaldo Castellucci


and Ronald R. Lemon


and Arnaldo Castellucci







Visiting Professor of Restorative Dentistry, Univeristy of Siena Dental School,
Siena, Italy, during 2002-2006. Active Member of the Italian Society of
Endodontics and of the Italian Academy of Restorative Dentistry.
Private practice limited to Prosthetics and Restorative Dentistry, Florence, Italy.


Founder and Director, Pacific Endodontic Research Foundation, San
Diego, California, USA; Lecturer, University of California at Los Angeles;
Consultant in Endodontics, VA Medical Center Long Beach, California;
Diplomate, American Board of Endodontics.


Visiting Professor of Clinical Endodontics, University of Florence Dental
School, Italy; President, Warm Gutta-Percha Study Club; Founder and
Director Micro-Endodontic Training Center, Florence, Italy.


Associate Dean of Advanced Education and Endodontic Program Director
at the UNLV, School of Dental Medicine, Las Vegas, NV.


Assistant Professor, Deparment of Graduate Endodontics, Loma Linda University, Loma
Linda, CA, USA; Adjunct Assistant Professor, Department of Endodontics University
of the Pacific School of Dentistry, San Francisco, CA, USA; Consultant Department of
Graduate Endodontics Long Beach Veterans Medical Center, Long Beach, CA, USA


Private Practice of Endodontics, Scottsdale, Arizona, USA; Visiting Clinical Instructor,
Pacific Endodontic Research Foundation, San Diego, California; Adjunct Assistant
Professor Graduate Endodontics Goldman School of Dental Medicine, Boston,
Massachusetts; Assistant Professor Graduate Clinical Endodontics Loma Linda
University School of Dentistry, Loma Linda, California; Instructor and Co-Founder
Clinical Endodontic Seminars, Scottsdale, Arizona.


CHAPTER 28 ENDODONTIC-PERIODONTIC INTERRELATIONSHIP..... ... .............. ................. ... ... ..... 756

Endodontic-Periodontal communications...... ..... .. ........ .......... ................... ..... .......... 757

Apical foramen. .... ..... ........... .. ..... ........ ... .. ..... ..... .. ... .... ............................. ... 758
Lateral canals.......... ........ ........................ ..... ..... ... ................... ....... .. ..... .... ... 758
Dentinal tubules ........... ...... ... ...... ......... ......... ... .. ............. .. .... .. ............ ...... .. 760
Etiologic classification of the Endodontic and Periodontal
diseases of the attachment apparatus............................... ....................................... 760
1. Primary endodontic lesion. ...... ................ ... ..... ... .. ............... ... ................... .. 761
2. Primary endodontic lesion with secondary
periodontal involvement. .... .......... ....... ... .......... ........ .. .. .. .. .. .. ..... .. .. .. ... ... .. ... 770
3. Primary periodontal lesion....... .... .... .. .... .. .... .. .. ...... .... ...... ......... .. ................ 771
4. Primary periodontal lesion with secondary
endodontic involvement......... ......... ............................ .... .... .......... ........... .. 775
5. Coexisting primary endodontic endodontic and
primary periodontal lesions........... .. ... ... ...... ... .. ....... ... .. .... ............. .... .......... 778
6. "True" combined lesion.... .. ..... .... .......... ..... ... .. ... .... .................. ..... .. ........... 779
Healing potential and prognosis.............. ..... ...... ............. ...... ... .. ... ........... .. .. ..... .... 781
Differential diagnosis and treatment plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ... .. .. .. ... ... .. .. .. ... ... 782
The influence of pulp disease on the periodontium.......... .... .. ... ........ .. .. .. ... ... .. ... ... .... 783
The influence of endodontic therapy on the periodontium.. .. ........ ... ... ....................... 787
Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................ 788
Root fracture.... ..... ......... ...... ............ ..... ... .... ...... ......... ............. .... ............... 807
The influence of periodontal disease on the endodontium. ..... ....................... .. ........... 820
The influence of periodontal therapy on the endodontium........... ....... .. .. .. .... ............ . 822
Bibliograpy.......................... ............................. .................. .............................. 826

CHAPTER 29 TREATMENT OF TEETH WITH IMMATURE APICES ... . .. .... . ... .. . .... ...... .................. ..... 830

Apexogenesis.................................................................... .. .. .. ............. .... .. ... .... 831

Apexogenesis with calcium hydroxide ...... ..... .. ..... ....................... .. .... .. ............ . 836
The role of calcium hydroxide .. ... ... ..................... .......... .. .............................. 839
Apexogenesis with Mineral Trioxide Aggregate.................................................. 841
Apexification..................................................................... ................................. 842
Technique.. ... ....... .... ..... .... ... ..... .... .. .. ... ..... ........... ............ .. ... ..... .... ... ....... .. 843
Types of apical closure ... ......... ..... ... ...... .. ... .... ......... ............. ............... ........ . 845
Histology of the apical barrier........ ... ...... ...... .. ... ............ .. .. ........ ....... .......... ... 845
The role of calcium hydroxide.. ... .. ............ ... ... .......... .. .... ............ .... ............. . 845
Techniques of obturation.................. .......................... .. .. ............ .................. 851
Apical barrier technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... .. ... .. ... .. .. .. .. .. .. .. .. 851
Prognosis. ....... .......... .... ..... ... ... ... ... .. ... ..... ................. ...... .. ...... ....... ......... ... 863
Bibliograpy. ... ... ... .. ....... .......... .. ... ..... ....... .... ...... .. . .... ....... .. ............................... 863

CHAPTER 30 RooT REsoRPTION.. . ..... .. ....... .... ....................... . . .. .. .. . . . . . . . .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. . 868


Inflammatory resorption....... .... ............... ............ .......... ..... . ................................ . 869

Transient inflammatory resorption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. 869
Progressive inflammatory resorption ............ ......... .. ........ .... ....... .. ...... .... ...... .... . 870
Resorption secondary to pressure. . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. ... .. .. ... .. ... .. .. .. .. .. .. .. 870
Resorption secondary to infection.... ......... .. ...... .... ........... .... ....... .... ... .... .. 873
Internal resorption... ....... .............. ....... .. .......... ....... ... ............ .. ...... 873
External. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. ... ... .. .. ... .. .. .. ... .. .. ... .. .. 878
Resorption with ankylosis and replacement..... ..... ............... ... .... .... ......... .. ..... .. ... .... .. 887
Extracanal invasive resorption.. ......... .......... ... .... ... ......... ....... .. ..... .. ......... ... ..... .... ... 892
Bibliograpy.. .......... .......... .. ..... ..... ... ........... ... ..... .......... ... ........................ ..... ...... 901

CHAPTER 31 BLEACHING NON VITAL AND VITAL TEETH....... .... .. .. ....................... ........................ 904

Section I: Bleaching non vital teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .... .. .. .. .. ... ... ... .. ... .. . .. .. 904
Classification......................................................... ....... ........... .................... 904
Genetic discolorations.. .... .... ... ... ...... .. ....................... ..... ............................... 905
Metabolic discolorations .............. ........... .... ... ..... .... . .. .... ..... ... ... .. .. ... .... .. .. ... .. .. .. . 905
Medicine-related discolorations..... ........... ... ................. ........... .... ............. .. .. ... 905
Causes of pigmentation of pulpless or endodontically treated teeth... .. ..... .... .. ..... .. ... ..... 905
Pulpal hemorrhage ......................... ....... ....... .. ............... ..... .. .... ......... ... .... .... 906
Decomposition of pulp tissue .. .............................................. .......................... 908
Intracanal medicamento and sealers............. ........... .... ......... ......... ..... .... .... ...... 910
Restorative materials............ .. ........................... .. ..... .................. .... ............... 912
Contraindications.......... .. ........... .................... ..... ........ ... ..... .... ........... .. ......... .. ..... 915
Bleaching agents

Hydrogen peroxide.... ....... ............... ... .... .... .. .. ... ..... .. ... ............... ......... ..... ... 915
Sodium perborate ... ..... ..... ..... ....... ...... ......... ... .. ..... .. . .................................. .. 916
Preparation of the tooth. .... .... ...... .... ....... ..... ... .. ... ......... .... ............................ ........ 916
Bleaching techniques ·
Walking bleach... .......... ..... .. .. .... .. .. .. .... .. ......... ... ... .... ...... .... ..... ...... ....... ....... 921
Thermocatalytic technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .................................... 924
Combined technique ... ... .... ... ... ..... ... ... ....... .... .. ........................... .. .. ...... ..... ... 925
Final obturation... ... ........... .. ... .. ............ ..... ..... .. ..... ....... ... ...................... ...... .... .. .. 925
Prognosis .......... ..... ..... ..... ............. .. ........ .... ............. ... .. .. ............... ........... .. ... .. .. 925
Complications .. .. .... ... .. .......... ....... ..... .... ..... ..... .... ........................................ ......... 926
Guidelines for the prevention of discoloration ...................... .. ...... .... .... ...... .. ....... .... .. 930

Section II: Bleaching vital teeth.......... .... ...... ....... ........ ... ... .... .... ... ... .. ........ .. ........... ... .. ...... ..... 932
Dental lightening procedures... ......... .... ........ ..... ... .... ... ...... .... . ..... ............. ............. 932
Stains of enamel and dentin. Treatement considerations..... .. ......... ...... ... ..... ...... ........... 932
Fluorosis stains
Etiology.... ....... ........ .. ... ...... .. .. ..... ... .. ... .......... ........ .................. .................. . 932
Diagnosis ... .......... ..... ..... ....... .. ... .. ........ ,..... .... ....... . ........ ............ ......... ... .. .. 933
Treatment........ ............ .. ...... ........... .... ........ ............ .... .. ....... ........ ...... ...... ... 934
Special considerations: orthodontics and bonding.......... ............. ............... .. ..... .. 934
Combination procedures ........ .... .... ...... .... ... ... ........ ........................ .... ........... 935
Microabrasion and developmental enamel defects.. .. .. .. .. ... .. .... ............ .. .. ........... 935
Tetracycline stains
Etiology.... ....... ..... ..... .. ..... ......... ......... ..... .. ......... ............ .. ................... ..... .. 938
Diagnosis and treatment planning.... ... ... .... .......... .... ........... ....... ........ .......... .. .. 939
Treatment. ... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................................... 939
Special considerations. ...... ........ ....... ...... ... .. ... ..... ... .... ...... ...... .... ........ .... ....... 940
Physiologic stains
Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ..................................... 942
Diagnosis. .. ......... ........ ...... .... .. .. .... ...... ......... ... ...... . ... ......... ........ ....... ......... 942
Development of vital bleaching techniques ......... .. .. .. ...... ..... .. .......... ........... .. .... 942
Treatment planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .................................. 943
Treatment.. .... .. .. .......... ..... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................... 944
Special considerations .... ....... .. ..... .... ...... .... .. ......... ...... .. .. .. ....... .......... .......... . 947
Exogenous (calculus-like) stains. .. .. ..... ..... .... ..... ........ ...... ................. .. .... ............ .. ... 949
Combination procedures. .. .. .... ......... .... .... ........ ... ... ... ... .. .. ... ........... .............. .... ..... 950
Incorporating dental lightening procedures into practice .. .. .. . .. .. .. .. . .. ... ... .. ... .. .. ... ... .. ... . 950
Bibliography.. ......... .. ..... .... ... .... .............. ... .. .. ... ... .. .. ... ... ... .... .................. .... ..... .. 953

CHAPTER 32 THE USE OF THE OPERATING MICROSCOPE IN ENDODONTICS.... ... . ... .. .. .... .... ... .... .. 956

Introduction... ..... ............. .... ...... .. ..... ...... ... ............. .... ... .. .. ............ ... ..... ............... 956
On the relative size of things... .. .. .. .... ... .... ... ........... ... ... .... ..... .. ........ ........ .. .... ....... . 956
The limits of human vision.. .. .... ... .. .... ..... ...... .. .... .. ... ... ... .. .. ..... ........ ........... .......... 957
Why enhanced vision is necessary in dentistry.. .. . .. .. .. .. .. . .. .. . .. . .. .. .. .. ... .. .. .. .. .. .. .. ... ... .. .. .. .. 958
Optical principles ... ...... ... .. ..... ... ........... .. ...... .... ....... .. .... ... ....................... ... .. .. ...... 958
Loupes... .. ....... ... .. .. ......... ... ..... . ... .. .. ...... ... ....... .... .. .... .. ... ... ..... ....... ....... ...... ...... 960
The problem of light.... ...... ... ....... .......... .... ...... .. ... .. ... ..... ... ....... .. .............. .......... 961

The operating microscope in endodontics... ....... ...... .. .. ..... ... ... . . ....... ..... ...... .. .. ......... . .. . 961
The anatomy of the surgical operating microscope
The supporting structure......... ............. ................. ......... .......... ... ... .. .. ... .... .. . 963
The body of the microscope ... .... .. .......... ............ ... .. .... ....... .... ....... .... ... ... ...... 963
The light source ........ ............ ....... ... ... ...... ...... _.. ... ..... ... ... ..... .. . .. .. .. .... .. .. ....... 967
Accessories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................. 968
The laws of ergonomics ....... ...... .... ....... ....... .. ..... .. ... ..... ......................................... 970
Positioning the microscope... ... ............ ........ ... .... ........ ............. ... ....... .. .... .... ........ . 970
Ergonomics and the microscope. .. .. .... ........................ ...... ............................ ... .... .. . 976
The use of the operating microscope in endodontics
Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... ..... ..... .. .. .. ... ... ... .. 978
Locating the canal orifices........ ...... ..... .... ........ .. ... .. ..... ..... ............. .. .. .. .. .. ...... 978
Retreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .... .... .. ... .. ... .. .. 979
Surgical endodontics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................ 984
Learning curve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................................... 995
Conclusion ... .... .... .......... ..... .. ... .. .. .. ........ ... .. ..... ... ..... .. ....... .. ... .. .. ............. .. ...... ... 996
The future .... ...... .... .... ... ....... .. ... ...... ....... .. .... ... .. ....... .... ... .. .. ................. ........... ... 997
Bibliography. .. ... ... .. ..... ...... ...... .... .. ..... ............ ........ .......... .. ... ........ .. .............. .. .. 997

CHAPTER 33 NONSURGICAL ENDODONTIC RETREATMENT . .. . . ... . . .. .. . .... ..... . .... ... ... ...... .. ............. 998

Introduction and definition. .... ... ..... .............. ... ..... ....... .......... .... .. ... ................ ...... 998
Foreword.... .. ..... ... .. ..... .... .... .. .... ...... .... ...... .... ... ........... ... .. ........... ........ .... ......... 999
Rational for retreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .... ..... ..... .. .. .. .... .. . 1000
Criteria for success................. .. ...... ..... .... .... ...... ....... ................ .. ... .... ... .... .. .. 1001
Nonsurgical versus surgical retreatment.... ....... ...... .. .. . ........ .. ..... ..... .......... ....... 1003
Factors influencing retreatment decisions... ..... ................ ..... ..... .. ................... .. 1004
Coronal disassembly..... ...... .. .. ................ ....... ......... ......... .. .. ....... ........................ . 1007
Factors influencing restorative removal.. .. ...... ... ....... ...... .... ............................ .. 1007
Coronal disassembly devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. ... .. .. .. ... .. .. .. .. ... ...... 1007
Post removal..... .... ................. .................... ........... ..... .... ....... ... ............... ... ... ..... . 1010
Factors influencing post removal..... .. .. ...... ...... ... . . . . . . . . . . . . . . . .. .. .. ...... ... .. .. .... .... .. 1111
Techniques for post re~oval.... ... ................................. .. .. ... ............. .............. 1015
Nonmetallic post removal.......... . ..... ................ .. ... ... .. .................... .......... ... .. . 1020
Removal of obturation materials. ............. ....... ..... ... .. ......... .. .... .. ... ..... ...... ... ........... .. 1020
Gutta-percha removal......... ..... .......... .... ... ... .. .. . ... ... ....... .............. .... ... .... .... . 1022
Silver point removal.. ..................... ..... ... .... .. .......... .. .. ... .. .. .. .... .. .. .... ... .. .. ... .. 1026
Carrier based gutta-percha removal...... .. ... .... .... .. .... .... ..... .. ............. .. .. ..... ... ... 1034
Paste removal.. ................. ....... .. .. ..... .... .. ..... ...... ...... .............. ...... ... .... ...... .. 1036
Broken instrument removal.. .......... ............. ............ ..... .... .. .... ... .. .... ...... .... .... ... .. .. 1038
Factors influencing broken instrument removal.... ............. ..... .. ... .. .. .. .. ... .. .. .. ... .. 1038
Coronal and radicular access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ............................ 1041
Techniques for removing broken instruments... ... ... ..... ...... ....... ......... ...... .... ... .. 1043
Blocks, ledges and apical transportations .. .. ..... ........ .... ....... ...... .. .......... ..... .... ...... ... . 1048
Techniques for managing blocks.. .. ..... ....... .... ..... .... ...... ...... .. ..... ... ... .. .. .. .... .. .. 1048
Techniques for managing ledges...... ........ ......... .... ... ... .. ... ... ....... ... ..... ... ......... 1050
Techniques for managing apical transportations ...... ..... . .... ... .... ... .... .... ......... .. ... 1053
Endodontic perforations ........... ............ .... .............. ...... ...... ..... .............. ... ............ 1057

Considerations influencing perforation repair.. ... .. ....... .. ... ..... .......... ........ .......... 1057
Materials utilized in perforation repair. . .. .. .. . . . . . . . . . . . .. . .. . . . . . .. .. ... .. ... .. .. .. .. .. .. .. .. ... .. 1058
Techniques for repairing perforations..... ...... .... .... .. ... ... ... ............ .. .................. 1060
Missed canals ... ........ .... .. ..... ....... .. ... ...... .... ... .. .. .... ........ ........ ........... ...... ......·........ 1063
Canal anatomy... ... .. ............. .. .... ... ................ ... ... ... ..... .. .. ......... ..... ........... ... 1063
Armamentarium and techniques... ... ... .. .......... .... ......... .. ............................ .. .... 1067
Future ... .... .... .. ....... ........ ............... ........ .... .. ...... ........ . .. ..... ...... ............. .... ... .. ... 1069
Bibliography... ............. .. .. ... .............. ..... ...... ... .... ..... ... ........ ....... ..... .......... ...... ... 1070

CHAPTER 34 MICRO-SURGICAL ENDODONTICS ...... .. . .. .. .... .... .. .. .. . .. .. . .. .. . .. .. . .. . .. .. ....... .. .. ... .... ... 1076

Introduction.... .... ....... .. .... ................ ...... ......... .... ... ........... .. . ... ......... .... ... ........ .. 1076
Microscopes and endoscopes for enhanced vision .. .. .. ... ... .. .. .. ... .... .... ... ... .. .. ..... ... .. .. . 1076
Endodontic Surgery or Surgical Endodontics ?... .. .. .. ........ .. ........ ... ........ ... . .. ......... .... .. .... .. .. 1078
Indications for surgical endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ........................... 1078
Contraindications for surgical endodontics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... .. .. .. .. .. .. ... ... .. .. 1079
Lateral lesions of endodontic origin .... .. ..... ................ .. ... .... ...... ........ ....... ........ 1079
Unfavorable crown-root ratio .. .. .... ..... ....... ....... ...... ...... .. ........ ................. ....... 1081
Vertical root fractures .. ... ........ ... .. .. ..... .. .. ... ........ ... ... .. .. .......... .................. ..... 1081
Medical considerations
Past medical history. .. ...... ... .. ..... .... .......... .. ...... .... .... .. ................. .. .. .... ..... ... . 1081
Antibiotic medication. ....... ...... ..... ...... ........ ......... ........ .. ........ ............ .... ...... . 1083
Anti-inflammatory medications.......... .......... ...... ...... .... .. ...... .... .... ....... ..... ....... 1083
Psychological considerations ...... ........ ... ..... .. ..... ..... ..... .... ... . ........... ............ .......... . 1083

Section I: Preparation of the patient, surgical team and instruments

Preparation of the patient ... ...... ................. .. .. ... .......... ... ................ ..... ..... ...... .. ........ 1084
Preparation of the surgical team....... ...... ... ..... ..... ....... .. ...... ..... .. .. .. .. .... .......... .. ... ....... 1084
Preparation of the instruments.... ............... ................ .......... ...... .... ..... ....... .... .. .. ...... . 1086
Local anesthesia........ ..... ........... .... .. ... .... ... ... .... ... ... ............ ... ..... ......... .... ... ........ ... 1088
Hemostasis staging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. ... ... .. .. .. .. ... .. .. ... ... ... ... .. .. .. 1090
Toilet and stabilization of the surgical site. ..... ...... .... .... .... ...... ..... ............... .. .. ......... .. .. 1091

Section II: The incision and atraumatic flap elevation

Anatomical considerations for incision.. ...... ....... ...... ........ . .... ..... ... .. .... .... .. .. .. .. .. ..... .. .. 1092
Inferior alveolar nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ............................................ 1092
Mental nerve ... ... ....... ...... ........ ........ ... ....... .. ..... ..... ......... .......... ................ ... .. 1093
Greater palatine artery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ............................................ 1093
The incision ....... ... .. ... .... ... .... .. ........ ..... ... .... ....... .... ................ .... ...... ..... .. .. ............ 1093
Reflection of the flap .. ... .. ................. ........... .... ....... ............ ........ .... ..... .... ...... .. .. .. ... 1097
Atraumatic flap retraction ... ... .. ... ..... ... ..... ... ..... ... ..... ... .. .. ...................... .... .. ... ......... . 1098

Section III: Access and crypt management

Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ............................................. 1100
Crypt management. ...... .......... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .. .. .. .. .. ... .. ... ...... ... .. .. .. ... ... ... .. 1101
Ferric sulfate.. ... .... .. ... .... ... .... ........ ... ...... .. .... .. .. ..... ..... ..... ................ .. ... ..... .. ... 1101
Slight hemorrhaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .. .. .. .. .. .. ... .. ... ... ... ... .. .. .. .. .. .. .. 1103
Moderate hemorrhaging...... ......... .. .... .... .. ... .... ... ......... ................. ....... ...... .... ... 1104

Calcium sulfate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ............................... ................ 1104

Severe hemorrhaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .............................................. 1106

Section IV: The root-end bevel and root-end preparation

The root-end bevel..... .. ..... ... ............. ... ...... ... .... ...... ......... ...... ................................ 1106
Methylene blue staining... ...... .... ...... ... .. .. ......... ..... .. .. ... ......... ....... ............ ... .... ...... .. 1110
Ultrasonic root-end preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .......................................... 1111

Section V: Root-end filling

Root-end filling materials.... .... ..... ....... ... ....... ................................ .. ......................... 1118
SuperEBA. .............. .. ......... .. ......... ..... ... ......... .......... ....................... ... ..... ....... 1119
Bonding.. ........... ....... ... .... .. ........ ... .... ....... .. ..... ..... ....... .... ........... .. .......... .... ... 1120
Mineral Trioxide Aggregate .... ... ... .. ..... ....... .... ..... .................. .. .......... ............. ... 1122
Optional microsurgical procedures
Trans-sinus apical surgery..... ... ...... .... ... .... .. ..... ... ... .. .... .. ..... .......................... 1126
Pre-surgical restorations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............................. 1130
Prior to root resection. .. .. ................... ...... .. ... .... .. ...... ... ... ........................... .. 1130
Prior to root-end resection.............................. .. ............ .. .... .................. ........ 1130
Surgical repair of perforation or resorption defects..... ........... ....... ... ... ............ .... ........ 1131
Guided bone regeneration
Materials for GBR. .. . . . . . . . .. ... ... . . ... . .. . . . ... .. ... .... .. ... .. .. . ..... ....... ... ...... ........ ........ 1133
Calcium sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................... 1134

Section VI: Sutures and suturing techniques

Closure of the surgical flap. .. ......... .... ....... ... .... .... ..... .... .. .............. ............... ........... 1136
Suturing technique using the surgical operating microscope...... ... ......... ..... ................... 1137
Suturing considerations..... ...... ..... ............ ..... .. .. ...... .... .............. ............. ........... ...... 1138
Flap tissue: re-approximation management.. ... ..... .... . . . . . . . . . . .. .. ........ .. ...... ....... .. ..... ... .. .. 1140
24 hour suture removal. .... .. ..... .. .. .... ..... ..... ..... ... .. .. ..... .... ........ .. ......... .......... ... ..... .. 1140

Postoperative care . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . .. . . . . . . .. . . .. . . . . . . . . .. . . . . . .. . .. .... .. ... .. .. ... ... .. ... ... .. .. 1142

Post surgical home care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................. 1142
Conclusion.... ...... .............. .. ... .. .... ... .... ... ....... ........ .. .. .... ..... .. ....................... ...... 1143
Bibliography.... .. ...... ... ...... .... .... ..... .... ... ... ... ... .... ... ... ... .... .. .... .. ................. .......... 1143

CHAPTER 35 RESTORATION OF T HE ENDODONTICALLY TREATED TOOTH .. . .. .. .. . . . .. . . .. .. . .. .. . .. .. .. 1146


Introduction. ... .......... ....... .. ........ ... .... ..... .. ...... ........ .... .. .... ........ ... .......... ...... ....... 1146
History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ................................ 1146
Biomechanics ...... .... .... .. .... .... ... ...... ........... ...... .. ........... ..... . .. ..... ............... ......... 1147
Operative sequence ... . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. .. .. . . . .. . . . .. . . . . . .. .. . . . .. .. .. .. .. .. .. ... ... .. .... .. .. .. .. 1150
Preliminary data collection and evaluation........... .. ...... ... .... ..... ......................... 1150
Treatment plan. ... .. .. ... ... ..... .... .... ..... ... .... .. ... ..... .... .... .... .... ......... .... ....... ....... 1150
Materials and techniques ....... ...... .......... ... .... ... ....... ......... .. .......... ........ ........ .. 1156
1) Posts. .. ...... .... ... ...... ... .... ... .. ....... ... .. ...... .... .. ... .. ... .... ... ............... .... .. .......... 1157
Prefabricated posts.... ... ....... ... . ... ....... ........ .. .. .. ...... ................ ... .............. 1165
Cast post and core . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................. 1174

2) Cements for posts cementation....... ...... .. ... ..... ..... .. ..................... ..... ...... .. .... .. 1184
3) Prosthetic crowns ... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................ 1186
4) Conservative restorations.......... ..... .... ... ... ... .. .. ........... .... ................... .. ......... . 1188
Amalgam ..... ....... .. .... .. ... ..... .... .... .. .... .. .. ... .............. ............ ........... :.. ...... 1188
Glass ionomer cements.............. ....... . .. . .. ... ... ....... ................ ................... 1192
Composite and the adhesive techn ique ... ... ... . .. ..... ..... .... .. ............. ............. 1193
Severely periodontally compromised teetb.. ... ...... .. ............ .... . .. ... ..... .............. .. ...... . 1220
Chapter outline... .. ... .... ..... .... .. ... ..... ... ...... .. ....... ........ ....... ............. ................ ...... 1223
Bibliography.... .. .... ... ............. ... ........ .. ...... .. ...... .... ... ...... ... . .... .................. .......... 1224

INDEX.. ... ..... .. ..... ......... ...... ... .. ................ ...... . ......... .... ..... ... ..... ................ ........................ ...... .. .. .. 1232
756 Endodontics


Endodontic-Periodontal Interrelationship

The vital organ of the tooth is the attachment ap- of particular importance in diagnosing the endodontic
paratus, which consists of three components: cemen- and periodontal components of lesions.
tum, bone, and periodontal ligament. 100 The function As a matter of fact, this is the most frequent com-
and durability of the tooth depend upon it. bination of pathologic processes, and it often causes
In fact, the viability of a tooth in the arch depends great diagnostic problems. The two disease proces-
more on the health of its attachment apparatus than ses may have many signs and symptoms in common,
on the presence of pulp tissue within its root canal sy- such as edema of the marginal gingiva, the presence
stem. 22 Destruction to this vital organ impairs the ulti- of fistulae draining through the gingival sulcus, pro-
mate retention of the tooth. 99 bing, sensitivity to percussion, mobility, and periradi-
The attachment apparatus can be affected by a va- cular or even periapical radiolucency. This can cause
riety of diseases, which may be of endodontic, perio- great diagnostic difficulties which become even grea-
dontal, or occlusal origin (Fig. 28.1). ter when the two pathological processes coexist or
These different pathologic processes may also coe- when one simulates the clinical or radiographic ap-
xist in the attachment apparatus of the same tooth, gi- pearance of the other.
ving rise to so-called "combined" lesions. The importance of a correct diagnosis is obvious
Awareness of the reciprocal relationship between (Is the lesion of endodontic origin? Is it of periodontal
endodontic and periodontal pathologic processes is origin? Is it a combined lesion?), inasmuch as proper

Fig. 28.1 . In the mouth of the same patient, the three pathologies of different etiology are present.The lower right central incisor, which gives a positive response to
the pulp vitality tests, has been subjected to occlusal trauma and requires an occlusal adjustment.The lower left central incisor does not give a positive response to
the vitality tests; it requires endodontic therapy.The left lateral incisor responds to the vitality tests and is seriously compromised periodontally.It requires periodon-
tal therapy and, consequently, endodontic therapy. A. Preoperative radiograph. B. Recall radiograph 8 months later.
28 - Endodontic-Periodontal Interrelationship 757

therapy depends on it (Is only endodontic therapy cal- could not expect to achieve.
led for? Is only periodontal therapy indicated? If one Of course, the greater success with the treatment
has to perform both, which must be done first?), as of the attachment apparatus by the endodontist, as
does the prognosis of the affected tooth. compared with the success encountered by the perio-
The goal of this chapter is to examine the reciprocal dontist, is not due to greater skill or magical powers
influences that the pulp and periodontal tissues exert on the part of one specialist as opposed to another,
on each other, the means of communication, and the but is due to the more favorable anatomic environmet
interrelationship between pulp disease and periodon- encountered by the endodontist as compared to that
tal disease and between pulp therapy and periodon- encountered by the periodontist: the endodontist is
tal therapy. working in a closed system, while the periodontist is
In setting a discussion of the lesion of endodontic working with an open system.
origin in a more general chapter on the diseases of Once the rubber dam is placed, and access is gai-
the attachment apparatus of the tooth, one may con- ned through the crown of the tooth to its apex, the
sider endodontic therapy to be a specialized form of noxious protein breakdown products, tissue debris,
periodontal therapy. After all, its final goal is also to bacteria, and toxic products can be eliminated, and
maintain the health and function of the tooth's sup- the eventually sterilized root canal may be filled.
port tissues. On the other hand, in the crevicular space, inflam-
Periodontists treat damage to the attachment appara- mation and reinfection, introduction of food particles
tus at its "margin". Endodontists treat damage to the at- and bacteria are constant occurrences.99
tachment apparatus in the "periapical" area. 99 There is Since, even though their therapies have the sa-
one clear difference between the two cases, as is well me goals, the two diseases have different prognosis,
known to most clinicians: attachment apparatus lost a correct diagnosis and treatment plan are extremely
due to crestal resorption is rarely regained, while the important, especially when the two pathologic pro-
result of an endodontic treatment is complete regenera- cesses are or seem to be combined.
tion of periapical bone, and with it, regeneration of the
previously destroyed attachment apparatus. 22·99
Many infra-bony pockets fill in with bone, while ENDODONTIC-PERIODONTAL
many do not, the chances increasing with the num- COMMUNICATIONS
ber of walls remaining in the original infra-bony poc-
ket defect. A three-walled pocket has a greater chance In addition to the apical foramen or foramina (Fig.
of repair than does a two-walled pocket. On the other 28.2), the pulp communicates with the periodontal
hand, as every endodontist knows, the chances for
reapair of periapical endodontic lesions are enormou-
sly high. In periodontal terms, we are dealing with a
six-walled infra-bony pocket in most cases, occasio-
nally with a five-walled pocket, and in our worst si-
tuation, when the buccal and palatal plates have been
destroyed, with a four-walled pocket.
With classical periodontal lesions, the clinician must
frequently satisfy himself with elimination of infection
and inflammation, and arresting of the lesion. Many pe-
riodontal procedures are predicated on the acceptance
that the lost attachment is gone for good, and that the
result of therapy should be to stop its further loss.
On the other hand, as already said, in case of an en-
dodontic lesion, the result of endodontic treatment is
is complete regeneration of periapical bone and of the
attacmnet apparatus. In this case, the endodontist has
performed periodontal therapy in the periapical area.
He has effected therapy on the attachment apparatus Fig. 28.2. S.E.M. micrograph of the apex of a lower lateral incisor with three api-
that a periodontist treating a tooth with crestal defects ca l foramina (x25).
758 Endodontics

foramen of a root canal whose pulp has become necro-

tic and the entrance of these substances into the periapi-
cal tissues gives rise to an inflammatory response and all
the consequences already described in Chapter 8, such
as destruction of the apical periodontal ligament and the
resorption of bone, cementum, or even dentin. 111
On the other hand, as will be examined in greater
detail below, the effects of even advanced periodon-
tal disease on the pulp tissues through the apical fora-
men are much debated and not universally accepted.
Nonetheless, they seem to be minimal; it appears that
they occur only when the entire root surface is cove-
red by bacterial plaque.


The existence of lateral canals is recognized univer-

sally. They are present in such large numbers that not
taking them into consideration may represent the dif-
ference between success and failure.12•67
The location and incidence of lateral canals grea-
Fig.28.3.A. Mesia I wall of the distal root of a lower first molar viewed by S.E.M.
Note the presence of numerous lateral canals (xSO). B. Detail of the preceding tly influences the health of the dental pulp and perio-
figure at higher magnification (x800). dontium.57 They may occur at any point on the entire
root surface and at the bifurcation of multirooted teeth.
Embryologically, they arise from blood vessels in the
area of the developing root that course between the
papilla and the dental sac. These vessels create defects
in Hertwig's epithelial root sheath (see Chapter 2).
The first, classic study on the morphology of the
root canals was that of Hess and Zurcher 51 in 1925.
They demonstrated the presence of accessory apical
canals in 43.5% of their cases.
The first study to relate lateral canals to periodon-
tal disease was that of Seltzer, Bender, and Ziontz 102 in
1963, and the first to correlate the importance of the pre-
sence of lateral canals with the outcome of periodontal
therapy was that of Rubach and Mitchell 91 in 1965. The
Fig.28.4. Dentinal tubules seen at 9,000 magnification. largest study of the frequency of lateral, secondary, and
accessory canals is fairly recent (DeDeus, 34 1975).
These and many other studies have clearly demon-
ligament through lateral canals (Fig. 28.3) and dentinal strated that lateral or accessory canals are a normal ana-
tubules (Fig. 28.4). tomical component of many teeth, which are found at
relatively high frequency in the apical third of the root
APICAL FoRAMEN (Fig. 28.5) and in the bifurcations of the molars (Fig.
28.6). They represent an important means of commu-
The apical foramen is the principal means of com- nication between the endodontium and periodontium,
munication between the endodontium and periodon- so much so that they may be considered endodontic-
tium. It is thus the principal two-way window by which periodontal "portals of exit" of the pathologic processes
the two pathologies may spread. or periodontal-endodontic "portals of entry."
The issuance of irritating substances from the apical In the former case, it is universally accepted that the
28 - Endodontic-Periodontal Interrelationship 759

same inflammatory process that occurs at the apex fol-

lowing pulp necrosis can happen at the level of the
periodontal ligament facing a lateral canal, with the
formation of a radiolucency on the side of the root of

Fig.28.5.An upper right central incisor with a lateral

canal running almost parallel to the principal canal.

Fig.28.7.A. Preoperative radiograph of a lower right first molar:the tooth has a

fistula arising from a lateral canal. B. Postoperative radiograph: note the filling
of the lateral canal. C. The recall radiograph 24 months later shows the com-
plete healing of both the apica l and the lateral lesions.

the tooth (Fig. 28.7).

As far as the reverse pathway is concerned - as will
be discussed at greater length below - since it is im-
B possible to determine in a vital tooth whether a lateral
canal is present, and since it is likewise impossible on
Fig. 28.6. A. A lower right first and second molar with lateral cana ls opening in
the bifurcation. B. An upper left second molar with a lateral canal in the me-
clinical grounds exclusively, to determine the exact hi-
sio-bucca l root. stologic condition of the pulp, the hypothesis that pe-
760 Endodontics

riodontal disease can be transmitted to the pulp by ex- endodontium to the periodontium, there is no proof
tension of the inflammatory process to the tissue of a that the infected contents of the dentinal tubules of
lateral canal is still doubtful and much debated. a tooth with a necrotic pulp can inhibit periodon-
Furthermore, since the lateral canals are much mo- tal reattachment to the root surface, nor that endo-
re frequently found in the apical third, the periodon- dontic therapy facilitates reattachment in such ca-
tal pathology must be very extensive to involve a ses. The condition of the pulp thus has no influen-
dental pulp through a lateral canal. Obviously, the ce through the dentinal tubules on the prognosis of
prognosis of that tooth will depend only on the pos- periodontal disease. Although the size of the denti-
sibility of saving the tooth from the periodontal point nal tubules may permit the passage of bacteria and
of view. their toxins, an intact layer of cementum acts as an
Lastly, regarding the therapy and presence of late- effective barrier to penetration into the periodontal
ral canals, if the tooth requiring periodontal therapy structures. 108
has a necrotic pulp, the reattachment may be ham- Nonetheless, it is obvious that if a tooth that requi-
pered if the periodontal treatment is performed be- res periodontal therapy also has a necrotic pulp, en-
fore the endodontic treatment, because of the bacte- dodontic therapy must be performed first. If a surgical
rial toxins that continue to pass through the lateral approach becomes necessary to seal the root canal sy-
"portal of exit." stem, this can be done during the periodontal proce-
If the pulp of the tooth is vital, treating it endodon- dure, thus sparing the patient two incisions in the sa-
tically only because there is a remote possibility that a me area for two different purposes.47
lateral "portal of entry" may be present would be pu-
re folly, as this would mean endodontically treating all
teeth with periodontal disease. 47 ETIOLOGIC CLASSIFICATION OF THE
This classification was proposed by Simon, Glick,
The dentinal tubules, whose diameter is about 2.5 and Frank 106 in 1972. It has the distinction of having
µm at the pulp end and about 1 µm at the opposi- clarified the relationships that connect endodontic and
te end,43 run from the pulp to the dentinoenamel and periodontal lesions, especially when the presentation
dentinocemental junctions. of one simulates the pathology of the other or when
Normally, the dentinal tubules do not communica- the two processes coexist in the same tooth.
te with the periodontium, because of the interposition
of the radicular cementum. If, however, the periodon-
tal disease has denuded a certain amount of the exter-
nal root surface, a communication can be established
between the contents of the dentinal tubules and the
oral environment, both in the case of congenital ab-
sence of cementum in the area of the cementoenamel
junction and in the case of complete removal of ce-
mentum in the process of root planing. In this way,
about 15,000 dentinal tubules/ mm 2 appear on the ex-
ternal surface of the root in the area of the cementoe-

namel junction. They could represent a means of tran-
smission of disease in either direction.
Regarding the periodontal-endodontic direction,
the incidence of pulpitis or pulp necrosis secondary
to exposure of the dentinal tubules following root
planing is unknown. Nonetheless, clinical experience Fig. 28.8. Schematic representatio_n of a primary endodontic_lesion. A. An in-
suggests that it occurs in a relatively small percentage fection arising from the apex or from a lateral canal 1s draining through the
periodontal ligament on one side of the root. B. The fistu la arising from the
of periodontally involved teeth.47 apical fora men or from a lateral canal of the b1furcat1on has opened in the gin-
Considering the transmission of disease from the gival sulcus and has caused a lesion of the b1furcat1on.
28 - Endodontic-Periodontal Interrelationship 761


In the chapter on periapical diseases, chronic apical
periodontitis or granulomas were shown to be some-
times associated with the presence of a fistula. It was

also shown that an acute alveolar a scess coutcl spon-
taneously drain throu _h th stulous sinus tract.
Such dramage, arising from acute or c rome lesions
of endodontic origin, can occur along the root surface
and open through the gingival sulcus, thus sirr'ililatffig
a periodontal 1 sm - ' A
• -fie infection can arise from the apex of the tooth
or from a lateral canal situated at any level of the root
(Fig. 28.8). In a multirooted tooth, the drainage may

open along the mesial or distal aspect of the root or
may involve the area of the bifurcation.

Fig. 28.9. The drainage of the periapical lesion

occurs in the space of the fibers of the perio-
dontal ligament.

In any case, this is not a periodontal pocket, but a

simple fistula which, rather than opening in the buccal
or lingual mucosa, has opened in the gin ival sulcus.
Genera ly,clrainage through the gingival su cus can D

follow either o W-G Rathw i s: 64 -

1) The pus courses through the fibers of the perio- Fig. 28.10. A. Preoperative radiograph of a lower left second premo-
lar. The tooth has a necrotic pulp and a lesion at the apex that is
dontal ligamenl fffg zSJ)J . It is possible to probe a draining through the gingival sulcus. Note the radiolucency that
very narrow, deep defect to the apex. In this case, one accompanies the entire mesial aspect of the root. B.The periodon-
tal probe reveals the presence of a tubular defect. C. One week af-
is not "~ ng" a periodontal et, but rather a fi- ter cleaning and shaping of the root canal, the defect is no longer
stulous smus tract (Figs. 28.10, 28.11). probeable, as the fistula has closed. D. Six month recall.
762 Endodontics


Fig. 28.11. A. This chronic lesion at the apex of the lower left second molar with a necrotic pulp has created a drainage through the periodontal ligament.
Note the radiolucency that rises mesially. The defect can be probed beyond the root apex. Preoperative radiograph. B. Recall radiograph 24 months after
completion of the endodontic treatment. The patient did not undergo any periodontal therapy.

In multirooted teeth, this drainage very often occurs ted teeth, drainage through the periodontal ligament
along the area of the bifurcation, and radiographical- and sulcus can be manifested as a slight radiolucency
ly the resulting lesion resembles a periodontal through along the mesial or distal aspect of the root surface (Fig.
and through lesion of the bifurcation (Fig. 28.12). Since 28.10). If, however, the drainage occurs on the buccal
the fistula involves only one aspect of the root, this en- or lingual side, it will not be visible radiographically.
dodontic lesion of the bifurcation is as a rule associated 2) Pus originating in the apical region perforates
with a normal-appearing mesial and distal crestal bone. the cortical bone near the apex, raises the periostium,
This is a great diagnostic aid (Fig. 28.13). In singleroo- runs between the periostium and the underlying al-

Fig. 28.12. A. The chronic lesions at the apices of the lower
right first molar with a necrotic pulp are draining through the
gingival sulcus and have caused a lesion of the bifurcation.
Note the healthy periodontal condition both mesially and di-
stally . B. The bifurcation probe demonstrates the defect. C.
Recall radiograph 3 months later.The lesion of the bifurcation
was evidently of endodontic origin (primary endodontic le-
c sion) with no periodontal involvement.
28 - Endodontic-Periodontal Interrelationship 763

Fig. 28.13. Endodontic lesion of the bifurcation: restitutio ad integrum occurs after endodontic therapy alone.A. Preoperative radiograph. Note the presence of: a)
penetrating caries, b) a periapical lesion in addition to that of the bifurcation, and c) the optimal level of the mesial and distal crestal bone.The pulp tests were ne-
gative. B. Postoperative radiograph. C. Recall radiograph 2 years later.

veolar bone, and finally opens in the gingival sulcus swelling (especially in the bifurcations), and possibly
(Fig. 28.14). This extraosseous fistulization is more of- slight discomfort for the patient. Pain is never present.
ten buccal, produces a very wide opening, and cannot The defect can be probed with a gutta-percha cone or
be probed because the periodontal ligament and sur- with a periodontal probe. Either will descend to the
rounding bone are not affected by the process. origin of the infection, namely the apex or the level of
Clinically, the primary endodontic lesion is manife- the lateral canal. In contrast to the infrabony pocket of
sted by drainage through the sulcus, sometimes by slight periodontal origin (Fig. 28.15), the defect is very nar-

,,,,/ I

\ I I
\ I , \ I
\ I I \ I
\ I \ I \ I I I


Fig. 28.14.The fistula has opened in the gingival sul- Fig. 28.15. A. The infrabony pocket of periodontal origin is usually wide and
cus, but the pathway is extra osseous. shallow. B. The periodontal probe reveals the "soup-plate" defect.
764 Endodontics

Fig. 28.16. In the primary endodontic lesion, the defect is narrow and deep, or

row and deep (Fig. 28.16).

There are other clinical situations in which a long,
narrow periodontal defect occurs, with a sinus tract
type of proping, but they are distinct processes. These
situations are:
1) Enamel pearls. These are portions of enamel,
usually hemispherical, located on the root surface.
The most frequent site is the distal surface of the third
molar (Fig. 28.17), but they may also be found on
the buccal surface of a molar in the bifurcation (Fig.
28.18). They may form as the result of the persisten-
ce of a small group of cells of Hertwig's epithelial ro-
ot sheath which, instead of separating from the new-
ly-formed dentin and dispersing into the periodontal
ligament, remain adherent to the dentin and differen-
Fig.28.17.A. Enamel pearl on the distal surface of the distal root of a third mo-
tiate into ameloblasts by the same process of recipro- lar. B.The periodontal defect corresponding to the pearl, seen at higher mag-
cal induction that occurs at the coronal level, whe- nification (Courtesy of Prof. A. Bloom, Boston University).

re the newly-formed dentin induces the differentia-

tion of the cells of the inner epithelium of the enamel
organ into ameloblasts, which begin to produce and
deposit prisms of enamel on the underlying dentin 76
(see Chapter 2). Masters and Hoskins 70 have descri-
bed these projections of enamel into the bifurcations
of molars. The projections lack a true attachment and
are thus highly susceptible to the creation of a narrow,
deep periodontal pocket. 90
2) Developmental grooves. These are frequent,
especially on the palatal surface of maxillary lateral in-
cisors, where they have the'appearance of an invagina-
tion or vertical sulcus of the root surface and cause ir-
reversible periodontal disease. 9·105 Their particular fre-
quency in maxillary lateral incisors is easily explained
if one considers that this is an area that is embryologi- A B
cally at risk. Many malformations, including cleft pala- Fig. 28.18. A. Enamel pearl in the buccal bifurcation of an upper first molar. B.
te, missing, supernumerary and peg-shaped lateral inci- Enamel pearl in the buccal surface of a lower molar.
28 - Endodontic-Periodontal Interrelationship 765

Fig. 28.19. An upper left lateral incisor with a distolingual sulcus extending to the root apex. A. In the preoperative radiograph, the sulcus originating distally to the
cingulum is already visible. B.The sulcus appears to be partially concealed by calculus. C.The probe disappears into the defect.

sors, dens in dente, and the developmental grooves or thelium, is present. 39 They may vary in depth from a
distolingual grooves, arise in this area. 39 These grooves simple groove involving part of the dentin to the com-
usually begin at the level of the central fossa, cross the plete absence of closure of the calcified tissues, with
cingulum or run alongside, and proceed apically for va- consequent direct communication between the pulp
riable distances (Figs. 28.19, 28.20). They must be in- tissue and periodontal tissue.62•81 These teeth develop
terpreted as an attempt to form another root or as an with this radicular anomaly and remain asymptomatic
early stage of dens in dente, since only a mild form of as long as the epithelial attachment near the sulcus re-
invagination, due .to the folding in of the enamel epi- mains intact. Nonetheless, this situation does not persist

Fig. 28.20. An upper left lateral incisor with a distolingual sulcus of moderate depth. A. Preoperative radiograph. B. The sulcus is visible distally to the cingulum. C. The
defect can be probed for about 5 mm. D. Postoperative radiograph.
766 Endodontics

very long, since the defect represents an invitation to tire extent of such a defect from a preoperative radio-
the accumulation of plaque and to the apical migration graph. Even if it were possible, there is no safe method
of the epithelial attachment. As soon as the integrity of to determine whether one is dealing with a total defect
the seal is lost, a narrow, deep pocket is established. It through which the pulp and periodontal tissue com-
extends the entire length of the groove, and pulp ne- municate. The prognosis is therefore always uncertain.
crosis is inevitable, especially if there is a communica- One must always advise the patient of this before com-
tion between the periodontal tissue and the pulp at so- mencing any endodontic or periodontal procedures.81
me level of the root. It is also possible for the defect to It is very important to ascertain whether these groo-
transform into a self-perpetuating periodontal lesion ves are present on the palatal surface of maxillary la-
as a consequence of an endodontic lesion. Bacteria teral incisors. The groove must be sought carefully, as
and necrotic debris can spread from the root canal sy- it may sometimes be concealed by an obturation in a
stem to the apical end of the groove, giving rise to an previous access cavity (Fig. 28.21). In the absence of
inflammatory process that, flowing along the groove, generalized periodontal disease, the presence of a ve-
slowly proceeds coronally. The entire length of the ry deep, narrow pocket in this area, must always be
defect becomes a source of chronic inflammation with judged highly suspect. At the time of observation, the
subsequent periodontal involvement. Most of the li- pulp of the tooth may still be vital; thus, the pulp tests
terature concurs that teeth with this type of develop- may also be positive. Radiographically, there may be
mental defect and the secondary endodontic and pe- a lateral radiolucency that extends the entire length of
riodontal problems that ensue have a very severe pro- the root. If the pulp has become necrotic, the patient
gnosis. Most such teeth cannot be treated; if the endo- will present with any of the various symptoms of a le-
dontium-periodontium communication extends along sion of endodontic origin. In this case, the radiograph
the entire root surface, the only practical therapy is can reveal a typical teardrop-shaped radiolucency that
extraction. 80•95 Nonetheless, the severity of the defects surrounds the entire root (Fig. 28.20). A vertical groo-
can vary considerably. If periodontal therapy can eli- ve can sometimes have the appearance of a dark li-
minate the groove by simply flattening the root defect ne on the radiograph. It must be differentiated from a
for its entire depth in the absence of a direct endodon- vertical root fracture, which can present with identical
tium-periodontium communication, combined therapy clinical and radiographic findings (Fig. 28.22).
can lead to a successful outcome and thus to preserva- 3) Vertical root fractures. In this case also, a tu-
tion of the tooth.45•72•98 One must keep in mind, howe- bular periodontal defect develops and the probe advan-
ver, that in practice it is impossible to determine the en- ces as if it were entering a fistulous tract (Fig. 28.23).


Fig. 20.21. A. Palatal view of an upper right lateral incisor with a distolingual Fig. 28.22. A.The periodontal probe enters about 8 mm into the defect at the
sulcus. The tooth has already been endodontically treated, and the amalgam distolingual sulcus. B.The sulcus is radiographically visible parallel to the root
that obturates the access cavity concealsthe origin of the sulcus. B.The defect canal.
can be probed for more than 1Omm.
28 - Endodontic-Periodontal Interrelationship 767

(and re-checked following therapy) with the curved

bifurcation probe, not with the straight probe. These
lesions must also be distinguished from periodontal
lesions of the bifurcation. This distinction is based on
vitality pulp tests and radiography. If the lesion is of
endodontic origin, the pulp tests will reveal the pre-
sence of a necrotic pulp, and the radiograph will de-
monstrate the disappearance of interradicular alveolar
I 1
bone in the presence of a healthy periodontium in the
\ 'II .\
I \
other sectors of the mouth, particularly at the level of
\ \
I the mesial and distal crestal bone (Fig. 28.25).
I \ 'I These endodontic lesions can also develop in
'~ ~ ~
deciduous teeth, especially if lateral canals opening
within the bifurcations are present (Fig. 28.26). They
can also develop in a short period of time 86 (Fig.
28.27), but being primary endodontic lesions, they
Fig. 28.23. A. Schematic representation of a periodontal defect that has deve- have a favorable prognosis and one can therefore
loped at a vertical fracture. B. Probing the defect.
expect complete healing after traditional endodontic
treatment, without the need for periodontal therapy.
These pockets are very narrow (1-2 mm), with a sul- They can even involve the adjacent tooth (Fig. 4.10,
cus of normal depth, both mesially and distally to the Fig. 8.8).
defect 84 (Fig. 28.24). Once the diagnosis has been made, it is neces-
If the primary endodontic lesion has established a sary to intervene quickly to prevent the development
drainage at a bifurcation, the defect must be probed of a secondary periodontal lesion.

Fig.28.24.A. Preoperative radiograph of a lower left second premolar. B. Recall radiograph 2 years later.The radiolucency on the side of the root has almost complete-
ly resolved, but a widening of the space of the periodontal ligament is still present. C. Recall radiograph 4 years later. D. Mesia I probing (continued).
768 Endodontics



Fig. 28.24 (continued). E. Distal probing. F. Introducing

the probe at a point intermediate to the two preceding
ones reveals the presence of a tubu lar defect. G. The full-
thickness marginal flap reveals the fracture line. H. The
fracture line in the middle third of the root is evident in
the extracted tooth. It is probably due to the incongrui-
ty of the prosthesis.


Fig.28.25.A.A lower right first molar reveals a conspicuous le-

sion of the bifurcation. The tooth does not respond to the vi-
tality tests, and the periodontium is healthy. B. Postoperative
c radiograph. C. Two year recall.
28 - Endodontic-Periodontal Interrelationship 769

Fig.28.26.A primary endodontic lesion at the bifurcation of the deciduous second molar, in the presence of agenesis of the corresponding permanent tooth.A. Preoperative ra-
diograph.Note the penetrating caries and the lesion of the bifurcation, in addition to the absence of the germ of the permanenttooth.B.Postoperative radiograph.The 4 canals
of the deciduous tooth have been obturated with the Schilder technique by introducing the necessary modifications,given the narrowness of the root canals. Note the filling
of two lateral canals in the bifurcation, which have caused the radiolucency.C.After 10 months,complete restitutio ad integrum has already occurred. D. Seven year recall.

Fig. 28.27. A. Preoperative radiograph of a lower right first molar with an acute alveolar abscess. The tooth has been opened and left open for drainage. B. This
young patient returned after one month with a significant lesion of the bifurcation. C. Postoperative radiograph. 0.Three year recall.
770 Encloclontics

2. PRIMARY ENDODONTIC LESION WITH SECONDARY pulp, plaque, and calculus on the root surface and of
PERIODONTAL INVOLVEMENT a pocket that can be demonstrated by the periodontal
probe and radiography.
Hiatt 52 states that continuous drainage of an en- Endodontic therapy alone will lead to healing of
dodontic fistula through the sulcus may prevent the only the endodontic component of the lesion. The
accumulation of plaque on the surface of the root, prognosis depends on the severity of the periodon-
and the proliferation of granulation tissue of endo- tal lesion and the possibility of resolving it (Fig. 28.29)
dontic origin may prevent apical migration of epi- with appropriate therapy.
thelium. From a practical point of view, this lesion may not
Nonetheless, if the primary endodontic lesion re- be distinguishable from the preceding one. In this ca-
mains untreated for a long period of time, the accu- se, once the proper endodontic therapy has been per-
mulation of bacterial plaque along the course of the fi- formed, one must reassess the patient to confirm that
stulous tract with the secondary formation of calculus, the drainage has ceased, the fistula has closed, and
apical migration of the epithelial attachment, gingivi- the fibers of the periodontal ligament have healed.
tis, and periodontitis are inevitable (Fig. 28.28). A pe- The persistence of probing 15 days after completion
riodontal lesion can thus develop as a consequence of of endodontic therapy suggests a posteriori the dia-
the endodontic lesion. This complicates the diagnosis gnosis of a primary endodontic lesion with secondary
as well as the prognosis and therapy. periodontal involvement and the need also of the pe-
The diagnosis is based on the presence of necrotic riodontal therapy.

Fig. 28.28. A primary endodontic lesion with secon-

dary periodontal involvement. With time, plaque
and calculus have deposited along the fistulous
tract with secondary apical migration of the epithe-
lial attachment.
28 - Endodontic-Periodoncal Interrelationship 771

A B c
Fig. 28.29. A. Inadequate endodontic therapy performed years before on the left central incisor has caused the development of a lesion with secondary
drainage along the space of the periodontal ligament on the mesial aspect of the root. B. Postoperative radiograph. C. The prognosis of this tooth de-
pends solely on the possibility of resolving the periodontal lesion, given the persistence of probeability after completion of endodontic therapy.


This lesion is caused by periodontal disease (Fig.

28.30) and therefore requires only periodontal therapy.
The diagnosis is based on probing of the pocket,
which reveals the presence of bacterial plaque and
calculus in a wider defect of conical shape, quite dif-
ferent from the "tubular" defect of a primary endodon-
tic lesion. A fistula may be present, whose clinical ap-
pearance is identical to that of an endodontic fistula
(Fig. 28.31).
The pulp tests indicate that the pulp is vital.
Radiographic examination demonstrates the pre-
sence of a bony defect along the lateral aspect of the
root (Fig. 28.32) or in the area of the bifurcation (Fig.
28.33). Sometimes, however, the periodontal disease
may have progressed so far apically that radiographi-
cally it appears as a loss of periapical bone, identical
to that of lesions of endodontic origin (Fig. 28.34).
The prognosis of these lesions depends entirely on
the success of periodontal therapy; endodontic the-
rapy is completely useless.
In the case of lateral radicular lesions, just as in
lesions of the bifurcation or in the case of fistulae , it
is necessary to distinguish them from similar lesions
of endodontic origin (Figs. 28.35, 28.36). As alrea-
dy indicated, the diagnosis is based on a periodon-
tal assessment of the other areas of the mouth and
Fig. 28.30. Schematic representation of a primary
the tests of pulp vitality. periodontal lesion. The pulp is vital. The periodon-
tal disease is proceeding apically.
772 Endodontics

Fig.28.31.A.A fistula is present

over the upper left central in-
cisor. The tooth gives positive
responses to the vitality tests.
B. Radiography confirms that
this is a primary periodontal

Fig. 28.32. A. The distal root is almost entirely surrounded by a radiolucency. Clinically, the distal side can be probed to about 10 mm. The tooth gives positi-
ve responses to the vitality tests; therefore, this is a primary periodontal lesion. Compare this lesion with that of Fig. 28.35. B. A radiolucency is present on the
mesial aspect of the third molar. The presence of calculus, the appearance of the crestal bone between the first and second molars, the absence of caries or
restorations, and the positive responses to the vitality tests indicate a primary periodontal lesion. Compare this lesion with that of Fig. 28.11.

A :;._;.. _, B

Fig. 28.33. A.The area of the bifurcation has a through-and-through lesion. B. A gutta-percha cone has been introduced from the buccal side and exits lin-
gually. Note the status of the periodontium of this quadrant, the absence of caries or restorations, and the fact that the tooth responds to the vitality tests.
This is a primary periodontal lesion. Compare this lesion with that of Fig. 28.36.
28 - Endodontic-Periodontal Interrelationship 773


Fig.28.34.A, B. Radiographic and clinical appearance of a periodontal lesion in the palatal root of an upper right first molar.The tooth gives positive respon-
ses to all the tests of pulp vitality.

Fig. 28.35. A. On the distal aspect of the distal root of this lower left first molar, a radiolucency that runs along the entire root is present. B. A gutta-percha
cone has been introduced in the fistula.The tooth does not respond to the vitality tests, therefore the diagnosis of primary endodontic lesion can be made.
C. Postoperative radiograph. D.Two year recall.
774 Endodontics

Fig. 28.36. A. A lower left first molar presents a through-and-

through lesion of the bifurcation. The pulp is obviously ne-
crotic. Note the appearance of the periodontium mesially
and distally to the area of the defect. B. One week later, ha-
ving observed that the defect cannot be probed, the treat-
ment proceeded to obturation of the root canals with warm
gutta-percha using the Schilder technique. The tooth was
pretreated with a copper band.C.Two year recall.

Fig. 28.37. Schematic representation of a primary periodontal lesion with se-

condary endodontic involvement. Once the lateral canal is exposed to the
oral environment because of the periodontal disease, pulpal necrosis occurs.
28 - Endodontic-Periodontal Interrelationship 775

4. PRIMARY PERIODONTAL LESION WITH SECONDARY Bauchwitz,15 and Brammer,23 who stated that conta-
ENDODONTIC INVOLVEMENT mination and infection of the pulp tissue by disea-
sed periodontal tissue is possible. In 1919, Collins and
In its slow apical progression, the primary perio- Lyne 29 demonstrated the presence of bacteria in al-
dontal lesion provokes increasing destruction of the most all the pulp of the teeth they extracted. Turner
attachment apparatus of the tooth with increasing de- and Drew 121 have described bacterial infection in the
position of plaque and calculus on the root surface. pulp of "pyorrhea!" teeth, which has been confirmed
Bacteria and their toxins can reach the pulp through by Health 49 and Colyer. 30
existing means of communication (i.e., lateral canals and Several years later, Craney 31 noted that "pyorrhea"
dentinal tubules) and produce injury, possibly leading to has an influence on the status of the pulp tissue, but
pulp necrosis (Fig. 28.37). that this influence is inconsistent and unpredictable.
The pulp tissue would thus be exposed to the oral In critically analyzing all the studies cited to this
environment through these means of communication point, one must note that none classified the teeth ac-
that had previously functioned as portals of exit, but cording to the severity of periodontal disease, patient
now function as portals of entry for inflammation and age, or condition of the tooth or pulp. Especially sin-
infection. ce they did not describe precisely the condition of the
Since pulp disease on one side can influence the periodontium of the teeth examined, it is impossible
adjacent periodontal structures through the lateral ca- to determine whether there was any relation between
nals, on the other side it would be logical that perio- the severity of periodontal disease and pulp changes.
dontal disease can influence the pulp through the sa- Furthermore, there were no controls. Craney's study
me canals. 17 was more realistic, since he made an attempt to classi-
This subject is much debated in the literature. Not all fy the teeth in groups. Indeed, his conclusion that the
authors agree on the sort or degree of injury that perio- influence of "pyorrhea" on the pulp is not consistent
dontal disease may cause in the endodontium. is a significant consideration and represents an impor-
In a 1963 article, Seltzer, Bender, and Ziontz 102 state tant advance.
that periodontal disease can cause atrophy, dystrophic It is worth observing that all the studies cited abo-
calcifications, deposition of reparative dentin, inflam- ve, which demonstrated the presence of bacteria in
matory lesions of variable intensity, internal resorp- "pyorrheal" pulp, pre-date the famous study of Fish
tion, and pulp necrosis. and MacLean, 40 who demonstrated that it is possible to
The histologic observations of the three investiga- contaminate the pulp tissue during dental extraction.
tors seem to indicate that periodontal lesions have a Several years later, Sauerwein 97 found that the pulp
degenerative effect on the pulp of teeth with perio- degeneration described by investigators at the begin-
dontal disease. This is due to interference (mediated ning of the century was not necessarily a consequen-
by the lateral canals) with the blood supply of the ce of periodontal disease; rather, the condition of the
pulp. The afferent blood vessels supplying a small pulp was completely independent of the type and ex-
area of pulp tissue are compromised by the periodon- tent of periodontal disease.
tal disease. The loss of the blood supply to this small In their celebrated 1964 article, Mazur and Massler 71
area leads to death of these pulp cells and their secon- reported that in all the preceding literature and in par-
dary calcification, as a natural consequence of the nu- ticular in the study of Seltzer, Bender, and Ziontz, no
tritional privation. correlation had ever been made between the pulp
Inflammatory lesions of the pulp may also arise changes described and the severity of periodontal di-
from toxic products that reach the pulp through canal sease. In a careful review, it could not be determined
openings that are normally covered by bone or heal- whether these changes were limited to teeth with pe-
thy periodontal ligament, but are now exposed to the riodontal disease or whether they could also be ob-
oral environment. Microorganisms present in the pe- served in other teeth, not periodontally involved, from
riodontal lesions may produce pulp necrosis by the the same patient. In other words, the changes could
action of their metabolic products, destructive enzy- have been due to the general condition of the patient,
mes, or other mechanisms. his age, habits, previous restorations, preceding perio-
The negative influence of periodontal disease on dontal therapy, or other causes independent of perio-
the condition of the pulp had already been descri- dontal disease.
bed about the beginning of the last century by Cahn,25
776 Endodontics

The conclusions of Mazur and Massler's study are:

a) periodontal disease has no influence on the con-
dition of the pulp (Figs. 28.38-28.40);
b) there is no relationship between the severity of
periodontal disease and pulp disease;
c) the changes noted in the pulp are independent of
the condition of the surrounding periodontium;
d) the pulp of teeth with varying degrees of perio-
dontal involvement (from minimal to advanced) pre-
sent in a similar manner;
e) analysis of control teeth extracted from the mouth
of the same patient and free of periodontal disease
revealed the same pulp changes as those observed in
periodontally involved teeth;
Fig. 28.38. In this lower right second molar, the periodontal disease is so ad-
vanced that it has already provoked secondary pulpal necrosis.The first molar D since none of the pulp studied appeared "nor-
still responds to the tests of pulp vitality! mal" (young or old, healthy or with periodontal disea-
se, with or without previous restorations), changes in
the pulp could more directly be related to the syste-
mic condition of the patient, than to the local environ-
ment. The adult pulp can be affected by the systemic
condition of the patient, even long after the formation
of the dentin has been completed. The structural mor-
phology of the pulp tissue is therefore peculiar to the
individual person, no matter what the status of the pe-
riodontium. In conclusion, the systemic condition of
the patient may have a greater influence on the con-
dition of the pulp than does the status of the surroun-
ding periodontium or his chronological age.
In a 1971 study, Czarnecki 32 found that, even if
surrounded by advanced periodontal disease, the
pulp is histologically within normal limits. He con-
curred with Mazur and Massler, concluding that the-
Fig. 28.39. The upper left first premolar of this patient has been extracted be-
cause it was hypersensitive to cold stimuli! re is no relationship between the severity of perio-
dontal disease and the presence or absence of pulp
disease. This conclusion was confirmed subsequen-
tly by Czarnecki and Schilder 33 in 1979, Torabinejad
and Kiger 119 in 1985, Dongari and Lambrianidis 37 in
1988, and Mascarello and Marini 69 in 1990. These
studies also confirmed that there is no correlation
or cause-and-effect relationship between periodon-
tal loss in the attachment apparatus and changes in
the pulp tissue.
In this author's opinion, destruction of the pulp can
occur only when the periodontal disease has reached
the terminal phase, or when the bacterial plaque in-
volves all the principal apical foramina. This agrees
with the findings of Langeland et al.. 60 They believe
that it has absolutely not been proved that the enti-
re pulp succumbs because one or more lateral canals
Fig. 28.40. This lower right first premolar gives positive responses to the vi- or a certain number of dentinal tubules are affected
tality tests. by inflammation. The pulp retains its vitality until the
28 - Endodontic-Periodontal Interrelationship 777

Fig.28.41 .A. Bacterial plaque has colonized the root. The bacteria-specific Brown-Brenn stain reveals its presence within the dentinal tubules, toward the pulp.
B.The bacteria in the dentinal tubules at higher magnification.C.ln a more advanced stage, the bacterial plaque causes true radicular caries with massive invasion
of bacteria in the dentinal tubules. It istherefore no wonder that at a certain point the pulp becomes infected and dies apico-coronally (Courtesy of Dr. N. Perrini).

principal canal - that is, the primary means of blood These affirmations have been confirmed by
supply - is seriously involved. Total disintegration and Bergenholtz and Lindhe,21 who in a study on apes, ha-
necrosis occur when the bacterial plaque involves all ve found that most (70%) of the roots with periodontal
the principal apical foramina. disease that they examined did not demonstrate any
It is known that caries of the coronal dentin causes pathological changes in the pulp tissue, notwithstan-
pulp inflammation. It is therefore not surprising if ca- ding the fact that about 30-40% of the periodontal at-
ries of the radicular dentin [which can be demonstra- tachment had been destroyed.
ted by invasion of the dentinal tubules by bacterial In conclusion, the development of pulp infection se-
plaque (Fig. 28.41)] provokes a similar pulp involve- condary to periodontal involvement is quite rare. As long
ment in the apical zone. Whatever causes the removal as the periodontal disease associated with plaque is of
of cementum from the radicular surface (e.g., curetta- moderate severity, the pulp remains vital and in good
ge, abrasion, erosion, or caries), the bacterial plaque health.64 Pulp vitality is lost only when the periodontal
present finds access to the adjacent dentinal tubules disease is very advanced and the bacterial plaque rea~
and therefore initiates the same inflammatory process ches the apical foramina: the pulp becomes infected, just
that occurs in the pulp underlying a carious lesion of as it would become infected after exposure of the pulp
the coronal dentin. to the oral environment at the level of the crown. ·
In this very advanced stage of periodontal disea-
se, the pulp is practically exposed to the oral envi-
ronment, and when all the principal apical foramina
are involved by bacterial plaque, it totally disintegra-
tes (Fig. 28.38).
778 Endodontics



This category was not contemplated by the classi-

fication of Simon, Glick, and Frank, but it would be
useful to recall it before actually describing the "true"
combined endodontic-periodontal lesion.
The two lesions, which have distinct etiologies, may
coexist in the same tooth without communicating with
each other 13•123 (Figs. 28.42, 28.43). In this case, both
therapies are obviously called for. If the endodontic
therapy can be performed only by surgical means, it
must be performed during the periodontal procedure
so that the patient does not have two incisions in the
same area for two different purposes (Fig. 28.44).

Fig. 28.42. Schematic representation of the simultaneous presence of the two

independent processes in the same tooth.

Fig. 28.43. This lower right first molar has a necrotic pulp, which sustains the
periapical lesions; at the same time, the tooth presents a periodontal lesion of
the bifurcation.We cannot speak of a"true" combined lesion, because the two
lesions, although of independent etiologies, have not converged.

Fig. 28.44. A. Preoperative radiograph of an upper left second premolar.The tooth simultaneously presents periodontal and endodontic pathologies. The latter can
be resolved only by surgery. B. In the same periodontal sitting, apicectomy with retrofilling is performed. C. Seven year recall (Courtesy of Dr.G. Ricci).
28 - Endodontic-Periodontal Interrelationship 779


The "true" combined endodontic-periodontal lesion

occurs when the two independent processes coexisting
in the same tooth communicate (Fig. 28.45).
Both radiographically and clinically, the presenta-
tion may resemble that of the other lesions with se-
condary involvement. Histologically, it is impossible
to establish where the granulation tissue of endodon-
tic origin ends and where that of periodontal origin
begins (Fig. 28.46).
The tooth presents with periodontitis, an accumula- Fig. 28.45. Schematic represen-
tation of a "true" combined le-
tion of plaque and calculus, and, naturally, a necrotic sion. The two lesions of inde-
pulp, as a result of caries or other cause. pendent etiology have come
together to form the "true" com-
This presentation was first described in March bined endodontic-periodontal
1972 by Bender and Seltzer, 17 who proposed the term lesion.
"Pulpodontic-Periodontic Syndrome," meaning a syn-
Fig.28.46. Histologically, in the true
drome that comprises pulp inflammation or degenera- combined lesion, it is impossible
tion and the presence of a clinical pocket in the same to establish where the granulation
tissue of the endodontium ends
tooth. This syndrome can be initiated either by pulp and that of the periodontium be-
disease or periodontal disease. By definition, therefo- gins (Courtesy of Dr. G. Ricci).
re, any tooth with a periodontal pocket is a potential
candidate for this syndrome.
However, this definition does not precisely reflect
what Simon, Glick, and Frank 106 and other, subse-
quent authors 47•111 mean by "true" combined lesions,
by which one should mean the coexistence and fusion
of the two "independent" processes.
The same confusion in defining the combined lesion
arises in Blair's 22 article of April 1972. When he speaks
of combined pulp-periodontal lesions, he clearly refers
to a primary endodontic lesion that drains through the
sulcus, with periodontal involvement only apparent.
The diagnosis of "true combined endodontic-perio-
dontal lesion" is based on radiographic examination
and clinical probing.
Radiographically, a loss of crestal bone extending
apically along the side of the root is evident.
Probing reveals a typical bony pocket at whose base
there is a "tubular" defect that may extend as far as the
apex. This is the characteristic endodontic fistula that
drains into the space of the ligament and opens at the
base of the periodontal bony pocket (Fig. 28.47).
This lesion obviously requires both therapies, sin-
ce endodontic therapy alone would lead to healing of
only the endodontic component of the disease.
Endodontic therapy must be performed first to pre-
vent the continuous drainage through the sulcus from
interfering with periodontal healing (Fig. 28.48). Fig. 28.47. A. At the base of the periodontal defect, there is a tubular defect,
which is characteristic of endodontic lesionsthat drain through the periodon-
tal ligament.B.The periodontal probe demonstrates the tubular defect (endo-
dontic fistula) at the base of the periodontal defect.
780 Endoclontics

Fig. 28.48. A. Preoperative radiograph of the lower right central incisor. B.The probe has entered the tubular defect. C. The gutta-percha cone
introduced in the sulcus exits from the mucosa! fistula. D. Another cone introduced in the fistula exits from the sulcus. E. Postoperative radio-
graph. F. Follow-up radiograph 2 years later. G. Appearance of the gingiva on recall (Courtesy of Dr. G. Ricci).
28 - Endodontic-Periodontal Interrelationship 781
HEALING POTENTIAL AND PROGNOSIS can be considered a six-walled infra-bony pocket,
which thus has a very high probability of healing.
The endodontist works in a closed system. Once
Following correct endodontic therapy, primary the rubber dam has been placed and the access cavity
endodontic lesions heal completely. Drainage through performed, he can eliminate the infected contents of
the gingival sulcus and radiolucency at the bifurcation the canal and achieve its disinfection. Once it has
are the clinical and radiographic signs of fistulae, been three-dimensionally obturated and coronally
which heal after the first or second visit. As already sealed, there is no longer any possibility of reinfection
suggested, teeth with fistulae are the easiest to treat, from outside. The "sterility" thus achieved can be
since they never have exacerbations and they provide maintained by three-dimensional obturation of the
rapid control of the efficacy and completeness of root canal system.
canal cleaning. Thus, the fact that in such cases the In contrast, the periodontist works in an open sy-
periodontal probe is able to penetrate deeply, even to stem that is continually subjected to reinfection and
the apex, to reveal the presence of a "tubular" defect, inflammation because of the continuous accumula-
should not be alarming, as it calls for the same type of tion of plaque, which the patient is not always able
treatment as any other fistula of endodontic origin. to keep under control. It is as if the endodontist we-
When the lesions "also" have an endodontic com- re performing cleaning and shaping of the canal and
ponent, one can predict the complete healing only of then, instead of performing the obturation, left the
this part. tooth completely open and entrusted the patient with
In this way, in lesions secondarily compromised by the daily task of keeping his canals clean!
periodontal disease or in periodontal lesions with se- The last great difference between the two diseases
condary endodontic involvement, one may expect, fol- that renders the prognosis so different in one case or
lowing endodontic therapy, healing of only the por- the other is that in endodontic disease the fibers of the
tion of the lesion that is not related to the periodontal periodontal ligament (among which the lesion begins
disease. Furthermore, the overall prognosis of the le- to develop) are disarrayed, disorganized, and beco-
sion depends solely on the degree of advancement of me afunctional, but are not destroyed, as happens as
the periodontal disease: the more extensive the perio- a consequence of periodontal disease. The periodon-
dontal disease, the less favorable the prognosis, while tal lesion may be considered to be a loss of connecti-
the greater the endodontic component of the lesion, ve tissue attachment with destruction of the connecti-
the better the prognosis. ve fibers inserting in the cementum, with a prolifera-
At this point, one might raise the question: Why is tion of the junctional epithelium along the root surfa-
the prognosis so different in endodontic and perio- ce, which had previously been occupied by fibers of
dontal diseases? Especially in light of the fact that the the periodontal ligament, with subsequent loss of ce-
endodontist can be considered a "periodontist of the mentum and bone resorption.36
periapex," why is the "marginal" loss of the attach- In contrast, although it provokes an inflammatory reac-
ment apparatus rarely regained, while the "periapical" tion in the periodontium with the production of exuda-
loss is completely restored? te which can drain along the periodontal ligament, thus
As it has been described earlier in this chapter, the simulating a pocket, an endodontic lesion never causes
greater success of the endodontist in the treatment of changes in the connective tissue fibers that insert in the
lesions of the attachment apparatus of the tooth as bone or cementum. 122 The infiltrate rises among the fi-
compared with the success encountered by the perio- bers and runs coronally; however, it does not provoke a
dontist is not due to greater skill on the part of one loss of connective tissue attachment or subsequent api-
specialist as opposed to another, but is due to the mo- cal proliferation of the junctional epithelium. 36
re favorable ~matomical environement encountered by Consequently, it is logical that while for the endodon-
the endodontist as compared to that encountered by tist success lies not in preventing the lesion from beco-
the periodontist. 99 ming larger but derives from the total resolution of tl1e
It is recognized that the prognosis of infra-bony lesion and the restoration of a normal lamina dura and
pockets depends on the number of bony walls. A periapical periodontal ligament, for the periodontist the
three-walled pocket has a greater chance of repair prior loss of the attachment apparatus is almost always
than does a pocket with two or only one wall. In taken for granted, and the success of his therapy is rela-
periodontal terms, the periapical endodontic lesion ted to his success in preventing further loss. 99
782 Endodontics

DIFFERENTIAL DIAGNOSIS AND TREATMENT tion of the apical periodontium, occasionally exten-
PLAN ding coronally; furthermore, they are present in a sin-
gle tooth. Naturally, there are exceptions to this rule,
which could be misleading; thus, the radiograph must
Differential diagnosis of the various situations of the always be examined together with other tests, never
Simon, Glick, and Frank 106 classification is not always alone.
possible, given that it is not a clinical classification, Pulp vitality: since the pulp tissue stays healthy
but etiologic. even if contained within a tooth with periodontal di-
Once fracture, anomalous developmental grooves, sease, as already discussed in detail, it follows that the
enamel pearls, and primary periodontal lesion have responses to the thermal, electrical, and cavity tests
been excluded, all the other situations that require the are within normal limits (Fig. 28.49). The test of denti-
existence - actual or apparent - of the two processes nal stimulation or cavity test is particularly important,
cannot always be distinguished tout court from one as it often cannot be substituted in distinguishing pe-
another. Very often, the diagnosis is made a posterio- riodontal and endodontic disease. In a primary en-
ri.1 22,123 dodontic lesion, the pulp is, without a doubt and wi-
The clinical approach must therefore consider en- thout exception, necrotic; thus, the tests of vitality are
dodontic therapy each time the indication exists (to all negative. In the true combined endodontic-perio-
be performed before any other procedure) to elimina- dontal lesion, the tooth with periodontal disease also
te the endodontic component of the lesion. gives negative responses to the vitality tests, but the
If, on reassessment, the lesion has not completely pulp necrosis is due to causes other than periodon-
healed (e.g. , the drainage through the sulcus conti- tal disease, such as deep caries, previous restorations,
nues), there must also have been a periodontal com- trauma, or others.
ponent, and periodontal therapy is also required. Probing: a periodontal probe introduced in a perio-
The only case in which periodontal therapy can be dontal lesion usually reveals wide defects that do not
planned from the start (always, however, following extend to the apex of the involved roots; in contrast,
endodontic treatment) is the "true" combined endo- defects arising from endodontic lesions (fistulae, not
dontic-periodontal lesion, in which the two indepen- pockets) usually appear on probing to be narrow and
dent processes are clearly recognizable. deep, extending as far as the apex or to the emergen-
Thus, one must be very careful not to reach a hur- ce of a lateral canal. This situation may be encounte-
ried diagnosis and not to fall prey to the easy temp- red in a developmental groove, an enamel pearl, or a
tation of classifying all lesions as combined lesions. vertical fracture , but not in a periodontal lesion unless
There is no point in performing a hemisection or pre- it is part of a true combined lesion. In this case, one
molarization in a molar whose bifurcation has been can sometimes find a narrow, deep defect originating
destroyed as a result of pulp necrosis. It is obvious at the peak of the wider defect (Fig. 28.47).
that this defect can be probed, but it is still only an en-
dodontic fistula, at least until the concomitant presen-
ce of a secondary periodontal component has been
It is also necessary to perform the various diagno-
stic tests (see Chapter 4) from whose careful overall
evaluation the correct treatment plan will derive.
Anamnesis and symptomatology: periodontal di-
sease is usually a chronic, generalized process associated
with little or no pain. In contrast, endodontic lesions are
localized and often associated with acute symptoms.
Radiographic examination: periodontal lesions
are often manifested by angular bony losses, beginning
with the cervical region directed apically, and they are
generalized to the various sectors of the mouth, even Fig. 28.49. This second lower right molar has a fistula and a radiolucency sur-
though they can sometimes localize to a single tooth. rounding the root apex. The tooth responds to thermal tests, therefore the le-
Endodontic lesions, in contrast, present with destruc- sion is not of endodontic origin but rather is a periodontal lesion.
28 - Endodontic-Periodontal Interrelationship 783

Fig. 28.50.A. Preoperative radiograph of a lower right first molar with pulpitis. Note the radiolucency at the apex of the distal root, already evident in the to-
oth with still-living pulp, although not vital.The responses to the tests of vita lity were all positive, as this was a case of pulpitis. B. Follow-up radiograph 11
months later.

Finally, in the sometimes difficult clinical distinction THE INFLUENCE OF PULP DISEASE ON THE
between endodontic and periodontal diseases, other PERIODONTIUM
factors must be taken into consideration; these inclu-
de caries, restorations, and discoloration of the den-
tal crown. Their absence, as in the case of pockets, As already noted in Chapter 7, the inflammatory
strongly indicates the diagnosis of periodontal disea- process in a still-living, but no longer vital, pulp does
se, just like the presence of plaque, calculus, and ge- not readily cause changes in the periapical periodon-
neralized gingivitis. tium. However, when it does occur, the inflamed pulp
accumulates in the surrounding tissues a quantity of
irritants sufficient to involve the adjacent periodon-
tium. Sometimes, teeth with pulpitis already demon-
strate the signs of periapical compromise, which is ra-
diographically visible as enlargement of the space of
the periodontal ligament or initial resorption of the
bony trabeculae in the immediate area of the apical
foramen (Fig. 28.50).
The influence of pulp pathology on the periodon-
tium begins to become evident once the pulp tis-
sue has started to become necrotic and gangrenous,
and thus when the endodontic lesion develops (see
Chapter 8).
As is well known, the chronic lesion can develop
not only in the root apex, but at any point on the side
of the root or at a bifurcation where there is a lateral
canal, the portal of exit of the pathologic process.
Lateral canals are well recognized and have been
widely demonstrated. According to De Deus,34 they
are much more frequent in the apical third .(17%)
(Fig. 28.51), less frequent in the middle third (8.8%)
(Fig. 28.52), and less frequent still in the coronal third
(1.6%) (Fig. 28.53). The last percentage also includes
canals of the coronal third of bi- and threerooted teeth
Fig. 28.5 1. Lateral canal in the apical one third of the root of
this lower left second premolar. A. Preoperative radiograph. B.
(Fig. 28.54).
Postoperative radiograph. As stated above, lateral canals are rarely demonstra-
784 Endodontics

c D

Fig. 28.52. A lateral canal in an upper right first premolar. A. Preoperative radiograph. We may suspect the presence of the lateral
canal by observing the site of the lesion, which is visible on the distal side of the root. B. Follow-up radiograph 2 years later.The le-
sion, sustained by the lateral canal which opens distally in the middle one third of the root, has completely resolved. C. D. Two la-
teral canals are present on the mesial aspect of the two central incisors.

' l
Fig. 28.53. A lateral canal in the coronal one third of an upper left central incisor. A.
Preoperative radiograph. B. Postoperative radiograph.
28 - Endodontic-Perioclontal Interrelationship 785


Fig. 28.54. A lateral canal in the bifurcation of a lower right first molar. A. Preoperative radiograph. B. Follow-up radiograph 2 years later (Courtesy of
Dr. M.J. Scianamblo).

Fig. 28.55. Cleaning and shaping of a lateral canal in a lower left second premolar. A.The instrument at the radiographic terminus of the canal. B. The same
instrument introduced with the precurvature facing distally is now at the radiographic terminus of the lateral canal.C.A # 10 file is in the principal canal, and
a# 08 file is in the lateral canal. D. Postoperative radiograph.
786 Endoclontics

ble clinically. Their presence may be suspected after Injmy to the periradicular periodontium can al-
the radiograph of a necrotic tooth has demonstrated so result from acute endodontic lesions, especially if
a lesion on the side of the root, or it may be identi- they drain spontaneously through the gingival sulcus.
fied a posteriori after the obturating material has filled As already stated several times in this chapter, the pe-
it. In vital teeth, it is practically impossible to iden- riodontal injury in such cases is only "apparent," sin-
tify them pre-operatively. A small endodontic instru- ce this drainage has the same prognosis and requi-
ment may enter one by chance (Fig. 28.55), or their res the same therapy as any other fistula of endodon-
presence may be suspected by examining the paper tic origin.
point which, at completion of canal cleaning and sha- As already stated, all periodontal injuries of endo-
ping, emerges with blood part-way along its length dontic etiology occur without the permanent loss of
(Fig. 28.56, 28.57) - obviously, after having excluded connective attachment to the root surface. 111 This is
that one has created a lateral perforation of the root quite different from what happens in periodontal di-
or caused a stripping perforation. sease. Indeed, it is this difference that accounts for the
different prognosis of the two processes.

Fig.28.56.A. Preoperative radiograph of an upper right first molar.The tooth has only two canals in a taproot. B.Atthe conclusion of cleaning and shaping of the buc-
cal canal, the paper point is spotted with blood about 4 mm from the apical fora men.A lateral canal at the same distance from the end of the preparation is suspec-
ted. C. The postoperative radiograph confirms that the diagnosis was correct.

Fig. 28.57. A. lntraoperative radiograph of the upper left cuspid. B. The paper points show bleeding about 5 mm from the working length. C. Same at higher magnifi-
cation. D. The postoperative radiograph shows the extrusion of sealer from a lateral canal about 5 mm from the apical fora men.
28 - Endodontic-Periodontal Interrelationship 787



Destruction of the periradicular periodontium may

also occur in the course of the common procedures of
endodontic therapy.
The use of very strong medications can cause a che-
mical insult, which may be so serious as to lead to loss
of the tooth (Fig. 28.58). For this reason, the use of pa-
raformaldehyde-based devitalizing pastes is very dan-
gerous, since it can lead to serious injury in the perio-
dontal ligament and bony sequestrations (Fig. 28.59).
The periodontium can also experience a mechani-
cal insult as a result of the extrusion of canal obtura-
ting material beyond the apex. Numerous studies ha-
ve more than sufficiently demonstrated that the mate-
rials commonly used (gutta-percha and "inert" canal
sealers) are perfectly "tolerated" by the organism and
that any damage is irrelevant (see Chapter 24).
The most serious periodontal destructions occur
with perforation and root fracture.

Fig. 28.58. Serious periodontal injury caused by the use of devitalizing

pastes, such as Toxavit. A. The light "stain" visible lingually in this lo-
wer left first molar is not an "overflowing composite," but a bony se-
questrum. B.The probe indicates the presence of a perforation of the
floor. C. Postoperative radiograph following extraction of the seque-
strum and tooth.

Fig.28.59.A devitalizing paste containing paraformaldehyde has been used in

this upper right second premolar. A. The mesial papilla has disappeared and
the bony sequestrum has appeared. B.The bony sequestrum has just been re-
moved. C. Radiographic appearance of the injury experienced by the inter-
c proximal bone.
788 Endodontics

PERFORATIONS -Time. As stated, perforations create an inflamma-

tory reaction in the adjacent tissues, and consequen-
Perforations are pathologic or iatrogenic commu- tly a loss of attachment. Therefore, to discourage fur-
nications between the root canal system and the at- ther loss of attachment and periodontal breakdown,
tachment apparatus. The clinician must be particular- perforations should be sealed as soon as possible,
ly concerned about avoiding perforations of the tooth preferably during the same appointment when they
during endodontic therapy, since a perforation will occur.
necessitate additional treatment. If a perforation oc- Apart from these iatrogenic lesions, there are spon-
curs, the tooth does not necessarily require surgery, taneous perforations due to caries, or internal or ex-
intentional replantation, or extraction; in fact, it can ternal resorption. The last two will be discussed in
be treated successfully in a conservative manner and Chapter 30.
continue to function as it did before the perforation.
Today, there is no reason to believe that the tooth will P ERFORATIONS OF THE APICAL ONE THIRD
be lost prematurely because of this complication.48
An inflammatory reaction is established in the sur- These may occur in the course of instrumentation
rounding periodontium at the site of the perforation. of curved canals, from external transposition of the
This is due both to mechanical trauma and to intro- apical foramen (see Chapter 14).
duction of microbial-derived substances that inevita- If, once the perforation has been made, the endo-
bly accompany the perforation. The perforation crea- dontist succeeds (with small, precurved instruments,
tes an "additional" portal of exit in the root canal sy- a lot of irrigation, and a great deal of patience) in fin-
stem. Once identified, it must be sealed as quickly as ding the original canal, damage due to the perfora-
possible, since periodontal involvement arising from tion will be minimal, inasmuch as, especially if the
the perforation can become irreversible with time. perforation is small, it will behave as though it we-
Treating a perforation may often require a multidi- re a lateral canal and will be easily obturated (Fig.
sciplinary approach in order to establish the appro- 28.60).
priate treatment plan. The decision must be made to If the path of the original canal has become ob-
either extract the tooth or direct efforts towards non- structed by dentinal debris and the instrument follows
surgical retreatment, surgical correction, or both. the wrong path to the perforation each time, the ca-
When evaluating a perforated tooth, 4 variables nal must be obturated directly using the traditional
should be considered: level location, size and sha- techniques with subsequent surgical removal of the
pe, an d time. · 93 ~--- -., apex containing the untreated portion of the canal
-- -U vet. erforations can be considered to occur in (Fig. 28.61). This is particularly necessary in a tooth
the coronal,..middk, and_:Qical op e third of the tooth. with a necrotic pulp.
The prognosis o f radicular perforations of the apical On the other hand, according to Nicholls,79 if the
and middle third is much better than perforations of tooth has a vital pulp, treatment of a perforation of
the coronal~ or of th~ P- chamber floor of..,J;,U.ul- the apical third depends on the length of the por-
t' roo t:ffi eth. 1•3·7 tion of canal situated apically to the perforation and
- Location. Perforations occur circumferentially on on whether the perforation has occurred at the be-
the buccal, lingual, mesial, or distal aspects of the ro- ginning or at the end of cleaning and shaping. If the
ots. This is an important consideration if surgical ac- distance between the apical foramen and the perfo-
cess is considered, while it is not as important in the ration is greater than 2 mm, or if the perforation oc-
case of nonsurgical retreatment. curs after a considerable enlargement of the most
-Jj,z..e..f111IL.s-h_ape. The establishment of a good seal is apical portion of the canal (without, however, fur-
influenced primarily by the dimension and shape of ther being able to negotiate the original canal), ob-
the perforation. The larger the bur causing the perfo- turation of the canal is indicated, followed by api-
ration, the bigger the area to seal. Furthermore, lateral cectomy coronally to the defect. If the perforation
perforations are never round, but are elliptical in sha- occurs within 2 mm and at the beginning of canal in-
pe, since the bur meets the canal wall at a 45° angle. strumentation, the missing obturation in the most
Finally, the perforating cavity has no taper, and this apical portion of the canal will not have a wor-
makes it difficult to establish a good apical seal wi- se prognosis than cases free of perforations with
thout disturbing the surrounding periodontium. slightly short obturations.
28 - Endodontic-Periodontal Interrelationship 789

Fig. 28.60. Perforation of the apical one third of the mesiobuccal root of the upper left second molar, treated nonsurgically. A. Preoperative radiograph. Note the
marked curvature of the mesiobuccal root. B.Agutta-percha cone has been introduced in the fistula. C.A # 08 file at the radiographic terminusof the mesiobuc-
cal canal. D. A# 20 file has gone straight ha head! E.The # 08 file isagain at the radiographic terminus of the canal. Cleaning and shaping can thus be completed. F.
Postoperative radiograph. Using thermoplastic gutta-percha, the perforation has been obturated as if it were a lateral canal. G. Follow-up radiograph 1 year later.
790 Endodontics

Fig. 28.61 . Surgical treatment of a perforation of the apical one third of the root of an upper left canine. A. A # 08 file enters the small distal perforation made in the
course of the previous treatment. B. Since the apical one third of the root canal was not negotiable, a quick thermoplastic gutta-percha obturation was performed
prior to the surgical procedure. Note that the obturating material appears at the opening of the original canal. C. Apicoectomy has been performed for removal of
the untreated portion of the canal, as has amalgam retrofilling. D. Seven year recall.

P ERFORATIONS OF THE MIDDLE ONE lliIRD These perforations also occur fairly frequently in
the mesial roots of lower molars and the mesiobuc-
Perforations of the middle third of the root can oc- cal roots of upper molars, where the injury caused by
cur during the preparation of the access cavity (Fig. excessive enlargement can become evident long after-
28.62) or, more often, it occurs during cleaning and wards (Figs. 28.65, 28.66) .
shaping of the canal or during preparation of a post Such roots must never be enlarged to receive a
space with rotating instruments such as Peeso, Gates- post, since the risk of stripping or perforation is ve-
Glidden, Largo, or similar drills. ry high. In molars, the safest roots in which a space
In the second instance, the perforations are more can be prepared for a post are the distal root of lo-
frequent in the molars and are due to lack of appli- wer molars and the palatal root of upper molars. This
cation of the anticurvature filing method described by space, however, must always be performed by kee-
Abou-Rass, Frank. and Glick 1 (see pag. 512). The ro- ping in mind the inclination of the tooth, the curvatu-
ots most often affected are the mesial roots of lower re of the canal, the anatomy of the root, its thickness,
molars (Fig. 28.63) and the mesiobuccal roots of up- as well as the size of the bur. 2 The preparation of the
per molars (Fig. 28.64), in which it is easy to thin ex- post space, furthermore, must consist just in the remo-
cessively the dentinal wall facing the bifurcation, with val of the root canal obturating material. The operator
consequent stripping. must avoid to even touch the dentinal walls, and must
In the preparation of the space for a screw or post, use the space prepared by the endodontist during the
perforation can occur in any root. shaping procedure.
28 - Endodontic-Periodontal Interrelationship 791


Fig. 28.62. Non-surgical treatment of a perforation of the middle one third of the root of an upper left lateral incisor.A. Preoperative radiog r
The perforation and issuance of material in the adjacent periodontal tissues are evident.B.The original canal (left) and the opening of_th
foration (right) are visible through the access cavity. C. lntraoperative radiograph of the con e fit:the perforation is treated as though_,
true canal. D.The correct way of cutting the cone before compaction, to prevent partial extrusion from th e perforation. E. Postopera
graph. F.The fistula that had been present has now completely healed. G. Six month recall.This case, as well as cases of figs. 28.63 JI
been treated before the introduction of MTA. II?

792 Endodontics

Fig.28.63. Stripping of the mesial root of a lower left first mo-

lar. A. Preoperative radiograph. B. Postoperative radiograph.
C. Follow-up radiograph after 3 months: the defect, sufficien-
tly intraosseous, is nonetheless healing after the immediate

Fig. 28.64. Stripping of the mesiopalatal canal of an upper right Fig. 28.65. Perforation by a screw post in the mesial root of a lo-
first molar. The canal, merging with the mesiobuccal canal in a wer first molar.The damage was manifested at the recall four ye-
common apex, could have been enlarged less, thus preventing ars after the completion of endodontic therapy and of recon-
the stripping. struction performed elsewhere.

Fig. 28.66. Perforation by a cast post, probably in both roots of

the lower left second molar. In this case also, the damage beca-
me evident 18 months after completion of endodontic therapy
and of the reconstruction performed elsewhere.
28 - Endodontic-Periodontal Interrelationship 793

PERFORATIONS OF THE CORONAL THIRD AND OF THE BIFURCATIONS fibers. As a consequence, an apical migration of the
epithelial attachment occurs, and then an advanced
Perforations of the coronal third may occur when periodontal defect forms. 55
an access cavity (Fig. 28.67) or cavity for a post or
screw (Fig. 28.68) is prepared without taking into con- Prognosis
sideration the inclination of the tooth in the arch or
the anatomy of the roots (Fig. 28.69) . The prognosis of perforations depends on many
At the level of bifurcations, they can be due to the factors, including their level (coronal, middle, or
search for the orifice of a canal in a calcified pulp apical one third), location (buccal, palatal, mesial,
chamber; for example, the removal of an excessive or distal), size (small or large), time interval between
amount of dentin in the wrong direction can lead to the perforation and obturation. Further, the prognosis
perforation of the pulp chamber floor (Fig. 28.70) or depends on the material used to repair the defect,
perforation of the most coronal portion of the root ca- whether there is concomitant bacterial infection, and
nal (Fig. 28.71). whether there is overfilling resulting in extrusion of
In other cases, perforation is simply due to prepa- the repair material.
ration of an inadequate access cavity (Fig. 28.72). This - Leve/. As previously noted, the literature concludes
can be avoided with the use of a large enough bur to that perforations of the coronal one third and of the pulp
open the roof of the pulp chamber and directing the chamber floor have a less favorable prognosis because
bur toward the orifice of the wider canal (the distal of their vicinity to the gingival crevice. 38•48·53.55,68 ·103 If an
canal in the lower molars and the palatal canal in the adequate amount of connective tissue and bone remain
upper molars). 79 coronal to the defect, there is less chance that permanent
Particular attention must also be paid during the po- periodontal damage will occur, and healing is facilitated.
sitioning of small dentinal posts (Fig. 28.73) and amal- For this reason, the prognosis is better in the case of
gam pins (Fig. 28.81) that may cause damage in the perforation of the pulpal floor in long-trunk molars
bifurcation. ("Trunk" is the distance between the cementoenamel
As a consequence of the mechanical trauma of per- junction and the furcation) (Fig. 28.74).
foration , there is rapid destruction of the periodontal -Location. Location of the perforation is not important
ligament. The alveolar bone immediately adjacent to if the perforation can be treated nonsurgically. On the
the perforation is resorbed with consequent vertical other hand, it becomes critical if surgical access is
loss of bone. The inflammatory process then extends the treatment of choice (Fig. 28.75). Without access,
coronally from the site of the perforation along the fi- extraction is indicated.
bers of the periodontal ligament, with destruction of -Size. As stated, a larger perforation with no taper and
the ligament, alveolar bone, and supracrestal gingival an ovoid opening makes treatment very challenging.


Fig. 28.67. Perforation at the cervical level of the root of the upper right second premolar.The perforation occurred during preparation of the access cavi-
ty, probably because of incorrect positioning (inclined) of the rubber dam clamp. A. Preoperative radiograph. B. Postoperative radiograph (By kind permis-
sion of Dr. G. P.).
794 Endodontics


.. D

Fig. 28.68. Perforation of the coronal one third of the root of

the lower left first premolar, caused by erroneous placement
of two root canal screw posts. A. Preoperative radiograph.
Note the inclination of the screw with respect to the root. B.
The prosthesis and screws have been removed. C. Above, the
original canals, below, the artificial canals. D. Postoperative
radiograph. Space for a new post has been left in one of
the canals. E. Follow-up radiograph 4 years later. Following
lengthening of the clinical crown, the root has become one
E of the mesial abutments of the new prosthesis.

Fig. 28.69. Perforation by a cast post in the buccal bifurcation of the two buccal roots of a first premolar with three roots. A. Preoperative radiograph . Given the
presence of the post,of the lesion, and of a fistula, the treatment plan includes apicoectomy and retrofilling. B.With the paramarginal flap raised, the perforation due
to unrecognized endodontic anatomy is evident.C.The extracted tooth demonstrates its anatomy.
28 - Endodontic-Periodontal Interrelationship 795

_,. i,_ 1", .

, ,, ..:.!;, ~
• ~ .L~!~


G ' . ·: H

Fig. 28.70. A. Perforation of the floor of the pulp chamber of the lower left first molar. Preoperative radiograph. B. The perforation is evident
between the distal and the mesiolingual canals.(, D.After positioning a small amount of gutta-percha at the canal orifices using the Obtura
II, the perforation has been sealed with MTA. E. Postoperative radiograph, after positioning the MTA. F. At the following visit, the MTA is set
and the gutta-percha has been removed from the canal orifices. G. Postoperative radiograph. H. Two year recall.
796 Endodontics



Fig. 28.71 .A. Preoperative radiograph of the lower left first molar. In the attempt to find the calcified mesial canals, a small perforation had been made. B. A
small hand file has been introduced into the perforation. C. After filling the defect with resorbable collagen (Collacote), in order to have a matrix to avoid
extrusion of the obturating material, the perforation has been filled with SuperEBA. In the mean time the resorbed distal canal has been obturated. D.
Postoperative radiograph. E. Two year recall. This case, as well as cases of figs. 28.72 and 28.73 have been treated before the introduction of MTA.
28 - Endodontic-Periodontal Interrelationship 797

A B c
Fig. 28.72. The preparation of an access cavity that is too small and too deep has caused a perforation of the pulp chamber floor of this lower left first molar. A. A# 08 file is
in the perforation. B. Postoperative radiograph. The perforation has been obturated with warm gutta-percha. C. Six month recall.

c D

Fig. 28.73. Perforation caused by a small para-pulpal post of the pulp chamber floor of this lower left first molar. A. Preoperative radiograph. B. lntraoperative rad io-
graph:the small post has been removed.C. The perforation is visible on the buccal side of the access cavity.D. The small post removed.E.Postoperative radiograph.
F.One year recall.
798 Endodontics

Fig. 28.74. The second molar has a long trunk (trunk= distance between
the cementa-enamel junction and the height of the bifu rcation), while
the first has a short trunk.


c D

Fig. 28.75. Surgical repair with MTA of a perforation of the middle one third of the central incisor. A. Preoperative radiograph. B.A gutta-percha cone has been intro-
duced in the fistula. C. Postoperative radiograph. D. Four year recall.
28 - Endodontic-Periodontal Interrelationship 799

In these situations, it is difficult to establish a complete

seal without overfilling.
- Time. Perforations result in inflammatory reactions
with resultant loss of attachment. Loss of attachment
can lead to the development of combined endodontic/
periodontic lesions that often require a surgical
procedure, and the result is a poor prognosis. For this
reason, the time interval between the perforation and
treatment must be as brief as possible; in fact, it is
strongly recommended that these defects be obturated
immediately 103 during the appointment at which
the perforation occurs. This helps prevent bacterial
contamination and thus a lesion of the adjacent
structures (i.e., epithelial attachment, periodontal Fig. 28.76. Col lacote.
ligament, and bone). If still intact, these structures can
function as a matrix and prevent gross overfilling at perforation is to select a restorative material that is easy
the time of obturation. to use, seals well, is not resorbable, is aesthetically
pleasing, and is biocompatible and supports new
Materials and techniques tissue formation. The materials commonly employed
to repair perforations include amalgam (decreasing in
When repairing a perforation, visualization is popularity), SuperEBA resin cement (Bosworth Co.,
extremely important and is achieved by illumination Skokie, Illinois), composite bonded material, and
and magnification. The operating microscope has Mineral Trioxide Aggregate or MTA (ProRoot MTA,
dreammatically the predictability of nonsurgical Dentsply Tulsa Dental, Tulsa, Oklahoma).
retreatment. Currently, all the restorative materials used, except
Beavers et al. 16 have demonstrated that if the lesions MTA, require a dry field to ensure a proper seal.
heal in association with a biocompatible material, and Barrier material must be selected that produces a dry
especially in the absence of bacterial contamination, preparation, contains the placement of the restorative
complete healing of the defect may occur following material, and prevents overfilling. The use of MTA
perforation of the bifurcation or with lateral perforations does not require barrier material.
near the gingival sulcus, with no apical migration of
the epithelial attachment. PERFORATION REPAIR WITH CoUACOTE
Many different materials have been suggested to
aid in the healing of a perforation, including Cavit This technique is particularly indicated when, due
(3M ESPE), 48 amalgam, 18 ,38 calcium hydroxide, 42 and to the chronicity of the perforation and subsequent
gutta-percha. 61 Regardless the material used, clinicians leakage, a large lateral root lesion has formed (Fig.
who seek to repair perforations have always had two 28. 77A). As already stated, in such a case, the clinical
challenges. 94 challenge is to properly place a solid external resorba-
The first challenge is to establish hemostasis and ble matrix that will produce a consistently dry prepa-
avoid overfilling, which can be accomplished by ration and a backstop with which to pack the restora-
placing a barrier that conforms to the furcal or root tive material against. It is important, therefore, to esta-
surface. Selected barriers should be biocompatible, bilish a length from the refence point to the consistent
absorbable and supportive of new bone growth, and drying point that defines the cavo surface of the root.
are placed nonsurgically through the access cavity Collacote is an absorbable collagen material (in only
into a three-walled osseous defect. The internal 10/14 days), has excellent working properties that
matrix provides a barrier to control the placement of provide complete hemostasis and a controlled barrier
a restorative material; the barriers that are currently to pack the restorative material against, is relatively
employed today are Collacote (Calcitek, Carlsbad, inexpensive, biocompatible, and supportive of new
California) (Fig. 28.76), freeze-dried bone, tricalcium tissue growth. Collacote is packaged in sheets from
phosphate, and calcium phosphate. which small pieces are cut and carried into the access
The second challenge to successfully repair a cavity. Absorbable barriers are intended to go in the
800 Endodontics

Fig. 28.77. A. Preoperative radiograph of the upper right central incisor: the root appears to have been perforated mesiallly in the coronal one third with an associa-
ted large lesion of endodontic origin. B. After the removal of the post and of all the existing sealer and gutta-percha, and after the three-dimensional obturation of
the root canal with warm gutta-percha using vertical condensation technique, the working length of the perforation is measured, checking the consistent drying
point. C. With the Schilder plugger the Collacote pieces are packed into the lateral root lesion. D. The small pieces of Collacote are progressively pressed into the os-
seous defect. E. The lateral lesion has been completely packed with Collacote which now can provide a solid and dry barrier. F. A small amount of Super EBA is carri-
ed into the preparation with a Schilder plugger.G. The restorative material is packed into place. H. The defect is now completely filled. I. Postoperative radiograph. J. The
six month recall shows excellent apical and lateral healing. K. The clinical photograph demonstrates new crowns, scarring from previous surgery, but otherwise normal
architecture of the soft tissue (Courtesy of Dr. C. Ruddle) (This case has been treated before the introduction of MTA).
28 - Endodontic-Periodontal Interrelationship 801

bone and not left within tooth structure. Paper points PERFORATION REPAIR WITH MTA
are used to determine the level of the perforation and
the boundary line between tooth and the attachment The prognosis for a perforation has improved with
apparatus. Furthermore, they measure the distance the use of the operating microscope 92 and with the
from the desired reference point to the fur cal or root availability of MTA to seal the defects (Fig. 28.78). 27
surface (Fig. 28.77B). Specifically, the part of the paper MTA was developed by Torabinejad and collegues. 114
point that is consistently dry is measured and represents It is an endodontic cement that is extremely
the length from the reference point to the perforation biocompatible, hydrophilic, and capable of stimulating
site. The wet part of the paper point represents the healing processes and osteogenesis (Fig. 28. 79).96,110
extent it is extruding beyond the furcal or root surface. MTA is a powder that consists of fine trioxides and
Additional methods used to assist in determining the other hydrophilic particles which set in the presence
level of the perforation site are electronic apex locators of moisture. Hydration of the powder results in a
78 and chemicals. Radiopaque chemicals (The Ruddle colloidal gel that solidifies to a hard structure in about 4
Solution, Proprietary Chemical with FDA Approval for hours. This cement is different from all other materials
Field Testing) injected into the defect provide valuable used because of its biocompatibility, its antibacterial
information as to the position, extent and treatment activity, its marginal adaptation and sealing properties,
required to resolve these clinical events. and of primary importance because it is hydrophilic
The largest Schilder plugger is selected that fits fre- and therefore resistant to moisture.
ely and does not bind on tooth structure. Based on Concerning biocompatibility, 87 ·88 Koh et al.58·59 and Pitt
the size of the defect and the available access, small Ford et al. 83 demonstrated that MTA was not cytotoxic for
pieces of Collacote are appropriately cut, progressive- fibroblasts or osteoblasts, and promoted the formation
ly carried into the access cavity and then firmly pres- of dentin bridges when used in direct pulp capping. 56
sed through the perforation and into the three-wal- Other studies 26·54 ·112 ·113 •117 demonstrated the formation of
led osseous defect (Fig. 28.77C). The plugger packs cementum, periodontal ligament, and bone adjacent to
the Collacote piece through the perforation defect and MTA when used to seal perforations and as a retrofilling
out into the lateral root lesion (Fig. 28.77D). In a lar- material in surgical endodontic procedures. 10
ge osseous defect typically filled with granulation tis- Concerning antibacterial activity, 4.1°7 Torabinejad
sue, the pieces will initially disappear as they "squish" et al. 115 have demonstrated that MTA is superior to
into place. The pieces of Collacote are incremental- amalgam, zinc-oxide eugenol cement, and SuperEBA.
ly placed progressively, filling the osseous defect and Nonetheless, its spectrum of activity is limited, and if
providing a dry barrier at the consistent drying point a bacterial contamination is suspected, it is advisable
that corresponds to the cavo surface of the root (Fig. to use calcium hydroxide before MTA. 115
28.77E). The access cavity and perforation defect is Marginal adaptation and sealing properties of MTA
flushed thoroughly with sodium hypochlorite to re- are far superior compared to those of amalgam, IRM
move any remaining exudate from the cleaned prepa- (Dentsply Caulk), and SuperEBA. 3,4,6,14,41,112116,126
ration, and the perforation defect is dried. As noted, the characteristic that distinguishes MTA
With a barrier type technique, the restorative mate- from all the other materials used to repair iatrogenic
rial selected to repair a perforation site should be ba- perforations is that it is hydrophilic. Materials used
sed on personal judgement, experience, research, its to repair perforations, seal the retro-preparation in
ease of handling, and the advantages or disadvantages surgical endodontics, close open apices, or to protect
of a particular material in a particular clinical setting. If the pulp in direct pulp cappings are inevitably in
SuperEBA is the material of choice, the resin cement is contact with blood or other tissue fluids. MTA is the
spatulated incorporating as much powder into the liquid only material that is not affected by moisture or blood
as possible so a heavy, viscous, putty-type mix is crea- contamination.11 3 On the other hand, MTA sets only in
ted. A small conically shaped aliquot of SuperEBA re- contact with moisture. Due to the above-mentioned
sin cement is attached to the working end of a Schilder characteristics and primarily because it is hydrophilic,
plugger (Fig. 28.77F). The plugger carries and delivers MTA can be considered the ideal material to seal
the restorative into the preparation and packs the ma- perforations (Fig. 28.80). 11 ·35 ·66·127
terial purposefully into place (Fig. 28.77G). Progressive The following is the operative sequence to treat a
placement and packing of small increments of Super perforation of the root or of the floor of the pulp
EBA resin cement fills the defect (Fig. 28.77H-K). chamber:
802 Endodontics

Fig. 28.79. Tissue response to an MTA root-end filling. New cementum has
grown over the cut root-end dentin and over the root-end filling; there is no
inflammation in the adjacent connective tissue (Original magnification x20,
Hematoxylin and eosin) (Courtesy of Dr. M. Torabinejad).

Fig. 28.78 A.White MTA (ProRoot MTA, Dentsply Maillefer).

B. Grey MTA (ProRoot MTA, Dentsply, Maillefer).


( D

Fig. 28.80. Stripping of the mesial root of the lower left first molar, caused by the introduction of a screw post in the mesiobuccal canal. A. Preoperative radiograph.
B. After non-surgical retreatment, the obturation with Schilder technique has been made in the distal, in the mesiolingual and in the mesiobuccal canal apical to the
perforation. C. Postoperative radiograph: the coronal one third of the mesiobuccal canal has been completely obturated with MTA, from the perforation up to the
orifice. D. The recall radiograph after five years shows the complete healing.
28 - Endodontic-Periodontal Interrelationship 803

At the patient's first visit, (1) isolate the operative orifice (Fig. 28.82).
field with rubber dam, (2) clean the perforation site; In order to do this, it is necessary to measure the level
in case of bacterial contamination, medicate with of the perforation using the operating microscope and
calcium hydroxide for one week, (3) apply a 2- to then to partially cut or score the pre-fitted gutta-percha
3-mm-thick layer of MTA; radiograph to verify the cone just apical to that level. Once it is introduced
correct positioning of the material, ( 4) apply a small into the root canal, the gutta-percha cone is digitally
wet cotton pellet in contact with MTA, and (5) place rotated, separating it into two pieces: the coronal
temporary cement. fragment pulls away, leaving the apical fragment in
At the second visit (after 24 hours), remove the the canal, which is just apical to the perforation. After
temporary cement to check if MTA has set and then compaction of the apical gutta-percha cone, the canal
complete the therapy. is filled with MTA to the orifice, sealing the perforation
As far as the operative sequence is concerned, it is site.
important to differentiate between a perforation that
has the configuration of a cavity with four walls Criteria for assessing success
having no association with the root canal space (eg.
the perforation of the pulp chamber floor in a molar) To achieve success following treatment of a
and one that is a strip perforation inside the canal perforation, the treated tooth must meet the following
space. requirements: 109
If the perforation is in the floor of the pulp chamber - absence of symptoms, such as spontaneous pain or
and therefore is a cavity completely independent of pain on palpation or percussion
the canal orifices, the situation is different from a - absence of excessive mobility
perforation that is in the middle third of a root and is - absence of communication between the perforation
caused by stripping due to excessive enlargement of and the gingival crevice
the root canal. In the latter case, the perforation is not - absence of a fistula
independent from the root canal but is inside the root - the tooth must be functional
canal (in a root canal wall). It is not a cavity with 4 - absence of radiographic signs of demineralization of
walls, but is rather a thinning of the root. the bone adjacent to the perforation
In the first instance, it is advisable to seal the perforation - thickness of the periodontal ligament adjacent to the
before obturating the root canals. This approach is obturating material should be no more than double
easier and saves time. Since one consideration for the thickness of the surrounding ligament.
prognosis is the time interval between perforation If even only one of these requirements cannot be
and treatment, the longer treatment is delayed, the met, therapy cannot be considered as a success.
more likely the perforation will be contaminated, with
resultant periodontal involvement. After positioning
small amounts of gutta-percha at the orifices of the
canals using the Obtura III (Obtura Spartan) (Fig.
28.70), or in a retreatment case before removing the
previous obturating material to prevent the blockage
of the canals with MTA (Fig. 28.81), MTA is used to
completely fill the perforation. Once the complete
set of the material is verified at the second visit, the
cleaning, shaping and obturation of the root canal
system is completed in the standard fashion.
In the case of a strip perfora~n due to a thinning of
the root dentinal wall, it is extremely difficult to repair
the perforation site with MTA before obturating the
root canal without blocking the canal itself with MTA.
Therefore, it is advisable to obturate the canal space
apical to the perforation first, and then to repair the
perforation using MTA to seal the perforation site and
fill the entire coronal portion of the root canal, to the
804 Endodontics


Fig.28.81.Perforation of the mesial aspect of the distal root caused by the preparation ofthe space for an amalgam pin in this lower right first
molar.A. Preoperative radiograph. B. Clinical aspect of the perforation adjacent to the old amalgam. C. The amalgam has been removed and
the perforation has been repaired with MTA. D. At the following visit the MTA is set. E. MTA at higher magnification. F. The radiograph shows
the MTA in place. G. Postoperative radiograph. H. Three year recall.
28 - Endodontic-Periodontal Interrelationship 805

Fig. 28.82. In the attempt to find the mesiobuccal canal, a perforation was made in the floor of the pulp chamber.A. Preoperative radiograph.B.Clinical
aspect of the access cavity.The red tissue on the left is the pulp tissue of the lingual canal.The bleeding on the right comes from the perforation nearthe
orifice of the buccal canal.C.A small file has been introduced in the bleeding area and has been connected to an electronic apex locator to confirm the
diagnosis of a perforation.D.On the mesial aspect of the perforation is now visible the orifice of the canal.E.A # 10 KFile is negotiating the original me-
siobuccal canal. F. Working length of the mesiobuccal canal. G.After cleaning and shaping, now the perforation is the little opening about 7 mm below
the canal orifice. H. Fitting the gutta-percha cones (continued).
806 Endodontics

Fig.28.82 (continued).I. The gutta-percha cone of the mesiobuccal canal has been partially pre-sectioned apical to the perforation, bended and coated
with sealer before been introduced in the canal.J. Because of the partial cut, the gutta-percha point is separated in two fragments:one apical, which re-
mains in the canal apically to the perforation, and one coronal which is removed.K. The canal has been obturated with the Schilder technique only apical-
ly to the perforation. L. Deepest packing point in the mesial canals. M. Positioning the MTA with the Dovgan carrier. N. The canal has been filled with MTA
up to the orifice. 0. At the following visit the material is completely set. P. Postoperative radiograph.Q. Two year recall.
28 - Endodontic-Periodontal Interrelationship 807

ROOT FRACTURE - Progression of "cracked tooth syndrome" which

had not been diagnosed earlier (Fig. 8.33). In these
Periodontal destruction caused by vertical root frac- cases, the fracture may pre-date the endodontic tre-
ture is the most serious injury that can occur seconda- atment. 63
ry to endodontic therapy, since, apart from very ex- The following causes may be added to the above:
ceptional cases, the fracture is untreatable, and there - "Screwing" rather than "cementation" of a screw
is no alternative but to extract the tooth. post (Fig. 28.84).
Among the causes of vertical root fracture reported - Construction of an inadequate prosthesis with one
in the literature, the following are noted: (Fig. 28.85) or two cantilevers (Fig. 28.86) or with er-
- Loss of the 9% of the water content by the hard roneous Spee's curve (Fig. 28.87).
dentinal tissues in endodontically-treated teeth. 50 - Inadequate protection of the cusps of an endo-
- Destruction of the dentinal bridge overlying the dontically-treated tooth (Fig. 28.88).
pulp chamber, which is necessary for preparation of The diagnosis of vertical root fracture is not always
the access cavity 85 (this and the preceding are predi- easy to establish. Very often, the fracture is not radiogra-
sposing factors). phically visible, especially at an early stage (Fig. 28.89).
- Use of excessive force during lateral or vertical The patient may only complain of a slight gingival an-
condensation of the gutta-percha. This appears to be noyance that is occasionally exacerbated, causing slight
the most common. 73 Recent studies 44 have shown that pain on percussion or palpation. In other cases, a true
the lateral condensation technique is more often re- periodontal abscess or a fistula may be present (Fig.
sponsible for vertical root fractures than the Schilder 28.90). Acute pain is quite rare; very often, the presen-
technique, as already discussed on page 618. tation is completely asymptomatic. 74 Radiographic exa-
- Volumetric expansion of posts or screws as a re- mination may be completely negative; sometimes, the-
sult of corrosion. 82 Meister et al. 73 state that the corro- re is slight widening of the periodontal ligament space
sion occurs secondary to fracture, which provides a (Fig. 28.91) or a slight, variably extensive radiolucency
means of access to the metal for oral fluids. along the side of the root (Fig. 28.92).
- Use of excessive force during cementation of an The fracture line may sometimes be visible radio-
"inlay" in an endodontically-treated tooth 65 or in a vi- graphically if amalgam has been inserted there in the
tal tooth.75 course of retrofilling (Fig. 28.93).
- Use of excessive force in the cementation of a post The most important instrument in establishing a dia-
125 in an endodontically-treated tooth (Fig. 28.83). gnosis of vertical root fracture or at least in perceiving
clues to its presence is the periodontal probe (Figs. 28.94
A-C). The probing characteristic of these pockets (Fig.
28.23) is quite different from that of the crateriform po-
ckets of chronic periodontitis, which originate in the sul-
cus and gradually progress apically (Fig. 28.15).
If a tooth that has already been endodontically tre-
ated and possibly reconstructed with a screw or post,
presents with a tubular periodontal defect, one must
suspect a vertical root fracture, especially if the pro-
beable defect is present on both the buccal and pala-
tal or lingual sides and if the canal therapy appears to
be well performed (so that the presence of a fistula is
not explained).
Suspicion of a vertical root fracture may become a
certainty simply by raising a full-thickness marginal
flap to reveal the root at the defect (Fig. 28.94 D).
Within certain limits, visualization of the fracture
may be possible without a surgical procedure if gin-
gival recession is present or if the gingival margin
Fig. 28.83. Vertica l fracture of an upper left canine. The patient reported that
can be slightly retracted by the tip of ·a probe (Fig.
he felt a"crack" during cementation. 28.95). Furthermore, a characteristic "click" may be
808 Endodontics

Fig. 28.84. Vertical fracture of the distal root of a lower left

first molar. A. Preoperative radiograph. A gutta-percha cone
has been introduced in the fistula. During the preceding at-
tempt to retreat the tooth, the screw post broke within the
root canal. B. The periodontal probe indicates a tubular de-
fect. C. The access cavity demonstrates the fracture line di-
stal to the screw post. D. With the screw post removed, the
vertical fracture of the distal root is even more evident. The
fracture involves the pulp chamber floor only minimally. E.
Postoperative radiograph. The mesial canals have been re-
treated, and the distal root has been removed. F. Two year
recall. The lesion has healed, but... a new screw post has be-
en placed!

Fig. 28.85. Fracture of a lower right second premolar, the last abutment of a pros-
thesis with a cantilever.
28 - Endodontic-Periodontal Interrelationship 809


Fig. 28.86. A. Vertical fracture of an upper left second premolar, the last abutment of a prosthesis with a long cantilever. B.The ex-
plorative surgical procedure confirms the previous diagnosis. A paramarginal rather than marginal flap has been performed, be-
cause in the unlikely case that there was no fracture, the patient would have wanted apicectomy with retrofilling without the es-
thetic insult that gingival retraction would have caused to his prosthesis!

Fig. 28.87. A. Vertical fracture of a lower right first premolar,

terminal abutment of a gold-ceramic prosthesis extending
from the third molar to the first premolar. B. Note the Spee's
curve. C. The bridge extracted together with the tooth, seen
from the lingual side.
810 Endodontics


c D

Fig. 28.88. A vertical fracture of a previously endodontically-treated lower right second molar. A. Preoperative radiograph:the tooth, which was symptoma-
tic, had been sent for retreatment. Note the previous amalgam restoration without protection of the cusps. B.With the amalgam partially removed, the me-
siodistal course of the fracture is already evident. C. With the access cavity completed and the silver cones removed, the fracture is even more apparent. D.
With the dam removed, the probeability of the lesion is demonstrated (tubular defect). E.The tooth just extracted.
28 - Endodontic-Periodontal Interrelationship 811

Fig. 28.89. Vertical fracture of an upper left first premolar. A.The preoperative radiograph gives no information about the existence
of the vertical fracture, except for the small radiolucency distal to the screw post. B.The periodontal probe indicates the existence
of a tubular defect. C. A small, exploratory full-thickness marginal flap confirms the suspicion of a vertical fracture, which could not
be diagnosed radiographically. D. The tooth extracted.

A B c
Fig. 28.90. Vertical fracture of a lower right first premolar.A.The preoperative radiograph demonstrates a radiolucency at the apex of the tooth already treated endo-
dontically in an apparently correct manner. B. A fistula is present, as is the typical tubular defect. C. Displacing the gingiva with the probe, the fracture line is
812 Endodontics

Fig. 28.91. Vertical fracture of a lower right second premolar. A.The radio-
graph demonstrates a slight widening of the space of the periodontal li-
gament and an apparently correctly performed obturation. B. Because of
the presence of pain and typical tubular probing, extraction was perfor-
med without an exploratory flap. Note the thin fracture line, which is re-
vealed by a caries indicator. B


Fig. 28.92.Vertical fracture of the mesial root of a lower right first

molar. A. The preoperative radiograph demonstrates marked
widening of the space of the periodontal ligament, which ac-
companies the entire root.B. Postoperative radiograph following
hemisection. C. D. The mesial root extracted.
28 - Endodontic-Periodontal Interrelationship 813

Fig. 28.93.A. Preoperative radiograph of an upper right second premolar.The 75-year-old patient was sent for apicectomy of the symptoma-
tic premolar.B.The amalgam, in addition to obturating the canal, has obturated the pre-existing fracture line, beginning apically.The patient
informed refused both extraction and deepening of the bevel of the apex. C. Postoperative radiograph. D. Follow-up radiograph 3 years la-
ter. E. Follow-up radiograph 4 years later. F.The tooth extracted.
814 Endodontics


Fig. 28.94.A. Distal probing is normal. B. Mesia I probing is al-

so within normal limits. C.The probe introduced in a point
intermediate to the preceding points reveals the existence
of a tubular defect. D.Afull-thickness marginal flap con-
firms the diagnosis of vertical root fracture.


c D

Fig. 28.95. A-C.The probe indicates the presence of a tubular defect. D. Slight retraction of the gingival margin with the tip of the
probe confirms the diagnosis of vertical root fracture.
28 - Endodontic-Periodontal Interrelationship 815

audible when the sharp probe passes over the fracture sence of a vertical root fracture inspecting the ro-
line. Obviously, the diagnosis can be facilitated using ot surface from the inside the root canal walls (Figg.
magnification, from simple loops up to the microsco- 28.97 A-D), before confirming it with a surgical flap
pe, and a dye like methylene blu (Fig. 28.96). Using (Fig. 28.97 E).
the operating microscope one can diagnose the pre-

Fig. 28.96.A-C. The use of magnification and methylene blue are very usefull to make a diagnosis of a vertical root fracture.

Fig.28.97.A. Recall radiograph two years after the root canal therapy was completed at the upper right canine. B. Ten years later the same patient comes with a fistu-
la and a lesion on the mesial aspect of the same tooth. Note that in the mean time the teeth distal to the cuspid have been extracted and the cuspid has been used
as an abutment for the removable prosthesis.(. Suspecting the presence of a vertical root fracture, the crown has been removed and the gutta-percha also has been
removed from the coronal one third of the canal, to check the internal walls through the operating microscope. D. A vertical root fracture is present on the buccal as-
pect of the root canal. E. With the permission of the patient, a marginal flap was raised to document the vertical fracture also on the external surface of the root.The
vertical line became more evident after using the dye.
816 Endodontics

The reason why the periodontal attachment is lost In other cases, acute symptoms return, accompa-
at the fracture line is easy to understand, especially nied by new radiographic (i.e., increased radiolucen-
if one considers that within such a line bacterial pla- cy) and clinical (probing) signs, as in the case of Fig.
que accumulates 44 which neither endodontic instru- 28.103, in which the pre-existing vertical root fracture
ments nor periodontal curettes can ever remove (Figg. had passed unobserved. That which in the post-ope-
28.98, 28.99). rative radiograph had seemed to be the filling of a la-
Rapid loss of bone and inflammation of the perio- teral canal was aposteriori interpreted as partial filling of
dontium adjacent to the fracture line seem to be cau- the pre-existing fracture line.
sed by the contents of the canal and the fracture it- Obviously, the prognosis of vertical root fractures is
self, including bacterial toxins, 19 ·77 necrotic pulp tis- always poor. The only definitive therapy is extraction.
sue, 104 components of the endodontic sealer, 8•24 food If the fracture involves only a single root of a
particles, and products of disintegration of the tissue multirooted tooth and the remaining portion of the
fluids. 89 tooth is salvageable and functional, amputation of
If the fracture is not identified in time, the pictu- the fractured root or hemisection of the tooth can
re clarifies with the appearance of other suspicious be performed, thus preserving the remainder (Fig.
radiographic signs. The first is the appearance of a 28.104).
dark line next to the radiopaque obturating material Cases in which healing has occurred as a re-
(Figs. 28.100, 28.101). In more advanced cases, there sult of spontaneous setting of the fracture line fol-
may be a clear separation of the radicular fragments. lowing calcium hydroxide therapy have been repor-
In these cases, the dislocation of the fragments is ted. Unfortunately, they are quite rare. 101
caused by the proliferation of chronic inflammatory In their histologic studies, Walton et al. 124 have ne-
tissue. This continuously expanding mass prolifera- ver been able to document any attempt at "healing" or
tes within the fracture line, eventually provoking se- "bridge setting" of the fracture line, as occurs in hori-
paration of the fragments 74 •124 (Fig. 28.102). zontal fractures. 7

Fig. 28.98.A. S.E.M. of a root with a vertical fracture (xl 3). B. At higher magnification, the accumulations of plaque with in the fracture line are visible (xl ,000).
28 - Endodontic-Periodontal Interrelationship 817

Fig. 28.99. A. S.E.M. of the fracture line surface. An accumulation of bacterial plaque above the dentin al tubules can be recognized (x2,000). B. The same area at hi-
gher magnification (xS,000).

Fig. 28.101. The radiolucency that surrounds the entire root, the presence of a
cantilever, the dark shadow next to the obturating material, and the radiolu-
Fig.28.100.The radiolucency distal to the obturating material and to the screw cent line oriented distally halfway along the root are certain signs of a root
post is a clear sign of the presence of a vertical root fracture. fracture.
818 Endodontics

B c


Fig. 28.102. Separation of the fragments of a vertical root fracture caused by granulation tissue.A.Preoperative radiograph. B.Recall radiograph 1year later.
C. Recall radiograph 2 years later.The presence of the incongruous old prosthesis with the cantilever, the return of symptoms after initial healing, the pre-
sence of a subtle radiolucency surrounding the entire mesiobuccal root, and the probing revealing a tubular defect are diagnostic of a vertical root fractu-
re. D. After 3 years, the lesion has increased. E. After 4 years, separation of the fragments has occurred.
28 - Endodontic-Periodontal Interrelationship 819

.,.' .

A ... . B

Fig. 28.103. A. Preoperative radiograph of an upper right second premolar. There is a mesial radiolucency. 8. Postoperative radiograph. Note the presence of obtu-
rating material departing from the principal canal at an acute angle halfway along the root facing the mesial radiolucency. C. Follow-up radiograph 5 months later:
the lesion has increased, a widening of the space of the periodontal ligament on the mesial side of the root is present, a gutta-percha cone has been introduced in
the fistula, and finally a probeable tubular defect is present both buccally and palatally. The diagnosis of vertical root fracture is obvious and it is also obvious that
the fracture was already present at retreatment.The obturating material seen earlier on the side of the root does not fill a lateral canal, but the fracture line. D. Buccal
view of the extracted tooth. E. Lingual view.
820 Endodontics

Fig. 28.104. Hemisection of a lower right first molar with vertical fractu-
re of the mesial root. A. The diagnosis of fracture is obvious. B. A gutta-
percha cone has been introduced in the fistula, and the tooth has been
reconstructed with amalgam and a distal amalgam pin. C. The fractured
c mesial root has been extracted.

THE INFLUENCE OF PERIODONTAL DISEASE follows a pulp-periodontal direction, not the converse.
ON THE ENDODONTIUM As a matter of fact, in the every day practice we can
find teeth with vital pulp in spite of the fact that their
As already stated, most investigators agree that pul- apex dips into the endodontic lesion of the adjacent
pal involvement in the course of periodontal disea- tooth (Fig. 28.105), as well as teeth periodontally in-
se can occur only when the periodontal disease is ve- volved, which maintain their pulp vitality in spite of
ry advanced and the bacterial plaque involves all the the advanced periodontal disease (Fig. 28.106).
principal apical foramina. If this were not true, endodontists would be called
This is the only case in which the pulp becomes in- to perform an enormous number of endodontic thera-
fected apically: it represents retrograde pulpitis arising pies in all teeth with periodontal disease. This
from the periodontal disease. does not happen.
It does not suffice that the vascular peduncle of a to- On the other hand, it is obvious that when, in prac-
oth is surrounded by granulation tissue (of endodon- tice, periodontal disease denudes the apex of the root
tic origin, originating in the adjacent tooth, or of perio- and exposes the pulp to the oral environment (Figs.
dontal origin, originating in the tooth itself), because the 28.107 , 28.108), infection and retrograde inflammation
pulp comes to be infected and then first becomes pulpi- of the pulp tissue and its subsequent necrosis will oc-
tic, then necrotic. Chacke 28 states that the inflammation cur (RETROGRADE PULPITIS FROM PERIODONTAL
follows the venous drainage and the venous circulation DISEASE) .
28 - Endodontic-Periodontal Interrelationship 821

Fig. 28. 105. A, B.The upper left lateral incisor responds positively to the vitali-
ty tests, in spite of the fact that its apex dips into the endodontic lesion of the
adjacent tooth.

Fig. 28.106. A. A lower left third molar with a periapical radiolucency. B. A fistula is present on the lingual side. Having diagnosed a lesion of endodontic origin, the root
canal therapy is initiated. However, during preparation of the access cavity obviously without anesthesia, the tooth was shown to contain a vital pulp.The class I prepa-
ration performed as a "cavity test"was then obturated with amalgam and the periodontal origin of the lesion wa s identified. C. Healing of the periodontal fistula after
curettage (Courtesy of Dr. G. Ricci). D.The tooth was then treated endodontically, because it was a candidate for amputation of the mesial root. E.Two yea r reca ll.
822 Endodontics

Fig. 28.108. A. The palatal root of this upper right first molar is completely de-
Fig. 28.107. The fenestration of the alveolar mucosa has exposed the pulp to nuded.The same probe enters the apical foramen . B. Extracted, the palatal
the oral environment. It is no wonder that this pulp had a retrograde pulpitis. root reveals the presence of calculus almost as far as the apical foramen.

THE INFLUENCE OF PERIODONTAL pulp necrosis progressing apico-coronally.

THERAPY ON THE ENDODONTIUM The first study to document the histological effects
of periodontal therapy on the pulp was that of Marion
While the influence of periodontal disease on the 67 in 1979. Studying the pulp of 110 vital teeth with pe-

endodontium has been studied by many investigators, riodontal disease, 62 of which had undergone curetta-
little has been done to document the influence of pe- ge and root planing, he concluded:
riodontal therapy on the pulp. 1) There is no correlation between the severity of
In 1965, Rubach and Mitchell 91 described five cases of periodontal disease and the degree of pulp pathology.
pulpitis arising from periodontitis and spreading to the The pulp is not influenced at all by the "sea" of perio-
pulp through the lateral canals and six cases of necrosis dontal inflammation in which it sits.
associated with periapical extension of periodontal dise- 2) Seven of the 110 teeth studied developed pulpi-
ase. In addition to maintaining that periodontal disease tis and then total necrosis. This could be directly attribu-
was responsible, in their conclusion they pointed out the ted to the therapy applied. Histologically, one of these
possibility of pulp exposure during gingivectomy. This teeth demonstrated more degeneration in the apical re-
could have been the cause of their histologic findings. gion and in the area of the bifurcation. This indicates the
In 1972, Bender and Seltzer 17 hypothesized that cu- direction of the inflammatory response, which is from
rettage of periodontal pockets and root planing was an apical direction. In another of the seven teeth, the cu-
another way (in addition to that mediated by periodon- rettage was performed around the root apex. The sub-
tal disease) of interfering with the blood supply of the sequent development of an acute alveolar abscess indi-
pulp. The loss of blood supply to a small area of the cated the loss of blood supply from the apical region,
pulp could lead to death of the cells supported by the which caused the inevitable pulpitis and necrosis.
capillaries, with the development of a small area of in- Thus, since each control tooth was unaffected, the
farction, coagulative necrosis, and pulp calcification. pulps of these teeth were not affected by periodontal
In 1975, Bergenholtz and Lindhe 20 hypothesized disease, but rather a result of the periodontal therapy.
that pathologic reactions of the pulp could derive 3) Ten teeth from seven different patients manife-
from mechanical exposure of the lateral canals during sted signs of pulpitis 14-20 days following periodontal
deep calculus removal. curettage. Since none of the control teeth showed in-
In 1978, Schilder 100 listed among the causes of so- creased sensitivity, this also was evidently due to the
called "retrograde pulpitis" sectioning of the vascular treatment performed.
peduncle of a large accessory canal or of the principal 4) Fourteen teeth from 10 patients demonstrated si-
canal by a curette, with consequent inflammation and gns of clinical hyperemia. This was due to root surfa-
28 - Endodontic-Periodontal Interrelationship 823

ce exposure, as well as root planing the cemental sur- be mediated not only by the curette, which admitte-
face, exposing dentin. dly are the most relevant cause, but also by the use
5) Nine teeth from four patients did not demonstra- of dental floss , which patients are instructed to use in
te any significant clinical changes. This is not surpri- the entire depth of the pockets, by the use of parti-
sing, since curettage may not always involve accesso- cular technique of periodontal therapy (especially in
ry canals. bifurcations), or even by extensive periodontal pro-
This important study suggests that before starting bing, which can also cause severing apical or lateral
any periodontal treatment it is always advisable to test canals.67
the vitality of all teeth with periodontal disease, not Whatever the cause, sectioning of a lateral or api-
only to reach a more accurate diagnosis but also to be cal blood vessel (e.g., periodontal curettage or trau-
able to assess the condition of the pulp at subsequent ma) leads to loss of blood supply to the pulp with
follow-up examinations. It is therefore obvious that consequent ischemic necrosis and then pulpal death.
if the pulp of a tooth becomes necrotic shortly after- In these cases, the degeneration that is observed hi-
ward so that it requires endodontic therapy, the cau- stologically proceeds from the apical region or lateral-
se is evidently the therapy, not the periodontal disease ly through the severed accessory canal, since this is
(Fig. 28.109). where the insult to the pulp was made.
On the other hand, that the pulp disease is comple- Consequently, a retrograde pulpitis may progress
tely independent of the periodontal disease but not from the apex or a large accessory canal into the pulp,
from the therapy does not mean that the pulp must when the periodontal therapy interferes with a large
be indiscriminately extirpated before each periodontal vessel of one of these portal of exit (RETROGRADE
procedure. This would be sheer folly. PULPITIS FROM PERIODONTAL THERAPY).
However, if a pulp becomes necrotic as a result Finally, periodontal therapy may lead to the need
of periodontal therapy, endodontic treatment must be for endodontic therapy when it is necessary to per-
undertaken as soon as possible so as not to contribute form hemisection (Fig. 28.115), root amputation (Fig.
(with an endodontic source) to the disease of the at- 28.116), or bicuspidization (Fig. 28.117) in a perio-
tachment apparatus of the tooth. dontally-diseased tooth with vital pulp. In these cases,
Furthermore, lateral canals of discrete size that are the reciprocal dependence is obvious, but it must be
easily reached by the curette are not so uncommon specified that the periodontal therapy does not "pro-
(Figs. 28.20D, 28.53B, 28.110-28.114). voke" the inflammation and pulp necrosis, but rather
The dentist must also realize that the negative ef- "requires" endodontic therapy, which must always be
fect of periodontal therapy on the lateral canals can performed before the periodontal therapy.

Fig. 28.109. Pulp necrosis and subsequent acute alveolar abscess, as a conse-
quence of the curettage which was done two weeks before. A. Preoperative
radiograph. B. Postoperative radiograph . Note that the orifice of the lateral ca- Fig. 28.110. A lower left lateral incisor with a lateral cana l coronal to the cre-
nal cou ld be easily reached by the curette. stal bone.
824 Endodontics

Fig. 28.11 2. The lateral canal of this

upper left central incisor was sec-
Fig. 28.111 .The lateral canal of the distal root of this lower second molar is in tioned during periodontal therapy
an area accessible to the curette. about two weeks before.

Fig. 28.113. Another example

of a lateral canal accessible to
the curette.

Fig. 28.11 4.A. Preoperative radiograph of a lower left third molar. Note the lesion around the distal root. B. Postoperative radiograph.C. Follow-up radiograph 17
months later.The primary endodontic lesion, sustained by the lateral canal, has healed with only endodontic therapy.
28 - Endodontic-Periodontal Interrelationship 825

Fig. 28.115.The need for hemisection has required preceding endodontic therapy of the lower left first molar. A. Preoperative ra-
diograph. B. Postoperative radiograph. C. Follow-up radiograph 6 months later. The mesial root of the tooth has been removed. D.
Three year recall.




Fig. 28.116. Amputation of the mesiobuccal root hiJS previ-

ously required endodontic therapy of this upper left first mo-
lar. A. Preoperative radiograph. B. Postoperative radiograph.
The access cavity has been obturated with amalgam with an
amalgam pin in the mesiobuccal root to be amputated. C.
c One year recall.
826 Endodontics


Fig. 28. 117. The lower right first molar has been endodontically treated prior to bicuspidization. A. Preoperative radiograph.
B. Postoperative radiograph. C. The molar has been premolarized. D. Two year recall.


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pp. 433-446.
Microscopes in Endodontics, Dental Clin. North Am. WB
Saunders, Philadelphia, 41(3):429, July 1997 112 TORABINEJAD, M., WATSON, TF., PITT FORD, TR.: Sealing
ability of mineral trioxide aggregate when used as a root-end
94 RUDDLE, CJ: Retreatment of root canal systems. ]. Calif.
filling material. ]. Endod. 19:591, 1993.
Dent Assoc. 25:11, 1997.
95 SANTA, M.C., LARA, V.S., MORAES, LG.: The palato-gingival
FORD TR.: Dye leakage of four root-end filling materials: ef-
groove. A cause of failure in root canal treatment. Oral Surg.
fects of blood contamination. ]. Endod. 20:159, 1994.
85:94, 1998.
FORD, TR.: Physical and chemical properties of a new root-
KAWASHIMA, I.: Physicochemical basis of the biologic pro-
end filling material.]. Endod. 21 :349, 1995.
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97 SAUERWEIN, E.: Die histopathologie der zahnpulpa bei pa-
KETTERING JD.: Antibacterial effects of some root-end fil-
radentopathien. Deutsche Zahn. , Mund., V. Kieferh. 22:289,
ling materials.]. Endod. 21 :403, 1995.
1955. .
98 SCHAFER, E., CANKAY, R., OTT, K.: Malformations in maxil-
FORD, TR.: Comparative investigation of marginal adapta-
lary incisors: case report of radicular palatal groove. Endod.
tion of mineral trioxide aggregate and other commonly used
Dent. Traumatol. 16:132, 2000.
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99 SCHILDER, H.: The relationship of periodontics to endodon-
tics. In Grossman L.I. ed.: Transactions, Third International
ABEDI, H.R.:Histologic assessment of mineral trioxide aggre-
Conference on Endodontics, Philadelphia, University of
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100 SCHILDER, H.: Perio-endo relationship. Continuing educa-
118 TORABINEJAD, M., CHIVIAN, N.: Clinical applications of mi-
tion course. B.U.S.G.D. Boston, Nov. 1978.
neral trioxide aggregate.]. Endod. 25:197, 1999.
101 STEWART, G.G.: The detection and treatment of vertical root
119 TORABINEJAD, M., KIGER, R.D. : A histologic evaluation of
fractures.]. Endod. 14:47, 1988.
dental pulp tissue of a patient with periodontal disease. Oral
102 SELTZER, S., BENDER, I.B., ZIONTZ, M.: The interrelation- Surg. 59:198, 1985.
ship of pulp and periodontal disease. Oral Surg. 16:1474,
leakage with mineral trioxide aggregate or a resin-modified
103 SELTZER, S., SINAI, I., AUGUST, D.: Periodontal effects of glass ionomer used as a coronal barrier. ]. Endod. 30:782,
root perforations before and during endodontic procedures. 2004.
]. Dent. Res. 49:333, 1970.
121 TURNER, JG, DREW, A.H. : An experimental inquiry into
104 SHOVELTON, D., SIDAWAY, D.: Infection in root canals. Br. the bacteriology of pyorrea. Proc. Roy. Soc. Med. (Odont.)
Dent.]. 108:115, 1960. 12:104, 1928.
105 SIMON, ].H.S., GLICK, D.H., FRANK, AL.: Predictable endo- 122 URBANI, G., LOMBARDO, G., CAVALLERI, G.: Le lesioni en-
dontic and periodontal failures as a result of radicular anoma- do-parodontali. II Dentista Moderno 7:1150, 1992.
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123 VIGNOLETTI, G.: Le relazioni endo-parodontali. G. It. Endo.
106 SIMON, ].H.S., GLICK, D.H., FRANK, A.L.: The relationship of anno 2, 3:27, 1989.
endodontic-periodontic lesions.]. Periodontol. 43:202, 1972.
124 WALTON, R.E., MICHELICH, RJ , SMITH, G.N.: The histopa-
107 SIPERT, C.R., HUSSNE, R.P. , NISHIYAMA, C.K., TORRES, S.A.: thogenesis of vertical root fractures. ]. Endod. 10:48, 1984.
In vitro antimicrobial activity of fill canal, Sealapex, Mineral
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Endod. ]. 38:539, 2005.
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seal provided by some root-end filling materials.]. Endod. 24:
Endodontic treatment of traumatic root perforations in man: a
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presenceof Mineral Trioxide Aggregate.]. Endod, 29:407, 2003.
830 Endodontics

The Treatment of Teeth with
Immature Apices

Hermetic sealing of the apical foramen or forami-

na by the introduction into the root canal of an obtu-
rating material that can be well compacted is essential
to a successful outcome in endodontic therapy. It is
equally recognized that the first requisite a root canal
must have to allow a good obturation is the continuo-
usly tapering conical form, with cross sectional diame-
ters progressively diminishing in a corono-apical di-
rection. This can be easily achieved in mature perma-
nent teeth in which there is an apical constriction and
the canal tends to be wider coronally than apically.
Teeth with immature apices do not have this apical
constriction; instead, the foramen is very wide (Fig.
29.lA). The canal walls can be parallel or even diver-
ge corono-apically, depending on the degree of ma-
turity. In the latter, so-called "blunderbuss" canal, the
apical foramen is even wider than the widest portion
of the canal, so that its shape is exactly the opposite
of that required (Fig. 29. lB, C).
Clearly, with such an endodontic anatomy it is not pos-
sible to compact any canal obturating material without
gross excesses of material beyond the apex; it would be
tantamount to trying to obturate a second-class cavity
without matrices.

Fig. 29.1 . A. Upper premolar extracted for orthodontic reasons before the root
completed its development. B. Histological section of a tooth with an immatu-
re apex. Note the divergence of the canal walls in the apical portion. C. Detail
of the preceding figure (Courtesy of Dr. N. Perrini).
29 - The treatment of teeth with immature apices 831

Therefore, when as a consequence of caries or trau- helpful. On the other hand, the clinician should
ma, endodontic therapy of a tooth with an immature also remember that vitality testing in the immature
apex becomes necessary, prior to undertaking routi- tooth is inherently unreliable as these teeth provide
ne therapy, one must stimulate the maturation of the unpredictable responses to pulp testing. For all
apex or the formation of a "matrix" against which the these reasons sometimes to make a correct diagnosis
obturating material can be compacted in the traditio- could be difficult, but it is hoped that combining the
nal manner. results of the history, examination and diagnostic
At this point, one must distinguish between teeth tests, an accurate clinical diagnosis of pulpal vitality
with immature apices and vital pulp and teeth with can be made in most cases. 109
immature apices and necrotic pulp, as the treatments When the pulp is deemed vital, apexogenesis tech-
differ. The importance of careful case assessment niques can be attempted. A necrotic pulp condemns
and accurate pulpal diagnosis in the treatment the tooth to apexification. The two treatments differ,
of immature teeth with pulpal injury cannot be but share a final common goal: establishing in the
overemphatized. 109 Clinical assessment of pulpal apical region an anatomy that permits conventional
status requires a thorough history of subjective canal obturation without overfilling. 111
symptoms, careful clinical and radiographic
examination and performance of diagnostic tests. As
far as the radiographic examination is concerned, the APEXOGENESIS
clinician should remember that its interpretation can
be difficult. A radiolucent area normally surrounds "Apexogenesis" (Fig. 29.2) refers to a vital pulp the-
the developing open apex of an immature tooth with rapy whose goal is to preserve the vitality of the ra-
a healthy pulp. It may be difficult to differentiate dicular pulp, particularly the apical pulp, so as to al-
between this findings and a pathologic radiolucency low continued physiological development and forma-
resulting from a necrotic pulp. Comparison with tion of the root end, in particular the closure of the
the periapex of the contralateral tooth may be apex (Fig. 29.3).

Fig. 29.2. A, B. Schematic representation of the apexogenesis.

832 Endodontics

This treatment becomes necessary when the pulp is

exposed by caries or trauma (Fig. 29.4) or has irrever-
sible disease, while it is contained within a tooth with
a still-immature apex.
In addition to lacking the apical barrier, the tooth
with an immature apex presents a variety of problems,
including an unfavorable crown-to-root ratio and extre-
me thinness and fragility of the radicular walls. These
can complicate, if not preclude, normal endodontic the-
rapy and thus seriously compromise the prognosis.
When an immature apex is present, it is essential
to make every effort to try to maintain the vitality of
the radicular pulp, since the completion of root deve-
lopment and closure of the apex depend on the sur-
vival of the pulp tissue and the odontoblasts present
within it.
The goal of apexogenesis, as stated by Webber, 154
are as follows:
Fig. 29.3. Fragment of apex following apexogenesis. Note the new physiolo-
1. Sustaining a viable Hertwig's sheath, thus al-
gical apex that has formed within the diverging walls of the immature root lowing continued development of root length for a
(Courtesy of Dr. N. Perrini). more favorable crown-to-root ratio.
2. Maintaining pulpal vitality, thus allowing the
remaiming odontoblasts to lay down dentine, produ-
cing a thicker root and decreasing the chance of root

Fig.29.4.Apexogenesis of a traumatized upper left central incisor.A. Preoperative radiograph.B.The crown fracture has exposed the pulp.C.The exposed pulp as seen
at higher magnification. D. Pulpotomy has been performed. E. Calcium hydroxide (Stomidros) has been applied (continued).
29 - The treatment of teeth with immature apices 833

Fig. 29.4 (continued). F. With the placement of a cotton pellet, the access cavity has been sealed with oxyphosphate cement. G. Follow-up radiograph 15 months la-
ter. Closure of the apex and the formation of the dentin bridge are evident. H. Macroscopic appearance of the dentin bridge. I. Postoperative radiograph. L. Follow-
up radiograph 4 years later.

3. Promoting root end closure, thus creating a The same treatment can and must also be performed
natural apical constriction for root canal filling. in the posterior teeth, which in children are sometimes
4. Generating a dentinal bridge at the site of the affected by penetrating caries even before the develop-
pulpotomy. While the bridging is not essential for the ment of the root has been completed (Fig. 29.6).
success of the procedure, it does suggest that the pulp The treatment of choice are direct pulp capping and
has maintained its vitality. pulpotomy, for both the anterior and posterior teeth.
The teeth which require this therapy are usually Naturally, they must be performed only on pulp free
front teeth which have been subjected to trauma with of infection and still relatively healthy. In fact, they are
consequent exposure of the pulp at a time when the contraindicated when there are signs of infection of the
root still has not completely developed (Fig. 29.5). The radicular pulp and in the following circumstances: 1)
patients are therefore young; their ages range from 6 pulp necrosis, 2) a noxious odor at the opening of the
to 10 years . On average, the root completes its deve- pulp chamber, 3) the presence of spontaneous, throb-
lopment 3 to 4 years after the eruption of the tooth; 22 bing pain, 4) pain on percussion or palpation, and 5)
thus, even before examining the radiograph one can the presence of periapical radiographic changes.70
estimate the degree of development of the affected In anterior teeth pulpotomy is preferable to di-
tooth based on the patient's age. rect pulp capping, because its success rate is higher.
834 Endodontics




Fig. 29.5. Apexogenesis of a traumatized upper left central incisor. A. Preoperative radiograph. B. Three month recall. A certain narrowing of the apical zone, in addi-
tion to the formation of the dentin bridge, is evident. C. After 12 months, the maturation of the root is judged to be sufficient. The dentin bridge is demolished, and
pulpectomy is performed. D. Postoperative radiograph. E. Five year recall.
29 - The treatment of teeth with immature apices 835

Fig. 29.6.A.An upper left first molar has a deep carious lesion exposing the pulp and immature apices. B. Only 4 months after pulpotomy with calcium hydroxide,
the apices appear to be closed. C.The dentin bridge at the orifice of the palatal canal is visible through the access cavity. D. With the dentin bridge demolished,
pulpectomy is performed. Note the degree of maturation of the apex. E. One yea r recall.
836 Endodontics

Histologic examination on traumatized pulp showed Once the amputation is performed, the small pul-
that the depth of inflammatory reaction did not exce- pal and dentinal fragments are removed coronally to
ed 2 mm from the exposed surface within 48 hours. 42 the site of the pulpotomy. Bleeding is controlled with
Therefore, injured pulp can be successfully removed copious irrigations with saline solution or, even better,
leaving the non-inflammed pulp to reorganize. 19· 41 with an anesthetic solution.
Furthermore, in pulptomy, the dressing is placed wi- One must have the greatest respect for the residual
thin the confines of the pulp chamber, where it is pro- pulp stump, since the fate of the tooth hangs on it.
tected from the overlying cement base, so that the Caustic, irritating solutions must therefore be avoided
remaining pulp does not risk being recontaminated, in controlling the bleeding.
even if the temporary restoration is lost. With direct A sterile cotton pellet moistened with an anesthe-
pulp capping, the loss of the temporary restoration tic with a vasoconstrictor may be helpful if applied to
results in the loss of the dressing, resulting in pulpal the pulp stump for 2-3 minutes, as it accelerates clot
contamination and possible consequent failure .90 formation.
Once the bleeding has ceased, the pulp chamber is
carefully irrigated again and dried with sterile cotton pel-
Ai>EXOGENESIS WITH CALCIUM HYDROXIDE lets. The use of the surgical aspirator is contraindicated,
as it may displace the delicate newly-formed blood clot.
After having administered anesthesia and having Calcium hydroxide is then applied above the am-
applied the rubber dam, an access cavity is made in putated pulp in the form of a fairly thick paste of pu-
the conventional manner. re calcium hydroxide (Stomidros), mixed with distilled
Care must be used to minimize embedding of denti- water, saline solution or anesthetic. Alternatively, one
nal debris in remaining pulp tissues, as this will cause may use calcium hydroxide in a methylcellulose vehi-
further pulpal inflammation and dystrophic calcification. cle, which is available commercially in a ready-to-use
It is therefore advisable to use a copious spray of water form (Pulpdent).
and to reduce considerably the thickness of the dentin Although the literature 49 describes the use of self-har-
of the floor of the access cavity before penetrating the dening pastes of calcium hydroxide (Dycal), they should
pulp. 49 When supplemental anesthesia is called for, one be avoided in this author's opinion, because the harde-
can perform intraligamental anesthesia. Intrapulpal ane- ners in the paste may be toxic to the pulp tissue. It has
sthesia should be avoided, as this could cause the conta- been shown that the catalyzing resin (which contains a
minants in the coronal pulp tissue to be forced into the mixture of paraffin oil and a salicylate) has a toxic effect
radicular pulp, in addition to tissue laceration.90 on the pulp and can even cause necrosis. 57•120
Using a sterile, sharp spoon excavator or a large Using light pressure, the calcium hydroxide is ap-
diamond bur in such a way as to obtain the cleanest plied in a thickness of 1-2 mm and covered with a
cut possible, the pulp is then amputated to the level temporary cement (IRM), both to protect the pulp
of the cervical line in anterior teeth and to the level of against leakage of salivary contaminants around the
the orifices of the root canals in posterior teeth. final restoration and to provide a rigid base to the fi-
A long-shank spoon excavator is preferable to a nal restoration, which can be placed without subjec-
bur, as it allows more precise control in separating the ting the pulp to additional pressure. 49
coronal pulp from the radicular pulp. Nonetheless, in It is advisable to place the final restoration to avoid
anterior teeth, in which the pulp chamber is small and the risk of the temporary filling wearing away, with
in continuity with the root canal, a bur (preferably a consequent bacterial contamination and pulp necrosis.
high-speed diamond bur) may be necessary to remo- The patient must be followed at regular, three-month
ve the coronal portion of the pulp. One must leave as intervals to check the pulp vitality and the degree
much pulp tissue as possible within the canal, not just of apical closure. Depending on the degree of root
a small portion, to encourage maturation of the enti- maturation, follow-up may be required for variable
re root beside the closure of the apex. An immature periods ranging from 6-9 months to 2 years.
root is fragile and liable to fracture from occlusal for- In general, by the second or third follow-up visit, it
ces alone. 91 Furthermore, the more apical the level of will be possible to document radiographically the for-
the amputation, the more apical the formation of the mation of a dentin bridge between the calcium hydro-
dentin bridge, and therefore the more difficult its de- xide and the pulp stump, lengthening of the root with
molition if root canal therapy becomes necessary. thickening of its walls, and initial closure of the apex.
29 - The treatment of teeth with immature apices 837

Fibroblasts adjacent to the pulp exposure (Fig. 29.7) stump take part in lengthening of the root, thickening
and undifferentiated mesenchymal cells that differen- of its walls, and closure of the apex.
tiate into odontoblasts or osteoblasts, initiating the de- Once the root apex is formed and the den-
position of hard tissue, participate in the construction tin bridge is clearly evident, according to many au-
of the dentin bridge. 58 The odontoblasts in the pulp thors ,61,68,101,121,155 routine endodontic therapy must be
initiated (Fig. 29.8).

Fig. 29.7. Histologic section of a dentin bridge with a tubular structure ma-
de of newly-formed odontoblasts. The underlying pulp is vital (Courtesy of
Dr. N. Perrini).

Fig. 29.8. Apexogenesis of a traumatized upper right central incisor. A. Preoperative ra-
diograph. A periodontal dressing had been applied as an emergency treatment after the
trauma! B.The fractured crown.C.After 6 months, the dentin bridge has formed; more no-
tably, the apex has matured. Note the degree of closure of the apical fora men as compa-
red to the adjacent tooth: apexogenesis is associated with more rapid maturation of the
roots than physiological processes alone. D. Macroscopic appearance of the dentin brid-
ge (continued).
838 Endodontics

Fig.29.8 (continued).E.lntraoperative radiograph of the apical compaction:the root was wrongly judged to be mature,and the gutta-percha cone has slipped beyond
the apex. F.The original coronal fragment, which was preserved for the entire time in saline solution. G, H. Re-apposition of the fragment. The enamel has been beve-
led without touching the dentin, not to jeopardize the joint. I. Appearance of the tooth at completion of restoration. L. Six year reca ll: the growth and closure of the
apex has progressed above the gutta-percha cone, which now no longer protrudes into the periodontium, but is entirely wrapped by the root apex.

Following anesthesia and isolation of the field with the exposure. 21 .113·156
the rubber dam, the access cavity is made and the Microscopic examination of this structure reveals
dentin bridge is demolished for pulpectomy, cleaning the presence of porosities; 67·97·153 thus, the underlying
and shaping of the root canal(s), and for their obtura- pulp is not completely isolated from the restorative
tion with the traditional techniques. materials or from the risk of bacterial contamination.
The presence of a dentin bridge is not necessa- The pulp stump remaining in the canal can cause in-
rily an indication of pulp health or vitality 101 (Fig. ternal resorption or complete calcification of the ca-
29.9); likewise, its absence does not indicate failure.131 nal.106 It may also become chronically inflamed and
Indeed, pulpotomy is sometimes followed by success necrotic. 121 If the last two processes do not significan-
even without the formation of a dentin bridge above tly compromise the prognosis, the calcification or re-
29 - The treatment of teeth with immature apices 839

Fig. 29.9. A, B. Histologic section of a lower molar following pulpotomy

with calcium hydroxide. The dentin bridge has formed, but the under-
lying pulp reveals signs of chronic pulpitis and partial necrosis. C. The
pulp beneath this dentin bridge is comp letely atrophic (Courtesy of Dr.

sorption can be so extensive as to make endodontic and root canal obturation) must be initiated once the
treatment either very risky, impossible or useless. pulpotomy has served its purpose (Fig. 29.10).
For these reasons, once the apical closure has Not all authors agree on the need to intervene en-
occurred and the root has matured, and once the pulp dodontically just when the apex closes. In fact, so-
and its odontoblasts have accomplished their primary, me feel that vital tissue may be left within the root ca-
formative function of completing the development and nal for a long period, possibly for ever. 43 They believe
formation of the root, leaving the pulp within the root that endodontic treatment is indicated only if pulpitis
canal only constitutes a large risk that is not worth or necrosis develops, 49 or if a canal post is required to
taking in modern practice. restore the dental crown prosthetically. 1s,9o
One must not forget that the young patients who re-
quire this therapy in one of their front teeth as a conse-
quence of trauma often experience further trauma, pos- THE ROLE OF CALCIUM HYDROXIDE
sibly in the same tooth, with further pulp injury. In adul-
thood, prosthetic restoration of the tooth with a porce- Calcium hydroxide has been for many years the
lain crown and a post and core may become necessary. agent of choice in apexogenesis. 122 It has antibacterial
Thus, endodontic treatment is required, even if for activity 26 •57 and seems to function very effectively.
only prosthetic reasons. 15 If endodontic treatment is Its precise mechanism of action, however, is still
not performed when the patient was 10 or 11 years unknown. 121
of age, it may be extremely difficult, if not impossible, It is known that calcium ions liberated in the area
to do so when he/she is 18 years old. For this reason, of the pulp exposure by the calcium hydroxide su-
pulpotomy with calcium hydroxide performed during spension are not incorporated into the dentin brid-
apexogenesis should be used as a temporary therapy, ge . Radioisotope studies have shown that the calcium
and the definitive endodontic therapy (pulpectomy ions of the dentin bridge do not derive from the cal-
840 Endodontics

Fig. 29.10. A. Preoperative radiograph of a traumatized upper right central incisor. B. At the
9 month recall the dentin bridge and closure of the apex are evident. C. Macroscopic ap-
pearance of the dentin bridge. D. Postoperative radiograph.

cium hydroxide applied, but from the systemic circu- formation of the dentin bridge do not depend uni-
lation and vessels of the pulp stump. 11 •11 9 quely on the presence of calcium hydroxide and its
Calcium hydroxide may induce superficial coagula- medicinal power. In the literature, similar results have
tive necrosis in the pulp tissue with which it comes in- been reported with other substances: tricalcium pho-
to contact. 116 With its basic pH, it maintains an alkali- sphate,79 dentin shavings, 9 alkaline phosphatase,121
ne environment, which is necessary for the formation calcium hydroxide combined with corticosteroids 55
of bone and dentin. 121 Below this area of coagulative or methacresylacetate, 62 formocresol mixed with zinc
necrosis induced by calcium hydroxide and saturated oxide, 155 and zinc-oxide eugenol. 63•151
with calcium ions, undifferentiated mesenchymal cells Calcium hydroxide in an aqueous or methylcellulo-
differentiate into odontoblasts 117 or osteoblasts 82 and se vehicle as been the medication of choice for many
begin to produce the matrix 35 on which calcium ions years because of its high rate of positive results, ease
from the systemic circulation then deposit until it forms of use, and availability but it doesn't make miracles.
this dentinal or osteodentinal structure. As stated already, it is absolutely necessary to check
Nonetheless, the vitality of the pulp stump and the these young patients at regular, three-month intervals
29 - The treatment of teeth with immature apices 841

with clinical and radiographic examinations. If failure de separates into calcium and hydroxide ions, resulting
occurs, if the pulp becomes necrotic, or if signs or in increased pH and calcium ions release. Calcium ions
symptoms develop (i.e., pain, abscess, or fistula) may cross the cell membrane by depolarization or acti-
apexification must be pursued. vation of membrane-bound calcium channels, therefo-
re, it is likely that this ion would play a greater role in
the reparative process than would the hydroxyl ion.81
APEXOGENESIS WITH MINERAL TRIOXIDE AGGREGATE In conclusion, calcium ions are necessary for the diffe-
rentiation and mineralization of pulp cells. 115
Data from pulp capping experiments suggest that ini- For all the above reasons, MTA is today considered
tiation of reparative dentin formation occurs not becau- the material of choice to maintain the pulp vitality, es-
se of specific dentinogenic effect of calcium hydroxi- pecially when treating vital teeth with immature api-
de but because of its controlling infection and stimu- ces, so that normal root development can occur. 158 By
lating the wound healing process.83 In addition, it is maintaining pulp vitality, apexogenesis can occur. 97.I 24
well known that when further bacterial contamination This is the preferred treatment, because it promotes
is prevented with a biocompatible material, the expo- healing by regeneration rather than repair.
sed pulp has the capacity to maintain vitality and build Depending on different situations, both therapy are
a new dentin bridge.107•127 valid, direct pulp capping and pulpotomy. 160 Direct
A number of new agents have been introduced du- pulp capping involves the disinfection and protection
ring recent years.105 Of these, mineral trioxide aggrega- of the exposed pulp tissue, while pulpotomy involves
te (MTA), introduced by Torabinejad and colleagues at the surgical removal of a portion of an affected vital
Loma Linda University, has become the widely prefer- coronal pulp tissue, leaving the radicular tissue in situ
red material to use in contact with vital tissue to promo- to allow for normal root development.
te healing and has been suggested to have more pre- The operative sequence for pulp capping has been
dictable effects in pulp capping than previously used described in Chapter 7. The operative sequence for
materials. 1•3•51 •108,152 According to these studies, the pulp pulpotomy is the same as described for the use of cal-
responds favorably to the protection by a MTA layer cium hydroxide.
and the reparative dentin is consistently thicker and mo- If one considers all the physical and biological pro-
re uniform under MTA compared with calcium hydro- perties, like biocompatibility, antibacterial effect, alka-
xide. Dominguez et al. 45 demonstrated that when MTA linity, and the sealing property of MTA, compared to
is used for direct pulp capping, it shows better interac- the caustic actions of calcium hydroxide and to its to-
tion with dental pulp tissue than did calcium hydroxi- xicity to cells in tissue culture,75 then one can easily
de. MTA has been shown to induce less pulp inflamma- come to the following conclusion: the main difference
tion and more dentin bridge formation compared with between MTA and calcium hydroxide is that using the
calcium hydroxide cement. 51 It has been speculated first, there is no need to proceed with the pulpectomy
that hard tissue stimulation may occur because of the after the apexogenesis has been completed. The pulp
biocompatibility, sealing properties and the alkalinity of remains vital, responds normally to the vitality tests
MTA. 83 Cox et al. 40 have shown that pulp healing is mo- and radiographically shows no sign of inflammation,
re dependent on the capacity of the capping material to calcification or resorption (Fig. 7.26).
prevent bacterial microleakage rather than the specific Of course the clinician should also take into conside-
properties of the material itself. Therefore, if a tight seal ration the fact that so far, only case reports have been
is achieved and a reasonable material is selected, matu- published, with promising results achieved when MTA
re dental pulp possesses the ability to differentiate into was used for vital pulp therapy, root end closure and ·
the specific cell lineage forming tubular dentine. 125 perforation repair. No clinical studies have yet evalua-
Many in vivo and in vitro studies have repor- ted the long term success rate of using MTA. Therefore,
ted the superior physical and biological properties of because MTA is a relatively new material, it is necessary
MTA. 51 •108•152 In an ex vivo study, MTA showed to release to recall treated patients on a regular basis to determi-
a number of calcium ions significantly higher compare ne if treatment has been successful, or if pulpectomy or
to calcium hydroxide and consequently MTA was able apexification is needed. If it is determined that the pulp
to stimulate a higher proliferation of cells.132 MTA is rich has become irreversibly inflamed or necrotic, or if in-
in calcium oxide, which is converted to calcium hydro- ternal resorption is evident, the pulp should be extirpa-
xide on contact with tissue fluid. The calcium hydroxi- ted and apexification therapy initiated. 109
842 Endodontics

APEXIFICATION Instead of retrofilling, some authors at that time sug-

gested overfilling of the root canal, followed by peria-
"Apexification" refers to a form of therapy of teeth pical curettage. In all cases, however, an unfavorable
with immature apices and necrotic pulp whose aim crown-root ratio resulted.
is to induce the formation of a calcific barrier at the Furthermore, teeth with immature apices were ve-
open apex against which the conventional obturating ry often found in very young patients, who were ap-
materials may be condensed without overfilling. The prehensive and fearful of the dentist. Because of their
death of pulp in an immature tooth causes premature poor cooperation, they were not ideal candidates for
arrest of normal root growth, leaving an open apex. a surgical procedure.
Prior to the advent of this technique, cases of apex In spite of the fact that there are some authors 74 who
closure following normal endodontic therapy in teeth even today consider the tooth with necrotic pulp and
with necrotic pulp and divergent canal walls were de- an immature apex to be an indication for retrograde en-
scribed. They were relatively infrequent, however, be- dodontic treatment, the vast majority agree that apexifi-
cause of the understandable difficulty in achieving a cation is the treatment of choice in these cases.
good direct apical seal in cases with inverted anatomy. Among the first descriptions of growth of the root and
Very often, the therapy of these teeth was surgical, closure of the apex in the course of treatment of open
with the anatomical and psychological implications of apices are those of Cooke and Rowbotham 37 in 1960.
such a procedure. 15•16 They noted these favorable results following treatment
The tooth with an immature apex has extremely thin, with an antiseptic paste used as a temporary root canal
fragile walls surrounding a very wide canal (Fig. 29.11). filling material until the tooth could be subjected to api-
Consequently, an enormous amount of amalgam was coectomy (when the patient reached 15 or 16 years of
introduced into a cavity with extremely weak walls, age) or until it was extracted and prosthetically replaced.
with a high risk of fracture. 6 The surgically-treated ca- Interval radiographs demonstrated that growth and matu-
ses often failed because the fragile canal walls permit- ration of the root had occun-ed in many cases, so much
ted neither the preparation of an undercut - and thus of so as to obviate surgical intervention because canal obtu-
a retentive cavity - nor the application of the pressure ration could be performed with conventional techniques.
necessary for the condensation of the amalgam, so that This fortuitous observation led to the abandonment of the
it was often impossible to obtain a good apical seal. 25 surgical approach and raised the possibility of allowing
indefinite preservation of the health of teeth that previou-
sly had been considered to have a very poor prognosis.
The growth of the root and the closure of the apex
were correctly interpreted as evidence of the persistence
and function of Hertwig's epithelial root sheath, which
had remained intact and ready to resume its function
once the infection was removed.
Another advance in the therapy of teeth with ne-
crotic pulp and immature apices came in 1966 when
Frank, 60 starting from the fortuitous results of his pre-
decessors, introduced and first described the proce-
dure of apexification using calcium hydroxide (Fig.
29.12). Like the previous authors, Frank also recom-
mended reducing as much as possible the contami-
nants present within the root canal w ith precise instru-
mentation and canal irrigations and temporarily filling
the endodontic space with a resorbable paste.
In contrast to the preceding authors, though, Frank
recommended the substitution of resorbable paste
with a filling material (e.g. , gutta-percha) that can as-
sure a permanent seal, as soon as closure of the apex
Fig. 29.11. An upper first premolar with immature apices. Note the thinness has occurred, to prevent the possible recurrence of
and fragility of the roots. periapical pathosis
29 - The treatment of teeth with immature apices 843

with ultrasonic files can be useful to this end.z9

The goal of this phase is the complete removal of
the necrotic pulp debris, infected dentin, and tissue
degradation products so as to inhibit the periapical
inflammation and bony resorption and to initiate the
healing process.
Once the cleaning phase has concluded, the root
canal is ready to receive the temporary dressing, cal-
cium hydroxide.
If on the first visit the patient presents with signs
and symptoms of acute inflammation, it is advisable
to wait until they have resolved before proceeding
with filling of the canal. One may even elect to lea-
ve the tooth open for several days for drainage, if ne-
Calcium hydroxide in a methylcellulose vehicle,
which is commercially available in the form of ready-
to-use sterile syringes [Pulpdent (Fig. 29.13A)], may be
used; alternatively, a paste may be prepared by mixing
powdered pure calcium hydroxide (Stomidros) with
Fig. 29.12. Schematic representation of apexification. distilled water or a saline solution (Fig. 29.13B).


During apexification, one must improve the intra-

canal environment through total removal of the toxic
substances present in the pulp chamber and root ca- t>Ut.P(U I N T
j;>Ut.P CAPP, .... r, Pjll,.TJ; IIIYUI NO• ..:n
nal, maximally respecting any apical pulp tissue that,
if still present and vital, might participate in the closu-
re of the immature apex.
Following isolation of the field with the rubber
dam, the access cavity is created in the traditional
manner without the use of anesthesia, since the tooth
has a necrotic pulp. The root canal is then irriga-
ted generously with sodium hypochlorite and the
working length is radiographically determined. This
must be about 2 mm short of the radiographic apex,
so as not to damage any apical pulp tissue that may
be present. Examining the radiograph with the first
file inserted, one must confirm that the instrument
advances no further than the flaring of the radicu-
lar walls (Fig. 29.17B). The instrumentation must be
performed with large Hedstroem files , working them
circumferentially, so that the instruments make con-
tact with as large a surface area of the canal walls as
The walls of these canals are particularly thin and
fragile; therefore, the instruments must be used very
delicately. These canals only need to be cleaned and Fig. 29.13. A. Calcium hydroxide in a methylcellulose vehicle (Pulpdent). B.
not necessarily to be shaped. Cleaning the canal walls Pure calcium hydroxide (Stomidros).
844 Endodontics

The first is a fairly creamy paste that must be in- gular, three-month intetvals until closure of the apex is
troduced in the canal with a Lentulo's spiral, which evidenced on the radiograph. According to Finucane et
however does not ensure good control of the depth al.54 the main factor influencing the time for an apical
of introduction. barrier to form is the rate of change of calcium hydro-
With the second, which is definitely preferable, one xide dressing: in his study the barrier was formed more
can obtain a mixture of greater consistency that can rapidly in cases where the dressing was replaced mo-
be compacted within the root canal with pluggers, af- re frequently. At this point (generally speaking, 9-12
ter it has been introduced with a Messing gun.15·91 This months after the initiation of therapy,72 but sometimes
method is associated with better filling, and it is easier to as many as 2 years 25), after having removed the cal-
avoid extrusion of material beyond the apex. This does cium hydroxide from the root canal, the presence and
not compromise the prognosis, because it is a resorbable consistency of the apical closure are tested.
material; however, overfilling may cause an acute inflam- To do so, many authors recommend a file.3o,49,6o,6s,71
matory reaction, since calcium hydroxide is a non-speci- In this author's opinion, use of a file entails the risk
fic irritant 130 which causes immediate coagulative necro- of injuring the precious barrier that in the meantime has
sis when it comes into contact with periapical tissues.8 formed and also does not provide all the needed infor-
The canal must be filled to the level of the previous mation. A sterile paper point (# 4 or size medium) is
instrumentation, that is, about 2 mm from the radio- preferred. Applied carefully to the apex, it provides in-
graphic apex. The excess calcium hydroxide is then formation about the presence of the barrier without per-
removed from the pulp chamber and from the mar- forating it. Furthermore, it informs whether the barrier is
gins of the access cavity, after which it is sealed with complete, that is, whether it extends the entire circumfe-
a temporary cement (IRM) with a sterile cotton pellet rence of the apex. It must issue from the canal comple-
in the pulp chamber. This ensures the integrity of the tely d1y, not moistened by periapical fluids or blood.
coronal seal until the next appointment. If at some point the paper point sinks more, irri-
There is disagreement in the literature about the ap- tating the patient, and issues moist or soaked with
propriate time interval for the follow-up visit. Some au- blood, the barrier has still not completely developed,
thors 47 suggest re-opening the canal every 3-6 months, and there is still the risk of overfilling. In this situation,
others 30 only in the presence of symptoms; yet others 104 it is advisable to replace the calcium hydroxide and
suggest substituting the calcium hydroxide only if there wait another three months. When on one of the seve-
are empty spaces or if the paste appears radiographically ral check-ups the paper point issues completely dry
less dense. Some 33 even suggest emptying the canal only and clean, this is the best proof that the canal is ready
to confirm the existence of the calcific barrier. Chosack to be obturated with the traditional techniques.
et al.36 in an in vivo study on monkeys demonstrated that As already suggested, the time required for forma-
after the initial root filling with calcium hydroxide there tion of the barrier is on average 9 months. This depends
was nothing to be gained by repeated root filling either solely on the width of the apical opening; it is inde-
monthly or after 3 months, for at least 6 months. pendent of the patient's age and the preoperative pre-
Each technique has its merits. However, this author sence or absence of inflammation. 161The apical barrier
agrees with Kleier and Barr 86 and numerous other au- can also form prior to the resolution of the periapical
thors 59·161 that after three months one must check the radiolucency, which can also require several years.86
condition of the soft tissues and the integrity of the In this author's clinical experience, the closure of
temporary coronal seal, as well as the radiopacity of such apices occurs more quickly in children and pro-
the root canal and the degree of apical closure. gressively slower as one progresses to adolescence and
Because calcium hydroxide is resorbable, it may ha- adulthood. Considering that in the vast majority of cases
ve been removed by the fluids of the periapical tissues the patients subjected to apexification are children, one
during this time interval. question that is often asked of orthodontists is whether
If the canal appears emptier than in the postopera- orthodontic therapy is compatible with the formation
tive radiograph of 3 months earlier, the rubber dam of the apical barrier. Antony 10 states that the two treat-
must be repositioned and all the steps of the first vi- ments can be confidently performed simultaneously in
sit must be repeated: irrigate the root canal, re-check the same young patient, since there is no contraindica-
the working length, and dry and re-fill the canal with tion. Indeed, documented cases of apexification in the
a dense mixture of calcium hydroxide. literature indicate a successful outcome when perfor-
The patient is then discharged and re-checked at re- med concomitantly with orthodontic therapy.
29 - The treatment of teeth with immature apices 845

TYPES OF APICAL CLOSURE toblasts and thus continue the development of the root
Depending on whether Hertwig's epithelial root sheath In the other two more frequent cases, there is no in-
or residual apical pulp is present, Frank 60 and more crease of the length of the root, which radiographically
recently Feiglin 52 list four types of apical closure: appears shorter and stockier than normal, since the api-
1) If the root sheath is still present in its entirety cal calcification grows and develops horizontally rather
and if there are still odontoblasts in the most apical than vertically. In these teeth, the absence of Hertwig's
portion of the root - namely, the level of the flaring - root sheath has been histologically demonstrated. 48
(Andreasen 7 states that pulp necrosis in developing According to Finucane et al.54 the location of the
teeth is often limited to the most coronal portion of apical barrier (at the radiographic apex or one or more
the pulp, while the most apical portion preserves its millimeters coronal to the apex) depends on the number
vitality) physiological closure of the apex occurs: the of placements of calcium hydroxide dressing. They stated
root elongates, the canal narrows, and the walls thi- that if calcium hydroxide is not replaced often enough,
cken (Fig. 29.14). This is the preferred outcome; un- its dissolution from the apical area would create a void
fortunately, it is not the most frequent. In this case, thus allowing ingrowth of tissue and increasing the
the pulp necrosis has not involved the extreme apical likelihood that the barrier formed is coronal to the apex.
portion where the odontoblasts, which are responsi- The level of formation of the apical barrier seems to
ble for this type of apical maturation, were still pre- depend also from the level where the dressing is placed
sent. Evidently, the episode of trauma that caused the inside the root canal. Webber 154 states that it is important
pulp necrosis is very recent, and our intervention was for the calcium hydroxide to contact the periapical tissues
timely. One can understand once again the importan- and that when the calcified barrier occurs, it most likely
ce of not disturbing with the endodontic instruments forms at the level of the termination of the paste
the tissue that may be present at the level of the radi- From a clinical point of view, the calcific barrier is
cular flaring (Fig. 29.15). very useful and more than sufficient for one's purpo-
2) If Hertwig's root sheath is still present, but the ses, as it provides an optimal barrier against which the
odontoblasts within the root canal have all been lost, permanent filling material can be directly compacted.
vertical growth of the root and the formation of an ap-
parently physiological apex occur without any nar-
rowing of the root canal (Figs. 29.16, 29.17). HISTOLOGY OF THE APICAL BARRIER
3) If Hertwig's root sheath no longer exists becau-
se it has been destroyed, a barrier of hard, calcific tis- Numerous studies 50•74•87•103•110•128 have examined the
sue develops, possibly at the radiographic apex (Figs. histologic nature and appearance of this "apical bri-
29.18, 29.19). dge" (Fig. 29.23). It is constituted of a cementum or
4) The same calcific barrier can form in a site sli- osteoid tissue, which is variously described as bone,147
ghtly coronal to the apex (Figs. 29.20, 29.21). dentin, osteodentin, 48 or cementum. 5•128
In the first two cases, the cells responsible for fur- In appearance, the barrier is discontinuous, 68
ther growth (i.e., odontoblasts and cementoblasts) de- inasmuch as it has numerous porosities that contain
rive from the undifferentiated mesenchymal tissue un- soft tissue. The necrosis and degredation products
der the influence of the present and vital Hertwig's arising from this tissue could be the cause of failure
epithelial root sheath 25 (Fig. 29.22). The induction of which, in the long term, can occur in some cases after
formation of dentin, the shape of the tooth's root, and the canal has been filled and the case completed. 49
then the deposition of cementum on the root surfa- For this reason, apexification must always be followed
ce from the surrounding mesenchyme depend on the by a permanent gutta-percha root canal obturation.30
root sheath 134 (see Chapter 2).
It appears that Hertwig's root sheath is fairly resistant
to trauma and infection and can remain intact for as THE ROLE OF CALCIUM HYDROXIDE
much as one year or longer.5•111 On the other hand, the
mesenchymal cells of the periapical region of a trau- It is once more necessary to emphasize that calcium
matized immature tooth preserve their pluripotentiality. hydroxide is the medication of choice in the therapy of
Under the organizing influence of the root sheath, they teeth with immature apices because of its availability,
can differentiate into fibroblasts, cementoblasts, or odon- ·1· ant1m1cro
ease o f use, resorb ab11ty, . . b"1a1 act"1v1'ty ,16·32·46
846 Endodontics

Fig. 29.14. Frank's Type I apical closure: physiological closure of the canal and apex to a normal configura-

Fig.29.15.Apexification of a traumatized up-

per left central incisor. A Preoperative radio-
graph. B. Obturation of the canal with cal-
cium hydroxide. The filling is not complete,
but this does not compromise the final re-
suit. C. Follow-up radiograph 3 months later:
with the calcium hydroxide removed, one
better appreciates the physiological closu-
re of the apex. D. Postoperative radiograph.
E.Two year recall.

29 - The treatment of teeth with immature apices 847

Fig. 29.16. Frank's Type II apical closure: the apex has closed, but the canal retains its "blunderbuss" shape.

Fig. 29.17. Apexification of a traumatized lower first premolar. A. Preoperative ra-

diograph. B. lntraoperative radiograph: the file is working as far as the begin-
ning of the canal flaring. C. The canal has been filled with calcium hydroxide. D.
Six months later, the lesion has healed, but the apex is still not well-closed. E. At
12 months, the apex appears to be closed. The therapy proceeded with obtura-
tion. F. Postoperative radiograph. G. Three year recall. Note the "blunderbuss" sha-
pe of the canal.
848 Endodontics

Fig. 29.18. Frank's Type Ill apical closure: no radiographic change is noted, but a thin osteoid or cementum
barrier provides an optimal barrier at the level of the apex or in its immediate vicinity.

Fig. 29.19. Apexification of a lower left first premolar requiring retreatment in a patient with Gori in-Golz Syndrome (see Fig. 7.21). A. Preoperative radiograph. B. Follow-
up radiograph 2 years after the beginning of therapy with calcium hydroxide. In the distal zone, which is edentulous because of agenesisof the second premolar, a kera-
tocyst is developing. C. Follow-up radiograph 4 years later:the keratocyst has been surgically removed, and the apex finally seemsto be closed. D. Radiograph of the co-
ne fit.The cone has been prepared by rolling several warmed cones with a small spatula on a glass plate. E.Postoperative radiograph. F. Eighteen month recall.
29 - The treatment of teeth with immature apices 849

Fig. 29.20. Frank's Type IV apical closure: a barrier forms coronally to the apex.

Fig. 29.21. Apexification of a traumatized upper left central incisor. A. Preoperative radiograph. 8. The file is cleaning the canal, working about 2 mm short of the end
of the canal walls. C. Follow-up radiograph 9 months later: the apical barrier is evident. D. Postoperative radiograph. E.Two year recall.
850 Endodontics

Fig. 29.22. Hertwig's horizontal epithelial root sheath.

and physico-chemical properties, but the formation of

the apical barrier is not related to its presence.
In fact, calcium hydroxide is not the only material
that has been used and yielded positive results. In the
literature, the use of calcium hydroxide mixed with B
camphorated paramonochlorophenol, 60 of tricalcium
Fig. 29.23. A. Histologic appearance of an apical barrier made of cementum.
phosphate,87 of a collagen-calcium phosphate gel,103 Note the porous appearance of the structure. B. Cementum apical barrier fol-
of an antiseptic paste containing zinc oxide and euge- lowing apexification.Though more compacted, it still has porosities (Courtesy
of Dr. N. Perrini).
nol,37·80 of an antibiotic paste,12 and of iodoform paste
24 have been described.
Even though the closure of the apex occurs with
these and many other materials, a successful outcome
of this therapy has also been reported in the absence
of any treatment or obturation material within the root
canal after the simple removal of the necrotic pulp tis-
sue.14·23·34·44·49·50·100·114·148 As already emphasized by Frank cently Whittle 159 have described cases in which the api-
in 1966, this confirms that the most important factor cal portion of immature, traumatized, subluxated, or re-
in obtaining apexification is total cleansing of the root planted teeth have completed the apical closure, not
canal system (namely, the removal of all necrotic pulp only without the benefit of calcium hydroxide, but even
tissue) and its three-dimensional filling. without any type of endodontic treatment (auto-apexi-
The improvement of the canal and apical environ- fication) (Fig. 29.24). This was probably due to the re-
ment allows the interrupted process of root develop- tention of odontogenic cells in the apical portion of the
ment and apical closure to once again continue.61 Safi pulp that remained vital and active. The good blood
and Ravanshad 112 recently showed a case of apical root- supply that characterizes young permanent teeth could
end completion following trauma and subsequent root be responsible for the permanence of these odonto-
canal treatment, similar to the one showed in figs 29.8. In genic structures that could have been involved in the
similar cases, despite the loss of pulp vitality, apical root apexification of these traumatized teeth.
formation continued, probably because of residual odon- At the present time, calcium hydroxide remains the
togenic cells of the apical portion of the pulp, including material of choice in apexification. Combining it with
Hertwig's root sheath that remained vital and active. other antibacterial substances seems pointless, since cal-
To further confirm how secondary the role of cal- cium hydroxide itself has potent bactericidal activity 86,126
cium hydroxide is, Barker and Mayne 14 and more re- and keeps its antimicrobial activity for several weeks. 28
29 - The treatment of teeth with immature apices 851

gutta-percha cones together and modeling them with a

warm spatula on a glass plate (Fig. 29.25), until the co-
ne enters the canal with the appropriate "tug-back."
Kerezoudis et al. 84 suggest to plasticize the end
point of the primary gutta-percha cone with a heated
instrument and then to insert it into the root canal to
record the internal morphology of the apical portion.
Once the apical 2-3 mm of the master cone have ir-
regularities which seem to reflect the morphology of
the root canal, then a sealer is placed into the canal
and the master cone is inserted very gently to be com-
pacted in the traditional manner.
Another variant is the use of an inverted cone (Fig.
29.26), which requires the introduction of the gutta-
percha cone with its base facing the apex and the tip
Fig. 29.24. A, B. The two upper central incisors experienced trauma 6 years be- facing the access cavity.
fore. In spite of the pulp necrosis, the lesions of endodontic origin, and arre-
sted root development, the apices of both teeth are visible. An alternative to the Schilder technique has been
suggested by some authors 71 •114 who use thermopla-
stic gutta-percha which, in this author's opinion also, is
TECHNIQUES OF 0BTURATION best indicated for the obturation of teeth with immatu-
re apices after the apical closure (Fig. 29.27). If the bar-
The literature contains descriptions of various techni- rier is well-formed, as it should be, there is no risk of
ques of obturating these canals once the apical barrier overfilling. It is advisable to perform the filling of the
has formed. Obviously, preference must be given to canal with two or three successive introductions of gut-
the techniques that require the use of gutta-percha, of ta-percha (Fig. 29.28), as a single introduction would
which the preferred is undoubtedly the Schilder techni- leave voids. The gutta-percha introduced at each phase
que of vertical compaction of warm gutta percha. should be compacted, re-heated with the heat carrier,
In the application of this technique, several and re-compacted with the aim of preventing the gutta-
difficulties may present during the phase of the cone percha cooling within the canal from shrinking, leaving
fit, since the canal is very wide and has almost parallel empty spaces in the process (see Chapter 23).
walls, while the large-size cones that are available
have a very conical shape.
In these cases, it is advisable to adapt a cone to the APICAL BARRIER TECHNIQUE
canal shape in question by simply rolling two or more
Despite the clinical success of the calcium hydro-
xide apexification technique since it was first descri-
bed, there are some disadvantages. 73 We can expect
more than one type of apical closure and it is un-
predictable . Sometimes the time necessary to get to
the final result is very long and if one is treating an
adult patient, it might take forever, still without any
result. The treatment requires multiple appointments
for reapplication of calcium hydroxide or at least to
check its presence inside the root canal and the time
interval between visits is at least three months.
This may lead to the loss of the coronal seal
with consequent recontamination and exposure of
the healing tissues to bacteria, then acute exacerba-
tion and delayed healing response may occur. For
Fig. 29.25.A large gutta-percha cone can be custom-made by rolling 2 or 3 co- all these reasons, from several years many authors
nes on a glass plate with a warm spatula. felt the need to obturate the teeth with open apices
852 Endodontics

Fig. 29.26. Inverted cone technique for warm gutta-percha obturation of the canal after apexification. A. Preoperative radiograph. B. Depth of instrumentation. C.
Fitting the "inverted" cone. D. Postoperative radiograph. E.Two year recall.
29 - The treatment of teeth with immature apices 853

Fig. 29.27. Obturation of the canal, after apexification, using thermoplastic gutta-percha (Obtura). A. Preoperative radiograph. B. Follow-up radiograph 2 years later:
the lesion has healed, and the apex has closed. C. The needle of the Obtura syringe contacts the calcific apical barrier. D.Three year recall.

Fig. 29.28. Sectional technique of obturation with thermoplastic gutta-percha (Obtura) of an upper left central incisor following apexification. A. Preoperative radio-
graph.B.The follow-up radiograph 1 year later demonstrates the presence of the calcific barrier.C. A small amount of thermoplastic gutta-percha has been placed in
contact with the apical barrier.After being compacted, heated with the heat carrier and compacted again, it is checked radiographically. D. The obturation has been
completed with thermoplastic gutta-percha. E.Two year recall.
854 Endodontics

without inducing a natural apical barrier. Actually,

the concept of obturating teeth with immature api-
ces without first acquiring a natural apical barrier is
not new: several investigators 47·64 ·101·129 have likewi-
se indicated that success is attainable without first
inducing an apical barrier with repeated applica-
tions of calcium hydroxide. On the other hand, the
predictability of treatment time necessary for indu-
ced apical closure in pulpless teeth in humans has
not been estabilished.38,110
The apex should be viewed as a dynamic region,
capable of self repair. 101·162 Occasional instances of
continued root growth and apical closure in the pre-
sence of a periapical rarefaction are explained on the
basis of vital tissue remnants. 20 A procedure that requi-
res multiple appointments involving frequent dressing
changes and instrumentation may tend to cause injury
to tissue rather than healing. Tissue within and coro-
nal to a calcifying barrier seems destined to succumb
to the irritation of these dressing changes and to the
final filling procedure. 149,150
For all the above mentioned reasons, and taking
into consideration the previous study of Koenigs 87
and Roberts et al. 110 in 1974, Coviello and Brilliant
39 in 1979 and Harbert in 1996 76 suggested a one-
appointment procedure for obturating permanent teeth
with non vital pulps and open apices, using tricalcium
phosphate as an immediate apical barrier against
which gutta-percha could be condensed. In their study,
they found no statistical difference between the multi-
appointment and the one-appointment technique; Fig. 29.29. A. Maxillary central incisor with dead pulp and immature apical
they had no overfilling among teeth treated with anatomy. B. Immediate postoperative film showing ideal gutta-percha fill
against bone graft matrix. C. Ten year recall film showing slight root end
the one-appointment technique; the procedure was maturation and ideal periradicular bone pattern (Courtesy of Dr. Stephen
extremely faster; less radiographs were required, with Buchanan).
consequent less discomfort for the patient; finally, the
results were always predictable. 39 Goodell et al. 69 in an red to calcium hydroxide and to the osteogenic pro-
in vitro study demonstrated that teeth with an apical tein-1, MTA induces the same amount of apical hard
barrier of calcium phosphate cement had significantly tissue formation, without any inflammation.123 Other
less leakage than teeth without any apical barrier. studies demonstrated the newly formed bone, perio-
Buchanan 27 in 1996 suggested the use of freeze- dontal ligament and cementum in direct contact with
dried demineralized bone to be packed to the end of MTA. 136,143 Therefore, because it provides a good api-
the immature root canal to create a one-visit biocom- cal seal (better than amalgam, IRM, and Super EBA),2
patible apical matrix. The use of an operating micro- ,4,18,56,95,102,133,136,144-146,16o because of its antimicrobial pro-
scope in such cases was extremely helpful, if not man- perties,139 because it is highly biocompatible, 85·88·89,m-
dato1y , to literally see down the canal walls to the pe- 139·142,143 and most of everything because it is hydrophi-
riapical tissues, or bone graft matrix (Fig. 29.29). lic, taking into consideration·the successful clinical ca-
More recently a new material has been indicated as ses reported in the literature, 31 ·65 ·66.78,98,118.I35,157 for all
the ideal material to obtain the formation of an api- the above mentioned reasons MTA should be consi-
cal barrier in a one-visit procedure: Mineral Trioxide dered to day the material of choice for the apical bar-
Aggregate (ProRoot MTA, Dentsply Tulsa Dental) (Fig. rier technique in the treatment of pulpless teeth with
29.30).135 According to recent studies, when compa- open apices. Its application results in predictable api-
29 - The treatment of teeth with immature apices 855

sodium hypochlorite, better if ultrasonically activated.

As already stated before, these root canals need only
a minimum shaping and because of their size and the
thickness of the dentinal walls, they need to be clea-
ned more than shaped, in order not to increase their
fragility. To increase their disinfection, Torabinejad i35
suggests to use an intracanal medication with calcium
hydroxide for one week (Fig. 29.31 A-D). After rin-
sing calcium hydroxide from the root canal with irri-
gation and drying it with paper points, mix the MTA
powder with ·saline solution or sterile water and car-
ry the mixture to the apical area with the pre-fitted
Dovgan carrier (Fig. 29.31 E-H). MTA must be positio-
ned exactly at the foramen, as the material must be in
direct contact with periapical tissues, without overfil-
ling. In general, the resistance of the periapical tissues
is enough to prevent overfilling; nevertheless, there
is no contraindication to the use of a resorbable ma-
trix (Collacote), against which MTA could be conden-
sed to the apical end. For this purpose, the pre-fitted
Schilder pluggers can be used as well as paper points.
The thickness of the apical plug must be 3-5 mm.99
In order not to have voids, the application of ultra-
sonics is suggested: 93 while slightly condensing MTA
with the plugger, the dental assistant is asked to touch
the plugger with the ultrasonic tip. Then, check radio-
Fig. 29.30. A, 8. Gray MTA and White MTA (ProRoot MTA, Dentsply Tulsa
graphically the extension of the apical plug. If creation
Dental). of the apical plug is not satisfactory at the first attempt,
rinse out the MTA with irrigation with saline solution
and repeat the above steps. When the radiographic
cal closure and reduction of the treatment time, num- appearance looks ideal, place a wet paper point in di-
ber of appointments and radiographs, particularly in rect contact with MTA (Fig. 29.31 I, ]) and close the
young patients. 53 access cavity with a temporary seal, to let the material
MTA is available as white and gray mineral trioxide ag- set in the next 3-4 hours. At the next visit place the
gregate. The principal components of gray MTA are tri- rubber dam, remove the temporary seal and the paper
calcium silicate, dicalcium silicate, tricalcium alluminate, point, check the hardness of the material (Fig. 29.31
tetracalcium aluminoferrite, and calcium sulfate dihydra- K-M) and then complete the root canal therapy, filling
te. In addition to these components, mineral oxides ha- the rest of the root canal with warm gutta-percha (Fig.
ve been added that are responsible for the chemical and 29.31 N-V). If the canal walls appear to be extremely
physical properties of this aggregate. 94 Tetracalcium alu- thin and fragile, some authors suggest to fill comple-
minoferrite is reportedly removed in white formulation. tely the rest of the root canal with adhesive compo-
According to Matt et al. 99 an ultrasonically compacted site resin (without using gutta-percha at all) to stren-
gray MTA apical barrier of 3 to 5 mm provided the har- gthen the root. 73
dest, most impervious apical barrier. As already stated before, in this author opinion
the use of the operating microscope is mandatory,
in order to perform correctly the entire procedure.
CUNICAL PROCEDURES Furthermore, to facilitate the positioning of the mate-
rial, could be easier to carry only the powder instead
After application of the rubber dam and prepara- of the already mixed material. Then one can touch the
tion of an adequate access cavity, the root canal sy- powder with a wet paper point: by capillarity, MTA
stem should be cleaned with copious irrigation with will absorb the necessary moisture.
856 Endodontics

Fig. 29.31 A. Clinical view of the crown of the maxillary right central incisor. B. Preoperative radiograph. Note the periapical radiolucency, the unusual anatomy, and the
wide open apex. C. The main (central) root canal has been medicated with calcium hydroxide. D. The calcium hydroxide has been removed and a thin layer of MTA has
been used for the direct pulp capping of the pulp exposure of the distal canal. E. The apical foramen as seen through the operating microscope (20x). F. The Dovgan car-
riers, specifically designed for placement of MTA (Quality Aspirators). G. Three millimeters of MTA have been placed in the apical one third of the canal (continued).
29 - The treatment of teeth with immature apices 857

Fig. 29.31 (continued).H. lntraoperative radiograph. Note the thickness of MTA without any overfilling. I. The wet paper point is positioned in contact with the MTA.J.
A wet cotton pel let is used in the pulp chamber before sea ling the access cavity with Cavit. K, L. At the next visit the hardness of MTA is checked with a paper point
and with an endodontic probe. M. The MTA aher setting (20x) (continued).
858 Endodontics

Fig. 29.31 (continued). N, 0. The canal walls are coated with Kerr Pulp Canal Sealer carried with a paper point. P, T. The canal is obturated with thermoplastic gutta-
percha (continued).
29 - The treatment of teeth with immature apices 859

Fig.29.31 (continued). U. Postoperative radiograph. V. Two year recall.

Although a one-visit apexification procedure with material to set for a minimum of 4 hours and comple-
MTA has been suggested,157 Matt et al. 99 strongly sug- ting the obturation on a second visit.
gest the two-step technique. MTA powder consist of The apical barrier technique with MTA is for su-
fine, hydrophilic particles that set in the presence of re indicated in adult patients with pulpless teeth and
water. It is possible that moisture from the apical en- immature apices (Fig. 29.32): in this kind of patients,
vironment could be sufficient for MTA to set, but it se- using the traditional technique with calcium hydroxi-
ems clear that additional moisture from a cotton pel- de is just a waste of time, since no apical calcific bar-
let or from a paper point is crucial for the material to rier will ever develop after a certain age. The same pa-
establish its optimum properties. This concurs with tient often are busy and have aesthetic requests, the-
the manufacturers' recommendation of placing a moi- refore the traditional technique with calcium hydroxi-
st cotton pellet in the canal, temporizing, allowing the de is even more contraindicated.

Fig.29.32.A. Preoperative radiograph of the upper left central incisor in an adult patient.The open apex is evident together with the inadequate previous root filling.
B. Two gutta-percha cones have been removed without any effort.C. Fitting the Dovgan carrier (continued).
860 Endodontics

Fig. 29.32 (continued). D. An apical plug of three millimeters of MTA has

been positioned at the fora men site, working under the operating micro-
scope. E. Postoperative radiograph.

The apical barrier technique with MTA is also indi- The same technique using MTA is also indicated in
cated in adult patients with pulpless teeth and trau- the young patient (Fig. 29.35, 29.36), only if the traditio-
matic horizontal root fractures (Fig. 29.33) or in teeth nal access cavity will allow a perfect visualization of the
with an apical inflammatory root resorption or ove- apical foramen using the operating microscope. If this is
ristrumented foramen (Fig. 29.34). In both cases, the not obtainable and a further removal of crown structure
apical foramen is too large to be obturated with con- should be necessary, in this case the traditional technique
ventional methods without risk of big overfilling. with calcium hydroxide remains the treatment of choice.

Fig. 29.33. A. Preoperative radiograph of two central incisors with a traumatic horizontal fracture. B. About 3-5 mm of MTA have been positioned at the fracture line,
after the "new" large fora men has been localized with an electronic apex locator. C. The coronal portion of the root canals have been filled with thermoplastic gut-
ta-percha (Obtura). D. Two year recall.
29 - The treatment of teeth with immature apices 861

Fig. 29.34. A. Preoperative radiograph of the lower left first molar. B. Working length of the distal canal: the size of the fora men is bigger than a 50. C. Three
millimeters of MTA have been positioned at the fora men. D. Postoperative radiograph. E. Six month recall. F. One year recall.
862 Endodontics

Fig. 29.35. A. Preoperative radiograph of the upper right central incisor. The tooth has an open apex and the pulp is necrotic. The previous dentist was looking for
the canal in the wrong direction. B. The root canal has been filled with calcium hydroxide. C. Three millimeters of MTA have been positioned at the fora men. D. Three
year recall.

Fig. 29.36. A. Preoperative radiograph of the upper central incisors. The teeth have an open apex and a necrotic pulp. B. After one week of calcium hydroxide, 3 mm
of MTA have been positioned at the foramina.C. Postoperative radiograph. D. Two year recall.

TEETH WITH APICAL PERIODONTITIS The combination of a disinfected canal, a matrix into
which new tissue could grow, and an effective coronal
A new technique has been recently presented by seal appears to have produced the environment neces-
Banchs and Trope 13 to treat immature permanent sary for successful revascularization. The root can then
teeth with necrotic pulp and apical periodontitis. The continue to grow, suggesting that the vital tissue insi-
treatment consists in: de the root canal contains odontoblasts and then can be
• disinfection of the canal space with copious ir- considered pulp tissue. In the case described by the two
rigation and a combination of three antibiotics authors, the root continued to grow, the walls of the ro-
• mechanical irritation of the apex to initiate ble- ot appeared to thicken in a conventional manner and the
eding into the canal to produce a blood cloth to the development of the root apical to the restoration was si-
level of the cementa-enamel junction milar to that of the adjacent and contralateral teeth.
29 - The treatment of teeth with immature apices 863

We can explain this exceptional result assuming PROGNOSIS

that in teeth with open apices it is possible that some
pulp tissue may have survived apically, even though Even though apexification is associated with a high
most of the pulp is devitalized and heavily infected. rate of success, the roots of treated teeth are thinner
Therefore, even though a large apical lesion is pre- than usual and therefore more fragile and susceptible
sent, it is probable that some vital pulp tissue and to fracturing, following even minor trauma (Fig.
Hertwig's epithelial root sheath remained. When the 29.37).
canal is disinfected and the inflammatory conditions For this reason, each time it is possible, in teeth
reversed, these tissues can proliferate. with immature apices one must try to maintain the vi-
The two authors conclude that the predictability of tality of even a small portion of the pulp, because not
this procedure and the type of tissue that develops in only closure of the apex, but also and especially, thic-
these cases are still to be studied. However the be- kening of the radicular walls and thus the strength of
nefit are so great, that in their opinion it is worth at- the tooth, depend on it.
tempting. If no root development can be seen within Apexification therefore must be seen as a last chan-
3 months, the more traditional apexification procedu- ce, when the pulp has become completely necrotic and
res can then be started. all attempts to perform "vital" therapy have failed.

Fig.29.37.Vertical root fracture of an upper right central incisor 9 years after the completion of apexification.A.Preoperative radiograph. B. Postoperative radiograph after
6 months of therapy with calcium hydroxide.C. Follow-up radiograph 9 years later. D.Probing of a tubular defect from the palatal side, typical of a vertical root fracture.


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xide. Odont. Rev. 23:211, 1972.
S.B.: Comparative study of white and gray mineral trioxide 118. SCHWARTZ, RS., MAUGER, M. , CLEMENT, DJ, WALKER III,
aggregate (MTA) simulating a one- or two-step apical barrier W.A.: Mineral trioxide aggregate: a new material for endo-
technique. J. Endod. 30, 876, 2004. dontics. J. Am. Dent. Assoc. 30:967, 1999.

100. McCORMICK, J.E., WEINE, F.S., MAGGIO, JD.: Tissue pH of 119. SCIAKY, I., PISANTI, S.: Localization of calcium placed over
developing periapical lesions in dogs. J. Endod. 9:47, 1983. amputated pulps in dog's teeth. J. Dent. Res. 39:1128, 1960.

101. MOOD NIK, R.M.: Clinical correlations of the development of the 120. SELA, ]. , HIRSCHFIELD, Z. , ULMANSKY, M.: Reaction of the
root apex and surrounding structures. Oral Surg. 16:600, 1963. rat molar pulp to direct capping with the separate componen-
ts of hydrex. Oral Surg. 35:118, 1973.
102. NAKATA, TI., BEA, K.S. , BAUMGARTNER, J.C.: Perforation re-
pair comparing mineral trioxide aggregate and amalgam using 121. SELTZER, S., BENDER, LB.: The dental pulp. 3rd ed.
an anaerobic bacterial leakage model. J. Endod. 24:184, 1998 Philadelphia. J.B Lippincot, 1984, pp. 281-302.

103. NEVINS, A.]. , FINKELSTEIN, F., BORDEN, B.G. , LAPORTA, R.: 122. SELTZER, S., BENDER, LB., TURKENKOPF, S.: Factors affec-
Revitalization of pulpless open apex teeth in rhesus monkeys, ting successful repair after root canal therapy. J. Am. Dent.
using collagen-calcium phosphate gel. J. Endod. 2:159, 1976. Assoc. 67:651 , 1963.

104. OSWALD, R.J., VAN HASSEL, H.J.: Calcium hydroxide root clo- 123. SHABAHANG, S., TORABINEJAD, M. , BOYNE,P.P., ABEDI,
sure, in Gerstein H. ed: Techniques in clinical endodontics, H., McMILLAN, P.: A comparative study of root-end induction
W.B., Saunders Company, Philadelphia, 1983, pp. 162-171. using osteogenic prtotein-1 , calcium hydroxide, and mineral
trioxide aggregate in dogs. J. Endod. 25:1 , 1999.
B. , ESKANDARIZADE, A., SHABAHANG, S.: A comparative stu- 124. SHABAHANG, S. , TORABINEJAD, M.: Treatment of teeth with
dy of white and grey mineral trioxide aggregate as pulp cap- open apices using mineral trioxide aggregate. Pract. Period.
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106. PATIERSON, S.S.: Pulpal calcification due to operative proce- 125. SMITH, A.].: Dentin formation and repair. In Hargreaves K.M. ,
Goodis, H.E. eds. Seltzer and Bender's Dental Pulp, Charter 3,
29 - The treatment of teeth with immature apices 867

3rd edn. Chicago: Quintessence Publishing Co; 2002. P.41-62. 144. TORABINEJAD, M. , RASTEGAR, A.F. , KETTERING, JD., PITT
FORD, T.R.: Bacterial leakage of mineral trioxide aggregate as
126. SJOGREN, U., FIGDOR, D., SPANGBERG, L., SUNDQUIST G.: a root-end filling material. J. Endod. 21:109, 1995
The antimicrobial effect of calcium hydroxide as a short-term
intracanal dressing. Int. Endod.]. 24:119, 1991. 145. TORABINEJAD , M., SMITH, P.W. , KETTERING, JD. , PITT
FORD, T.R.: Comparative investigation of marginal adapta-
127. STANLEY, H.R., LUNDRY, T.: Dycal therapy for pulp exposu- tion of mineral trioxide aggregate and other commonly used
res. Oral Surg. 34:818, 1972. root-end filling materials.]. Endod. 21:295, 1995.
128. STEINER, J.C., VAN HASSEL, H.J.: Experimental root apexifi- 146. TORABINEJAD, M. , WATSON, T.F., PITT FORD, T.R.: Sealing
cation in primates. Oral Surg. 31:409, 1971. ability of a mineral trioxide aggregate when used as a root-
129 STEWART, D.: Root canal therapy in incisor teeth with open end filling material.]. Endo. 19:591 , 1993.
apices. Br. Dent.]. 114:249, 1963 147. TORNECK, C.D., SMITH,].: Biological effects of endodontic pro-
130. STUART, W.W., CROWLEY, L.V., TURNER, D.W. , PELLEN, cedures on developing incisor teeth. Oral Surg. 30:258, 1970.
G.B. Jr., OSETEK, E.M.: Humoral response to endodontic ce- 148. TORNECK, C.D., SMITH, JS, GRINDALL, D.: Biologic effects of
ments.]. Endod. 5:214, 1979. endodontic procedures on developing incisor teeth. Part II: Effect
131. TAINTOR, J.F., BIESTERFELD, R.C., LANGELAND, K.: of pulp injury and oral contamination. Oral Surg. 35:378, 1973.
Irritational or reparative dentin. A challenge of nomenclature. 149. TORNECK, C.D. , SMITH, J.S., GRINDALL, P.: Biologic effects
Oral Surg. 51:442, 1981. of endodontic procedures on developing incisor teeth. 3.
132 TAKITA, T. , HAYASHI, M., TAKEICHI, 0., OGISO, B. , SUZUKI, Oral Surg. 35:532, 1973.
N., OTSUKA, K. , ITO , K.: Effect of mineral trioxide aggrega- 150. TORNECK, C.D., SMITH, JS. , GRINDALL, P.: Biologic effects
te on proliferation of cultured human dental pulp cells. Int. of endodontic procedures on developing incisor teeth. IV.
Endod . ]. 39:415 , 2006.
Oral Surg. 35:541, 1973.
133. TANG, H.M., MORROW,S.G. , KETTERING, JD., 151. TRONSTAD, L., MJOR, I.A.: Capping of the inflamed pulp.
TORABINEJAD , M.: Endotoxin leakage of four root-end fil- Oral Surg. 34:477 , 1972.
ling materials (abstract 42).]. Endod. 23:259, 1997.
134. TONGE, C.H.: Tooth structure and development. Dental G., PAPADIMITRIOU, S.: The dentinogenic effect of mineral
Update 1:35, 1973. trioxide aggregate (MTA) in short-term capping experiments.
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136 TORABINEJAD, M. , HIGA, R.K. , McKENDRY, D.]., PITT scopy of calcium hydroxide induced bridges. J. Oral Pathol.
FORD, T.R.: Dye leakage of four root-end filling materials: ef- 1:244, 1972.
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137. TORABINEJAD, M. , HONG, C.U., LEE, S.J., MONSEF, M., PITT North Am. 28:669, 1984.
FORD, T.R.: Investigation of mineral trioxide aggregate for 155. WEINE, F.S.: Endodontic therapy. 3rd ed. St. Louis. The C.V.
root end filling in dogs.]. Endod. 21:603, 1995. Mosby Company, 1982, p. 571.
138. TORABINEJAD, M., HONG, C.U., PITT FORD, T.R., 156. WEISS, M.B. , BJORVATN, K.: Pulp capping in deciduous
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ling materials.]. Endod. 21:403, 1995.
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159. WHITTLE, M.: Apexification of an infected untreated immatu-
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KARIYAWASAM, S.P., TANG, H.M.: Tissue reaction to implan-
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assessment of mineral trioxide aggregate as a root-end filling
in monkeys. J. Endod. 23:225, 1997.
868 Endodontics

Root Resorption

There is considerable confusion and disagreement like tissue, both within the root canal and on the
in the literature regarding the manner of considering - root surface, 87 where obviously not all that has been
and thus classifying - root resorption. lost (i.e. , the dentin) is re-formed. However, the la-
Many textbooks do not dedicate a specific chapter cunae or resorbed surfaces are covered by cemen-
to the resorptive processes. Indeed, the same patholo- tum, with regeneration of the associated periodon-
gic and histopathologic entities are referred to by dif- tal ligament.
ferent names, depending on the author. In contrast, in the process of resorption with
This chapter will consider the various entities, diffe- ankylosis, there is loss of the periodontal ligament
rentiating them not only on the basis of etiology and and the progressive substitution by bone of the den-
pathogenesis, but also their prognosis and therapy. tal hard tissues after they have been colonized by
According to Tronstad, 88 a fundamental distinction osteoblasts originating in the surrounding medullary
must be made between inflammatory resorption and spaces.47 The periodontal ligament does not regene-
resorption with ankylosis'. In the former, the dental rate, and, with the exception of cases of light trau-
hard tissues (dentin and cementum) are colonized ma with minimal damage to the periodontal liga-
by inflammatory multinucleated giant cells, which ment, the process inexorably and irreversibly evol-
initiate the resorption. 59 This occurs along the walls ves until the root has completely disappeared and
of the root canal (internal resorption) or on the the tooth has been lost, even after the stimulus has
external surface of the root (external resorption) . ceased. The tooth's root is slowly resorbed as it is
Depending on the duration of the stimulus that incorporated in the normal processes of alveolar bo-
had provoked the resorption, these processes may ne remodeling.
be termed transient or progressive. All forms of A separate entity - albeit related to inflammatory
resorption share a common precipitant, and they resorption - known to all endodontists but descri-
cease as soon as the cause is withdrawn. They bed by different names, is extracanal invasive re-
are thus reversible or self-limited and demonstrate sorption, which Frank 36 has correctly distinguished
spontaneous repair. from other types of resorption because of the im-
In fact, once the stimulus is removed, the repair portance of its early recognition and knowledge of
process begins with the deposition of a cementum- its therapies.

' Andreasen's6 classification includes another category, superficial or transient resorption. As will be discussed in more detail below, superficial or transient resorption
is also a form of inflammatory resorption; therefore, it is more correct to include it in this category. That which Andreasen calls inflammatory resorption on the basis of
the participation of bacteria is more correctly classified inflammatory secondary to infection. It corresponds to that which in the classification of Frank, Simon, Abou-
Rass, and Glick39 is called inflammatory pathologic.
30 - Root Resorption 869


EXTERNAL (ortho, perio, trauma, moderate stimuli in

the absence of infection)

I NTERNAL (pulp irritation, moderate trauma in the

absence of infection)
SECONDARY To PRESSURE (secondary to eruption of permanent teeth, impaction,
(only external) cysts, excessive orthodontic movement)

(chronic inflammation
of the pulp)



External {
(secondary to pulp [ NTRUSION

necrosis, trauma)


ANKYLOSIS AND REPLACEMENT (secondary to extensive necrosis of the periodontal ligament, subluxation, or avulsion)




INFLAMMATORY RESORPTION type of resorption, albeit completely asymptomatic,

is relatively frequently observed, even on the canal
It is a self-limiting process followed by sponta-
As already suggested, this type of resorption can oc- neous repair. 39 As the resorption defect is usually too
cur either on the root surface or within the canal wall; small to even be detected radiographically, it is of no
thus, it can be classified as external or internal. It cor- clinical significance.88
responds to that which other authors call "surface re- The cause of these resorptions may be a slight trauma
sorption,"16·39 obviously in reference to only the exter- causing slight injury that is localized to the periodontal
nal type. ligament (external) or pulp tissue (internal). It has also
A scanning electron microscopic study by this been described in teeth that had undergone orthodontic
author has confirmed the findings of others 30 that this or periodontal treatment, as well as in abraded teeth. 88
870 · Endodontics

weeks with the formation of new cementum and re-

attachment of new periodontal fibers), also called su-
perficial (because it involves only the most superficial
layers of dentin), and internal or external (depending
on whether it involves the external root surface or the
root canal walls).
For all these reasons, they are of relative clinical im-
It goes without saying that the affected teeth give
positive responses to all the pulp vitality tests and re-
quire no therapy (Fig. 30.2).

Fig.30.1.A. Small lacunae of internal resorption in the palatal root of an upper

first molar. They cannot be identified radiographically and have no clinical si-
gnificance (x60).B.The same area at higher magnification (x140).

From the histological point of view, such damage

is translated into denudation of a small area of dentin
which, following disappearance of the cementoblasts Fig. 30.2. An upper right canine with a small lacu-
and cementum on one side or the odontoblasts and na of external superficial inflammatory resorption.
Within the lacuna, the periodontal ligament can be
predentin on the other, is colonized by phagocytic identified.
cells originating in the surrounding tissues, which be-
gin the resorptive process.
As will be discussed in greater detail below, resor- PROGRESSIVE I NFLAMMATORY RESORPTION
bing cells require continuous stimulation during pha-
gocytosis.79 The denuded dentin or cementum sur- RESORPTION SECONDARY To PRESSURE
face can sustain the resorptive process for no more
than 2-3 weeks. After this, the denuded areas of the This form of resorption can only be external, since
tooth are colonized by regenerative cells originating before causing resorption of the canal wall, an increa-
in the surrounding healthy tissue which repair the de- se of pressure within the endodontium causes pulp
fect with formation of a cementum-like tissue. 87 The necrosis.
same process occurs both on the root surface and in The resorption results from marked, protracted
the root canal. In such cases, the resorption which pressure on the dental root, which can be caused by
occurs can be classified as inflammatory (mediated an orthodontic movement (Fig. 30.3), the eruption of
by multinucleated giant cells with phagocytic activi- a tooth (Fig. 30.4), the presence of an impacted tooth
ty, which are nothing if not inflammatory cells), tran- 71 (Fig. 30.5), or a cyst of any sort (Fig. 30.6).
sient (given the limited duration and self-repair in 2-3 In order to cause resorption, however, the increase
30 - Root Resorption 871

Fig. 30.4.A. External progressive inflammatory resorption secondary to pressu-

re on the upper left lateral incisor, caused by eruption of the canine. B. Because
of agenesis of the second premolar, the deciduous molar has not experienced
resorption of its roots.

Fig. 30.3. Extensive external progressive inflammatory resorption secondary

to orthodontic movement. A. The four upper incisors have lost about 50% of
their original length. B.The lower central incisors of the same patient have lost
about 30%. C, D. One year later, the teeth have preserved their pulp vitality.

of pressure must be gradual and prolonged.

Resorption secondary to an orthodontic movement
involving the root apex and leaving the tooth shor-
ter than normal, with roots that seem to have expe-

Fig. 30.5. An impacted third molar can cause resorption of the distal root of these-
cond molar.
872 Endodontics

Fig. 30.6. External progressive inflammatory resorption secondary to

pressure of the buccal root of an upper right first premolar, caused by a
large odontogenic cyst sustained by the incongruously-treated canine.
The tooth gives positive responses to the vitality tests. A. Preoperative
radiograph. B. Recall radiograph 2 years after surgical treatment of the
canine.The premolar has preserved its pulp vitality.

rienced true "apicoectomy", is fairly typical. There is ceded by ankylosis and later the root is replaced by
almost complete agreement in the literature that, to bone. This resorption occurs from all directions, inclu-
a greater or lesser extent, external resorption occurs ding both the apical region and the sides of the root,
in almost all patients who undergo orthodontic treat- whereas teeth undergoing orthodontic movement ma-
ment.65·66 Such resorption involves in equal measure nifest only apical resorption with no ankylosis and
both teeth with vital pulp and endodontically treated an intact periodontal ligament. Orthodontic resorption
teeth. 53·94 is identified with cementoclastic activity, whereas the
The resorptive process discontinues as soon as the avulsed replanted tooth is associated with osteoclastic
pressure is no longer present. 76•89 Thus, even though activity. Furthermore, as already stated, in the ortho-
it can cause considerable destruction, it has a favo- dontically treated tooth the resorption ceases when
rable prognosis, especially if diagnosed in a timely treatment is discontinued, whereas in the replanted
fashion. avulsed tooth replacement resorption of the root with
Although it may be surprising, the pressure cau- bone is progressive with ultimate loss of the entire
ses resorption of the dental hard tissues (cementum root.
and dentin), just as it causes resorption of bone, but In the case of resorption of the distal root of a lo-
spares the soft tissues. The vascular peduncle is not wer second molar caused by the pressure of an im-
at all disturbed by what is occurring around it, and pacted third molar, if the resorption has involved the
the teeth give positive responses to the tests of pulp pulp it is easy to understand how, especially following
vitality. The only treatment required is relief of the extraction of the impacted tooth, the pulp is irrever-
pressure. sibly compromised. Therefore, in such a case, endo-
The pressure resorption secondary to orthodon- dontic therapy of the second molar or even removal
tic treatment is also called Periapical Replacement of its distal root or of the entire tooth, depending on
Resorption,21 meaning by this definition the resorp- the degree of resorption, must be considered, in addi-
tion of the most apical part of the root and its repla- tion to removal of the cause, namely, surgical extrac-
cement with normal bone. The term is not to confu- tion of the impacted tooth. 50
sed with the replacement resorption which will be di-
scussed more in details later, and is usually identified
in avulsed replanted teeth.
In avulsed replanted teeth, resorption is always pre-
30 - Root Resorption 873


Most often, this is an endodontic complication that

can involve either the internal walls of the root canal
(internal progressive iriflammatory resotption or, more
simply, internal resotption) or the external surface of
the root (external progressive inflammatory resotption
or, more commonly, external inflammatory resotp-
tion). In an inflammatory process in which bacteria are
present, many substances that can activate the resorp-
tive processes are present, including prostaglandins,
macrophage- and osteoclast-activating factors, and en-
zymes such as acid phosphatase and Beta-glucuroni-
dase.49 In combination with the products of bacterial
metabolism and endotoxins, they may cause complete
destruction of the root in just a few months. 88

Internal Progressive Inflammatory Resorption

or Internal Resorption

This is easily diagnosed, since it generally produces a

characteristic, more or less rounded radiolucent image,
which reflects a well-defined enlargement of the pulp
chamber 39 (Fig. 30.7) or root canal (Fig. 30.8).
In most cases, it is symmetric; more rarely, it is ec-
centric (Fig. 30.9); it has uniform radiographic density
and can be compared to a balloon or rosary bead.
Most often, it is an incidental radiographic finding ,
as it produces virtually no clinical signs. As the resorp-
tion depends on the presence of vital tissue, the pulp
responds positively to the various tests. When the pulp
chamber is compromised, it may have a pink coloring
through the enamel. This may be the only sign. 70
However, the pulp may become necrotic, at which

Fig. 30.8. Internal resorption (progressive inflammatory secondary to infec-

tion) in an upper left central incisor. Note the characteristic rosary-bead ap-
pearance, its clear boundaries, its symmetry with respect to the canal, and the
absence of canal wall signs within the radiolucency (which distinguishes it
from extracanal invasive resorption): the walls widen in the shape of an am-
pule and are continuous with the canal walls. A. Preoperative radiograph. B.
Postoperative radiograph, following vertical condensation of warm gutta-per-
cha (Courtesy of Dr. M.J. Scianamblo).

point the tooth can become symptomatic, not becau-

se of the internal resorption but because of the peria-
pical inflammation.
The finding of a necrotic pulp in a tooth with in-
ternal resorption could cause one to defer endodontic
therapy in the belief that the resorption cannot evol-
Fig. 30.7. Internal progressive inflammatory resorption in an upper right se- ve further, since there is no more vital tissue within
cond molar.The process began in the pulp chamber. (Fig. 23.25).
874 Endodontics

Fig. 30.9. Internal resorption (progressive inflammatory secondary to infection) of the untreated palatal root of an upper right first premolar. Timely treatment is re-
quired, since even if the tooth clearly does not respond to the vitality tests, the defect could still contain vital tissue and the process cou ld progress. A. Preoperative
radiograph. B. lntraoperative radiograph to confirm that the no. 20 file is at the radiographic terminus of the canal.C. Postoperative radiograph.The resorption is not
symmetrical to the canal, but displaced slightly palatally. D. Recall radiograph 2 years later.

This is incorrect. On the contrary, internal resorp- and infected material that may be present must be re-
tion demands rapid intervention, inasmuch as the pro- moved scrupulously. Ultrasonic irrigation can be par-
cess can progress very quickly, even with negative re- ticularly useful in this phase of therapy. 24,56.85
sponses to the vitality tests. As Frank et al.39 state, enlargement of the canal to
Tronstad 88 and numerous other authors 92 state that the size of the defect or the-use of a bur within the le-
the resorptive process can be sustained by infection of sion, both of which were once recommended, is ab-
the necrotic pulp tissue situated in the root canal co- solutely contraindicated.
ronally to the area where the resorption is taking pla- During the obturation phase, the techniques that
ce. In other words, even if the pulp in the chamber require the use of heat-softened gutta-percha and its
is necrotic (so that the pulp tests are negative), there vertical compaction are preferred for three-dimensio-
could still be vital tissue within the root canal, and the nal filling of the defect. 29
pathological process may continue as far as complete It is important to ensure that the pluggers are also
destruction of the root. worked in the portion of canal situated apically to the
Therefore, the presence of internal resorption is a resorptive defect to obtain a good apical seal and pre-
definite indication for immediate endodontic therapy. vent the vertical force from affecting only the area of
Once the tissue within it is removed, and the root ca- the defect without sealing the apex.
nal therapy is completed, then the resorptive process Once compaction of the apical gutta-percha has
will stop. been achieved with the Schilder technique, the defect
Cleaning of the defect is primarily entrusted to irri- can be easily and effectively filled, even with thermo-
gating solutions, since, for obvious reasons, the instru- plastic gutta-percha. 44 •46
ments cannot make contact with the walls. Generous Regarding the etiology of internal resorption,
irrigation is therefore necessary, and all the pulp tissue Wedenberg and Lindskog 92 have recently made an in-
30 - Root Resorption 875

teresting contribution.
The consequence of this temporary colonization
of dentinoclastic cells is temporary resorption, ex-
ternal or superficial on one side and internal on the
If infection supervenes, colonization of the denti-
nal walls by the macrophages with dentinoclastic ac-
tivity is encouraged by the continuous bacterial sti-
mulation, because of the production of prostaglan-
dins, osteoclast activating factors , and macropha-
ge-chemotactic factors, 48 among others. Therefore,
the colonization is prolonged, with consequent pro-
gression of the resorption.
On the other hand, the cells responsible for resorp-
tion require a continuous stimulus for phagocytosis,79
while denuded dentin is sufficient to sustain the re-
sorptive process for no more than 2-3 weeks. Beyond
this, the resorption is no longer transient, superficial,
and self-limited, but progressive.
In conclusion, the two Swedish authors believe that
trauma and infection play a very important role as
etiologic factors in resorption in general and in inter-
nal resorption in particular:
- trauma Is the initiating factor
- infection is the continuous stimulating factor, re-
sponsible of the progressive resorption.
Apart from true physical trauma,7· 22•26·73 pulp "trau-
ma" may be caused by a vital pulp therapy, 78 such as
direct pulp capping, pulpotomy, and vital root ampu-
It is still unclear, however, why these phenomena Fig. 30.10. Internal resorption (progressive inflammatory secondary to infec-
tion) of the upper left central incisor with a small dens in dente. A. Preoperative
occur in some cases, but not others. Constitutional, radiograph. The defect is not symmetrical to the canal, but has all the other
hereditary, or other factors may play a role. characteristics of this type of internal resorption.The pulp is necrotic, and t he
tooth has already been "opened for drainage''. This case also demands ear-
Although the true etiology is still quite unclear, it is ly treatment, because the defect could still contain vital tissue and the pro-
known that the prognosis of internal resorption is ve- cess could progress. B. Clinical appearance of the buccal surface of t he dental
crown.C.Ten year reca ll.
ry good, especially if the diagnosis is made early (Fig.

The tests of pulp vitality are all negative.

INTERNAL RESORPTION WITH PERFORATION For years, this type of defect has been treated sur-
gically, 25 with the obturation of the perforation with
If the internal resorption presents late in its course, obturating materials such as amalgam if the defect was.
it may have eroded the canal wall so much that it has surgically accessible (Fig. 30.12). Alternatively, the
created a communication with the periodontium. portion of the root apical to the resorption was remo-
At this point, the pulp becomes necrotic, and the ved if the remaining portion had a favorable crown-
case becomes symptomatic; for example, an abscess root ratio, possibly with the introduction of an endo-
or fistula may develop (Fig. 30.11). dontic implant. 35
Radiographically, the defect and, if it is situated me- In 1973, Frank and Weine 41 proposed a reminera-
sially or distally, the perforation can be appreciated. lization therapy with calcium hydroxide with a non-
A radiolucent area may be present on the side of the surgical approach, similar to that which Frank 34 had
perforation. introduced several years before for the therapy of ne-
876 Endodontics

Fig. 30.11. Internal resorption (progres-

sive inflammatory secondary to infec-
tion) with intraosseous perforation in
an upper right lateral incisor. The pulp
has become necrotic, and the lesion
has manifested itself because of the
concomitant symptoms of the endo-
dontic lesion that has developed. A.
Preoperative radiograph: the walls of
the resorption appear very thin, but ra-
diographically the perforation cannot
be appreciated. B. Postoperative radio-
graph. The diagnosis of intraosseous
perforation was made a posteriori. C.
Recall radiograph 2 years later.

Fig. 30.12. Internal resorption (progressive inflammatory secondary to infection) with intraosseous perforation in an upper left canine. The defect is asymmetrical
with respect to the canal and the perforation is on the mesial aspect of the root. A. Preoperative radiograph. B. Postoperative radiograph. Because of the extreme
length of the tooth and the presence of resorption with perforation, compaction of the gutta-percha has not been performed optimally.This has also made neces-
sary retrograde treatment. C. Postoperative radiograph. D. Recall radiograph 3 years later.This case was treated several years before mineral trioxide aggregate be-
came available.

erotic teeth with immature apices (Fig. 30.13). consequently, the periodontium, so as to permit hea-
In fact, the two processes present clinical similari- ling of the lesion at the site of the perforation.
ties. They both have an opening (apical in one, late- In contrast to what occurs in apexification, where a
ral in the other) that hampers adequate compaction calcific barrier forms, no barrier forms in this case; ra-
of the obturating material without gross excesses in ther, simple healing of the periodontal structures, bo-
the surrounding tissues. A solid apical or lateral ma- ne and connective tissue, which function as an optimal
trix against which to condense the gutta-percha effec- matrix for the condensation of gutta-percha, occurs. 39
tively and safely is lacking. In practice, the canal is filled with calcium hydroxide
The non-surgical treatment proposed by the two and regular check-ups are performed at three-month inter-
North American authors consists of precisely cleaning vals until adequate healing of the lesion is radiographi-
and shaping the root canal to remove all its infected cally demonstrated. If, at an interval check the calcium
contents and temporarily filling it with calcium hydro- hydroxide appears to have been resorbed from the ca-
xide. This is done, not because of the miraculous nal, it is re-introduced, just as in apexification. Multiple
powers of the medication, but only with the goal of appointment in which repeated applications of calcium
improving the environment of the endodontium and, hydroxide for a long period of time are required in order
30 - Root Resorption 877

Fig. 30.13. Diagrammatic drawing of the calcium hydroxide therapy sug-

gested by Frank and Weine for the treatment of internal resorption with
intraosseous perforation (Adapted from Frank and Weine).

Fig. 30.14. Therapy with calcium hydroxide for the treatment of internal resorption with intraosseous perforation in the mesial root of a lower left first molar. A.
Preoperative radiograph. The young patient gave a history of trauma. 8.The canals have been cleaned, shaped, and temporarily obturated with calcium hydroxide.
No treatment has been performed on the mesial root apically to the defect, which contains vital pulp. C. Recall radiograph after 17 months of therapy with ca lcium
hydroxide.The medication was checked and replaced in the canal every three months. D. Postoperative radiograph.The apical portion of the mesial root contains vi-
tal pulp and therefore has not been treated, just as in horizontal fractures of the root, when the coronal fragment has become necrotic while the apical portion has
preserved its vitality. E. Recall radiograph 40 months later.

to create hard tissue closure of root perforations. 32 Once days after correct cleaning and shaping of the root
the lesion has resolved and the periodontium on the si- canal, and the periodontal lesion also heals within a
de of the perforation has healed, the calcium hydroxide few months, further confirming that the so-called "en-
is removed, and the canal is dried and obturated by the dodontic-periodontal lesion" heals completely after
traditional Schilder technique (Fig. 30.14). endodontic therapy alone if the cause was primari-
Frank and Weine assume that at this point the tis- ly endodontic and if the root canal is treated and then
sues will reorganize after the placement of the per- obturated adequately. 81
manent root canal filling. A fibrous connective tissue According to Webber, 90 the prognosis of reminera-
develops to separate the filling material from the sur- lization of root perforations using calcium hydroxide
rounding osseous structure. is poor.
If present, the fistula heals naturally within a few A new and more predictable therapeutic approach
878 Endodontics

to these kind of defects includes the use of Mineral crosi_s 63, 78 and, sometimes, periradicular inflammation
Trioxide Aggregate 86 (ProRoot MTA, Dentsply, Tulsa secondary to periodontal disease.
Dental), which can be used both with a non-surgical Inflammation secondary to pulp necrosis (according
approach,52 if the defect can be treated through the to Delzangles, 31 much more evident in the case of gra-
access cavity (Figs. 30.15, 30.16), or through a sur- nuloma and minimal, if not entirely absent, in the case
gical flap (Figs. 30.17, 30.18). For the characteristics of cysts) can be radiographically identified by erosion
and modality of utilization of MTA, see Chapters 29 of the apex. The tooth does not respond to the vitali-
and 34. ty tests, and on palpation there may be a swelling at
The prognosis of internal resorption with perfora- the apex or a fistula.
tion depends on the site of the perforation, in addition It may be difficult to distinguish a resorbed apex
to the extent of the destruction of the root. The more from an immature apex, since both may present with
intraosseous the perforation, the better the prognosis. a shorter than normal root and an open foramen .
If it is supraosseous or close to the alveolar crest, en- Nonetheless, the two may be differentiated on the ba-
dodontic intervention alone is contraindicated. Since sis of the shapes of their canal and apex. The canal of
the defect communicates with the oral environment, the immature apex is wide, with parallel or divergent
the calcium hydroxide would be washed away after a walls, and the apex may be blunderbuss-shaped. In
few minutes, and the gutta-percha obturation would external inflammatory resorption, the canal and apex
cause certain overfilling. This case, therefore, calls for are smaller, and the canal walls converge apically. 42
immediate filling of the canal with a permanent obtu- Endodontic therapy is indicated for this type of re-
ration material (gutta-percha) followed by surgical in- sorption. By eliminating the infection from within the
tervention aimed at exposing the defect and filling it canal, the inflammation of the periapical tissues is eli-
through the surgical flap. minated, and the resorption halts (Fig. 30.21).
The goal of filling of the canal (definitive or, if this Removing the necrotic cementum surgically, na-
is not possible, temporary, performed shortly befo- mely by apical curettage, is not indicated, as once be-
re the surgical procedure) is to prevent the external lieved. If this was necessary, one should surgically cu-
obturation of the defect from blocking the canal; fur- rette all the teeth with necrotic pulp, since resorption
ther, it serves as an internal matrix against which the is practically the rule in the case of pulp necrosis.
obturating material can be condensed. 51 Naturally, if Problems may arise in the course of endodontic
the surgical procedure becomes mandatory, the pro- therapy of such teeth, since localization of the apical
gnosis depends on whether there is good surgical ac- foramen may be very difficult, especially if the
cess to the defect and on the condition of the remai- resorption has eroded the root to the shape of a flute
ning periodontium.39 Instead of the surgical procedu- mouthpiece, with a 45° angle to the canal. In similar
re, one can perform the orthodontic extrusion in order cases, surgery may also ,be justified (Fig. 30.22).
to exposed the defect, like in the case of Fig. 30.35. It may also be difficult to achieve a good apical stop
If the resorption is localized to only the crown, en- and avoid overfilling.
dodontic therapy alone will suffice (Fig. 30.19). It is therefore advisable to clean, shape, and obturate
the root canal to the radiographic level which gives
the impression of being surrounded by canal walls
External Progressive Inflammatory Resorption at 360°. For a correct determination of the working
length, more than on the radiograph, is better to rely
Also called "external inflammatory resorption" and, on the electronic apex locator or, even better, on the
more simply by some authors, "external resorption", consistent drying point.
"inflammatory resorption" or "pathologic inflamma- If the obturation is slightly excessive, it will have
tory resorption, " this occurs at the apex of teeth with no significant effect on clinical healing, as long as it is
necrotic pulp as a reaction to the inflammatory pro- three-dimensional and provides a good seal.
cess (Fig. 30.20). The same substances that provoke If one finishes with a short obturation, either no
resorption of the bony trabeculae around the necro- healing of the lesion or the so called "remodeling of
tic tooth (e.g., enzymes, endotoxins, etc.) also cause the root apex" will occur. The latter as a matter of
resorption of the dental hard tissues, cementum and fact consists of external resorption which progresses
dentin. To a greater or lesser extent, it always accom- as long as there are canal walls (containing bacteria,
panies periapical inflammation secondary to pulp ne- which sustain the inflammation) to resorb. 14
30 - Root Resorption 879

Fig. 30.15. Internal resorption (progressive infl<)mmatory secondary to infection) with intraosseous perforation in an upper right central incisor already endodonti-
cally treated.A. Preoperative radiograph. B. The old gutta-percha of the previous treatment has been removed almost completely and the defect has been filled with
white MTA.C. Postoperative radiograph. D. Two year recall.

Fig. 30.1 6. Internal resorption (progressive inflammatory secondary to infection) with intraosseous perforation of an up-
per right central incisor. A. Preoperative radiograph. B. Medication with calcium hydroxide for one week. C. About 4mm
of MTA have been positioned in the apical one third to seal the apical perforation. D. Postoperative radiograph. E. One
year recall.
880 Endodontics

Fig. 30.17. Internal resorption (progressive inflammatory secondary to infection) with intraosseous perforation of an upper left central incisor, already endodontical-
ly treated.A. Preoperative radiograph. The defect was treated with lateral condensation. B. An off angle radiograph shows the gutta-percha cones laterally conden-
sed. C. A view of the gutta-percha cones through the micro mirror during the surgical procedure. D. The cast post. E. The Dovgan carrier is positioning gray MTA in
the defect. A few pieces of Collacote have been positioned on the bottom of the bony defect to collect the debris of MTA. F. The resoption has been filled with Gray
MTA. G. The cotton pliers are used to remove the Colla cote. H, I. The suture. J, K. Removal of the suture after 24 hours (continued).
30 - Root Resorption 881

Fig. 30.17 (continued). L, M. The suture has been removed. N. Postoperative radiograph. 0, P. Two year recall.

Fig. 30.18. Internal resorption (progressive inflammatory secondary to infection) with intraosseous perforation of an upper left lateral incisor, already endodontically
treated.A. Preoperative radiograph. B. Since it was not possible to negotiate the canal apical to the defect,after packing with the Obtura II the coronal portion of the
root canal, a surgical flap has been raised and the orifice of the canal was visualized under the operating microscope. C. Checking the working length (continued).
882 Endodontics

Fig. 30.18 (continued).D. Checking the tug back of the gutta-percha. E. The root canal has been cleaned, shaped and now is dried. F. Cone fit.G. The obturation of the
apical portion of the root canal has been completed. H. The defect after the back-packing with the Obtura. I. The defect has been filled with white MTA. J, K. Suture
of the flap. L. Postoperative radiograph (continued).
30 - Root Resorption 883

Fig.30. 18 (continued).M. Removal of suture 24 hours later. N.Clinical healing at the six month recall: no scar and
no tattoo are evident. 0. Three year recall.

Fig. 30.19. Internal resorption (progressive inflammatory secondary to infection) with supraosseous perforation in a lower left lateral incisor. Note the aggressiveness of the
lesion when the radiograph obta.ined atthe first visit (A) is compared to the preoperative film performed 3 days later (B):the mesial wall of the defect no longer exists.C.The
inflammatory tissue already faces the buccal wall. D.The lacuna following removal of the inflammatory tissue. E. Histological section of the tissue responsible for the defect
(xl 0). F. Detail of the upper region of the preceding figure.A small piece of dentin is visible in the tissue (x40).G. Postoperative radiograph. H. Recall radiograph 2 yea rs later.
884 Endodontics

Fig. 30.20. External resorption (progressive inflammatory secondary to infection) secondary to pulp necrosis of a lower right second premolar.A. Preoperative
radiograph. B. Cone fit: given the site of resorption, the radiographic terminus of the canal coincides with the true end of the endodontium.C. Postoperative
radiograph. D. Recall radiograph 2 years later.

Fig. 30.21. External resorption (progressive inflammatory secondary to infection) in the distal root of a lower left first molar. A. Preoperative rad iograph. B.
Recall radiograph 2 years later.
30 - Root Resorption 885

Fig. 30.22. Surgical endodontic therapy of the resorbed mesial root of a lower first molar. Because of the preceding incongruous therapy and the certain difficulty of
achieving a good seal nonsurgically, the retrograde approach was chosen. A. Preoperative radiograph. B. Postoperative radiograph.C. Recall radiograph 4 years later.

When the root apex is very resorbed and the root ly obturated with traditional techniques.
is straight, so that it is possible to see the apical one Just as the fistula can migrate from its site of origin,
third of the canal through the operating microscope, and just as the lesion of endodontic origin can wrap
in such case the MTA can be used like it was an open around the apex of the adjacent tooth with vital pulp,
apex (Fig. 30.23). Once the MTA has been carried and possibly fistulizing through its periodontium (Figs.
checked radiografically, a wet cotton pellet is positio- 4.10, 8.8), external inflammatory resorption can occur
ned in contact with the material, to allow its set. At in the adjacent tooth, while the apex of the affected
the next visit the root canal can be three-dimensional- tooth does not appear to have been resorbed at all 37

Fig. 30.23. External resorption (progressive inflammatory secondary to infection) of a lower left second molar. A. Preoperative radiograph. B. An apical plug of MTA
has been positioned and condensed in the last 5 mm of the resorbed root canal. C. Two year recall.
886 Endodontics

(Fig. 30.24). Obviously, in these cases as in external sorption, namely the bacteria, has been removed from
progressive resorption secondary to pressure (e.g., or- the root canal itself.
thodontic movement or cysts), the vitality of the pulp External inflammatory resorption can occur even in
is preserved, and the thermal and electric pulp tests teeth that have sustained significant trauma, such as
are essential in pointing to the correct diagnosis. Once subluxation, intrusion, extrusion, or complete avul-

Fig. 30.24. External resorption (progressive inflammatory secondary to infection) of the apex of an upper left lateral incisor, caused by pulp necrosis of the adjacent
canine, treated inadequately. The lateral incisor responds positively to the pulp tests. A. Preoperative radiograph. B. Postoperative radiograph. C. Recall radiograph
12 months later: the resorption has been arrested, the lesion has healed, and one can identify the lamina dura around the apex of the lateral incisor whose pulp has
obviously preserved its vitality.

the diseased tooth has been treated, the apical resorp- sion. In such cases, resorption proceeds very rapidly,
tion of the adjacent tooth, which has maintained its simultaneously involves the entire root, and can lead
pulp vitality, ceases. to complete loss of the tooth in a few months.
As therapy of external inflammatory resorption, the Radiographically, signs of root resorption with de-
Swedish schools 28•88 recommend a temporary dressing struction of alveolar bone and consequent periradicu-
with calcium hydroxide to maintain in the root canal lar radiolucency are visible. Histologically, the areas of
until a continuous periodontal ligament around the resorption represented by lacunae of cementum and
root outline can be radiographically identified. dentin are surrounded by intense inflammation of the
It is this author's belief that calcium hydroxide adjacent periodontal ti.ssue.33
should be used any time it is not immediately possi- Following trauma, there are areas of necrosis of the pe-
ble to use gutta-percha, because the clinical or anato- riodontal ligament at which external resorption begins.
mical situations impede its use. Examples of such si- Also as a consequence of trauma, the pulp becomes ne-
tuations are a canal that cannot be dried and an im- crotic and then, both by anachoresis (see Chapter 23)
mature apex or internal resorption with perforation. and through cracks in the enamel and dentin, it is easi-
In these cases, calcium hydroxide must be used as a ly infected.88 As a consequence, the areas of the root sur-
temporary medication until the clinical or anatomical face in which the external resorption is occurring (if the
situation improves. In external inflammatory resorp- pulp had remained vital, it would probably have been
tion, calcium hydroxide does not act at the apical fo- only areas of transient resorption) are, through the den-
ramen; much less does it cause regeneration of the tinal tubules, in direct communication with the bacteria
dentin or cementum that has been destroyed. It sim- and toxins present within the root canal. In this way, the
ply permits arrest of the resorptive process and re-for- root resorption begun by trauma comes to be sustained
mation of the periodontal ligament, but this would oc- by microbial stimuli arising from the infected root canal.
cur even in its absence or if gutta-percha was present Each lacuna of resorption, free as it is of radicu-
in the root canal. It is not the calcium ions in the canal lar cementum, becomes a "portal of exit" for the nu-
that lead to repair, but the fact that the cause of the re- merous dentinal tubules that open into the periodon-
30 - Root Resorption 887

tium. This explains why in traumatized teeth the re-

sorption involves not just the apex, but the entire ro-
ot and, furthermore, why it evolves rapidly. This also
explains why this type of resorption progresses much
more quickly in children, who have thin canal walls
and very wide dentinal tubules, than in adults. 2•10
In the case of replantation of avulsed teeth, extirpa-
tion of the pulp is recommended as early as possible
to prevent the development of inflammatory resorp-
tion. 20 It is therefore a good idea to have these patients
follow up several days after replantation and apply a
temporary calcium hydroxide dressing to prevent fur-
ther trauma to the periodontal ligament with the con-
densation manoeuvres. This dressing is then substitu-
ted by gutta-percha as soon as the tooth has consoli-
dated within the alveolus, generally after 4-7 weeks. 74
Only in the case of the tooth with an immature apex
and of a very short extra-alveolar time, can one hope
for revascularization and thus preservation of the vitality
of the pulp tissue. In these case, therefore, it is legitima-
te to postpone endodontic therapy until the appearance
of the first clinical or radiographic signs of inflammatory
resorption, in the hope of preserving a vital pulp. 64



Resorption with ankylosis occurs after extensive ne-

crosis of the periodontal ligament. It is characterized
by the fusion of the alveolar bone with the root surfa-
ce.6 The bone substitutes the dentin and for this rea-
son it is also called "resorption with replacement."
More than a result of a pathologic process, it must be
seen as an "error," since the cells responsible for bo-
ne remodeling cannot distinguish the dental hard tis-
sues from the bone .88
The process begins with ankylosis · or with the co-
lonization of osteoblasts and osteoclasts from the mar-
row spaces (Fig. 30.25A), with the subsequent depo-
sition of hard tissue on the root surface which gra-
dually comes to occupy the space of the periodon-
tal ligament and fuses the dental hard tissues with the
surrounding bone (Fig. 30.25B). With the loss of the
periodontal ligament and cementoblasts, the dental
hard tissues are resorbed by the activity of the oste-
oblasts and osteoclasts in the same way in which the
bone is remodeled (resorption/ apposition) under the
'Ankylosis of a tooth is defined as solid fixation of the tooth resulting from fu-
sion of the cementum with the alveolar bone, with obliteration of the peri- Fig. 30.25. A-C. Bone is replacing cementum and dentin (Courtesy of Dr. R.
odontal ligaments• Pontoriero).
888 Endodontics

stimulation of the parathyroid hormone. Obviously, are not under the influence of parathyroid hormone. 58
in consequence of the osteoclastic activity, the dentin This may explain why the dental hard tissues are
cannot reform, and the result of the subsequent acti- normally protected from resorption, while the adjacent
vity of the osteoblasts is the production of bone in re- alveolar bone is constantly remodeled. It has been
placement of the dentin. 47 shown 47 that, by the time a permanent dentoalveolar
Slowly but inexorably, this process leads to com- ankylosis was established, the cementoblasts and
plete "disappearance" of the root and loss of the tooth the periodontal ligament have been destroyed,
(Fig. 30.26). and the root of the tooth is covered by osteoblasts
This type of resorption occurs primarily after and osteoclasts in continuity with the cells of the
replantation of avulsed teeth that have experienced medullary spaces of the adjacent bone. At this point,
almost total destruction of the periodontal ligament5 the osteoblasts, under the stimulation of parathyroid
(Fig. 30.27). In these cases, it is thought that the hormone, can mediate the root resorption in the
same way as they take part in the sequence of events
leading to bone resorption.
It is clear that the terms ankylosis and replacement
resorption cannot and must not be used as though
they were synonyms, even if the permanent ankylo-
sis seems to be associated with root resorption and
its replacement by bone.15•16 Ankylosis should be re-
stricted to those cases in which the alveolar bone has
fused with the dental hard tissues, while replacement
resorption, the succeeding phenomenon, must be un-
derstood to mean root resorption of an ankylosed
tooth by cells originating in the surrounding medul-
lary spaces. This category of resorption would there-
fore be more correctly called replacement resorption
in teeth with ankylosis.
Fig. 30.26. Replacement resorption of the root of a lower right second premo-
lar, resulting from an intentional replantation that the patient reported having Resorption usually begins in the apical one third of
undergone 6 years prior. the root. 9 This seems to be related to the smaller num-
ber of attached periodontal ligament fibers in the api-
denuded root surface is colonized by progenitor cells, cal region as compared to the other areas of the root.
arising from the adjacent medullary spaces that have In fact, this anatomical characteristic makes the apical
osteoclastic and osteoblastic activities. These cells region more vulnerable to resorption (c.f.: progressi-
continue the normal healing process that begins in ve resorption secondary to pressure during orthodon-
an alveolus following extraction. 57 The integrity of tic movement). 19
the fibers of the periodontal ligament that insert onto Radiographically, the tooth undergoing ankylosis
the cementum therefore seem to be of fundamental presents with disappearance of the periodontal liga-
importance in protecting the root from resorption. ment, loss of the outline of the root which, following
Recent studies have demonstrated that a healthy an irregular line, appears to be replaced by bone.
periodontal ligament normally has an "anti-invasion There is no sign of periradicular radiolucency, which
factor" that hinders colonization of the bone cells. It would be typical of inflammatory resorption.
also seems that epithelial rests of Malassez play an im- Clinically, the tooth completely loses its physiologic
portant role in determining the resistance of the den- mobility. On percussion, it produces a more metallic
tal root to resorption and in impeding the ankylotic fu- sound than the surrounding healthy teeth (Fig. 30.27M).
sion between alveolar bone and tooth.59•84 These two clinical signs occur very early. Indeed,
Melcher 68 and Morris et al. 69 believe that the whole the diagnosis of ankylosis may be made even before
periodontal membrane inhibits osteogenesis, so that the appearance of radiographic signs. 3
damage or removal of cementoblasts inevitably leads In young patients the replanted tooth often appears
to ankylosis. 57 to be in infraocclusion (Fig. 30.27L), since the ankylo-
It is not known why an ankylosed tooth is resorbed. sis maintains the tooth in its replanted position and
It seems that, in contrast to osteoblasts, cementoblasts thus disturbs normal growth of the alveolar process.11
30 - Root Resorption 889

Fig. 30.27. Replacement resorption of the root of an upper left central incisor that was traumatically avulsed and replanted after an extra-alveolar period of 6 hours
during which it was preserved under dry conditions. A. Preoperative radiograph 12 hours after the replantation . B. Two weeks later, the canal was cleaned, shaped,
and temporarily obturated with calcium hydroxide.The treatment was maintained for 4 weeks. C. Postoperative radiograph:the calcium hydroxide has been remo-
ved, and the canal has been obturated with warm gutta-percha. D. Recall radiograph 8 months later. E. Clinical appearance of the dental crown after 8 months. F.
Recall radiograph at 13 months. G. Recall radiograph at 15 months. H. Recall radiograph at 19 months. I. Recall radiograph at 25 months. J. Recall radiograph at 32
months. K. Recall radiograph at 38 months (continued).
30 - Root Resorption 891

for which there is no good therapy.47

The type of splinting performed on the traumatized
tooth and the time for which it is maintained also
seem to have great importance. Rigid splints should be
avoided, and they should be maintained for no longer
than 7-10 days, since they have a negative effect on
ankylosis. The tooth must be quickly exposed to normal
functional stimuli. 3 The splint must therefore be rigid
enough to keep the tooth in its alveolus, yet flexible
enough to stimulate the periodontium functionally. 23
The integrity of the fibers of the periodontal ligament
of the replanted tooth seems to depend also on the pre­
sence or absence of a calcium-hydroxide medication
within the root canal. Andreasen 17 has demonstrated
that teeth that had been treated with calcium hydroxide
at the time of replantation experience replacement re­
sorption, especially in the apical region, at a higher rate
than teeth replanted after only pulp extirpation or fol­
lowing gutta-percha obturation. It appears that calcium
hydroxide injures the periodontal ligament (starting the
process of ankylosis and replacement resorption), cau­
sing coagulative necrosis in the apical region, as a re­
sult of its diffusion through the apical foramen.
For this reason, Andreasen recommends postponing
calcium hydroxide therapy in replanted teeth for about
two weeks, at least until a ce1tain degree of repair has
occurred in the fibers of the injured periodontal ligament.
As previously stated, calcium hydroxide can be maintai­
ned for 4-7 weeks,74 after which the canal can be obtura­
ted with gutta-percha using the traditional techniques.
In replanted teeth is obvious the importance of
distinguishing ankylosis from inflammatory resorption,
since the former has a poor prognosis and is a sure
sign of eventual loss of the tooth, while the latter has
a favorable prognosis.
Inflammatory resorption occurs frequently after the
replantation of permanent incisors especially in pa­
tients from 6 to 7 years of age.
The distinction is based on clinical and radiographic
signs. The tooth appears to be very mobile, extru­
Fig. 30.28. Long term result of replantation of an upper left central incisor that
ded, and sensitive to percussion, on which it gives a
was traumatically avulsed, preserved in a physiologic saline solution, and re­ characteristic dull, "cracked" sound. Radiographically,
planted after 3 hours. A. Preoperative radiograph 6 hours after replantation. B. there is a radiolucency around the root. If untreated,
The tooth has been stabilized. After only one week, the periodontal ligament
appears to have repaired itself. C.The recall radiograph after 2 years shows no inflammatory resorption may lead to loss of the tooth
sign of ankylosis or replacement resorption. D. 15 year recall. few months after replantation. As already stated, the
resorption is caused by pulp necrosis, and with ade­
foreign material remaining on the root surface, and quate endodontic therapy it can be arrested.
the prophylactic antibiotic therapy, which nonetheless In some cases, the replanted teeth can simultaneou­
can only slow. down and cannot prevent the resorp­ sly demonstrate inflammatory and replacement re­
tion associated with permanent ankylosis, a process sorption. This can be explained by superimposition of
which must be seen as a hormone-regulated process inflammatory resorption when replacement resorption
1110 Endodontics

The root anatomy is especially important when the- Methylene Blue Staining
re are more than two canals in one root. This occurs After the bevel is refined and crypt management
most commonly in maxillary bicuspids and in the me- is completely under control, the apical surface is rin-
sial roots of nearly all molars. However, the operator sed and dried with a Blue-Flo (Vista Dental), or Blue
has to be constantly aware that multiple canals can Max (Ultradent) plastic tip in a Stropko Irrigator (Vista
occur in any root, no matter what tooth is being sur- Dental). Either one works well and will be referred
gerized. to, from this point on, as a "blue plastic tip". At first,
The refinement of the bevel is best accomplished the dried surface does not show any anatomical ano-
with a #l l 71 carbide, surgical length, tapered fissu- malies, and there may not be any present to be con-
re bur (Brassler) in an Impact Air 45 handpiece (Figs. cerned about (Fig. 34.59 A). To be sure that all is-
34.46, 34.47). This hand piece has no air exiting from sues have been addressed, the dried surface is stained
the working end, which eliminates the possibility of with 1% methylene blue (SybronEndo, Vista Dental)
an air emphysema or air embolism beneath the flap. A (Fig. 34.60). It is important to allow the methylene
standard high-speed handpiece should never be used blue stain (MBS) on the tooth for a short period of ti-
for the above reason. On occasion, the refinement of me before gently flushing with sterile water. If there
the bevel can cause additional bleeding. The operator are any fractures, isthmus tissue, accessories, or any
should address this problem before proceeding any other anatomical variations present, the staining pro-
further. Remember: 1) Sometimes it is necessary to go cess will greatly enhance the operator's ability to vi-
back a step and 2) ft is of the utmost importance to ful-
sualize them. Also, the MBS will display the periodon-
ly complete one step before proceeding to another! tal ligament and so the operator can be sure the apex
has been completely resected (Fig. 34.59 B, C). If after
MBS, there is an accessory canal present, the easiest
answer is usually to bevel past it and restain to be su-
re the defect is completely eliminated. Or, if the occa-
sion allows, the accessory can be "troughed out", lea-
ving the bevel as is.

Fig. 34.59. A. It is difficult, and sometimes impossible to visualize anatomi-

cal variations on the unstained root surface. B. After staining with methylene
blue, any anatomic variations, such as: isthmus tissue, accessory and/or missed
canals, minute cracks, small fractures, periodontal ligaments, leaking fillings,
etc. are much more evident (Courtesy of Dr. Gary Carr). C. Another example of
a root surface after staining:the periodontal ligament is evident and the retro-
prep is well centered (Courtesy of Dr. Arnaldo Castellucci). Fig. 34.60. Unit dose Methylene Blue by Vista Dental, Racine, WI, USA.
34 - Micro-Surgical Endodontics 1111

When two canals are present in one root, it is ne- ULTRASONIC ROOT END PREPARATION (REP)
cessary to prepare for an isthmus between the two
canals even if the MBS didn't reveal one. It has be- With the advent of ultrasonics, and the array of tips
en shown that in the mesiobuccal roots of the ma- available to the operator, it is now possible to prepa-
xillary first molars with two canals, the 4mm section re the root end adequately and to predictably accept
displayed a partial or complete isthmus 100% of the several different root-end filling materials. The ultra-
time.71 In studies of maxillary molars, two canals sonic units vary as to performance and reliability. The
can be present as much as 93% of the time in the piezo electric units (Amadent, EMS, Satelec-PS, and
mesiobuccal root of the maxillary first molars, and Spartan) are the most common and all have a good
59% in maxillary second molars.64 It is important to reputation for reliability and accept most tips on the
routinely prepare the isthmus, whether, or not, it is market. Some older EMS units only accept tips made
defined by staining; because post surgical remode- for its European thread, but the newer models accept
ling of the beveled root surface may re-expose the all of the common tips manufactured in the United
canal system to bacterial invasion.69 Although stai- States.
ning doesn't reveal the presence of an isthmus, it
may lie just below the surface only to be exposed The basic requirements for a REP must include
during the remodeling process. The rule is to al- the following: 7
ways prepare an isthmus when there are two canals
in one root (Fig. 34.61). 1) The apical 3mm of the root end canal system
must be cleaned and shaped.
2) The preparation is parallel to the anatomic
outline of the pulpal space.
3) There is adequate retention form.
4) All isthmus tissue is removed.
5) The remaining dentinal walls are not
weakened, or fractured.

The REP can be accomplished utilizing a multitu-

de of different tips with various ultrasonic units. There
are multitudes of ultrasonic tips to choose from that
come in all shapes and sizes. The various ultrasonic
tips can be divided into three groups: uncoated, che-
mically coated, and diamond coated. Clinically spea-
king, the cutting efficiency of an uncoated tip is not
as great as the diamond coated tips, and the chemical-
ly coated tips (zirconium or titanium nitride), are so-
mewhere in between. Some newer ultrasonic tips uti-
lize port technology that delivers a constant stream

Fig. 34.61. Even though MBS may not show the presence of an isthmus, it may
lie just below the surface and needs to be prepared for a predictable long
term result
1112 Endodontics

of water aimed directly to the working end of the tip The niost important consideration is not the brand
(Fig. 34.62). They are very efficient and provide ex- of the unit, or type of tip, but how the instrument is
cellent vision for the operator during the REP. When used. The tendency for the new operator is to use
using these tips, the operator must keep in mind that the ultrasonic in the same manner (pressure and po-
the water flow dampens the action of the tip and a hi- wer-wise) as the hand piece and to begin with too
gher power setting may be necessary to increase the much pressure and too high a power setting. These-
cutting efficiency. cret is an extremely light touch and at the lowest be-
ginning power setting that is efficient for the tip in
use. The lighter the touch, the more efficient the cut-
ting and the lower power setting needed. Using the
lowest efficient power setting will also extend the li-
fe of the tips. The correct amount of water is also
important. If too much spray is used, visibility and
cutting efficiency are both decreased. If too little is
used, the necessary amount of cooling, or flushing
of the debris will not occur. This can cause over he-
ating of the cavo-surface, micro-cracks, and decrea-
sed vision may be the undesired result. Numerous
studies have shown that when ultrasonics is used
properly, micro cracks are not a normal occurrence
and should not be a concern to the operator.4,39,47
It is therefore important to arrive at a balance betwe-
en the amount of water coolant spray, power setting,
and pressure used, as soon as possible in the begin-
ning of the procedure.
Since the advent of ultrasonic techniques, the
use of a rotary handpiece is no longer accep-
ted as the standard of care for apical surgery.
The resultant use of ultrasonics for REP, instead of the
conventional hand.piece, has clearly demonstrated the
ability to provide an anatomically correct REP, better
sealing of the apical canal system, and fewer perfora-

Fig. 34.62. A-C. The coated ultrasonic tips, with water ports near the wor-
king tip, help prevent heat build-up and keep REP clean during prepara-
tion. The diamond coating on this KIS tip makes it a very efficient instru-
ment for REP
34 - Micro-Surgical Endodontics 1113

It is important to have the correct tip available when eking groove made by the explorer. This permits ex-
needed while preparing the REP. The essential tips re- cellent vision, but the groove should only be deepe-
commended to have on hand are: ned enough, without the water spray, to make a more
definitive "tracking groove" for the tip to follow. The
1) anterior angled tips (90° and "back-action" water spray should be resumed as soon as possible to
70°) (Fig. 34.63 A) allow for the cooling and cleaning of the tooth surfa-
2) posterior angled tips (Fig. 34.63 B). ce being prepared.
If difficulty is experienced when trying to establish
a tracking groove, especially if the isthmus is very
thin, the "Dot Technique" can be used. If the isthmus
prep walls are too thin, it might be advisable to con-
sider "going back a step" and do a little more beve-
ling, then proceed to the REP. Staining the isthmus,
prior to this step will greatly enhance the vision and
accuracy of the preparation. With a sharp pointed tip
inactivated and no water spray, place the tip exact-
ly where desired on the isthmus, and then ve1y quic-
kly "tap" the rheostat for just an instant. Then repeat
the process again, and again, as many times as neces-
sary, until there are a series of "dots" created on the
isthmus. Then it is a simple matter of connecting the
dots to create the initial shallow "tracking groove" as
described in the preceding paragraph (Fig. 34.64). In
this manner, accuracy is completely controlled and the
chance of "slipping off" a small, or thin, beveled sur-
face is eliminated.

Fig. 34.63. A. Carr Tips angled at 90 ° and 70° (back action). B. Posterior angled
tips (Kis Tips, Obtura Spartan).

It is also suggested that there be a variety of sizes

and coatings available if needed. If the canal is large
and/ or filled with gutta-percha, a large, coarse, dia-
mond coated tip can be used most efficiently. The va-
rious left and right tips are necessary on occasion, but
in most cases, the anterior angled tips will suffice. The
key is to slow down and be gentle, using a light, bru-
shing movement.
Fig. 34.64. (1) Whenever there are 2 canals in one root, the isthmus should al-
For the preparation of an isthmus, a CTX explo- ways be prepared. (2) A simple way to accurately prepare the isthmus is to
rer (SybronEndo) can be used to "scratch" a "tracking lightly place a sharp US tip where desired, with the water off, and "tap"the rhe-
ostat to activate it for just-a-second. (3) After several "dots" are placed, it is now
groove". Then, with the water spray turned off, a ve- a simple matter to connect the dots and create an initial "tracking groove" and
ry sharp pointed tip can be used to deepen the tra- prevent inadvertent"slipping-off"the desired isthmus track.
1114 Endodontics

As soon as possible, after the groove is just deep Throughout the process, it's is important to occasio-
enough to guide the tip, the water spray is turned nally use the Stropko Irrigator to rinse and dry the ro-
back on. Then, while using a fine, pointed ultraso- ot end preparation to remove debris .. This facilitates
nic tip, the preparation is deepened to approximately inspection of the REP, which should be done at va-
3mm. A larger tip can then be used to flatten out the rying magnifications to be sure it is kept within the
floor of the root-end preparation (Fig. 34.65). long axis of the canal (Fig. 34.66 A-C ). The cleaning,

Fig. 34.66. Utilizing the Stropko lrrigator, a precise, controlled stream of wa-
ter or air can directed into the root-end preparation (REP) and effectively en-
hancing vision and the inspection process. A. A fine stream of water is used to
Fig. 34.65. A-D. Diagrammatic view of the four steps of the preparation of isth- flush out debris. B. A regulated stream air is used to dry the REP for better vi-
mus (Courtesy of Dr. Gary Carr). sion. C. The clean and dry REP is ready for inspection.
34 - Micro-Surgical Endodontics 1115

drying, and inspection of the REP is more efficient if interior of the REP can be easily viewed. Always keep
the irrigating needle has been previously bent simi- in mind that cleanliness and dryness are essential for
lar to the ultrasonic tip that is used for the REP (Fig. good visibility when using the SOM. The most com-
34.17 A). A pre-cut and pre-bent 25 or 27gauge endo- mon errors made during REP are:
dontic irrigating needle (Monoject) works well for this Failure to resect completely through the root (Fig.
purpose. Rinsing and thoroughly drying the REP is es- 34.69).
sential for good vision. After drying the REP, it is ne- The preparation is not within the long axis of the
cessary to check the REP, at varying magnifications, root (Fig. 34.70).
for any remaining debris or unwanted material and to
be sure the REP is extended properly to include "fins"
and other anatomical aberrations that might be pre-
sent (Fig. 34.67). Various sizes of micro-mirrors can
be used to periodically inspect the preparation (Fig.
34.68). If an endoscope is available, many times the

Fig. 34.69. The retrofill has been positioned without resecting completely
through the root: the apical delta remained untouched, leaving three portals
of exit unsealed (Courtesy of Dr.John West).

Fig. 34.67. The inspection of the clean and dry REP.

Fig. 34.70. The preparation is not within the long axis of the root (Courtesy of
Fig. 34.68. EIE miniature retromirrors (Courtesy of Dr. Gary Carr). Dr. Gary Carr).
1116 Endodontics

The isthmus has not been adequately prepared (Fig. Failure to inspect and remove all debris from the
34.71). preparation.
Incomplete buccal or lingual extensions to the pre- Of particular interest is the buccal aspect of the in-
paration (Fig. 34.72). ternal wall of the prep. Often this area is not cleared
Failure to recognize and deal with anatomical varia- of all debris due to the angulation of the instrument
tions or complexities (Fig. 34.73). within the canal system (Fig. 34.74). If there is so-

Fig. 34.71. A. The preoperative radiograph shows a failing retrofill in an upper first premolar. 8. The two canals had been obturated separately and the isthmus had
been missed. C. The isthmus has been adequately prepared and sealed. D. Two year recall (Courtesy of Dr. Arnaldo Castellucci). E-G. More examples of missed isth-
muses (Courtesy of Dr. Gary Carr).

Fig.34.72.A, 8. The preparation has not been extended com-

pletely in a buccal to lingual direction (Courtesy of Dr. Gary
34 - Micro-Surgical Endodontics 1117

Fig. 34.73. A. The upper right central incisor has two fistulous tracks, one from the apical lesion and the other from the lateral lesion. Due to the crown and the post,
the surgical procedure is indicated. B. Postoperative radiograph. Both the root apex and the lateral canal have been filled. C. Two year recall (Courtesy of Dr. Arnaldo

Fig. 34.74. During the inspection process, one of the most common observa-
tions is gutta percha remaining on the buccal wall of prep (Courtesy of Dr
Gary Carr).

me gutta-percha "streaming up" the side of the wall, will enable the operator to verify the REP is comple-
and the REP is finished, the best thing is to take a ted. At this time, the REP is etched with a 37% phos-
small plugger and fold the gutta-percha coronally so phoric acid gel (Ultradent) to remove the smear layer
the wall is clean once more. It is usually futile to try if desired. After 20 seconds, the REP is again thorou-
to remove those small bits of gutta-percha with an ul- ghly rinsed, dried and re-examined under varying po-
trasonic tip. wers of the SOM. If all is as desired, the root end pre-
After completion of the REP, the preparation should paration is complete and ready to be filled.
be rinsed and dried with the Stropko Irrigator and in- Use of antimicrobials, such as chlorhexidine, in the
spected to be sure it is clean, within the long axis surgical crypt is debatable. Possible adverse effects on
of the canal system, and properly extended. The use bonding REF materials and retardation of the healing
of micro-mirrors and va1ying powers of magnification process may be considerations in its use.
1118 Endodontics

SECTION 5: ROOT END FILLING (REF) offender, consistently exhibiting the greatest amount
of leakage. 1 These observations, accompanied by the
RooT END FILLING MATERIALS general controversy over the presence of mercury in
amalgam, strongly suggest that there is no valid rea-
The operator is now at a stage in the microsurgi- son to continue its use as REF material. The only re-
cal procedure where the tissues have been atraumati- al advantage to amalgam is the favorable radiopacity
cally retracted, the crypt is well managed and the REP (Fig. 34.75).
is ready to fill. Ideally, the materials used for the REF
should meet the following requirements: 8
1. Provide for easy manipulation and placement
with adequate working time.
2. Have dimensional stability after being inserted.
3. Be able to hermetically seal the root end
preparation and the entire resected root surface
(if desired). The author prefers to only seal the
RliP, leaving the resected root surface exposed.
4. Conform and adapt easily to the various shapes
and contours of the REP.
5. Be biocompatible and promote cementogenesis.
6. Be nonporous and impervious to all periapical
tissues and fluids.
7. Be insoluble in tissue fluids, not corrode or
8. Be non-resorbable.
9. Be unaffected by moisture.
10. Be bacteriostatic, or not encourage bacterial
11 . Be radiopaque, or easily discernable on
12. Not discolor tooth structure of the surrounding
13. Be sterile, or easily and quickly sterilizable
immediately before insertion.
14. Be easily removed if necessary.
15. Be non carcinogenic, and nonirritating to the
periapical tissues.

There are several materials that are currently avai-

lable for REF: amalgam, IRM, Super EBA (SEBA),
Optibond, Gerestore, and more recently, Mineral
Trioxide Aggregate (MTA). Research can be found
supporting any of the above materials and success has
been claimed for them. The author doesn't want to re-
commend or condemn any REF material (except amal-
gam) , but will generalize and relate his, and other's
experiences with them and opinions about their ap-
Amalgam and IRM were used for many years as
the only commonly available REF materials. However, Fig. 34.75. Of all root-end filling materials, amalgam displays the best
radiopacity. A. Pre-op radiograph of patient referred for surgical endodontics.
in almost every "leakage" study published during the B. Postoperative radiograph. C. Two year recall (Courtesy of Dr. Arnaldo
past few years, amalgam has proven to be the worst Castellucci).
34 - Micro-Surgical Encloclontics 1119

Super EBA REP, then gently compacted coronally with the appro-
Since the advent of the anatomically correct, ultra- priate plugger. For even a well-trained assistant this
sonic REP, Super EBA (SEBA) has become an accepted '
was often the most stressful part of the microsurgical
and widely used REF material (Fig. 34.76). Drs. Carr, procedure. Two to five of these small segments were
usually necessary to slightly overfill the REP. Another
problem experienced by many, was that SEBA was
unpredictable as to its setting time: sometimes setting
too quickly, and at other times, taking much too long
for the tired surgeon. The ambient temperature and
humidity had a profound effect on the setting time.
Cooling the glass slab used to mix the SEBA could ex-
tend setting time. At any rate, after the REF was com-
plete, an instrument and/ or a multi-fluted finishing
bur were used to smooth the resected surface, produ-
cing the final finish (Fig. 34.78). A mild etchant was

Fig. 34.76. The SuperEBA has been used for many years as a root end filling

Rubinstein, Ruddle and Castellucci popularized SEBA

in their many lectures over the past several years. A
recent study demonstrated a success rate of appro-
ximately 91.5% using SEBA. 57 The author used SEBA
routinely from 1992 to 1996 with favorable results and
full confidence of its sealing capabilities.
The major drawback of SEBA is its technique sensi-
tivity. The surgical assistant had to mix the SEBA un-
til it was a thick, dough-like consistency, and roll it in-
to a thin tapered point. The "dough-like" tapered end
of the thin SEBA "roll" was segmented and handed to
the doctor on the end of either a small Hollenbeck, or
spoon (Fig. 34.77), and subsequently inserted into the

Fig. 34.77.The tapered end of the SuperEBA roll is being positioned inside the Fig. 34.78. Once the material is completely set (A), the excess is removed and
retroprep (Courtesy of Dr. Arnaldo Castellucci). the retrofill is finished (B). (Courtesy of Dr. Arnaldo Castellucci).
1120 Endodontics

then used to remove the "smear layer" that was crea-

ted during the final finishing process (Fig. 34.79).

Fig. 34.79. Typical post operative, clinical appearance of SEBA root-end filling
material in the buccal root-ends of a maxillary first molar (Courtesy Dr. Yosef

The removal of the "smear layer" and the demine-

ralization of the resected root end are thought to en-
hance cementogenesis, the key to dentoalveolar hea-
ling, by exposing the collagen fibrils of the dentin and
cementum. 14 One of the earlier disadvantages of SEBA
was a radiopacity comparable to that of gutta-percha,
so it was necessary to educate the new referring doc-
Fig. 34.80. A. Pre operative radiograph. B. Two year recall. The radiograph
tor that a REF had indeed been performed (Fig. 34.80). shows the radiodensity of a SEBA REF is similar to gutta percha. (Courtesy of
Today, this is not an issue because the profession is Dr. Arnaldo Castellucci).

not as "fixated" on radiopacity as in the past. Most

new materials (composites, MTA, glass ionomers, etc.)
have a similar radiopacity to that of SEBA and gutta- and demonstrates biocompatibility to the surrounding
percha. tissues. 61
Optibond (SybronEndo, USA) is also a very popu-
Bonding lar composite for bonding in the REP. It has excellent
Bonding, using composite REF materials, is now flow ability, easily placed with a Carr explorer, ade-
possible due to the ability to have total control over quate working time, and is dual-cure. The following
the apical environment (crypt management). It is es- series of pictures demonstrate a typical Optibond REF
sential that the crypt management process is uncom- in a maxillary first bicuspid shows how the insertion
promised if successful bonding techniques are desi- of the selected material, and curing by light is accom-
red. Even a small amount of contamination can cause plished in a routine manner when bonding into the
a failure of the bond to the dentin surface and result REP (Fig. 34.81). Note: Since the light source for the
in micro-leakage. 45 Theoretically, any dual cure com- SOM is so intense the light source on the microscope

posite can be used as a REF material. should be minimized as much as possible while pla-
Gerestore (Den-Mat, USA), a glass ionomer compo- cing a light cure or dual cure composite to prevent a
site, is popular to use as a REF because of its ease of signijicant decrease in setting time. Orange filters are
use and good clinical properties. It has good flow abi- readily available to replace the "blood filter" on most
lity, dual-cure properties, dentinal self-adhesiveness, SOM light sources. Using these orange filters, gives
34 - Micro-Surgical Endodontics 1121

Fig. 34.81. A. Micro-mirror view of the finished palatal root-end preparation. B. Micro-mirror view of the fi-
nished buccal retroprep. C. Using the Carr explorer to place Optibond into the palatal root-end prepara-
tion. D. Using the Carr explorer to place Optibond into the buccal root-end preparation. E. Light curing is
initiated to begin the dual cure process of both root-end fills. F. The completed palatal root-end fill with
a "mushroom-like" cap over the entire root-end bevel. G. The completed buccal root-end fill with a shal-
low"mushroom-like" cap.

the necessary working time when placing light cu-

red, or dual cured materials (Fig. 34.82). For most mi-
croscopes, an orange filter is available that easily and
inexpensively replaces the "blood filter" on the SOM.
After the composite is completely cured, the "mushro-
om-like" cap can be left alone and the REF is comple-
te. Or, if desired, the REF can be finished with a high
speed finishing bur and the resected root end etched
with 35% phosphoric acid gel (Ultradent) for about
15-20 seconds, to remove the "smear layer" and to de-
mineralize the surface.
Studies have shown a good long-term healing with
resin bonding techniques and many operators used it
as their technique of choice. 58 It is imperative that go-
od hemostasis is achieved so the bonding process is
Fig. 34.82. Using an orange filter before placing either a light cured or dual cu-
not contaminated with moisture. One of the disadvan- red composite gives the operator the working time necessary to place the
tages of some composite resins is their poor radiopa- material.

city, necessitating education of the patient and/ or re-

ferral source.
However, there is controversy as to whether the re- rial is placed (usually Gerestore or Optibond) over the
sected surface of the root should also be coated with entire resected root surface with the intention of sea-
the bonding material. 23 A "cap", or "dome", of mate- ling all of the exposed tubules .32 The operators cove-
1122 Endodontics

ring the resected surface believe it is necessary to en- ding tissues.1•40 ·67 MTA has been shown to have supe-
sure a good seal and the predictability would be bet- rior sealing qualities to either SEBA or amalgam. 72 The
ter. On the other hand, there is also the opinion that cellular response to MTA is also proven to be better
the exposed tubules are not a factor concerning the than IRM and does stimulate interleukin .production
predictability of the healing process. In fact, it is be- indicating biocompatability with adjacent cells. 34 •48
lieved that nothing would heal as well, or was more The main advantage of MTA is the forgiving han-
biocompatible than the clean, exposed dentin of the dling qualities. The material is easily placed with one
apically resected surface. 14 The author does not wony of the various MTA carriers. Some available carriers
about whether the exposed apical surface is covered used to place MTA into the REP include the Retrofill
or not, and is convinced the ju1y is still out on this is- Amalgam Carrier (Miltex, York, PA, USA), the Messing
sue! Clinical observation indicates that if all steps are Root Canal Gun (Miltex, York, PA, USA), Dovgan MTA
done properly, the surgery will be successful if the Carriers (Quality Aspirators, Duncanville, TX, USA)
REF is "mushroomed", or not. (Fig. 34.84 A, B), the MAP System (Produits Dentaires,
Vevey, Switzerland) (Fig. 34.85), the Lee MTA Pellet
Mineral Trioxide Aggregate (MTA) Forming Block (G. Hartzell & Son, Concord, CA, USA)
More recently, MTA (Dentsply Intl) has become ve- (Fig. 34.86) and other types (Fig. 34.87).
ry popular and is widely used as a retrofill material The Lee MTA Pellet Forming Block is a very simple
(Fig. 34.83 A, B). There are many publications extol- and efficient device for preparing MTA to be carried to
ling the virtues of this material regarding its sealing the REP. 36•37 Properly mixed MTA is simply wiped on-
capabilities and its biocompatability with the surroun- to a specially grooved block and the Lee Instrument is

Fig. 34.84. A. The three Dovgan MTA Carriers have different diameters. The
smallest size is best used for perforation repairs. They must be cleaned imme-
Fig.34.83.MTA is marketed as ProRootand is available in one gram (1 gm) packa- diately after use to prevent clogging. B. The three Dovgan MTA Carriers produ-
ges, from Tulsa Dental, Dentsply International. A. White MTA. B. Grey MTA ced by Quality Aspirators (Duncanville, Texas).
34 - Micro-Surgical Endodontics 1123

Fig. 34.85. A. The Micro Apical Placement (MAP) System. B, C. The piston is in silicone to better slide inside the curved needle. D. Thanks to the triple curvature of the
needle, the placement of MTA is facilitate in posterior teeth. E. The MAP System is carrying the MTA in the retroprep. F. The retrofill has been completed and finished.
(Courtesy of Dr. Arnaldo Castellucci).

Fig. 34.87.There are several other designs of MTA carriers available on today's
Fig. 34.86. The MTA carrier designed by Edward Lee. market. Pictured are some of the different styles to choose from.
1124 Endodontics

used to slide the desired length of MTA out of the one requires the correct powder/ water ratio of MTA for ea-
of the appropriately sized grooves (Fig. 34.88). The se of use. It is imperative that the mix be wet enough
MTA adheres to the tip of the instrument allowing for not to crumble, but dry enough to prevent "slumping".
easy placement into the REP. Using this method of de- Adding or removing water from the mixture easily ob-
livery is really efficient and fewer "passes" are requi- tains the desired "working consistency".
red to adequately fill the REP (Fig. 34.89). As with any Using the appropriate carrier, the MTA is extruded
other MTA carrier, use of the Lee Pellet Forming Block in a pellet form and "patted" or "tamped" to place

Fig. 34.88. The Lee MTA Pellet Forming Block greatly simplifies the process of delivering MTA to the root-end preparation (REP). A. The MTA is mixed to a 'putty-like'
consistency, placed on the end of a spatula, then placed into the appropriate size groove in the Lee MTA Block and (B,C) pressed into the groove with a finger, (D) the
desired length of the MTA is selected, (E) and is removed by the instrument, then (F) carried to the REP in an efficient manner. (Courtesy of Dr. Arnaldo Castellucci).

Fig. 34.89. A. The pre-measured aliquot of mineral trioxide aggregate (MTA) is easily delivered into the root-end preparation (REP). B. A sufficient quantity of MTA can
be carried on the instrument to minimize the number of 'passes' the surgeon has to make. C. Because of the efficiency of this system, in most cases, only two to
three aliquots will suffice to slightly overfill the REP with MTA.
34 - Micro-Surgical Endodontics 1125

with an appropriate plugger-type instrument. These

MTA carriers have greatly reduced the fru stration of
placing MTA accurately and easily into the REP. Their
various sizes enable the operator to place the MTA in-
to the REP. For example, the smaller .8 mm tip fits in-
to the average REP so the MTA can be expressed to
the floor of the preparation to insure excellent place-
Condensation, as we normally perceive it in dentistry,
should be avoided while placing this material. The
secret to using MTA is to keep it dry enough so it
doesn't flow too readily (like wet sand), but yet moist
enough to permit manipulation, maintain adequate
"hydration", and a workable consistency. The desired
"working consistency" is easily accomplished by
using a cotton pellet (dry or moistened with sterile
water) or a Stropko Irrigator (Vista Dental, Racine, WI,
USA) using air or water, depending on whether it is
necessary to add or subtract water from the surface of
the MTA mixture.
If the assistant touches the plugger with an ultraso-
nic tip during the placement process, flow is enhan-
ced, entrapped air is released, and the density of the
fill is improved (Fig. 34.90). Doing this "densification"
procedure also increases the radiodensity (radiopaci-
ty) of the MTA in the post-op radiograph, but it is still
similar to gutta-percha (Fig. 34.91).
MTA has a working time of approximately two
hours, which is more than adequate for apical micro- Fig. 34.91. After "densification'; the radiopacity of the MTA root-end fill (REF) is
slightly enhanced. A. Postoperative radiograph: the retrofill has been made
surgery and takes much "time pressure" out of the sur- using MTA. B. Three year recall (Courtesy of Dr. Arnaldo Castellucci).
gical procedure. Finishing the MTA is simply a matter
of carving away the excess material to the level of the

resected root end. The moisture necessary for the fi-

nal set is derived from the blood, which fills the crypt
after surgery. The MTA is hydrophilic and depends on
moisture for the final set, so it is imperative that the-
re is enough bleeding re-established after crypt ma-
nagement to ensure the crypt is filled with blood, un-
less Calcium Sulfate is to be used for GBR. The filling
of the crypt with either blood, or a GBR material, can
be considered the final step in "crypt management".
This is especially true when MTA is used as the REF
Based on current studies the operator can choose
Fig. 34.90. A, B. To "density" the MTA already placed into the root-end prepara- any one of the above mentioned REF materials and
tion (REP), bubbles of air and excess water can readily be removed.The surgi- be comfortable that if the proper protocol is followed,
cal assistant lightly touches the ultrasonic tip to the non-working end of the
instrument in contact with the MTA. This "densification" process enhances the the apical seal will be predictable and healing une-
"workability" and the radiopacity of the MTA root-end fill (REF). ventful.
1126 Endodontic~

OPTIONAL MICROSURGICAL PROCEDURES the surgical flap was large by necessity, and the
patient's post-operative discomfort usually mea-
TRANS-SINUS APICAL SURGERY surable. Added to this, the surgeon's vision was
severely compromised and the proximity to po-
Apical surgery on the palatal roots of maxillary tentially problematic anatomical landmarks was
molars has traditionally been performed by laying always a concern (the greater palatine and naso-
a relatively large palatal flap (Figs. 34.92, 34.93). palatine arteries and nerves, for example) (Fig.
This very thick soft tissue was difficult to manage; 34.94).

Fig. 34.92. A, B. Sulcular palatal flap to perform periapical surgery on the palatal root of a maxillary first molar. C. The flap
is being raised. D. View of the amalgam retrofill. E. Suture (Courtesy of Dr. Arnaldo Castellucci).

Fig. 34.93. A. Semilunar palatal flap to perform pe-

riapical surgery on the palatal root of a maxillary
first molar. B. Suture (Courtesy of Dr. Melvin Harris,
Boston, Mass.).
34 - Micro-Surgical Endodontics 1127

Fig. 34.94.The greater palatine fora men.

Since the advent of the SOM and the Endoscope (ES),

new surgical techniques, concepts and instruments
have been developed. The "Trans-sinus Approach"
to the palatal root has been a more favorable option.
The vision is far better and the access easier than
using the palatal approach. This, along with less
discomfort from the patient and more uneventful
Fig. 34.95. A. The pre-op radiograph of the first and second molars to have api-
healing, has increased the acceptance and popularity cal microsurgery due to an unfavorable response to non-surgical endodontic
of the technique. Clinical observations confirm that treatment. B. Post-op Radiograph resulting from apical microsurgery shows
the extent of access necessary to adequately treat the palatal roots does not
the snyderian membrane of the sinus has as great have to be excessive.
a potential for healing as that of the periodontal
ligament. Not too long ago, entry into the sinus was
thought to be a major event. In today's world, entry the buccal roots. If there is a wide variation to the me-
into the sinus is a non-event and even antibiotics sial-distal "swing" of the palatal root noted on the ra-
aren't routinely prescribed. diographs, the palatal root apex is probably a greater
There are limitations to non-surgical endodontic tre- distance to the lingual than if the "swing" weren't as
atment and not all problems can be successfully eradi- dramatic. The axial inclinations, and/or any rotations
cated. One of the most significant is the presence of a of the tooth, also need to be noted. An examination
periapical biofilm containing microorganisms that are of the patient's palate can also aid in determining the
resistant to antibiotics and can only be treated surgi- anatomical inclination of the palatal root. .A shallo~
cally (Fig. 34.95). The main concern is to prevent any palate may harbor a root that has a greater palatal in-
foreign objects, or medicaments, from entering the si- clination. On the other hand, if the palate is raised and
nus cavity. This is described later in this section. steep, the palatal root can be expected to have less of
The presurgical examination should include at least a palatal inclination and would be closer to the buccal
three different radiographic angles to better ascertain roots. If the tooth is crowned, the clinical examination
the palatal inclination of the palatal root in relation to has to determine if the molar is rotated, and in which
1128 Endodontics

direction. This is sometimes difficult to see if the tooth need to open into the sinus is one of them.
has been restored with a crown, but often the "emer- There are a few important concepts to keep in
gence form" of the cervical area of the crown can be mind when performing the trans-sinus, or buccal ap-
of great help in making this determination. It is impor- proach to the palatal root, especially the first few ti-
tant to keep in mind that the buccal to lingual distan- mes. Since the thickened bone around the zygomatic
ce between the buccal and palatal roots can be ve- process as it comes into the maxilla is a concern when
1y significant, because some of the instruments (ultra- planning the surgical access, consideration needs to
sonic tips for example) are not long enough to reach be given to making the access slightly more apical
an apex that has an unusual palatal inclination. In any and mesial than normally for the buccal roots of that
case, the surgeon should get as much information as molar. In other words, the access for the palatal roots
possible before the apical surgery is started. should be planned as a separate access, not the same
In the maxillary molars, either of the buccal ro- as the access for the buccal roots (MB & DB). The two
ots can occasionally be fused to the palatal root (Fig. different access openings may merge into one larger
34.96). In the process of performing the root-end re- opening, but they need to be different. The access for

Fig. 34.96. A. Preoperative radiograph of the upper left first molar. The tooth needs a non-surgical retreatment. 8. Post operative radiograph.After retreatment the to·
oth remained sensitive and surgery was scheduled. C. The disto-buccal and the palatal roots were fused and the bevel of the root involved also the palatal canal. D
The three retrofill in place. E. Post operative radiograph. F. Two year recall (Courtesy of Dr. Arnaldo Castellucci).

section on either of these roots can expose an isthmus the palatal root of the first molar should be adequatel1
leading to the palatal canal that must be prepared and opened and centered more mesial than a normal ac
sealed by means of a root-end fill. In any case, it is im- cess to the mesial buccal root of the molar would be

, I

portant for the surgeon to be prepared for any compli- Doing this prevents the unnecessary additional apiectior
cation that can arise during apical microsurgery. The or beveling of the buccal roots in order to get vision anc


34 - Micro-Surgical Endodontics 1129

access while instrumenting the palatal apex. Methylene cess, the snyderian membrane remains intact and hea-
blue staining is an important step so visualization of the ling is more uneventful. If a material for guided bone
root anatomy is uninterrupted, helping to prevent unne- regeneration is introduced into the defect, the snyde-
cessary tooth reduction (Fig. 34.97). rian membrane becomes a convenient barrier to have.
If the snyderian membrane is inadvertently pene-
trated, it rapidly "shrinks" from sight. This can be un-
comfortable for the novice, but rest assured, it has
not disappeared. The important thing is to prevent
any debris from the surgical procedure from entering
the maxillary sinus. This is effectively accomplished
by "packing" the sinus to create a barrier for any de-
bris created. The term "packing" is a poor choice of
words! To "place" a barrier, a continuous piece of 1/2
inch, plain, sterile gauze is used (Fig. 34.99 A). The 1/2
inch gauze is removed in one continuous piece from
the sterile bottle, as needed, and gently pushed into
the sinus with the beaks of a small, curved hemostat,
until a stable, but loose barrier is formed behind the
root(s) being operated on (Fig. 34.99 B). The gauze is

Fig. 34.97. The root-end bevels of the mesial-buccal, the distal-buccal and
the palatal root have been stained with Methylene Blue to enhance vision
(Courtesy of Dr. Gary Carr).

The apices of the maxillary teeth that do protrude in-

to the sinus are usually protected by a layer of cortical
bone, and the vessels and nerves associated with them
are normally not affected as long as the bone is left in-
tact over the teeth. In the event the sinus has to be en-
tered, the surgeon should not be alarmed. On occasion,
a large chronic lesion will be in, or near the sinus, and
often the careful surgeon can visualize the snyderian
membrane by its characteristic "blue-gray" color. As
long as the membrane is still intact, sinus curettes (Fig.
34.98) can be utilized to gently "lift" the membrane in-
wardly and out of the way. Then after the surgical pro-

Fig. 34.99. A. One continuous strip of Vi" plain, sterile gauze is used to gently
Fig. 34.98. Sinus curettes are helpful when manipulating the snyderian mem- "place" into the sinus to create a loose, but stable barrier. B. Small, curved he-
:l brane within the confines of the maxillary sinus. mostats are helpful to gently place the gauze strip into the sinus cavity.
1130 Endodontics

then cut, leaving about Vz" (1.0 cm) against the buccal PRIOR To RooT RESECTIONS
plate of bone at a convenient edge of the opening to
the crypt. A 3-0 suture is immediately tied to the free- The materials used to pre-restore a root resection
end with at least 12" (30 cm) of the left "hanging out" can be any bonded restorative composite or a fluori-
so safe retrieval of the gauze is assured. The suture de releasing glass ionomer cement such as Geristore.
should be of adequate length so its availability and se- The involved canal is instrumented to approximate-
curity is never in question. Caution: Never use iodo- ly one-half the length of the root (well past the inten-
Jorm or Vaseline impregnated gauze strips as they can ded resection line) and opened large enough to ac-
be very irritating to the sinus membranes and cause cept the desired filling material. The pulpal walls, pro-
unnecessary complications. ximal to the orifice of the root to be resected, are pre-
The full sulcular flap should always be used pared for adequate retention of the material used to
and extended more mesial than normal to accommo- seal the prepared canal. If there are two canals in the
date a slightly more mesial access opening and allows root to be resected, the isthmus must also be prepared
for complete closure of the antra-oral opening post and filled. When the root is resected, the filling mate-
operatively. In general, the longer a flap is (mesial to rial is trimmed leaving the canal(s) sealed and no fur-
distal) the easier it is to manipulate. When the maxil- ther restoration is necessary post surgically.
lary sinus is exposed, the complete closure of the ac-
cess opening with the appropriate flap design may PRIOR To RoOT END RESECTION (RER)
be the single most important factor leading to une-
ventful post surgical healing. The snyderian membra- In endodontic treatment, the presurgical REF should
ne has good potential for healing and is not of great be considered whenever possible to greatly simplify
concern when operating in the area of the palatal root the process. One of the best indications for the presur-
apex. Prophylactic antibiotics, such as Amoxicillin or gical REF is when apical surgery is planned for a diffi-
Keflex, can be prescribed post surgically if necessa1y, cult apex to access (the palatal apices of maxillary mo-
but normally this is not indicated. 20 Post-operative in- lars and apices of lower second molars). The difficul-
structions to the patient should include the following ty of creating an anatomically correct REP and placing
points: a REF in these areas is a well-known problem. If the REP
and REF steps can be eliminated and the apical surge-
1. Do not blow your nose for one week. ry be reduced to just an apicoectomy, much of the time,
2. Take antibiotics and other medications as directed difficulty and stress are eliminated from the procedure.
and for as long as directed. · The· canal is instrumented as close to the termi-
3. Avoid hard coughing or suppressing a sneeze, nus as possible, and large enough to permit the pla-
which may increase the air pressure in the sinus. cement of a filling material to the apical confines of
4. If you must sneeze, open your mouth wide and the preparation. By necessity, the canals are instru-
sneeze through your mouth. mented to a larger file size in order to allow for the
5. Do not smoke, or use a straw, for one week. placement of the material. The fundamental reason
6. Eat a softer than normal diet for 3-5 days. for apical surge1y is usually due to persistent infec-
Especially things like popcorn, nuts, chips, etc. tion of the root canal space. 10•24•26 Therefore, it is im-
must be avoided. portant that all treatment be directed at eliminating
7. Commonly a bloody discharge from the nose bacterial infection from within the REP. The use of
may be present for a few days. either 17% EDTA, 10% citric acid, 35% phosphoric
acid, or MTAD, followed by irrigating with 2% CHX
PRE-SURGICAL RESTORATIONS will decrease bacterial load and increase the predic-
tability of success. 18 •50 •51 Before placement of the pre-
In the event the tooth being endodontically surgical REF, temporarily filling the prepared canal
treated requires either periodontal surgery involving space with calcium hydroxide (Pulpdent, Watertown,
a root amputation, or root end resection (RER) with a MA, USA or UltraCal XS, Ultradent, Salt Lake City, UT,
root end filling (REF), a pre-surgical restoration can be USA) for a minimum of 7 days, has been demonstra-
placed prior to the procedure. This eliminates the post ted to reduce contamination of the dentinal tubules
surgical necessity of a restoration in the case of a root in the canal walls and will also increase predictabili-
amputation, or a REF after an apicoectomy. ty of complete healing. 6•35·62
34 - Micro-Surgical Endodontics 1131

The material of choice for the presurgical retrofill Whenever possible, it is desirable to seal in a moist
is mineral trioxide aggregate (MTA). However, Super cotton pellet for 24-48 hours . This will allow the
EBA, IRM or bonded composite can also be used, but hydrophilic MTA achieve better adaptation to the
not as easily. The MTA is best placed using a Dovgan walls of the preparation and acquire optimum
Carrier loaded with a 2 to 3mm "pellet" of MTA. The properties during the setting process. 63 Ideally, the
MTA is then "pushed" into place and gently "persua- apical surgery should be delayed until at least 24-48
ded" to the apical confines of the prep with the ap- hours after placement of the MTA to insure it has
propriate pre-fitted and pre-measured plugger. After completed the setting process. After confirming
the first pellet is placed, a radiograph should be taken the set of the MTA is complete, the final seal of
to verify the MTA is as far apically as desired and no the coronal portion can be completed by the
voids are present. The apical 6 to 8 millimeters should operator to "seal the rest of the canal system". It
be filled so there is at least 3mm left for an adequate is imperative that the entire coronal portion
seal, after the RER is completed. of the canal system be sealed with the final
To achieve a denser fill, ultrasonics can be used to coronal build-up, or foundation restoration. To
eliminate air and/or water from the MTA after placement. do apical surgery without the complete sealing
With the ultrasonic at its lowest power setting, the of the entire canal system would decrease the
assistant just touches the tip to the non-working end of predictability of the healing process.
the instrument being used by the operator (Fig. 34.90 Since the MTA does not adhere to the walls of the
A). It is only necessary for the instrument to just be preparation, it is suggested the apiection should be
in contact with the MTA to achieve "densification". done with as little vibration as possible. An 1171 sur-
This technique is most effective if gravity is working gical length bur (Brasseler) has spiral flutes and is well
in our favor (best on mandibular teeth). If the MTA is suited for smooth cutting and beveling of the apiected
too moist, excess water can be removed easily with surface (Fig. 34.47). Diamonds also offer a vibration-
the thick end of a medium or coarse paper point that less and efficient cutting action, but enough irrigation
fits to the coronal portion of the MTA (Fig. 34.100). must be used to ensure the bur doesn't get clogged
with debris that can cause unfavorable overheating.
As long as the simple precautions mentioned above are
taken, the resection should not affect the seal of the
"set"MTA. 2



If there is an iatrogenic or resorptive perfora-

tion of the canal system, and access is possible,
it is a relatively easy procedure to correct the de-
fect surgically. However, considerable thought
must be given to the timing of the repair. In many
situations, the surgical repair is wisely scheduled
to be performed after the conventional endodon-
tics is completed. By doing this , the doctor has
an opportunity to consider repairing the perfo-
ration non-surgically, thereby avoiding unneces-
sary surgical intervention. In the case of the fil-
ling material extending into the soft tissues, sur-_
gery may be the only effective way to debride the
area and provide an adequate seal and repair of
the defect.
After all considerations are given, and surgical re-
Fig. 34.100. If the MTA is too wet, the thick end of a fine, medium, or course ab-
pair of the defect is to be performed, a full sulcu-
sorbent point held in the beaks of cotton pliers can "wick" excess moisture. lar flap is recommended to gain access to the per-
1132 Endodontics

foration (Fig. 34.101 A). Either burs or ultrasonic tips A & B (Den-Mat) is now placed as a dentine conditioner
can be used to prepare the defect. In some cases, it is with a small brushes or micro applicators (Ultradent or
necessary to remove bone from the mesial or distal, to Vista), lightly dried with air, and anothercoat is applied
gain access for the margin of the final restoration (Fig. (Fig. 34.101 F). More conditioner is applied until the sur-
34.101 B). In some cases, a slight amount of bone ne- face appears "wetted". Usually, two applications, or co-
eds to be removed and usually some recontouring of the ats, are all that is necessary. The dentine conditioner is
osseous architecture (Fig. 34.101 C). The preparation is an "unfilled" resin that permeates deep into the denti-
etched with a blue etchant gel (Ultradent) for 15-20 se- nal tubules after the etching process, providing a stron-
conds (Fig. 34.101 D). After rinsing and drying, the den- ger bond between the composite and the dentine. The
tine should have a "duller" appearance than the surroun- Gerestor is applied in layers if the defect is large, but of-
ding "unetched" dentine (Fig. 34.101 E). Great care must ten a single layer will suffice. The material is light cured
be taken to not dry the dentine too much. Bonding has for the appropriate amount of time, depending on the
been shown to be stronger when the dentine is just dry strength of the curing unit used (Fig. 34.101 G). The re-
enough so there isn't any "pooling" of water left from the storation is contoured with composite burs and polished
rinsing of the etchant. If the tubules are too dry, with rubber point to achieve a very nice marginal inte-
they will collapse and not allow the conditioner to pe- grity (Fig. 34.101 H). Another example shown is the re-
netrate as deeply as desired for better retention. Tenure pair of an iatrogenic perforation on the buccal, mid-ro-

Fig. 34.101.A. A full sulcular flap is used to repair all root defects. B. Access is achieved to the defect. C. Bone recontoured to expose the mesial margin and prepared
using burs or ultrasonics. D. Blue etchant jel (35% phosphoric acid) is applied to the preparation for 15 - 20 seconds. E. When rinsed and dried, the dentin has an opa-
que appearance prior to placing the conditioner. F. Two coats of dentin conditioner (Tenure A &B, Den-Mat, USA) are applied with a micro-applicator. G. The dual cu-
re Geristore is light cured to begin the rapid setting process. H. The final restoration exhibits good marginal integrity.
34 - Micro-Surgical Endodontics 1133

ot, of the mesial root in a lower first molar (Fig. 34.102). with the lingual plate of bone. The long standing lesion
The glass ionomer is very compatible to the tissues and had destroyed all other boney support. The tooth was
easy to work with. In both of these instances of root de- so mobile; it had to be held in place during the entire
fect repairs, Geristore (Den-Mat) was the restorative ma- apical microsurgical procedure. The situation appeared
terial of choice. It is flowable, dual cure, simple to use, hopeless, but the patient desperately wanted to save
and has been shown to be very compatible with the pe- the tooth if at all humanely possible. The apices were
riodontal tissues. 61 However, the surgical repair of a ro- bevel~d, REP made and REF with MTA. A combination
ot defect should always be considered a last resort. All of Bio-Os and Guidor was used for GBR and the case
nonsurgical modalities of treatment should be conside- was sutured (Fig. 34.103 B). The follow-up radiographs
red before surgical repair. illustrate complete healing (Figs. 34.103 C, D).

Fig. 34.102. A repair of a mid-root iatrogenic perforation on the buccal of the

mesial root of a mandibular first molar.


Materials for GBR

The routine use of GBR in endodontics is gaining in
popularity, but this rapidly growing area is ever chan-
ging. Numerous products are available for GBR in api-
cal surgery. Some examples are Guidor, autogenous
grafts, Pepgen-15, Freeze Dried Bone (both deminera-
lized & mineralized), Grafton, Osteograft N-300, Bio-
Oss, Tefgen, Laminar, Hydroxyapatite, BoneGen, and
SurgiPlaster, just to name a few.
Combining some of the materials together is a com-
mon practice. The following case, illustrates the healing
that can be achieved using combinations of osseous re-
generating materials (Fig. 34.103 A). This case presen-
ted with deep probing of more than lOmm on all sur-
faces but the mesial-lingual, lingual, and distal-lingual
sulcus. The full sulcular flap was retracted and the en- Fig. 34.103. A. Pre-op radiograph of desperate attempt to salvage this mandi-
bular first molar. B. Immediate post-op of apical microsurgery using Bio-Os &
tire lesion thoroughly curetted. It was quickly apparent Guidor for guided bone regeneration. C. 6 month follow-up radiograph. D. 2
that only the lingual surface of the root was in contact year post-op radiograph demonstrates complete healing.
1134 Endodontics

Calcium sulfate (CS) The advantages are: l) it is easily stored, 2) requi-

Calcium sulfate is becoming one of the most practical res no special armamentarium, 3) can be placed in an
all-around materials to use if a soft tissue barrier, or enclosed defect, 4) a safe and effective biomaterial for
GBR, is indicated for the endodontic surgery. Calcium bone defect filling applications, and 5) has been used
sulfate has become a popular adjunct for endodontics successfully for over 100 years.
because it can be used in nonsurgical procedures as There are two main disadvantages: 1) CS does not
well, using it as a matrix for perforation repairs is just perform well in the presence of blood and, 2) in some
one example. The average defect after apical surge1y cases it resorbs too rapidly. When blood is present, it in-
lends itself to uncomplicated procedures. In fact, on filtrates the material and drastically prolongs the setting
many occasions a soft tissue barrier, or GBR, is not time. Blood also adversely alters the mechanical and dis-
even necessa1y. The blood clot itself is sufficient to solution properties. 54 However, by using less water, ad-
allow normal, uneventful and complete healing to ding accelerants like NaCl or K2S04, creating a "drier
occur. However, in large lesions approximating one mix", and keeping the bone site as free of moisture as
centimeter and larger, or if there is a dehiscence, possible, the disadvantages can be minimized. If "pre-set
the GBR is necessary to prevent the invagination of granules" of CS are used, the dissolution time can be ex-
epithelium and allow bone formation. tended allowing more time for bone formation.
If CS is to be used as a soft tissue barrier, or GBR, The following illustrations (Figs. 34.104 A-G) demon-
and intended to be left in after surgical closure, it must strate the rapid healing and usual radiographic respon-
be carefully screened for naturally occurring impuri- se to GBR using CS to fill the c1ypt during apical micro-
ties such as silicates, lead, strontium and fillers such as surgery on tooth# 1.2. This tooth was treated in two
silicates and/ or cellulose (wood) fibers. Medical grade visits, but was not responding favorably. A radiograph
CS must be used and is available under the brand na- (Fig. 34.104 A) taken immediately before apical mi-
mes BoneGen by Orthogen (USA) and SurgiPlaster by crosurgery, shows a remnant of calcium hydroxide re-
Classlmplant (Italy). maining from intra- appointment medication. After the
MTA-REF was placed, a Dovgan Calcium Sulfate Carrier
PROPERTIES OF CALCIUM SULFA TE (Quality Aspirators) (Fig. 34.104 B) was used to inject
The CS begins as gypsum that is mined from the CS into the 1 cm. defect (Fig. 34.104 C). The c1ypt was
earth as calcium sulfate dihydrate (CaS04 · 2H20). filled with CS and excess trimmed flush to the level of
The water of hydration is driven off with controlled the facial bone surface (Fig. 34.104 D). The case was
heating in a process called calcination and forms a closed routinely and the sutures removed in 48 hours.
hemihydrate (CaS04 · 1/ 2H20). When the proper The patient was recalled 5 days post-op. The follow-up
amount of water is added, it causes setting to form radiograph demonstrated a ve1y slight resorption at the
calcium sulfate dihydrate. The two forms, alpha and periphery of the CS (Fig. 34.104 E). Little change was
beta, clinically demonstrate similar bone regeneration observed at the 10 day post-op (Fig. 34.104 F). At the
results. beginning of the third week, 17 days after surgery, the-
re was a noticeable change in the amount of resorp-
MECHANISM OF A CTION AND CHEMISTRY OF CALCIUM SULFA TE tion at the ·periphery (Fig. 34.104 G). However, at the
The easiest way to imagine how CS works is to ima- one month post-op recall, there was marked periphe-
gine it as a piece of "hard candy" in the crypt. As the ral dissolving and there appeared to be beginning cal-
hard CS is dissolved in a bone-healing environment, cification of the bioactive calcium phosphate lattice left
calcium phosphate deposits form in the adjacent soft as the CS is resorbed (Fig. 34.104 H). 54 The four month
tissue. This mineral, which was probably a biologi- post-op showed complete disappearance of the CS ma-
cal apatite, appears to form as calcium ions are re~ terial and definite calcification of the periphery of the
leased from the CS upon reaction with body fluids. defect left by the cyst (Fig. 34.104 I). At seven months,
In vivo, these deposits became incorporated into in- there is more calcification and bone ingrowth and into
growing bone and were observed to be osteconduc- the osteoconductive matrix (Fig. 34.104 J-0).
tive. This strongly suggests that CS acts as a resorba-
ble calcium-releasing substrate that produces a cal-
cium phosphate lattice in adjacent tissue and is an
osteoconductive matrix for bone ingrowth as it dissol-
ves and recedes. 5·1
34 - Micro-Surgical Endodontics 1135

Fig. 34.104.A. Immediate pre-op radiograph showing poor response to all nonsurgical Retreatment attempts. B. The Dovgan Calcium Sulfate Carrier permits efficient
and accurate placement of CS into the confines of the crypt. C. Calcium sulfate filled crypt and excess trimmed to normal facial bone surface to match normal
anatomy of area. D. The crypt has been filled to the buccal plane. E. 5 days post-op, only slight peripheral dissolution of CS noted. F. 1Odays PO, not much more
change in periphery of CS noted. G. 17 days PO, more noticeable peripheral dissolution of CS is seen. H. At 1 month PO, there is marked dissolving of the CS. I. After 4
months PO, the CS has completely dissolved.J. At the 7 months PO, beginning bone ingrowth of osteoconductive matrix is seen radiographically. K. 9 months PO. L.
19 months PO. M. 30 months PO. N. 42 months PO, the 'through-and-through' lesion is clinically healed and asymptomatic. 0. 51 months PAX, and final PO indicates
asuccessful result.
1136 Endodontics




All steps have been meticulously followed, the root-

end fill has been placed, the crypt is clean and refilled
nicely with blood, the final radiograph has been appro-
ved and it is time to suture the flap into position. Sadly,
most operators now push the microscope aside and su-
ture without it. To do this robs the operator of an op-
portunity to demonstrate to themselves, and their pa-
tients, the amazing capabilities of the SOM. The doctor
must make a commitment to master the suturing tech-
nique using the SOM. It will never be accomplished
with the SOM pushed aside at this critical step in the
apical microsurgical procedure. It has been said, "You
have 'arrived' if you can suture 'under the scope"'.
When the surgical site is ready for closure, the flap
should be gently massaged to close approximation
with the osseous surface and the attached tissue and
compressed with a folded, moist, sterile 2" X 2" gau-
ze. If the initial incision was planned with this final
step in mind, the tissues should re-approximate wi-
thout any problem. Now is when the operator will
appreciate creating nice "scalloping" when designing
the incision. Remember the old saying, "Hindsight is
always 20/20". Due to possible slight shrinkage of
the flap during surgery, it may be necessary to use
the edge of a small #2 mouth mirror to hold the tis-
sue in position while the second surgical assistant
(the chief assistant on the same side of the chair as
the doctor) hands the doctor the needle holder with
the suture. Fig. 34.105. A. Tevdek 6-0 polyester suture (CK Dental Specialties). B. The
All suturing is accomplished using 6-0 black mo- Castro-Viejo needle holder and the EH Suture Scissor (Practicon). C. This scis-
sor have blunt blades and sever the suture from above, without cutting un-
nofilament nylon (Supramid, S. Jackson) or 6-0 gre- derlying tissue.
en polyester (Tevdek, CK Dental Specialties) (Fig.
34.105). Some micro surgeons are using 8-0 and,
even 10-0; but the 6-0 is stronger, and doesn't te-
ar through the tissue as readily. The results are no
different than with the more difficult to use, smaller
needles and thinner suture. Keep in mind, the su-
tures will be removed in 24hrs so it is really a mu-
te point as to whether the suture is 6-0, 8-0, 10-0, or
the needle is a little smaller in diameter. The results
achieved with 6-0 suture seem to be well suited to
apical microsurgery. The black silk suture, traditio-
nally used in surgery, is a detriment to the rapid he-
aling we are trying to achieve. Not only does the
plaque accumulate much quicker on it (Fig. 34.106), Fig. 34.106. The black silk suture accumulates bacterial plaque very quickly
but also, the braiding acts as a wick for the migra- (Courtesy of Dr. Gary Carr).
34 - Micro-Surgical Endodontics 1137

tion of bacteria into the wound resulting in incre- 60B) is used. This needle was chosen because the
ased inflammation and compromised healing. The larger size facilitates passing it through the contacts
type of needle used depends on the type of flap to when doing a sling, or mattress suture. The sling su-
be sutured. ture is routinely used to save time on closure, rather
For the Luebke-Ochsenbein Flap (also called a Muco- than doing individual buccal to lingual sutures. On
Gingival or Submarginal Flap) a taper point needle
1 many occasions, the smaller TPN may also be used to
(TPN) 3/ 8 circle attached to monofilament 6-0 sutu- suture the attached gingival area of the flap at the co-
re (Supramid, S. Jackson, code MEA-60B) or to a 6-0 ronal aspect of the releasing incision.
Tevdek suture are used. The TPN is superior to the
reverse cutting type needle (RCN) because there isn't SUTURING TECHNIQUE USING THE SOM
the tendency to cut, or tear, the "beginning" and "exi-
ting" needle points. As a result, the ·TPN is easier to To permit greater peripheral vision, the SOM should
guide through the tissues to a more accurate exit point be set at a lower power than has been used for the
when suturing the flap. They just seem to co-opera- rest of the microsurgical procedure. A magnification
te more when suturing this type flap! One of the ni- between 2.SX and 4.SX will usually be optimal. Using
cest things about using this flap design is the ability a small Castro-Viejo type needle holder, the beaks of
to easily demonstrate the healing that has taken place the holder should be grasping the needle approxima-
in only a day and the absence of scarring afterwards tely 3/ 4ths of the distance from the pointed end and
(Fig. 34.107). perpendicular to the axis of the needle. It is important
For the Sulcular Flap, a reverse cutting needle to ·keep the beaks of the holder away from either end
(RCN), 3/ 8 circle (Supramid, S. Jackson, code MPR- of the needle, as this is the area of its greatest weak-

Fig. 34.107. A. The Luebke-Ochsenbein Flap has been sutured with 6-0 Tevdek. B. The suture has been removed after 24 hours. C. Nice healing after 15 days. D. Three
year recall: complete absence of scarring (Courtesy of Dr. Arnaldo Castellucci).
1138 Endodontics

ness and can distort, or break easily (Fig. 34.108 A). is raised with the right (left) hand while the left (right)
Grasping the needle in this manner, gives the opera- hand descends as it gathers up the slack (Fig. 34.108
tor the most safety and control over its direction, sta- I). As the suture is gathered in the left (right) hand,
bility, and integrity (Fig. 34.108 B). the holder "descends" to relax the tension and allows
For the sake of simplicity1 the following descriptions more suture material to be pulled through the tissue
will primarily address a surgeon that is right-handed. with the left (right) hand (Fig. 34.108 ], K). It is an
Tbe left-handed surgeon will refer to the right or left alternating "up-and-down" rhythm of movement that
in the parenthesis. Thus, a left-handed surgeon will is difficult to describe in writing, but is actually very
have to substitute right for left, and left for right as easy for the beginning microsurgeon to learn.
indicated. While grasping the needle holder in the The "loops" are now slid off the beaks of the Castro-
doctor's normal working right (left) hand (remember Viejo forceps and the "surgical knot" is started. The
to use the parenthesis if you are left-handed), the first "positioning knot" of 3-4 "loops", is tightened un-
needle is passed through the desired entry and exit til the two edges of the incision are gently approxima-
points on both sides of the incision, always going from ted. The second, or "securing knot", of 1-2 "loops" is
unattached to attached tissue. Then, after regrasping now placed to secure the positioning knot. It is impor-
the emerging end of the needle, pull it through both tant to anticipate the further tightening effect the se-
sides of the incision with the needle holder in the curing knot may have on the tightness of the suture.
right (left) hand and deliver the needle so it can be Then, after the operator is satisfied with the tension of
grasped between the thumb and index finger of the the suture, the third "locking knot" is placed.
other hand (Fig. 34.108 C). As the doctor is doing this, The second surgical assistant now takes the Castro-
the second assistant (the "flight director") is taking Viejos from the doctor, replacing it with the micro-
hold of the end of the suture with their thumb and scissors, and the suture is cut as close to the knot as
forefinger (cotton pliers or a hemostat can also be practical (Fig. 34.108 L). After the second assistant ta-
used) so it won't inadvertently be pulled through the kes the scissors and the suture, the doctor is handed a
tissues. Now the doctor "winds", or "twirls" the suture micro-forceps so the knot can be moved as far away
3 or 4 times around the beaks of the holder to begin from the incision line as possible, preventing plaque
making the first knot and to create tension for the build-up over the incision. Note when moving the
"gathering" of the suture (Figs. 34.108 D, E). As the knot with the micro-forceps, it is important that the
doctor is making these "twirls", the second surgical knot be pushed to place, not pulled to place, always
assistant is placing the end of the suture into the keeping the knot between the micro-forceps and the
doctor's visual field of the microscope, so the end of final point where the knot is to be. Pulling the knot
the suture can be easily grasped in the beaks after the can loosen, or untie the suture, especially if the knot
"looping" or "winding" to make the knot is completed. isn't as tight as desired (Fig. 34.108 M-0). Doing this
In this way, the suturing can be accomplished with ensures the knot doesn't inadvertently get untied and
little movement in the relatively small field of vision its original integrity is maintained until removal.
present with the SOM (Fig. 34.108 F, G). The surgeon
now grasps the end of the suture with the beaks of SUTURING CONSIDERATIONS
the holder and starts drawing the suture to take up the
slack (Fig. 34.108 H). The "loops" around the beaks One of the most common mistakes made when su-
of the needle holder aren't "slipped" off the end of turing is to overly tighten the suture. It is better to ma-
the hemostat yet. The "loops" are left on to create ke it a little too loose than too tight. A tight suture
just enough friction to maintain a slight amount of can cause a crushing and/ or ischemic injury, possibly
tension between the doctor's hand (the hand holding compromising rapid and uneventful healing we can
the needle) and the beaks of the needle holder in normally expect. When making a sling or continuous
the right (left) hand. Care must always be taken that suture in a sulcular flap, it is easy to be too aggressi-
the tension is only between the left (right) hand and ve when tying the knot, causing the other end to get
the needle holder, and not exerted on the tissue. The too tight. So the tightness of all of the loops along the
purpose of maintaining this tension is to give the doctor entire length of the suture should be checked before
positive tactile sense when taking up the "loops" of completing the securing knots. ·
excess suture material in the left (right) hand. As the The releasing incision is usually an integral part of
suture is taken through the tissue, the needle holder every flap and may be considered differently from the
34 - Micro-Surgical Endodontics 1139

Fig. 34.108. A. Begin suturing, inserting needle thru
flap edges. B. Grabbing the pointed end of need-
le with the Castro-Viejo needle holders. C. Grasping
needle with thumb and fore-finger. D. Beginning the
knot by winding suture around the beaks of the ne-
edle holder. E. Using friction created by the 3 or 4 lo-
ops on the beaks of the needle holder to maintain
tension. F. Assistant presenting other end into 'sco-
pe' view. G. Grasping suture end from assistant's 'pre-
sentation'. H. Tightening knot. I. Begin to gather sutu-
re in hand and maintaining tension. J. Beaks of hol-
der in the 'down' position to begin 'gathering' suture
in other hand. K. Beaks of the holder are brought in-
to the 'up' position, while tension is maintained for'fe-
el'. L. Cutting suture close to knot. M. Knot begin to be
"pushed" away from incision. N. Knot pushed comple-
0 tely away. O. Suture completed.
1140 Endodontics

rest of the incision. Normally, the releasing incision FLAP TISSUE: RE-APPROXIMATION MANAGEMENT
is not necessary to be sutured, but if it is, the sutu-
re should be slightly looser than those in the attached Immediately upon completion of suturing, a folded
gingival tissues. Very close approximation of the inci- 2" X 2" piece of moistened, sterile gauze is again used
sed edges is not necessary in the releasing incision. to gently compress the flap and create as close appro-
It has been shown that epithelial creep, or strea- ximation as possible between the incisional and dis-
ming, occurs rapidly, or at a rate of about lmm per sectional wound surfaces as possible. This close ap-
side per 24 hrs. 56 In other words, a wound with ed- proximation of the surgical wound promotes rapid he-
ges separated 2 mm would be expected to come to- aling by permitting a thin fibrin clot in the dissectional
gether within a 24 hr period. In hundreds of surgeri- wound and better initial adhesion between the wound
es over the past nine years, there were only a few oc- edges. 29 If there are some minor discrepancies in the
casions the releasing incision wasn't completely clo- reapproximation of the flap edges, a gentle "massa-
sed without any sutures at all. Of those few that didn't ging" of the tissues can slightly move the flap into a
close within the 24 hr period, all closed within 48 hrs. better position and achieve better approximation.
To repeat: if th_e operator prefers to suture the relea-
sing incision, it should be sutured loosely to allow for 24 HOUR SUTURE REMOVAL
swelling, or else the suture will present itself buried
in the tissue and soh1e tearing may occur (Fig. 34.109 It is very important to consider the nature of the
A, B). The result will be a more difficult suture remo- endodontic surgery access incision and how it differs
val for the surgeon and increased discomfort for the from periodontal surgical incisions. Basically, the en-
patient. dodontist is dealing with healthy tissues and attach-
Another consideration is to be sure to suture to li- ments, depending on healing by primary intention.
ke tissues to like tissues. In other words, suture atta- The periodontist, on the other hand, is dealing with
ched gingiva to attached, and unattached to unatta- diseased tissues and attachments, and depending on
ched. Never suture attached gingival tissue to unatta- healing by secondary attachment. If the tissues are
ched gingival tissue, since the suture will tend to pull healthy and atraumatically handled throughout the
out of the attached side. When suturing the properly entire surgical procedure, and the incision is closely
designed incisional wound after endodontic surgery, approximated, prima1y intention healing will take pla-
this should never be a problem. ce. The following case is typical of the normal post-
surgical sequela (Fig. 34.110 A-C). The epithelial brid-
ge and subsequent collagen cross-linkage is normally
completed within 18-24 hours. If this is true, the su-
tures have completed their task, and in fact, are now
a foreign body that can cause irritation and excessive
inflammation, resulting in a retardation of the healing
process and possible scarring. If the SOM is utilized
during the entire suturing process, the incision can
be closed accurately with extremely good approxima-
tion. It is because of well-planned, nicely scalloped in-
cisions, atraumatic flap elevation procedures, and the
very close repositioning of the flap with thin, hair-like,
6-0 sutures that routinely allow suture removal in a 24
hr period (Fig. 34.110 D, E). As a result there will be
little, or no, resulting scar tissue formation (Fig. 34.110
F-I). The previous case is typical of what can be ex-
pected, if all steps are followed without exception.
For those that doubt the 24hr Suture Removal
Theory, an easy exercise is as follows: At the next
surge1y, be sure to place at least five sutures. After 24
Fig. 34.109. A. Tight suture - 24hr shows a tendency to get "buried" into, and
"tear"the tissue. B. Tight suture-mirror view (same suture) makes a more diffi- hrs, have the patient in and remove the worse looking
cult, traumatic, and uncomfortable suture removal visit. suture, the one you think isn't healing as well as the
34 - Micro-Surgical Endodontics 1141

Fig. 34.110. A. Immediate PO sutures. B. 24 hour PO, sutures before removal. C. 24 hour PO sutures #7 &8, high magnification. D. 24 hour sutures immediately after
removal. E. 24 hour sutures removed #7 &8 high magnification. F. 3 days PO visit. G. 5 days PO surgery. H. 10 days PO surgery. I. One month PO, demonstrating very
favorable healing typically expected using atraumatic techniques.

others. Then, the next day, remove the next worse lo-
oking suture. Then the next day do the same, and so
on. At the end of the fifth day, the worse looking su-
ture will be the one remaining! If that doesn't convin-
ce you, nothing will! With atraumatic techniques, clo-
se tissue re-approximation, and 24 hr. suture removal
you can easily guarantee the patient that, "The scar
won't show when you wear your bikini!". Except for
a few medically compromised patients, the author has
routinely removed sutures after 24 hrs in hundreds of
surgeries, without complication. If for convenience sa-
ke, the sutures are left in an extra day, or two, there is
no problem (Fig. 34.111). But, sutures left in for five
or more days will usually exhibit unnecessary inflam-
mation and delayed healing, probably due to either a
foreign body reaction and/ or bacterial invasion. The
peak tissue reaction to the sutures occurs between the
Fig. 34.111. The patient could not come back for suture removal before the
second and seventh day, so sutures should be remo- fifth day after surgery was completed. Note the complete absence of plaque
ved before this peak response occurs. 22 around the Tevdek suture. (Courtesy of Dr. Arnaldo Castellucci).
1142 Endodontics

PosT OPERATIVE CARE en achieved. Another very effective protocol is the use
of Motrin 600 mg. used alternatively with hydrocodo-
Post operatively, the usual result is very little pain ne Smg. When all three medications are used in com-
or swelling. The amount of discomfort and swelling bination, the patient receives three possible pathways
is considerably less than that normally observed with of pain relief: 1) the ibuprofen (Motrin) effect; 2) the
the old apical surgery protocol. The postoperative in- acetaminophen (Tylenol) effect; and 3) the narcotic
structions are: (hydrocodone) pain relief effect.
1) ice packs to the area "twenty-minutes-on-and- Although the use of steroids are an accepted me-
twenty-minutes-off" for the first six hours, thod of medication after surgery, the author has never
2) gentle rinsing with Peridex twice a day for the found the need for their use due largely to the proven
next three days, effectiveness, low cost, availability, patient tolerance,
3) have sutures removed at the next appointment, and safety of the NSAIDS.
usually within the next day or two. A word of caution: "Beware of the patient that
A non-steroid anti-inflammatory is normally prescri- expresses that "only Percodan", or "only Percocet" (or
bed for the next three or four days as described be- other named drug) works for them". This is especially
low. Antibiotics are not usually prescribed unless indi- true, if the medications are requested prior to surge-
cated by the patients past medical history and/ or sur- ry. Postoperatively, if all healing appears to be within
gical complications. normal limits, and there is no reason to expect undue
Many clinical studies have shown the use of non- amounts of pain, it is wise to avoid the indiscriminate
steroid, anti-inflammatory drugs (NSAIDs) to be ef- dispensing, or prescribing of narcotics. In all but rare
fective as a post surgical analgesic. Acetaminophen cases, they simply aren't indicated for endodontic api-
and ibuprofen are two of the most commonly used cal microsurgery. Great care must be given to the pre-
NSAIDs. Of the NSAIDs, ibuprofen 400 mg has been scription of narcotics ... a patient can overdose on just
shown to be the more effective than aspirin 650 mg or one prescription!"
acetaminophen 600 mg. 11 Ibuprofen 600 mg (Motrin,
Upjohn) is normally prescribed if the patient has no PosT SURGICAL HoME CARE
allergy or adverse reaction to it. A cross allergy usually
exists between ibuprofen and aspirin, so a patient al- If everything is within normal limits within the next
lergic to aspirin is likely to also be sensitive to ibupro- 24 to 48 hours, sutures are removed and the patient is
fen. In such cases, acetaminophen (Tylenol) is pre- instructed to begin gentle cleaning of the area starting
scribed. Ibuprofen has also been shown to be more the next day (day two or three after surgery). The pa-
effective than a combination of aspirin and codeine. tient is instructed to place a washcloth over their in-
However codeine does add a small amount of additional dex finger and to gently "wipe" the surgical area for a
analgesia when used in combination to ibuprofen. 12 few days, as often as possible. After day five, they can
Occasionally, the patient will need something stron- begin to use their "soft-bristled brush" and begin ve-
ger than Ibuprofen 600 mg every 6-8 hrs, but it is ry gentle brushing. The patient is instructed to conti-
the exception, rather than the rule. An effective va- nue the twice daily rinses of Peridex (chlorhexidine)
riation of the regimen, for the patient that is not al- for the next week, or so. The patient is scheduled for
lergic to NSAIDs, is take the ibuprofen as prescribed, a follow-up visit two weeks after surgery. At the two-
but along with the ibuprofen doses, take acetamino- week visit, normally the incision is barely visible, and
phen 400 mg. (Tylenol). For the patient that does ha- on occasion, cannot be detected. A word of caution:
ve a very low pain threshold level, stronger analge- Not all patients respond to treatment as well as others.
sic or narcotic medications are considered and pre- Don't be in a hurry to treat a problem that may not
scribed at the doctor's discretion. If pain medications exist. On a few occasions, patients may be slow to re-
are required, a good regimen is to have the patient ta- spond to treatment, sometimes taking several months
ke the NSAID first, and then 3 hrs later take the pain to heal as well as that of other patients in just weeks.
medications along with the Tylenol. Then every 6 hrs If there is any doubt, or delayed healing is suspected,
repeat the cycle for at least the next 2-3 days. Then, place the patient on antibiotics and an anti-inflamma-
if all is well the patient can do the same cycle eve- tory for a week as a precaution, but what is really de-
ry 8 hours for 1-2 more days. The patient is advised sired is more time for delayed healing to occur.
that all NSAIDs can be stopped once comfort has be-
34 - Micro-Surgical Endodontics 1143

CONCLUSION table results. But, these results can only be achieved

if the proper protocol is followed meticulously. The
The apical microsurgical technique described in the steps must be followed without compromise. If this
previous six sections has become a new standard of is done , apical microsurgery can be a stress-free and
care in endodontic treatment and raises endodontic predictable part of the daily regimen, for both the doc-
apical surge1y to a new and exciting level. For the first tor and the newly involved dental team!
time, apical surgery can be performed with predic-


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54. RICCI, ].L., et al: Biological Mechanisms of Calcium Sulfate
37. LEE, E.S.: Think outside the syringe. Endodontic Practice
Replacement by Bone. Submitted for publication, 2000.
3:26-28, 2000.
38. LEMON, R.R., STEELE, P.]., JEANSONNE, B.G. : Ferric sulfate
of NSAID Administration on Tissue Levels of Immunoreactive
hemostasis: effect on osseous wound healing. Left in situ for
Prostaglandin E2, Leukotriene B4, and (S)-Flurbiprofen
maximum exposure.]. Endod. 19:170-3, 1993.
Following Extraction of Impacted Third Molars, Pain
39. LIN, C.P., CHOU, H.G., CHEN, R.S., LAN, W.H., HSIEH, C.C.: 73:339-346, 1997.
Root deformation during root-end preparation. ]. Endod.
25:668-71, 1999.
BLOOM, A.A.: Healing of periodontal surgical wounds. In:
40. LIN, C.P., CHOU, H.G., KUO, J.C., LAN, W.H.: The quality Goldman HM, Cohen DW, eds. Periodontal therapy. 6111 edi-
of ultrasonic root-end preparation: a quantitative study. ]. tion. St. Louis: The CV Mosby Co., p.640-754, 1980.
Endod. 24:666-70, 1998.
57. RUBINSTEIN, R., KIM, S.: Long-Term Follow-up of Cases
41. LOCKER, D., LIDDELL, A,, DEMPSTER, L. , SHAPIRO, D.: Age Considered Healed One Year After Apical Microsurge1y, J.
of onset of dental anxiety.]. Dent. Res. 78:790-6, 1999. Endod. 25:378-83, 2002.

42. LOCKER, D., LIDDELL, A., SHAPIRO, D.: Diagnostic catego- 58. RUD,]., RUD, V., MUNKSGAARD, E.C.: Long-term evaluation
ries of dental anxiety: a population-based study. Behav. Res. of retrograde root filling with dentin-bonded resin composi-
Ther. 37:25-37, 1999. te,]. Endod. 22:477, 1996.

43. MALA.MED, S.F.: Sedation, A Guide to Patient Management, 59. SALEHRABI, R. , ROTSTEIN, I.: Endodontic Treatment
Third Edition, Mosby-Year Book, Inc, p.524, 1995. Outcomes in a Large Patient Population in the USA: An
Epidemiological Study,]. Endod. 30:846-50, 2004.
34 - Micro-Surgical Endodontics 1145

60. SCHILDER, H.: Filling Root Canals in Three Dimensions. 66. TONG, D.C., ROTHWELL, B.R. : Antibiotic prophylaxis in den-
Dent. Clin. North Am. 11: 723-744, 1967. tistry: a review and practice recommendations. J. Am. Dent.
Assoc. 131:366-74, 2000.
61. SHERER, W., DRAGOO, M.R.: New subgingival restorati-
ve procedures with Gerestore resin ionomer. Pract. Proced. 67. TORABINEJAD, M. , CHIVIAN, N.: Clinical applications of mi-
Aesthet. Dent. 7:1-4, 1995. neral trioxide aggregate. J. Endod. 25:197-203, 1999.
62. SJOGREN, U., FIGDOR, D., SPANGBERG, L., SUNDQVIST, 68. Webster's College Dictionary, New York, Random House,
G.: The antimicrobial effect of calcium hydroxide as a short- Inc. , p.1345, 1995.
term intracanal dressing. Int. Endod. J. 24:119-125, 1991.
69. WEINE, F.S.: Endodontic Therapy, 4r1i edition. St. Louis, CV
63. SLUYK, S.R., MOON, P.C., HARTWELL, G.R.: Evaluation of Mosby Co. p.498, 1989.
setting properties and retention characteristics of mineral trio-
70. WEINER, A.A. , FORGIONE, A.G. , WEINER, L.K. : Survey exa-
xide aggregate when used as a furcation repair material. J.
mines patients' fear of dental anxiety treatment. J Mass Dent
Endod. 24:768-71, 1998.
Soc 47:16-21, 36, 1998.
64. STROPKO, J.J.: Canal Morphology of Maxilla1y Molars: Clinical
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Observation of Canal Configurations. ]. Endod. 25:446-50,
tion of the canal isthmus. Part 1. Mesiobuccal root of the ma-
xillary first molar. J. Endodont. 21:380-3, 1995.
65. THOMSON, W.M., DIXON, G.S., KRUGER, E.: The West Coast
72. WU, M.K. , KONTAKIOTIS, E.G., WESSELINK, P.R.: Long-term
Study. II: Dental Anxiety and satisfaction with dental services.
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N. Z. Dent. J. 95:44-8, 1999.
24:557-60, 1998.
1146 Endodontics

Restoration of the Endodontically Treated


The current endodontic techniques which are ever form the basis of the specific reconstructive procedu-
more conservative and sophisticated 29•163 have incre- res for an endodontically treated tooth to ultimately
ased the potential longevity of endodontically trea- obtain an adequate rate of success.
ted teeth. However, in order for this to take place, it
is the responsability of the clinician, who carries out
the restoration, to make the correct choice of restora- HISTORY
tive materials and techniques indicated for the various
situations. The difficulty, often, is not to "work well" In 1747 Pierre Fauchard, 65 founder of modern denti-
from a technical point of view, but to know case af- stry, used gold and silver posts to anchor single teeth
ter case which treatment is best indicated without in- or bridges to roots of anterior teeth. These posts we-
curring errors by mistake such as not adequately pro- re cemented with a rubber solution, lacquer, powde-
tecting the tooth from fracturing, or in excess by pla- red coral and turpentine, which was then heated to
cing a post that is not necessa1y. The techniques and make it adhesive. At the time the implanted teeth we-
materials that are currently available allow for the re- re of various materials: ox or hippopotamus teeth, hu-
cove1y of extremely compromised clinical situations, man teeth, ivory, bovine bone and so on. Successively
but it is essential to know how to evaluate a procedu- these materials, quite unusual to us, were substitu-
re which falls into the group of "therapeutic obstina- ted with porcelain. In 1839 Chapin Harris 92 described
cy" and whether the relationship between biological the method of reimplanting artificial teeth with posts
cost and benefit is favourable. The restoration of en- into roots as " the best one could do". For many ye-
dodontically treated teeth with severe loss of structu- ars the material used for these first rudimenta1y posts
re is often a complex procedure which requires a pro- was wood, that due to the damp conditions expanded
found knowledge of endodontics, periodontics, pro- and became very retentive. One must remember (see
sthetics and restorative dentistry. For the clinician it Chapter 1) that endodontics in those years were just
is not always easy to formulate the correct treatment starting and so the metallic or wooden posts, whiche-
plan, because the proven and unequivocal scienti- ver used, were positioned in canals that were com-
fic guidelines are often lacking. The clinician has to pletely empty with all the imaginable endodontic pro-
know how to evaluate, before carrying out the treat- blems that subsequently occurred. The metallic posts
ment plan, whether this will be adequate with regards at that time were less successful because adequate ce-
to the duration of the tooth with respect to the general ments were not available. Therefore they were subject
oral condition of the patient, without creating dama- to notable corrosion processes and the internal move-
ge to the other teeth. In the case of restoring a severe- ment in the canal often caused wear or fracture of the
ly compromised tooth, one has to be able to propose root in which they were placed.
an alternative treatment, which may involve extraction Undoubtedly, compared to the work of these den-
and replacement with an osseointegrated implant. 143.1 46 tal pioneers, the techniques and materials have great-
The aim of this chapter is to describe the criteria that ly evolved and currently a predictably successful en-
35 - Restoration Of The Endodontically Treated Tooth 1147

dodontic technique is widely used giving the clinician

an ever increasing number of endodontically treated
teeth to restore optimally, both functionally and aes-
thetically. According to Tidmarsh, 203 from the patients
point of view, success depends on both the endodon-
tic as well as the restorative technique to restore the
tooth functionally but also aesthetically.


A general consensus exists that considers the endo-

dontically treated tooth more fragile and more suscep-
tible to fracture than a vital tooth. In reality, what dif-
ferentiates one from the other and why must particu-
lar caution be exercised when restoring these teeth?
In the past much research was carried out to veri-
fy the effective _differences between a tooth with a vi-
tal pulp and one which was endodontically treated ,
(Fig. 35.1); the loss of water was studied, 18• 94,156 the
hardness, 84 .3 7 the ultrastructure of the tropocolagen, 169
the architectural modification, 86•182 and the loss of pro-
prioceptors 164 of endodontically treated teeth was stu-
died, often obtaining results that were completely in
antithesis. Vice versa all the authors were completely
in agreement on attributing great importance to ano-
ther parameter: the loss of tooth structure due to ca-
ries, fractures, external and internal resorption, re-
storative procedure, endodontics and prosthetics. In
1994 Assif 13 re-examined the literature of this subject
and concluded that teeth subjected to endodontic the-
rapy have not changed with regard to their modulus
of elasticity, 74 their hardness or fracture resistance. 210
However, the more tooth structure that is lost, crea-
tes a lower resistance to physiological occlusal loa-
ding 184 and the higher the risk of fracture. 141•116•180,98 On
this point researchers all agreed and confirmed that as Fig. 35.1. A. Histological preparation of a molar. B. Endodontically treated and
diaphanized upper premolar (Courtesy of Dr. Arnaldo Castellucci).
soon as a tooth loses its integrity, even if only a small
amount of tooth structure, its resistance against loa-
ding starts to reduce. In 1989 Reeh, 167 using deforma-
tion detectors on a series of premolars, found that en- mostly follow a horizontal path with a coronal invol-
dodontic treatment alone reduces its strength maxi- vement, while in the endodontically treated tooth the
mally by 5%, while the preparation of a class two ca- origin would be more apical 111 and the path mostly
vity, with the consequent interruption of the marginal vertical with a radicular involvement, thereby making
crest, reduces the strength by 20% and an MOD cavity this tooth a candidate for extraction (Fig. 35. 3). A root
type is reduced by 63%. The scientific literature con- fracture having a mostly vertical direction mostly ver-
cords on this point that the interruption of both oppo- tical is the preferential route for bacteria to penetra-
sing marginal crests corresponds to a reduction in the te deep into the periodontium with consequent pro-
tooth's strength (Fig. 35.2) with a dangerous increase gressive bone resorption (Fig. 35. 4). One should re-
in fracture risk. Confronted with this event, the fractu- member that a fracture can be present with the tooth
re line in a tooth with an intact pulp chamber, would structure intact due to the kinetic effect of excessive
1148 Endodontics

Fig. 35.2. A. Upper premolar with interruption of both marginal crests. B. At hi- Fig. 35.4.A. SEM of a root with a vertical fracture (x13). B. Bacterial colonization
gher magnification a crack line is visible (arrow). within the fracture line (x1000) (Courtesy of Dr. Arnaldo Castellucci).

force, as in the case of trauma or severe parafunction,

or even on a more fragile structure with physiological
loading, which is what can sometimes occur with en-
dodontically treated teeth. Tidmarsh 203 considers the
biomechanical model of the tooth a hollow, lamina-
ted structure that deforms under load. This structure
is therefore able to deform notably under intermittent
and cyclic loading during chewing, but thanks to the
visco elastic properties of dentine, it is able to return
to its pre-deformation condition during intervals free
of loading. Why then are endodontically treated teeth
more prone to fracture?
The treated tooth with regards to loading presents
a more accentuated deformation and a return to the
original shape with a greater delay than the vital to-
oth. The reason for this different biomechanical beha-
viour seems to be due to the fact that the intact tooth
behaves as a preloaded structure. 85 This condition of
preloading is similar to that found in structural engi-
A B neering, in precompressed reinforced concrete, whe-
Fig. 35.3. In a vital tooth (A) the fracture line more frequently starts coronally
re steel bars are placed internally in a permanent sta-
compared to an endodontically treated tooth (B). te of traction. In this way the reinforced concrete fra-
35 - Restoration Of The Endodontically Treated Tooth 1149

mework is constantly in compression and can with-

stand much higher forces than a non precompressed
structure, before reaching the so called "deformation
by critical traction", which is the cause of the fractu-
re phenomena. In the tooth, this preloading condition
appears to come about during "odontogenesis" (Fig.
35.5) by the opposing outward movement of the ame-
loblasts and inwards by the odontoblasts. 203 This state
subsequently becomes frozen or stabilized by minera-

Fig. 35.6. In the integral tooth (left) the stress due to compression (C) if hal-
ved compared to that due to traction (T). In the endodontically treated tooth
(right) they are of equal value.

traction deformations in the region of 20% and above ,

the intermolecular chemical bonds weaken and finally
break. This regularly happens on the side where the
load is applied. In compression the yielding mechanism
is different and comes about by the creation of 45°
cutting forces which generally propagate themselves
unexpectedly and dramatically. The compression
yielding generally happens because of a high level of
Fig. 35.5.The opposing movement of the ameloblasts (upper arrow) and odon-
toblasts (lower arrow) develop the state of pre-stressing the tooth (Courtesy
axial loading and therefore is not physiological.
of Dr. Arnaldo Castellucci). Coming back to the type MOD cavity, in 1991, Kera
107 22
( confirming the results of research by Blaser in
lization of the matrix. When a cavity is prepared in a 1983) demonstrated that in the presence of this type of
tooth, there isn't the loss of the preloaded condition, cavity, the deformation and therefore the relative risk of
but there is stress release and a tendency of the cusps fracture increased much more with the depth of the
to draw closer together, counteracted by the integrity isthmus rather than with an increase in its width. It
of the central structure of the tooth. 85 If however, fol- is therefore easy to understand how this is important
lowing a pulpotomy, the dentine isthmus which con- when the clinician prepares an endodontic access ca-
nects the cusps to each other is interrupted, the con- vity in a tooth where the marginal crests have alrea-
dition of preloading is lost and even minor loads pro- dy been interrupted. In 1985 Hood 97 had verified that
duce increased deformations. in the case of an MOD cavity, the dentinal walls fol-
In the intact tooth the condition of preloading lowed the physical model of a cantilever beam (Fig.
cuts the compression force in half compared to the 35.7): doubling of the cavity depth increases the de-
traction, while in the tooth that has lost this important flection by a factor of eight. Similarly, decreasing the
biomechanical characteristic, finds itself in a linear cusp thickness by half increases the deflection by a
relationship and therefore of equal maximum value factor of eight. In an endodontically treated tooth the
(Fig. 35. 6) rendering the tooth more susceptible to depth of an MOD cavity is 3 to 4 times higher compa-:
deformation. The structural yielding due to fracture red to a "normal" one of a vital tooth. 89 Hence there is
generally happens, not so much as a result of stress a high risk of deformation of the walls in the absence
during compression, that is by axial loading, but as of the continuity normally provided by the marginal
a result of stress due to traction, which is by oblique crests. Therefore during chewing this condition could
loading. Although the mechanisms of fracture process bring about the addition of small deformations, which
due to traction are complex, it can be said that with could surpass the ability of elastic return of the denti-
1150 Endodontics



When one decides to carry out a dental procedu-
re on a patient it is fundamental to cany out a com-
plete collection of data, important to the subsequent
formulation of a correct treatment plan. An objective
examination of the patient must be carried out with a
relative static and dynamic occlusal analysis, a com-
plete radiographic examination, a periodontal evalua-
tion and, if required, clinical photographs (especially
in those cases where there is aesthetic involvement).
Once a full examination of the patient has been com-
pleted, the first evaluation to be carried out on tho-
se teeth requiring endodontic or restorative treatment,
especially if they are severely compromised, is to limit
Fig. 35.7. Deformation of the walls in the presence of an MOD cavity (left).
Physical model of a cantilever beam (right) (Adapted from J.A.A. Hood). such procedures to only those cases where the longe-
vity is predictable and sufficient to justify the comple-
xity of the treatment. One should exclude from treat-
ment all teeth which at the termination of treatment
present one of the following situations:
nal structure. The possibility of reversal of the defor- • high residualrrisk of root fracture (e.g. the presenceof
mation fails, a situation which normally occurs during an over prepared root canal)
the rest phases of the chewing cycle, with the subse- • crown-root ratio excessively altered (e.g. reduced
quent establishing of the physical "fatigue" phenome- periodontal support following surgery)
na, followed by microfractures starting from those in- • exposure of the bifurcation in a multirooted tooth
ternal points which are subjected to a higher concen- (e.g. following clinical crown lengthening procedure)
tration of stress. 14 •131 From this moment onwards the • requirement of an excessive clinical crown
evolution towards the fracture is only a matter of ti- lengthening procedure which would be damage the
me. One can therefore hypothesise that the biomecha- adjacent tooth.
nical structural complex of the tooth is normally safe-
guarded by three fundamental units, the two margi- TREATMENT PLAN
nal ridges and the interaxial dentine at the centre of Following the preliminary evaluation, a treatment
the tooth, which forms the roof of the pulp chamber. plan has to be established as well as a relative operati-
The interruption of the continuity of even one of the- ve sequence which considers the following factors:
se structures changes the solidity of the tooth, but the 1. segment of the mouth which the tooth pertains to
contemporary loss of all these structures can have ca- (anterior or posterior)
tastrophic consequences. 2. amount of structural loss
The endodontically treated tooth is more fragile be- 3. future loading that the tooth will be subjected to.
cause the loss of the dental structure has made it mo-
re prone to deformation even under physiological lo- MATERIALS AND TECHNIQUES
ading. Consequently, to protect the tooth, this incre- At this point one could decide to opt for a purely
ased capacity of deflection must be prevented, either prosthetic restoration or for a conservative type of re-
by fixing it in a rigid shell with a prosthetic crown or storation and therefore the type of restorative techni-
by reinforcing its walls with an adhesive material that que with its relative materials must be chosen.
will reduce the flexing. At the moment, the material 1) Posts (preformed or cast) and the pre-prosthetic
capable of fulfilling this function does not exist, but restorative materials
the latest generation of composites and the new adhe- 2) Cement for posts cementation
sive techniques should be given more consideration 3) Prosthetic crowns
in selected cases, as a complement to traditional pro- 4) Conservative restorations
sthetic techniques. 193
35 - Restoration Of The Endodontically Treated Tooth 1151

J. SEGMENT OF THE MOUTH functional guidance. The anterior segment also calls
Anterior teeth for the choice of techniques and materials which are
The original study by Sorensen and Martinoff in suitable for aesthetic need, as will be shown successi-
1984 190 (Tab. 1) clearly shows how anterior teeth, due vely, including the maintenance or the healthy resto-
to the type of masticatory load that they are subjec- ration of the periodontal support of which the correct
morphology and architecture contributes fundamen-
tally to the final aesthetic result. 71
Clinical Fracture Rate for Tooth Types
Posterior teeth
In the case of posterior teeth, one has seen that the
masticatory load with the relative stress to which the
teeth are subjected to makes occlusal coverage neces-
sary with the protection of all the cusps using a partial
(overlay) or full crown, with the exception of selec-
ted cases (see further on) in which the residual struc-
ture and the occlusal situation allow a conservative re-


Tab. l . Percentage of the fractures in relation to tooth type.

The factors that can cause loss of radicular struc-
ture are:
- internal root resorption (see chapter 30)
ted to, are less susceptible to the risk of fracturing. - external root resorption (see chapter 30)
Therefore protection with a crown is not always ne- - extracanal invasive resorption (see chapter 30)
cessary to extend their longevity. On the contrary, the - incomplete radicular development (see chapter
duration of a posterior tooth clearly increases if, af- 29)
ter the endodontic treatment, the tooth is prosthetical- - iatrogenic procedures (endodontic overinstrumen-
ly protected. From this we can conclude that if there tation, placement of large posts).
are no particular aesthetic requirements which oblige The loss of radicular structure can be a major factor
us to use a prosthetic solution or the need to place an of weakening, so much so that Morgano 146 concluded
anterior tooth in a larger prosthesis, then it would be that it is one of the most important risk factors in root
justified to do a conservative restoration of an endo- fracture (Fig. 35.8).
dontically treated anterior tooth using the same appro-
ach that would be used in a similar situation (as far as
the loss of tooth structure goes) of a tooth with a vi-
tal pulp. 82 .7 5,146 Furthermore, in the conservative resto-
ration of anterior teeth, one should absolutely avoid
the use of posts since they are useless and extremely
dangerous for the wholeness of the root. In this situa-
tion a post, apart from not being necessary for the re-
tention of material and reinforcement of the root, 17 in
the event of trauma, can transform a salvageable to-
oth into one which needs to be extracted. The cani-
ne is a separate issue, and in the case where it sup-
ports an effective lateral guidance, will be subjected to
strong transverse vectors and therefore require incre-
ased resistance to displacement and or coronal frac-
ture. 44 Consequently, a complete crown (in combina-
tion with an effective ferrule effect, which will be de-
Fig. 35.8. Radiograph of a central incisor with a post having enormous dimen-
scribed later), apart from providing an efficient coro- sions. The surrounding residual structure presupposes a high risk of fracture
nal protection over a period of time, keeps the same (Courtesy of Dr. Arnaldo Castellucci).
1152 Endodontics

The factors that cause loss of coronal structure can

- caries
- previous restorative procedures
- coronal fracture
- external resorption etc.

The loss can be so minimal as to enable the resto-

ration to be a simple closure of the endodontic access
cavity (Fig. 35.9), as often occurs in the case of ante-
rior teeth. However, it can be so extensive that it beco-
mes essential to totally restore the coronal portion of
the tooth before proceeding with a full crown covera-
ge (Fig. 35.10). Between these two extremes we also
Rnd the intermediate situation where it is difficult to
decide between a conventional conservative type of
restoration or protection by prosthetic means. The cri-
teria for making this choice, as suggested by Becciani
and Castellucci, 19 apart from evaluation of the segment
where the tooth is and the load it is subjected to, are:
- the amount of tooth structure lost
- the form of the principal cavity (0, MO I OD,
- analysis of cusp thickness
- the presence of secondary restorations.

Quite often the evaluation of the percentage of

crown structure 17 of an endodontically treated tooth
is not so easy ~r, and in many cases is not reliable if ta-
ken as the only data without other fundamental para-
When it comes to the restoration of a posterior to-
oth it is more important to analize the shape of the
main cavity. Some retrospective studies R9.1 9o show that
endodontically treated posterior teeth with MOD re-
storations done in a conservative way without cusp
protection have a shorter longevity than those with
MO or OD type cavities. The simultaneous interrup-
tion of the two marginal crests in the presence of en-
cloclontic treatment (even just a pulpotomy) increa-
se the risk of fracture so much so that the necessity
of coverage with an overlay becomes inevitable (Fig.
35.11). Sakaguci 172 (in a finite element analysis study)
shows the independence of the deformation of the
cusps of a posterior tooth under load. Other authors
119 1
· 'i" confirmed the impo1tant role of the thickness of

the residual dentine at the base of individual cusps af-

ter cavity preparation, showing the greater deforma-
tion of cusps adjoining an interrupted marginal crest
compared to one still joined to an integral marginal Fig. 35.9. A. An upper molar with only the opening of the access cavity. B-D.
crest. All of this is perfectly in accordance with the vi- Direct restoration of the case.
55 - Restora ti o n Of Th e Encloclonlically TreaLecl TooLh 1153

Fig. 35.10. A. An upper molar with extensive loss of coronal structure recon-
structed with a carbon fibre post and a composite for cores.B.The same tooth
restored with a full coverage ceramo-metal crown.

Fig. 35.11. A. Radiograph of an endodontically treated lower premolar (Courtesy of Dr. Arnaldo Castellucci). B. Clinical view after endodontic treatment. C. Protection
With an overlay was prescribed due to the presence of a small mesial carious lesion. The premolar following the build-up in composite and prepared for an overlay.
D.The composite overlay cemented adhesively. E. Two year recall.
1154 Endodontics

sco elastic properties of dentine. Therefore measuring ry restorations like a class V, then this should be re-
the thickness of all of the residual cusps at their base moved to exclude the presence of caries underneath
(Fig. 35.12) is essential to decide whether to opt for an and to evaluate the walls thickness (Fig. 35.14). Even
exclusively conservative restoration as well as evalua- in the case where the evaluation indicates a comple-
ting the necessity for a post, should prosthetic covera- te crown restoration, analysis and measurement of the
ge be needed (Fig. 35.13). A less than 2.5 mm thick- residual structure is essential to decide whether or not
ness should discourage restorations that don't foresee to place a post for the core reconstruction.

Fig. 35.12. Incorrect (A) and correct (B) measurement of the thickness of the Fig. 35.14. A.The presence of a class V restoration can cause an erroneous eva-
cusps. luation of wall thickness. B. Once the restoration has been removed the mea-
surement must be repeated.

Restoration of a single tooth
To evaluate the occlusal risk factors that a once re-
stored endodontically treated tooth, will be subjected
to we have to examine the occlusal scheme of the pa-
tient, i.e. the presence or absence of a valid anterior
and canine guidance and therefore the type of vectors
and stress the tooth will be placed under.
Even with the restoration of an anterior tooth, de-
pending on the amount of residual coronal and radi-
cular structure, the level of stress that the tooth will
Fig. 35.13. Measurement using a calipers of the cusp thickness of an endodon- be subjected to has to be evaluated so as to be able
tically treated molar. to decide between a direct restoration or a prosthe-
tic solution. For example, in the case of an upper in-
cusp coverage. The evaluation of the residual thick- cisor that has a particularly steep lingual surface (de-
ness must always be considered together with the ca- ep overbite and very little overjet), the principal load
vity shape. For example, according to the author, if in vector created by contact with the opposing teeth will
a DO I MO cavity the cusp has a reduced thickness be almost at 90° with the contact surface and therefore
and is adjoined to the interrupted marginal crest, then will be practically horizontal. 47 The forces that deve-
it should selectively be reduced and overlayed. On the lop in this situation are highly traumatic so that when
other hand, if the cusp is adjoined the uninterrupted the endodontic treatment is carried out it is associated
crest, then its reduction will change a DO I MO cavi- with a large loss of tooth structure and a conservative
ty into an MOD cavity and then an overlay protection restoration would probably not be recommended due
becomes mandato1y. If there happens to be seconda- to the elevated lateral stress that this tooth would be
3'i - Restoration Of The Encloclontically Treated Tooth 1155

subjected to. The prosthetic crown fitted to protect an the anterior teeth. Recently Ratcliff 1t observed that

anterior tooth in this situation must have the correct posterior teeth subjected to eccentric premature con-
lingual contour and a horizontal centric stop so that tacts are two to three times more liable to have frac-
the principal force vectors are directed mainly along tures than those without premature contacts while the
the long axis (making them more tolerable). With the- simultaneous presence of restorations and premature
se restorations it is important to check that there are a contacts increases the probability by six times. Before
number of teeth in simultaneous contact during pro- starting the reconstruction of an endodontically trea-
trusive and lateral excursions. ted posterior tooth it is a good policy to check if. with
In the case of posterior restorations the presence of minor adjustments, it is possible to eliminate the ec-
an effective anterior guidance during lateral excursion centric premature contacts, especially the balancing
becomes essential to protect the tooth at risk from type, present on the tooth to be restored. This proce-
dangerous horizontal stress overload. As we have se- dure allows us to ascertain if we are inside a tolerance
en before, the type of fracture one sees most frequen- range that. with a limited selective adjustment of on-
tly in a tooth that has lost its integrity is that due to ly the excursive contacts (absolutely avoiding the cen-
traction from force vectors that are applied laterally. tric contacts). allows complete disclusion of the to-
One can therefore easily conclude that the total ab- oth to be restored. Once completed. independently of
sence of guidance that one finds in certain occlusions the type of material or technique used, the occlusion
(open bite, class II with marked overjet, class III oc- of a tooth must be checked to ensure the presence of
clusion etc.) associated with numerous wear facets, punctiform contact points in centric and total absence
makes a non protective restoration unadvisable (Fig. of premature contacts in lateral and protrusive move-
35.15). In general, obvious wear facets on the surfa- ments (Fig. 35.16). One must bear in mind that in ti-
me the efficiency of the incisor/ canine guidance can
diminish due to wear factors and it is a good policy
to check the occlusion of the restorations at least on-
ce a year.

Fig. 35.15. The presence of numerous wear facettes and inefficient anterior
guidance creates a high risk situation for the restoration of endodontically
treated posterior teeth.

ce of the tooth to be treated as well as those adja-

cent indicate that a check should be made for pre-
mature contacts during eccentric mandibular move-
ments. We know from research by Williamson 2:iu that
the complete disclusion of posterior teeth during ec-
centric: movements of the mandible reduces the mu-
scular contraction of the elevators with reduction of
the load on these teeth as well as on the temporo-
mandibular joint. On the contrary, any interference of
posterior teeth during an excursion in fact provokes
Fig. 35.16. A. The presence of centric and excursive contacts on a ceramic re-
their hyperactivation with consequent increase in lo- storation of a lower premolar. B. Occlusal adjustment with elimination of the
ading of the whole system especially on the level of working and balancing contacts.
1156 Endodontics

Restorations of more teeth a cantilever bridge 154 in a patient with a traumatic oc-
In the case where the endodontically treated tooth clusion corresponds to high probability of failure (Fig.
has to be part of a prosthetic treatment involving other 35.17). In any case, the analysis of risk allows one to
teeth, it is even more important to evaluate all the risk propose an alternative treatment to the patient, for
factors that could lead to the fracture of the single to- example the implant therapy.
oth and compromise the entire prosthesis. Firstly the
type of loading must be determined with the relative
stress that each abutment of the prosthesis is subjec-
ted to. This evaluation, must take into account the in-
creased "fragility" of the endodontically treated teeth
so that they are not subjected to a load that exceeds
their strength limit.
The following situations must be considered when
evaluating the load on a fixed prosthesis when:
- The distal terminal abutment is subjected to a hi-
gher load than the mesial one because it is closer to
the point of force application (insertion of masticato-
ry muscles).
- The terminal abutment of a long bridge is subjec-
ted to a much higher load than that of a shorter brid-
- In the case of a ve1y long bridge without inter-
mediate abutments, the terminal abutment is subjec-
ted to mesio-distally directed forces that are much hi-
gher than usual.
-Terminal abutments with attachments for a remo-
vable prosthesis are subjected to transverse and tor-
sional loads that are particularly high.
- With a cantilever bridge in the posterior segment
Fig. 35.17. A. Radiograph of a cantilever prosthesis where the endodontically
the tooth next to the missing one is subjected to stress treated teeth were restored with large metallic posts. B. Clinical photograph
directly proportional to the length of the lever and.for- of the same case. The cantilever pantie, having the occlusal surface of a molar,
ce on the cantilever. In other words, a pontic shaped creates an elevated lever effect.

like a molar creates more stress than one shaped li-

ke a premolar and a distal cantilever is riskier than a MATERIALS AND TECHNIQUES
mesial one. Evaluating the entity of lost coronal tooth structu-
re and the necessity to successfully protect the cusps
To summarize, one must remember that other ag- with a complete crown or not, one opts either for a
gravating factors must be considered in one's analy- prosthetic or a conservative restoration. In the case of
sis of prosthetic loading to have a global evaluation of a severely damaged tooth to be restored. which has
the risk. Other aggravating factors are as follows: suffered. the loss of coronal tooth structure prevents
- Extensive loss of tooth structure the reconstruction with plastic material only, it then
- Necessity of posts for the restoration becomes essential to use a post with end.od.ontic an-
- Surgical lengthening of the clinical crown chorage (inside the root canal system).
- Orthodontic extrusion The post could be either of a cast post and core or
- Aggressive preparation of the crown core for aes- of a prefabricated type. In the case of prefabricated
thetic reasons. posts it is necessa1y to use a plastic material like com-
Evaluating all these risk factors for each single ca- posite and amalgam that allows one with the residual
se makes it easier to understand which situations are dentine to shape the correct morphology of the core,
at high risk for failure and hence a particular treat- i.e. the prosthetic core, necessa1y for the adequate se-
ment plan. For example, using an endodontically tre- ating of the crown. 146
ated premolar that is restored with a metallic post for In these cases and in all those teeth that have had
35 - Restoration Of The Endoclontically Treated Tooth 1157

severe structural damage it is essential to cover the 1. Posrs

cusps with a partial coverage coronal restoration (onlay If one has to correctly define a post, one would ha-
or overlay), or a full prosthetic crown (Fig. 35.18). In ve to ask what purpose it serves. In the past if this
the case of the loss of a medium or small amount of question was asked to certain authors, 35,101 .1s9,zo9 the re-
dentinal structure, a restoration using a plastic mate- ply would have been the following: "The post reinfor-
rial like amalgam, composite or glass ionomer could ces the tooth, protects it from the concentration of in-
be carried out. ternal stress, distributes the stress that the crown-ro-
ot complex is subjected to along a larger surface and
thereby reduces the risk of fracture". Therefore it fun-
ctions more or less like an internal reinforcement in-
side a more fragile material subjected to a deforming
load, for example like steel for reinforced concrete. If
this were the real function of the post, then it would
be necessary to place one in each endodontically tre-
ated tooth if not in each root.
Further studies and researches i1,1 3, 14,78,ss, 190,193 ,200.211
have shown that things are not exactly like this and
that "reinforced" roots with a post are those most like-
ly to fracture, especially if in placeing that post some
precious dentine was removed. A more current view
would be that the post should be considered a means
for restoring the coronal portion of the tooth with an-
Fig. 35.18. The restorative elements of an endontically treated tooth: the post
with its luting cement (A), plastic materials for the core (composite, amalgam chorage in the root so as to prevent partial or comple-
etc.) (B), the prosthetic crown with its luting cement (C). te coronal decementation both during the restorative
procedure (removal of provisional, taking impressions
These materials are retained by undercuts, as in the etc.) and successively during function. In other words,
case of amalgam, micro-retention and/ or chemical eve1y time the residual coronal structure is insufficient
adhesion in the case of composite and glass ionomer. to retain the material for the reconstruction of the co-
The plastic materials can be used for a definitive re, the post either directly reconstructs all of the co-
conservative restoration, for a provisional restoration ronal portion that is missing (cast post and core), or
or for a pre-prosthetic restoration. serves as retention for a plastic material for the re-
By conservative definitive restoration one means construction (pre-fabricated post). The post itself uses
the type of restoration to be used exclusively for the part of the root canal for its retention.
situation where the fracture risk is extremely reduced Currently all the authors 6.1 3.37.1 62 agree that the use
and even though it requires replacement a number of of a post should only be for those cases where it is
times during the patient's life, it does not require pro- essential for retaining the core and since it can tran-
sthetic coverage. sfer occlusal load to the tooth structure with the risk
The conservative provisional restoration is typical- of fracture, its use must always be combined with suc-
ly an interceptive procedure carried out in a young cessive prosthetic coverage of the tooth (Fig. 35.19).11
patient as a holding procedure until adulthood when In other words, if the endodontically treated tooth
a prosthetic crown can be used for definitive protec- has sufficient structure to be restored conservatively,
tion. the introduction of a post would be absolutely super-
With pre-prosthetic restoration, as mentioned befo- fluous, if not dangerous.
re, materials like composite and amalgam are used to Undoubtedly the use of a post increases the opera-
give the correct volume to the prosthetic core before tive time, complicates the procedure, increases both
coverage with a crown. Indirect restorations (which the risk of iatrogenic damage and the cost. Not wi-
require the use of a laboratory technician) using com- thstanding this there are still too many situations in
posite or ceramic for inlays or veneers can also be which unnecessary posts are placed, 197 motivated by
considered as a conservative procedure. the fear that the reconstruction could possibly detach
and therefore fail.
Often many of the failures are not due to defects
1158 Endodontics

retention brings about the removal of more dentine,

with the result of fu1ther weakening a tooth that is al-
ready fragile . This is surely a case of over-treatment.
The mechanism by which structural failure of an en-
dodontically treated tooth with a post and full crown
occurs has been examined by some authors.cVi, 117 They
define "preliminary failure" as the biomechanical si-
tuation in which a tooth with severe loss of coronal
structure, restored with a post and crown, is subjec-
ted to a loading cycle until the appropriate strain gua-
ge registers the occurrence of a significant deforma-
tion. This deformation is responsible of the crack in
the luting cement on the same side where the for-
ce is applied. In fact, a small flexing of the core itself
has occurred, invisible to the naked eye but registe-
red by the instrument. The failure has already occur-
red! This initial yielding, completely invisible, is follo-
wed by successive micro-movements of the crown it-
self on the core and thus onto the post that only suc-
cessively leads to the true clinically detectable failure
(Fig. 35.20).
The stress produced by these micro-movements
transferred rigidly to the root by a metallic or zirco-
nium post could cause fracture. This is the reason why
most recently an attempt has been made to pass from
the use of metallic materials, which are too rigid, to
others with mechanical characteristics closer to that
Fig. 35.19. A. Extensively compromised lower molar restored with two carbon
fibre posts and composite for core build-up. B. The prosthetic coverage with of dentine. Posts in resin with carbon fibre reinforce-
a ceramo metal crown. ment,60·61 in quartz, glass, silicate, zirconium etc. have
been commercialized and these have revolutionized
of retention but of a series of errors in the treatment the restorative technique of endodontically treated te-
planning of the case, of hurried operative procedu- eth. However, researchers have shown that the system
res or even inaccurate occlusal adjustments at the end that in reality best protects the tooth restored with a
of the restorative treatment or in the following years. post and crown from failure is represented by the so-
Furthermore, with the passing of time an efficient ca- called "ferrule effect".
nine guidance, due to wear, may not carry out its fun-
ction anymore and a restored posterior endodontically The ferrule effect = structural protection
treated tooth may become progressively loaded with
lateral stress of a considerable level. The phenomena Many authors who have been restoring endodon-
could explain catastrophic failure even after a mun- tically treated teeth have singled out the key to suc-
ber of years after restoring the tooth. If this tooth was cess, not so much with the type of materials used for
restored conservatively or covered with a crown, wi- the restoration, but in the residual coronal structure. t 91
thout a post, it could suffer with decementation of the These authors 11 ·77 ·207 maintain that in the presence of
restorative material or a fracture predominantly .hori- a crown that embraces the tooth 360° on an adequate
zontal of the core-crown complex. amount of healthy dentine of the core, that the type of
The presence of a metallic post would transfer the post used for the restoration loses importance becau-
stress component deeper into the root resulting in a se it is no longer stressed by occlusal forces.
vertical fracture. There is often too much attention gi- For many years we have know that a metal collar
ven to the search for retention,87 by both clinicians 4 63, Joo,170 that circumferentially embraces the root with
and by numerous researchers, even in situations whe- a metallic post inside, definitely reduces the fractu-
re it is in abundance. In these cases further search of re risk. The ferrule effect (term used by Eissman and
35 - Restoration Of The Encloclontically Treated Tooth 1159

Fig. 35.21.The ferrule effect is created by (A) the prosthetic crown margins (in-
correct); (B) the bevelled margin of the cast post and core (incorrect); (C) the
crown surrounding the parallel dentin walls extending at least 1 mm coronal
to the shoulder of the preparation (correct).

the radicular dentine; for Sorensen and Engelman 188

the ferrule effect ultimately is "a 360-degree metal col-
lar "of the crown surrounding the parallel walls of the
dentin extending at least lmm coronal to the shoul-
der of the preparation." The ferrule effect at the only
crown margin does not improve fracture resistance. 188
A long bevel on the post is seemingly useless 143 •188 and
in reality obliges one to remove an extra amount of
healthy dentine, which is an obstacle when checking
the seating of the post in the root and causes techni-
cal problems for the laboratory. To conclude, an ef-
ficient encirclement of the root with a "ferrule effect"
can only be achieved on a specific amount of circumfe-
rential healthy parallel dentine wall. In some publica-
tions 63•73 ·100.1 43 reference is made to 1 or 2mm of den-
tine that extends apically from the margin between
the core and the tooth, but without specifying whe-
ther this does or doesn't include the preparation of the
margin of the crown. The effectiveness of the ferrule
effect is only at a maximum on vertical walls and di-
minishes as this becomes more and more oblique to
finally finish at a horizontal level (Fig. 35.22). In fact
the definition of Sorensen and Engelman 188 specifies
Fig. 35.20. An example of 'preliminary failure'. A. Radiograph of two upper en-
dodontically treated premolars restored with fibre posts and ceramo-metal that the dentine walls must be parallel to each other
crowns joined together.The first premolar has a periapical lesion presumably and coronal to the preparation of the crown margin.
due to reinfection because of coronal leakage. B. The patient presented with
both crowns decemented.C.The prosthetic cores have an inadequate coronal It appears obvious that a very vertical preparation like
residual structure to have a correct ferrule effect. one that finishes in a knife edge could be considered
to have a ferrule effect, while the horizontal portion of
Radke in 1987 63) has been described in various ways a 90° shoulder preparation has no effect. A margin of
in the literature (Fig. 35.21) generating some confu- 135° chamfer preparation could also be considered to
sion: for some authors it means the reinforcement ring have a ferrule effect but with a 50% effectiveness. The
effect of the crown margins on the healthy root struc- height of this ferrule effect has been increased with ti-
ture; for others 183 it is done by the bevelled margin me and is currently needs at least 1.5 mm of healthy
of the cast post and core which embraces a part of vertical dentine walls, which can be embraced by the
1160 Endodontics

prosthetic crown. to the fracture, but also with the integrity of the luting
Furthermore, the literature gives no information cement at the crown margin64•73·118 . In fact, in the ca-
about what the minimum thickness of this dentine se where an adhesively cemented fibre post in the ab-
wall should be, but according to the Author, a thick- sence of a good ferrule effect is used, then the obli-
ness of less than 1 mm should not be considered suf- que ocdusal loads can in time produce flexing of the
ficient (Fig. 35.22). On the other hand, one should no- post and micro-movements of the core, capable of al-
te that all the endodontic procedures and those con- tering the luting cement at the margin of the prosthetic
cerning the placing of a post, remove internal dentine crown (Fig. 35.23). As a consequence of this "prelimi-
and consequently reduce the thickness of this strate-
gic area.

Fig. 35.23. In the absence of the ferrule effect a load that develops on one si-
de of the prosthetic crown could alter the luting cement seal, causing bacte-
rial leakage on the same side.
Fig. 35.22. Measurement for the height of the ferrule effect must be taken from
the core-dentin junction up to the point where the preparation of the core
changes from vertical to oblique for the finishing margin of the preparation.
nary failure" one could later find coronal leakage and
then caries of the core, decementation of the crown
Another biomechanical aspect to bear in mind is or post, 153 or fracture of the entire crown-core com-
that the preparation of the prosthetic abutment in the plex. Since an adequate ferrule effect is fundamental
interproximal area is more coronal with subsequent with any type of post, in the situations where this is
reduction of the ferrule effect in this area. In this case not present, it is essential to obtain it surgically (Fig.
the protection against a bucco-lingually directed for- 35.24). This however causes the patient an increase of
ce (the most frequent) is valid, while in the case of a inconvenience, discomfort, cost and operative time.
terminal abutment for a removable partial prosthesis
or a long bridge where mesio-distally directed torsion Other disadvantages to keep well in mind and to in-
may develop, it is essential to reclaim dental structu- form the patient about are:
re in the interproximal zone as well. It has been hypo- -post surgical discomfort
thesized recently 139•174 that the adhesive cementation -aesthetic problems (lengthening of the teeth involved,
of a post could create a sort of internal reinforcement opening of dark interdental spaces, exposition of
capable of replacing the external reinforcement cau- prosthetic margins on adjoining teeth)
sed by the ferrule effect. In other words, it was theo- -phonetic problems if the front teeth are involved
rized that in the absence of residual coronal structure, -increase in the crown I root ratio
it would be sufficient to adhesively cement the post -involvement of the furcation or anatomic concavities
to prevent failure. Successive studies have confirmed of adjacent roots
the contra1y, that there is no scientific evidence to di- -reduction of the periodontal support of the involved
minish the importance of the protective effect given tooth as well as those adjacent.
by the residual coronal structure 100 . Numerous clini-
cal 207 and in vitro 11 ·95 studies have verified the effecti- Other anatomic factors to consider which may di-
veness given by the ferrule effect, not only as regards scourage, prevent or at least limit the surgical outco-
:)'5 - Restorati on Of The Encloclontically Treated Tooth 1161

Fig. 35.24.A. Endodontically treated upper second premolar and first molar restored with screws and composite material. B. After endodontic retreatment and remo-
val of the defective restorations the amount of coronal destruction of these teeth becomes evident. C. Clinical crown lengthening procedure (Surgery by Dr.Stefano
Gori). D. During the periodontal tissue maturation the temporary crowns are kept short of the gengiva. E. Definitive preparation of the prostetic cores. F. All ceramic
crowns (IPS Empress II lvoclar Vivadent) (Technician Paolo Vigiani). G.The case finalized. H. Occlusal view at a three year recall.
1162 Endodonticti

me, should be evaluated. They are:

-the length of the root
-the state of the pre-existing periodontal support
-the crown I root ratio
-the height of the root trunk in multi-rooted teeth
,1 -the position of the declining portion of the
maxillary sinus
-the bucal depth
-the proximity of the mandibular ramus
-the position of the external oblique ridge
-the presence of attached gengiva distal to the
second (or third) inferior molar.

The typical surgical phase of clinical crown lengthe-

ning can be preceded by a phase of orthodontic extru-
sion (Fig. 35.25), which adds further costs and operati-
ve time but offers undisputed advantages:
-it enables one to maintain a better crown I root ratio
-it avoids the loss of periodontal support of the
adjacent teeth
-it minimizes the negative aesthetic effects.
When planning the treatment where the aesthetic

Fig. 35.25. A. Fracture of upper lateral and central incisors due to a bicycle accident. B. The fracture line extends up to the bone crest on the palatal side. C. Following
endodontic treatment orthodontic extrusion of the teeth is carried out. D. Surgical repositioning of the periodontal tissues with clinical crown lengthening. Note
the large triangular space opening between the central incisors. E.The first resin temporary crowns. F.A small composite restoration was done on the mesio-buccal
aspect of the left central incisor so as to modify the temporary crown on the right central incisor and thereby conditioning the interproximal papilla. (continued)
35 - Restoration Of The Encloclontically Treated Tooth 1163

Fig.35.25 (continued).G. At the end of the tissue maturation and conditioning phase the case is ready for finalization. H. All ceramic crowns (IPS Empress lvoclar
Vivadent) (Technician Paolo Vigiani).1. The case following cementation of the crowns. J. Clinical recall after two years.

result is important one must also remember that the cular zone where, due to radicular taper, the dia-
root emergence profile of an orthodontically extruded meter is reduced. The amount of dental structure
tooth that has undergone a clinical crown lengthening that has to be removed must be established, not
procedure will have a reduced diameter in relation to only from the parallelism of the preparations but
the degree of root taper. also from the realistic requirements of each case.
If on the one hand a surgical lengthening of the In the non visible areas of the mouth such as- in
clinical crown has as a biomechanical purpose the the case of a patient with a low smile line , the pre-
exposure of healthy dental structure, it is impor- paration of a buccal chamfer with a width of 0,8
tant to understand that this biomechanical advan- mm obliges the technician to have a ceramic that
tage does not get thwarted by an over zealous pro- is more opaque but allows us to save healthy den-
sthetic preparation. Gegauff 76 in fact warns against tinal structure, considered essential for long term
preparations of high widths (1.5 mm) in the radi- success (Fig. 35.26). 145 Of course, clinical crown
1164 Encloclontics

lengthening procedures have other indications, apart posts from indirect: posts, which are made for casting
from the biomechanical aim (Tab. II) (Fig. 35.27). or pressure casting in the dental technician's laborato-
One of the possible classifications of posts is the 1y. Both prefabricated and cast posts can be· differen-
one (Tab. III) in which one differentiates prefabricated tiated by the material from which they are construe-

Fig. 35.26. A. Pre-operative radiograph: the molar

needs removal of the distal root for periodontal
reasons and the premolars require endodontic
and restorative treatment. B. Surgical procedure
for root resection and clinical crown lengthening
of all three teeth (Surgeon Dr. Stefano Gori). C.
Preparation of the cores with a reduced chamfer
on the buccal side only. D. Finalization of the pre-
parations and maturation of the tissues. E. The
reduced aesthetic requirements of this case allo-
wed the preparation of a shallow buccal cham-
fer. F. The thickness of the crowns in this area are
less than a millimeter. G. The ceramo metal brid-
ge cemented. H. A 'forced ' smile by the patient
which does not show the portion of the ceramic
crowns which are more opaque (Techician Paolo

Table II Indications for clinical crown lengthening -pre-existing conservative or prosthetic restorations
procedures. ·-preceding finishing margins of prosthetic preparations

3) Prosthetic abuttments having insufficient height to en-

1) Exposing the healthy dental structure located sub-gin- sure retention and resistance form
givally due to :
4) Esthetic problems
- carious lesions - anterior teeth which are short and associated with a
- horizontal or oblique corono-radicular fractures gummy smile
- perforation or external resorption involving the coronal - asymmet1y of the gingival margin in the anterior sector.
third of the tooth
5) Gingival hype1trophy
2) Re-establish the biological width due to iatrogenic
causes. 6) Insufficient inter-arch space in the edentulous zones
35 - Restoration Of The Endodontically Treated Tooth 1165

Fig. 35.27. A. Severe loss of dental structure on the upper teeth. B. The teeth have been restored with quartz fibre posts and core composite while clinical
crown lengthening with root resection of the disto-buccal root was carried out on the first molar (Surgeon Dr. Stefano Gori). C. Note recovery of tooth struc-
ture obtained with the surgery. D. The case finalized with a ceramo metal bridge (Technician Paolo Vigiani).

ted. Each type has both advantages and disadvanta- re interfacing between different materials. The main
ges (Tab IV). defect of prefabricated posts is the necessity to mo-
dify the canal to adapt to the post and vice versa.
1a. Prefabricated posts This leads to removal of dentine from inside the ro-
Metal posts ot which causes further weakening of the tooth. The
Prefabricated posts have the undeniable advantage common error that is made is that generally a post is
of being able to be used directly for the reconstruction chosen (often with a larger dimension than is real-
of the core in one appointment without needing labo- ly necessary) and successively the canal is prepared
rato1y assistance. The method of use is standardized with the dedicated standardized drills until the post
and thanks to their widespread use the dental industiy is able to fit into the canal. The largely shared point
has marketed a large range to choose from. Particular of view that sees the removal of dentine as the main
advantages are offered by fibre posts, and these will cause of weakening endodontically treated teeth, ma-
be discussed successively. kes it therefore advisable to only remove gutta-per-
A disadvantage of using a prefabricated post is the cha from the portion of the canal which is destined
fact that once placed another material is required for for the post using standardized drills simply as a me-
the construction of the core, with consequently mo- ans to choose the size most suitable for the canal.
1166 Endodontics

Table III.
-- - - - -- ---- - - - - - - - - - - - -


Metal Posts


Carbon fibre


Non Metallic Quartz fibre

Silicate fibre
Metal alloys
Zirconium fibre


CAST POSTS Cast-pressed ceramic

Glass infiltrated alluminium

Zirconia/ Ceramic

Table IV.

one clinical session
Advantages no laboratory required
{ standardiz ed procedure
wide conimercial selection available


Disadvanta es { tbe ca~ial adaf:ts to tbe post

g more interfacing suifaces

tbe post adapts to tbe canal

more precise
less cement
f Advantages
more retention
{ reduced number of interfacing suifaces
increased strengtb

bigber cost
D' d t greater number of clinical sessions
isa van ages requires laborat;iy support
{ increased wedge effect

35 - Restoration Of The Endodontically Treated Tooth 1167

Standardized drills in good cutting condition can also sential to maintain optimum cutting efficiency because
be used by hand to very delicately refine the dentinal rounded blades or even worse, deformed blades, ma-
walls (Fig. 35.28). Therefore one removes that portion ke the rotational axis asymmetric and could cause vi-
of the dentine most contaminated with endodontic se- brations responsible for micro-cracks starting from the
aler and gutta-percha which is an essential condition internal wall of the canal.
In recent years endodontics is decisively less in-

Fig. 35.28. Standardized drills can be used by hand both as caliper to measure
and to rectify the canal walls.

for correctly carrying out the procedure for adhesively Fig. 35.30. Extracted upper premolar. Note the stripping created during the
cementing the post. Very often standardized drills ha- preparation of the post space for the subsequent cementation of a cast post.
ve a cutting surface which is too aggressive, acute an-
gles and blades that are too distant one from the other
(Fig. 35.29) with the risk of creating stripping, ledges, vasive and more conservative than ten years ago.
microcracks, etc. (Fig. 35.30). With their use it is es- Therefore, one cannot understand why the recon-
structive technique should thwart this effort, seeing
that at the end of endodontic treatment the space
for placing the post is often more than adequate.
If the reconstruction of the core is done at the sa-
me visit as the endodontic treatment, the back pa-
cking of the canal may be avoided, thereby leaving
space available for the post placement. Completing
the coronal reconstruction at the same visit as the
endodontic treatment is probably the correct pro-
tocol to avoid the risk of coronal leakage. If inste- ·
ad the reconstruction is postponed to a successive
visit, the removal of the gutta-percha can be done
with instruments such as Touch'n Heat, the System
B or with Gates Glidden drills which rotate com-
pletely inside the gutta-percha heating it for remo-
Fig. 35.29. Often the standardized drills have cutting surfaces that are too ag-
gressive and blades that are separated too much from each other. val (Fig. 35.31). The preparation of the post space is
1168 Endodontics

a delicate moment which can cause iatrogenic dama- creating microfractures in the dentinal walls of a ca-
ge such as perforations, stripping or even severe wea- nal, let's examine some general characteristics of pre-
kening of the root caused by asymmetrical removal of fabricated posts:
dentine. There are roots which are more at risk than Elasticity
others, 1•87 such as thin and ribbon shaped ones of up- Surfaces
per premolars or those that curve distally with a con- Width
cavity like the mesial root of upper and lower molars. Length
Even in the larger canals, such as the palatal upper Taper
molars which normally are used for post placement, With the exception of fibre posts of which we shall
rarely have a curvature that is not radiographically evi- speak separately, elasticity of metal or zirconium posts
dent. Therefore to avoid the risk of causing the above is extremely low. This rigidity can have the advanta-
mentioned damage, the following is essential: ge that the force necessary to cause a micro-flexion of
the core, which is the principal cause of "prelimina-
1y failure", must be superior to the one necessary to
obtain the same effect as in a core built up with more
elastic systems. The most serious disadvantage of rigid
posts is that of creating an unhomogeneous system
in which, if there is a transmission of occlusal stress
to the post (activation of the post) this will be large-
ly transferred to the root walls with predictable conse-
quences. Amongst the metal prefabricated posts tho-
se that present a higher elasticity are the posts in tita-
nium 194 which therefore, from this point of view, are
the most recommendable.
In regards to surface, it appears evident that a rough
surface, be it serrated or denticulated, is more re-
tentive towards reconstruction material and post ce-
ment than a smooth surface. Especially in the case
of adhesive cementation, the critical interface is not
so much that between post and resinous cement, as
much as between the latter and the dentine substrate.
In fact, in the case of decementation of a post, it regu-
larly detaches from the canal with the cement attached
to its surface. 53 A smooth post can in any case be ren-
dered extremely retentive through the use of a simple
micro sandblaster.
Fig. 35.31. A Gates Glidden drill rotating inside the gutta percha can heat it For the width, we know that its increase corresponds
making easy its removal.
to an increase in retention, but not as proportional-
ly as with an increase in length. 196 From a retrospec-
tive research by Morgano 146 carried out on 900 pa-
-radiographic evaluation of the canal portion which is tients, it was found that the most critical factor under-
to be used for the post space. If there is any doubt it lined in unsuccessful cases is precisely the length of
is useful to use two radiographic projections the post. When this exceeds half of the root length, the
-during removal of gutta-percha with magnification, risk of failure (fracture) is ve1y high. One must therefo-
one should check that the drill is centered on the insi- re absolutely avoid trying to increase retention or
de of the canal space and that its working action is on strength of the post by further enlarging the root ca-
the gutta-percha and not on the dentinal walls nal (Fig. 35.32).
-avoid going too deep in the canal where visibility and What we find in the literature, as regarding the ideal
tactile control are reduced. length of a post, is a river of ink with tests which have
Since we won't be speaking about screw posts, mo- various and bizarre conclusions. 198 Without any certain
re useful in a carpenter's workshop rather than for facts, therefore there is only total confusion surroun-
35 - Restoration Of The Endodontically Treated Tooth 1169

Fig. 35.32. Radiograph of an upper canine with an enormous post.The periapi-

cal lesion is due to root fracture.

ding this argument and if one has to answer the legi-

timate question about how long the post should be,
we find ourselves in great difficulty. Looking at pre-
sent literature, on the subject some points are certain
and one can start from these:
All the authors agree on the point that short posts
concentrate a large amount of stress in the coronal
portion of the root 2·96 .1 89 and can bring about a high
percentage of fractures in this area (Fig. 35.33).
Another fact, just as important and on which many
authors are in agreement, is that the minimal amount
of apical gutta-percha that must be left to avoid en-
dodontic failure must be at least 5mm 83, 137,233 (Fig.
On the basis of this, one can conclude that it is best
if posts (both cast and prefabricated) are long but not
so long as to compromise the apical seal. Generally a
1: 1 ratio between the part of the post in the canal and
the height of the core is considered sufficient by most
Regarding the taper, we know that the more cylin-
dric it is the more retentive it is and a minimal wed- Fig. 35.33. A. Radiograph of upper premolar where the presence of an extre-
ging effect occurs inside the canal. A cylindrical post mely short metallic post and the complete absence of any endodontic treat-
ment of the root canal system is noted. B. The ceramo metal crown with its de··
adapts poorely to most of the root canals which at the cemented post. C. The root of the premolar with an obvious radicular fractu-
end of endodontic treatment has a tapered form, un- re starting palatally.
1170 Endodontics

less dentine is removed.195 On the contrary, the mo-

re a post is cone-shaped the less retentive it is but
the more conservative is its use in a tapered canal. 146
However, the wedging effect of the post is the hi-
gher.187The choice of shape to be utilized must be ma-
de evaluating each case individually with post endo-
dontic X-rays and if necessary using standardized files

Fig. 35.34. Radiograph of a lower molar with an excessively long screw post
placed in the distal canal. Note the almost complete removal of the gutta per-
cha from inside the canal.

as calipers to access the endodontic anatomy of the Fig. 35.35. Examples of carbon fibre posts: A. Composipost (RTD - Dentsply). B.
available post space. As has already been mentioned, DT Composipost (RTD - Dentsply).
once the tooth is protected with a crown having a go-
od ferrule effect, the design of the underlying post lo-
oses its clinical relevance. 207 In this situation it is im-
po1tant to select a post that does not force one to re- sis of many root fractures of teeth restored with metal
move precious dentine. posts. The fibre post has the advantage of dampening
the transmission of stress to the dentinal walls and al-
Non metalposts:fibre bosts
so of being constructed of material that is extreme-
In the early 90's posts in resin reinforced with car- ly similar to the resin cement used to fix the post to
bon fibres, 60·61 and later with quartz, glass, silicate, zir- the root and the composite used for the core build up
conium, etc. were introduced on the dental market (Fig. 35.36). The parameter for reference, which cur-
and revolutionized the technique by which the endo- rently seems to be the most important when preparing
dontically treated teeth were restored (Fig. 35.35). The the various restorative materials, is the modulus of ela-
philosophy that forms the basis of these materials is to sticity or Young's modulus, which allows comparison
tty and create a monoblock as homogenous as possi- between many materials that are very different from
ble between the post, the restorative material and the one another, by measuring their deformity under lo-
tooth, and with the physical characteristics of the sin- ad. Dentine has a modulus of elasticity around 14 Gpa
gle constituents (as for example the modulus of ela- so.i 73 and it is currently thought that the best restora-
sticity) so that they are as similar as possible amongst tive materials for the prosthetic core should not vary
themselves and to the dentine. The aim is to obtain much from this value, neither in being to high (too ri-
a dental structure/restoration as uniform as possible gid) nor too low (too elastic). Reinforced posts in car-
that responds consistently to mechanical stress. It se- bon fibres, glass, quartz, etc, that are currently availa-
ems, in fact, that the ve1y unhomogeneity of the beha- ble on the market (Fig. 35.37) have a modulus of ela-
viour under chewing forces is the culprit in the gene- sticity that varies depending on the angle of force ap-

35 - Restoration Of The Endodontically Treated Tooth 1171

Fig. 35.36. A. Radiograph of endodontically treated teeth in the lower left qua-
drant (Endodontics by Dr. Arnaldo Castellucci). Note the invasion of the biolo-
gic width by the carious lesion. B. Clinical crown lengthening and extraction
of the third molar (Surgery by Dr. Stefano Gori). The second premolar and first
molar have been preventively restored with carbon fibre posts and self-curing
composite. The second molar, not being able to be isolated with rubber dam,
will be restored during the first phase of post surgical healing. C. The perfect-
ly matured tissues allow definitive preparation of the cores and impression ta-
king. D. Laboratory master cast. E.Clinical check after finalization.

Fig. 35.37. Examples of tran-

slucent fibre posts: A. DT
light-post Illusion (RTD -
Dentsply). B. Fiber post TechS-
Endoshape (ISASAN Rovella
Porro CO Italy) have five dif-
ferent conicities (from 6% to
14%) to adapt passively the si-
ze and the conicity of the ro-
ot canal.
1172 Endodontics

plication (anisotropic behaviour) and according to the firm the effectiveness of these means for the restora-
existing relationship between the resin and fibres. The tion of the endodontically treated tooth with a redu-
posts that use glass fibres , quartz and zirconium allow ced risk of root fracture .
the transmission of light and therefore, at least in theo- In the retrospective study by Fredriksson, 72 236 te-
ry, can be cemented with photo-cure materials. These eth were taken for examination and restored with the
posts do not create dark halos at neither the root le-
vel nor in the crown, allowing the restoration of a core
that is ideal for rehabilitation with all ceramic crowns
(Fig. 35.38). 25
The resistance test that the teeth restored with fibre
reinforced posts were subjected to showed that they
were less resistant compared to the metallic ones, but
there was a lower number and severity of root fractu-
res.51 It must be remembered though that these tests
are conducted with destructive techniques and with
load levels which have no similarity to the real phy-
siological situation. Even the studies in vivo either of
the retrospective or perspective type 79 ·179 seem to con-

Fig. 35.38. A. Upper premolar with an extended coronal fracture on the palatal side. B. After the surgery on the palatal side the premolar was restored with a fibre
quartz post and light-cured composite. C. The core prepared and ready for impression taking. D. The all ceramic feldspathic crown (Technician Paolo Vigiani). E. The
finished case after adhesive cementation of the crown. F. Five year recall.
35 - Restoration Of The Endodontically Treated Tooth 1173

Composi Post System. Recording of the data was do-

ne at 27 and 41 months after restoration (average 32
months). There was a 98 % success rate and no root
fractures were found. In the year 2000 Ferrari 66 pu-
blished a retrospective study of 1,304 teeth restored
with fibre posts and re-evaluated them after a period
between 1 and 6 years. The percentage of failures was
3,2% with 25 cases of cementation failure and 16 en-
dodontic lesions. No root fractures occurred in this
study, either.
A type of non destructive biomechanical study that
is very interesting and particularly indicated for fibre
post restorations is that which is based on the tech-
nique of finite elements analysis (FEA). This system
is particularly useful when one wants to apply a load
to a particular structure or material to study stress di-
stribution of. This is based on a computer simulation
with which one is able to compare various materials,
each one with its own physical properties. Studies
of this type 39 •168 have confirmed that fibre reinforced
posts transfer less stress to the root structure compa-
red to materials like gold or steel which are more ri-
gid. Sorensen,186•192 however, warns about doing a re-
storations that are extremely elastic (post-cement-co-
re) , as they loose their homogeneity when they are
covered with a rigid crown and are subjected to loa-
ding cycles. The microflexion that could occur due to
the absence of a sufficient amount of healthy dentine
(ferule effect) could cause the wash out of the cement
at the margin of the prosthetic crown which could ma-
nifest its disastrous effects even after a long time wi-
thout any early warning symptoms 68·118•143 (Fig. 35.39).
The risk of microflexion is particularly high with fi-
bre posts whith a small diameter, frequently used in
single rooted teeth with thin roots, because when we
have an equal modulus of elasticity and load, a thin
post tends to deform more than a post with a larger
diameter. 16 To limit this problem, posts 82 •114•148 such as
metal or zirconium, which are more rigid, should be
used. However, an extremely unhomogenous situa-
tion is created between the post and radicular denti-
ne risking root fracture. Even in situations like this the
only solution that can protect the core from the fle-
xing of a thin post is an adequate amount of healthy
dentine embraced by a prosthetic crown (ferule ef-
fect). The few clinical studies available confirm the
data that the most frequent type of failure which oc-
Fig. 35.39. A. Upper premolar and molar that need post-endodontic prosthe-
curs with the restorations where fibre posts were used tic treatment. B.The restoration of the molar with three quartz fibre posts.The
is not so often a fracture of the root but decementa- use of multiple posts has the aim of stiffening the core reconstruction and
thereby reducing the risk of microflexion. C. The prosthetic cores of the molar
tion. 66·72.79·178 Therefore , every time there is a failure of and premolar restored with light-cured composite. D.The finalized case with
this type , it is because there was a preceding break- ceramo metal crowns (Technician Paolo Vigiani).
1174 Endodontics

down of the cement at the margin of the crown due From a clinical point of view it is advisable to ha-
to microflexion of the core and post. One is therefo- ve various shapes, sizes and taper of fibre posts avai-
re dealing with structural failures that manifest with a lable so that each time one can select the post which
modality that differs according to the type of material. is best suited to the available canal space at the com-
In this case, these fibre posts they favour decementa- pletion of endodontic treatment (Fig. 35.41). Even in
tion and marginal infiltration (Fig. 35.20), while in the this case the standardized drill supplied with the posts
case of metallic posts root fractures are more frequent could be used as the caliper for selecting the best su-
(Fig. 35.40). We have to start with the assumption that ited post. The parameter for length used for metal-
eve1y time a post is loaded (activation of the post), lic posts cannot be used for fibre posts, which have
the failure has already occurred! Therefore the key to completely different theoretical assumptions and cur-
success is not so much in selecting a post that is bet- rently lack scientific studies that give precise guideli-
ter than another, but how much one can avoid loa- nes. Undoubtedly the adhesive cementation and the
ding the post. reduced transmission of stress carried by fibre posts
leads one to the conclusion that in order to have suf-
ficient retention and avoid dangerous stress concen-
trations, a length that is less than that required for a
corresponding metallic post should be sufficient. One
should use posts that, without further canal enlarge-
ment, fit the post space the best so as to reduce the
amount of cement to a minimum. In the case of nar-
row roots it is useful to use posts which have a coro-
nal portion with a greater taper (ie. larger diameter)
than the apical po~tion. Every time that it is not possi-
ble to obtain a good fit between the post and the post
space (such as with elliptical or over-instrumented ca-
nals) it is recommended to cement the fibre post with
the same composite that is to be used for the core bu-
ild-up (Fig. 35.42).

1b. Cast Post and Core

The cast post and core is constructed in the labo-
ratory from a model made from an accurate impres-
sion of the post space. Generally one obtains a casting
from a wax build up or a pattern resin using a pre-
cious or non precious metal alloy (Fig. 35.43). In the
case of using a full ceramic crown, there are sophisti-
cated laboratory techniques for constructing aesthe-
tic posts, 68 such as glass infiltrated alluminous ceramic
posts (In-Ceram, Vita, Germany), cores in pressed cast
ceramic on zirconium posts (Cosmo Empress, Ivoclar
Vivadent, Liechtenstein) and cores in baked ceramic
on cast metal posts.68·69 Currently, with the large avai-
lability of translucent fibre posts, the use of the for-
mer posts has very much changed. The main advan-
tage of a cast post and core is that the coronal por-
tion is one with the radicular part, so that in the case
of minimal residual structure there is no risk of sepa-
Fig. 35.40. A. Decemented ceramo metal crown of a lateral incisor. Note the ration between the post and the build up material of
presence of an extremely shorty post. B. A fistula is evident on the buccal the core with consequent prosthetic failure. The indi-
aspect. Note the absence of dentinal structure for an adequate ferrule effect.
C. The higher magnification shows the presence of a root fracture responsi-
rect construction of these posts has the advantage that
ble for the failure. they can adapt to a canal that has to accept them and
35 - Restoration Of The Encloclontically Treated Tooth 1175

Fig. 35.41. A. After an accident many years ago, the patient lo?t the lower right central incisor and fractured the lower left lateral incisor. B. Post operative radiograph
after endodontic treatment of the lateral incisor. C. Silicone index made from a diagnostic waxup, which acts as a guide for the enamel stripping of the adjacent te-
eth. The adjustment of these teeth was deemed necessary to create space for the missing teeth. D. The teeth prepared and gingival tissue shaped for an ovate pon-
tic. E. The lateral incisor restored with a quartz fibre post size ISO 90 and light-cured composite. F.The crown in feldspathic ceramic for the lateral incisor (Technician
Paolo Vigiani). G. The Maryland Bridge for the central incisor (Technician Paolo Vigiani ). H.The cementation under rubber dam of the Maryland Bridge. Note the pins
in the abutment preparations. I.The bonded bridge.J. The finalized case after adhesive cementation of the crown on the lateral incisor. K.The lateral incisor at higher
magnification. L. Two year recall. M. Clinical check after 2 years. N. Six year recall.
1176 Endodontics

Fig. 35.42. A. Upper premolars after termination of endodontic treatment. B.

Fitting the two fibre posts which will successively be cemented in the ca-
nals. Note the large amount of endodontic space between the posts. C.
Cementation of the posts with the same micro-hybrid composite that will be
used for core build-up. D. Restoration of the prosthetic core with micro-hy- Fig. 35.43. A. Upper molar with extensive coronal destruction. 8. Cast post
brid composite. E. The first and second upper premolars after preprosthetic and core dismantled. C. The two parts of the post cemented in the canals. D.
restoration. Cementation of ceramo metal crown.
35 - Restoration Of The Endodontically Treated Tooth 1177

not vice versa, as in the case of prefabricated posts.

As a consequence, the preparation of the post spa-
ce is more conservative. Is sufficient to only remove
the gutta-percha from the portion of the canal where
the post has to fit, without further removal of dentine.
Precision fit in this case is more precise than in prefa-
bricated posts, the cement thickness is extremely re-
duced and the strength is higher. In case of prosthe-
tic rehabilitation where multiple posts are required, it
is useful to make them parallel to each other in the la-
boratory. The cast post and core is also useful when
the core needs to be inclined with respect to the long
axis of the root at an angle that is superior to that to-
lerated by a prefabricated post. When they are to be
used in the reconstruction of teeth with divergent ro-
ots, they can be constructed in very precise separa-
te interlocking pieces. In the latter case, it is ve1y im-
portant that the cementation between the interlocking
pieces is passive (Fig. 35.44).

Fig. 35.44. A. Upper molar and premolar with almost complete destruction of
the clinical crown. B. Cast posts in gold on the laboratory model. The molar
post is in two parts. C. Fitting the coronal portion of the post. D. Fitting the pa-
8 latal portion of the post. E. The post cemented and finished.
1178 Endodontics

An undeniable disadvantage of a cast post and co-

re is that, in almost all cases, it has a conical shape
that tends to develop a dangerous wedging effect on
the inside of the root structure. In respect to prefabri-
cated fibre posts, a cast post and core has a much hi-
gher rigidity than dentine with consequently a massi-
ve transfer of stress to the canal walls. This, associa-
ted with the wedge effect, has placed the responsibi-
lity for a large number of root fractures on cast posts.
To reduce this risk, particular attention must be paid
to the construction phase and the seating of the ro-
ot. The technician must know how to manage the in-
vesting material, ie. powder/ liquid ratio, so as to ha-
ve a casting with a precise seating of the coronal part
Fig. 35.46. Cast post cemented in the root of an upper premolar. Note the ce-
and complete passivity of the intra canal portion. 68 •136 ment line along the post-dentin interface.
Successively the clinician must check, using a system
which highlights friction points (Fit-Checker GC), so gutta-percha must not be altered, the dentine must not
that there are no contact zones on the inside of the ca- be removed to enlarge the diameter to gain retention
nal as well as a precise marginal fit. The ideal situation and that short posts which concentrate stress in the
is to have a post that does not require adjustment af- coronal portion of the root must be absolutely avoi-
ter the laboratory returns it and after cementation do- ded. It is overriding importance that the maintenance
es not show a cement line at the tooth-post interfa- of a good ferrule ,effect is gained by having 1,5 mm of
ce (Fig. 35.45). The latter aspect, 68 in fact, could cor- healthy dentine cervical to the finishing line. In the ca-
respond to an imprecise seating that translates into a se of having to remove a cast post for endodontic re-
post that could potentially go down further in the ca- treatment it is useful to use ultrasonic tips and instru-
nal with a consequent wedging effect (Fig. 35.46). The ments like the "Post Removal System" (SybronEndo,
rule with this type of post, like the prefabricated metal Orange, CA, USA) (Fig. 35.47) (See chapter 33).
type, are that the integrity of the last 5 mm of apical The removal of a post must in any case be moti-
vated by the precise need, such as an endodontic le-
sion or caries, because the decementation procedu-
re is not without risks and if not done carefully it can
cause microfractures starting on the inside part of the
canal walls.

Aesthetic Considerations of Posts

Following the increase in the use of all ceramic re-
storations even for endodontically treated teeth, it has
become essential to use core build up systems that do
not mortify the excellent aesthetic characteristics of
these materials. The use of the classic metal post and
core or simple prefabricated metal post prevents the
passage of light through the all ceramic restoration
creating a grey shadow which compromises the ae-
sthetic result. Currently in this situation special posts
in ceramo-metal, all ceramic posts, zirconium posts
or translucent fibre posts can be used with success.
Before choosing the material to use, it is necessary to
consider the following aspects:
a) Quantity of residual structure
Fig. 35.45. Cast post cemented in the root of an upper cuspid. Note the preci- b) Degree of discoloration of the residual core
se marginal fit. c) The available space on the lingual side
35 - Restoration Of The Endodontically Treated Tooth 1179

d) The presence of both root discoloration and thin

periodontal tissue
e) Height of smile line
f) The necessity of reconstructing cores for a


We have already largely discussed the basic con-
cept of only using posts in cases of absolute ne-
cessity and also having or recuperating an adequa-
te amount of dentine to protect the root. There are,
however, situations in which a clinician is forced to
make compromises. For example, a clinical crown
lengthening procedure for restoring a very compro-
mised central incisor in a patient with a high smi-
le line could irreparably alter the aesthetics is this
area. To avoid this dire situation, it is essential, be-
fore the periodontal procedure, that the root be ex-
truded orthodontically (Fig. 35.25). The combina-
tion of this procedure could be refused by the pa-
tient, who sees a lengthy procedure , an increase
in cost and an aesthetically compromised anterior
segment for quite a long time. In a situation of this
type, especially if the occlusal analysis confirms a
modest loading of the element, one could be forced
to do a restoration with a post in absence of the fer-
rule effect (Fig. 35.48). To reduce risk certain pre-
cautions must be taken:

- the adhesive reconstruction of the core 99 and

the adhesive cementation 69 of an etchable all cera-
mic crown should carry out a protective action of the
whole complex
-there should be an accurate check of the lingual
surface shape to ensure a shallow anterior guidance
shared by the approximating teeth
-a nocturnal protective bite guard would be advisa-
ble for the patient.
In a clinical situation of this type the best aesthetic
results can only be achieved by using an all ceramic
crown, but apart from this it is essential to use a post
which has aesthetic characteristics (see later):68


The degree of core discoloration · guides the clin_i-
cian in the choice of crown material. A low degree of
Fig. 35.47. A. Cast post cemented in an upper first premolar that needs endo- discoloration (remaining for example after tooth blea-
dontic retreatment. B. The tap is engaging the post. C. The post removed with ching), could be corrected with a partially transluscent
the Post Removal System (PRS) kit (SybronEndo; Orange, California).
all ceramic crown (Vita-lnceram, Procera All Ceram,
Lava TM etc.) . Instead, if there is a high degree of di-
scoloration to cover a classic ceramo metal crown or
1180 Endodontics

Fig. 35.48. A. Fractured upper central incisor. B. Reconstruction of the co-

. re with a quartz fibre post having a double taper. C. The core was restored
using light-cured micro-hybrid composite. D. The all ceramic crown on the
laboratory master cast. E. The all ceramic bonded crown.

a foil crown is indicated (Captek, Auro Galva Crown, ly if it had a low abrasive effect (for example Empress
etc.) (Fig. 35.49). II core).

A reduced space on the lingual aspect (less than 0,8 RIODONTAL TISSUE
mm) would call for a ceramo metal crown with the Thin periodontal tissues in the presence of root di-
lingual surface in metal or an all ceramic crown whe- scoloration and a high smile line could direct the clini-
re one would only leave the core in occlusion, but on- cian towards a root bleaching, which would however
35 - Restoration Of The Endodontically Treated Tooth 1181

Fig. 35.49. A. Upper central incisor with a coronal fracture. The tooth was pre-
viously restored with a carbon fibre post and composite. B. Once the carbon
post was removed and the canal retreated, the core was restored with a quartz
fibre post having a double taper and microhybrid composite. Note the accen-
tuated dischromia of the core. C. The try in of the Aura Galva Crown. D. The ce-
ramic crown on an electro deposited gold coping. E. The finalized case with a
ceramo metal crown (Technician Paolo Vigiani).

carry serious risks of possible external resorption (See core as well, but it has the defect of having an adhesion
chapter 30). The introduction of a metal post in the root problem with this material. 53 •62 Amongst the fibre posts in
will further worsen the grey aspect, while a certain "whi- this type of situation it is advisable to use a post that is
tening" effect can be obtained by placing a post that has not too translucent but which has a chroma and opacity
the intra canal portion in a lighter colour. Posts of this similar to that of dentine.
type are posts and cores in zirconium with pressed ce-
ramic 138 (like the CosmoPost System with IPS Empress E) H EIGHT OF SMILE U NE
Cosmo, Ivoclar Amherst, New York) and in alluminous A high smile line completely exposes the cervical
ceramic such as the In-Ceram Post (Vita Zahnfabril<:, third of the patients teeth and part of the gingiva abo-
Sackingen, Germany) (Fig. 35.50) as well as the translu- ve. To obtain a better aesthetic result in this situation
cent posts in fibre glass, quartz or silicate. A post in zirco- it becomes essential to use aesthetic materials even in
nium can also be used for the retention of the composite the core build up stage (Fig. 35.51). Ceramic, zirco-
1182 Endodontics

Fig. 35.50. A. Discoloured central incisors. B.The coronal portion of the teeth is extensively compromised. C. Alluminum posts (In Ce ram) before the sinterization pha-
se. D. The posts during the glass infiltration phase. E. Cementation of the posts. F. The finalized case with the cementation of the all ceramic crowns (Courtesy of Dr.
Mauro Fradeani).
35 - Restoration Of The Endodontically Treated Tooth 1183

Fig. 35.51. A. A young patient with large incongruous restorations of the anterior teeth . Note the 'gummy' smile. B. Preoperative radiograph. The incongruous endo-
dontic treatments and compromised tooth crowns are evident. C.The removal of the old restorations reveals the almost complete destruction of the coronal tissue.
D. Restoration of the cores with .double taper quartz fibre posts and light-cured composite. During this initial phase the thin buccal enamel wall is left for aesthetic
reasons. E.The periodontal surgery has the aim of recovering healthy dental structure subgingivally for biomechanical reasons as well as correcting the gummy smi-
le (Surgery by Dr. Stefano Gori). F. First phase of tissue maturation. G. The second provisionals at the end of the tissue maturation. H. Preparation of the teeth for the
definitive impression. I. The all ceramic crowns (IPS Empress lvoclar Vivadent) (Technician Paolo Vigiani). J. The all ceramic crowns bonded. K. The patient's smile. L.
Two year recall radiograph. M.The smile from the lateral right side. N.The smile from the lateral left side.
1184 Endodontics

nium and ceramic and transluscent fibre posts are the ving outstanding precision and excellent aesthetics of
most indicated. One should remember that posts in zir- the core, but has the disadvantage typical of post and
conium have the defect of being extremely rigid and cores, which is a high cost. It should be remembered
in the case of retreatment the removal of the radicular that in the case where complete opaque crowns like
part of the post may prove to be impossible. A particu- those in ceramo metal are used an "umbrella" effect 123
lar type of post and core is one completely construc- can be created at the moment when the upper lip reve-
ted in alluminous ceramic infiltrated with glass (Vita als the margin of the restored tooth, causing greying of
Zahnfabrik, Sackingen, Germany). This solution has the the approximating papillae and gingival margins. This
advantage that the colour of the post can be individua- phenomenon is due to the fact that the opaque restora-
lized with the colour of the glass with which it is infil- tion prevents the passing of light and therefore its diffu-
trated (Fig. 35.50), but has the disadvantage of having sion through the gingiva. Only restorations that allow a
a long preparation time and high costs. When building good passage of light can avoid this unpleasant effect.
up the core with a fibre post it is advisable to utilize a In the case of a low smile line, the cervical area which
composite with the hue and degree of opacity as the is the most critical part to manage aesthetically, is not
dentine. Using a composite that is too translucent could exposed allowing a wider range of restorative options.
lower the value of the restoration considerably.
With an average smile line, as the gingival portion F) THE NECESSITY OF RESTORING CORES FORA BRIDGE
above the teeth is not visible, one can use a special With the restoration of teeth which are to be abut-
post and core with the radicular portion in metal and ments of a bridge in the anterior segment of the mouth,
the coronal_portion in ceramic, baked onto thin metal a ferrule effect is of particular importance. In the situa-
tags (Fig. 35. 52). 68 This post has the advantage of ha- tion where it is absent, in accordance with the other
parameters collected from a carefull aesthetic analy-
sis, 70 one must obtain it with the usual orthodontic/
surgical techniques. For bridges with multiple teeth in
the aesthetic zone, more frequently high strength ce-
ramics are being used (aluminium oxide, zirconium
oxide, etc.) which are cemented adhesively, although
this is currently considered controversial. 23


The main cements that can be used for cementing

posts are:
a) zinc oxyphosphate
b) glass ionomer cements
c) resin cements.
2a) Zinc oxyphosphate, a cement used frequently
because of its ease of use and long history of clini-
cal success, 171•198 creates a macromechanical retention,
especially if the surface with which it is in contact, on
both sides, are rough. The disadvantages of this ce-
ment are:
-an increase in its thickness is equivalent to a reduc-
tion in retention 196 (this obliges one to make posts
that are longer, more precise and therefore more trau-
-they develop a high hydrostatic pressure during ce-
mentation 142
Fig. 35.52. A. The wax-up of the coronal part of the post. The space available is -it's opacity creates problems with aesthetic rehabilita-
managed with a silicone index taken from a diagnostic wax-up of the case. B.
The cast post and core with the coronal portion in ceramic. C. The cementa-
tion when using all ceramic crowns.
tion of the ceramo metal post.
35 - Restoration Of The Endodontically Treated Tooth 1185

2b) The glass ionomer cements owe their populari-

ty to the release of fluorides 149 which has a preventive
effect with regards to secondary decay. They are ex-
cellent cements that have a particular chemical adhe-
sion to dentin and a retention similar to that of resin
cement. 224 The hybrid formulation, a glass ionomer ce-
ment reinforced with resin, has shown in some pro-
ducts to have a certain amount of hygroscopic expan-
sion that makes its use inadvisable for intra-radicular
cementation. 42 •143 •224

2c) The use of resinous cements, which has incre-

ased, 171 •198 started being used for post cementation af-
ter the research carried out in Boston by the group
Fig. 35.54. The micro-sandblaster "Miniblaster Deldent" uses a 50 micron alu-
Goldman and Nathanson. 81 The cement "Boston Post" minium oxide that can be used intraorally under rubber dam isolation.
(Fig. 35.53) was a fluid bis-GMA resin that was placed
in the canal after etching the dentin with 17% EDTA
ment and the resin of the fibre post, which is comple-
tely polymerized during the production process, ho-
wever the retention that develops between the micro
irregularities on the surface of the post and the resi-
nous cement is more than sufficient for it's clinical use.
Boston The situation on the dentin side is much more com-
Post plex and sensitive. In fact, in the case of cementation
Cleansing Solution A failure , it almost always occurs at the interface betwe-
28 Pro Oosfld P1pottes
2.5 ml each en the adhesive and the dentine substrate. 53 The resi-
Affordor No. 213
nous cements require an adhesive system·and the de-
·- ~?O'tDENT 11:':~,. gree of adhesion that develops with the radicular den-
,, 1 bCO 9~2 7167

tine is dependent on multiple factors . Amongst these

are the type of adhesive used the storage of the ma-
terial, the rigorous application of the clinical procedu-
re , etc. Self-etching systems modify the dentinal sme-
ar layer with successive adhesion to it. Instead other
systems (three-step etch-and-rinse) require etching of
the dentine with orthophosphoric acid to remove the
smear layer completely, the flaring of the initial part
of the dentinal tubules and the successive creation of
the so called hybrid layer (collagen fibres-resin). In an
Fig.35.53.The resinous cement"Boston Post''. the ideal situation, this adhesive system creates in the
initial part of the dentin tubules an excellent seal with
the formation of the hybrid layer and a very strong re-
and successive rinsing with sodium hypochlorite to tention via the resin plugs that deeply penetrate the
neutralize its action. depths of the dentinal tubules where they can form la-
The philosophy at the basis of these new cements is teral ramifications. 15 •134
that they have good retention even with high thicknes- The adhesive systems can have either a chemical,
ses 12 allowing the use of non frictioning i.e. passive physical (photo-activators) or dual activation. The die-
and shorter posts. 176 The resinous cements have an ex- mically activated systems may be used with all types
cellent micromechanical retention with both fibre and of posts, opaque or transluscent, while the photo-acti-
metal posts (especially after micro sandblasting) (Fig. vated or dual may only be used with posts that convey
35.54). On this issue, even if it is difficult to believe light. Currently, the three-step etch-and-rinse adhesi-
that a chemical bond is possible between a resin ce- ve systems represent the gold standard in terms of re-
1186 Endodontics

liability and adhesion over time, even inside root ca- sodium hypochlorite during the endodontic treatment,
nal systems. 40 •49 In reality there are many variables in- which reduces the availability of collagen fibres for
volved and this makes the predictability of obtaining obtaining an ideal hybrid layer. However, the use of
an excellent adhesion not that favourable. orthophosphoric acid as the first step in the adhesive
According to some authors 204 the use of endodontic process renews the availability of the collagen fibres.
sealers with high eugenol content (2-methoxy-4-aly- The dentin structure varies as well with the level of
phenol) could cause interference because of the phe- the canal (the number of tubules reduces as you mo-
nolic components, with the free radicals of the poly- ve apically) with relatively different degrees of affinity
merization process reducing the levels of adhesion. for the adhesive steps.
According to other authors 24 •103 •175 the interference that With the total etch technique the creation of an ide-
is caused is clinically irrelevant. al hybrid layer is very sensitive to the level of hydra-
To minimize this hypothetical problem it is advi- tion of the surface and the conditions that are crea-
sable to carefully clean the internal walls of the post ted on the inside of the canal often causes technical
space with alcohol and endo-brushes (Fig. 35.55). difficulties with dehydration of the zone at the canal
Another problem could be due to prolonged use of opening and excessive pooling of water in the dee-
per zones. In these situations it is advisable to remo-
ve the excess of water from the inside of the canal by
aspirating it with a non bevelled needle. Successively,
absorbent paper points can be used to remove the
remaining water, while leaving the walls damp (Fig.
In the case of photoactivated systems there is a doubt
that the light can efficiently and completely penetra-
te and irradiate the internal surfaces of the post spa-
ce even if it is placed at the entrance of the canal ope-
ning or indirectly via a translucent post. If this type of
cementation is chosen, one must use light sources that
are ve1y powerful and efficient, extended curing time,
translucent posts that have been sectioned coronally
at the definitive height of the core (Fig. 35.57). Light
cured cementation is indicated in the case of posts
which have generous dimensions and with a post spa-
ce that is not deep, while in the case of long and thin
posts it is better to put trust in dual cements.
Despite this difficulty, the clinical levels of reten-
tion that are achieved are very high and the cementa-
tion failures are quite few. The resinous cements offer
another important advantage, which is that they deve-
lop very low levels of hydrostatic pressure during the
cementati on phase, 142 and in ideal conditions they can
create an excellent seal at the root canal opening, ca-
pable of preventing the risk of coronal leakage.

The crown that is made to cover the core of the en-
dodontically treated tooth is the final act of the pros-
thetic rehabilitation of this element. This could be par-
tial or complete coverage and constructed using va-
rious materials:
Fig. 35.55. A. The "Hawe Post Brush'; (Hawe Neos, Kerr). B. The brush mounted - cast gold
on a contra-angled hand piece is very useful for cleaning the post space. - composite or policarbonate polimerized on gold or

35 - Restoration Of The Endodontically Treated Tooth 1187

Fig. 35.56. A. Application of orthoprosphoric acid as the first step of the etch -and -rinse tecnique.The acid gel can be applied in the canal using a long blunt need-
le. B.The next rinsing and aspiration of the excess water can be carried out with a blunt needle. C.The excess water at the bottom of the post space is removed with
an absorbent paper point. D.The primer and the bonding can be easily placed in the canal using a small microbrush. E. The post cement is placed in the canal, star-
ting from the most apical part, using a special tip on the syringe Centrix, (Hawe Neos, Kerr). F. After the cementation of the posts the reconstruction of the core is do-
ne with lightcured composite applied by using a suitable tip on the same syringe.

Fig. 35.57.The lightcuring of the adhesive and the cement on the inside of the
canal can only take place with very long exposu re times, high power lamps
and posts that are neither too long nor too thin.
1188 Endodontics


- ceramic baked onto an alloy 4a) Amalgam.
- ceramic baked onto electro-deposited gold This material has been used in dentistry for almost
- ceramic baked onto alluminium oxide or two centuries with excellent results, 21 low costs and
zirconium oxide a simple standardized operative procedure. The new
- all ceramic. generation of dental amalgams developed by Youdelis
As has already been mentioned, depending on the in 196221 have a high copper content and a reduced
prosthetic and aesthetic requirements, once the type and controlled gamma 2 phase. They have an excel-
of material for the crown has been selected it is possi- lent compression and tensile strength, high modulus
ble to previsualize the amount of tooth structure that of elasticity, 226 reduced corrosion strength and creep,
has to be removed during the preparation phase of and a good wear resistance (Fig. 35.59). This mate-
the core. This evaluation is also important with re- rial has been extensively used, especially in the past,
gards to certain choices that can be made when recon- for the restoration of endodonticaHy treated teeth, for
structing the prosthetic core. The prosthetic prepara- both the conservative temporary restoration in young
tion is identical whether it be for a vital or an endo- patients as well as for the pre-prosthetic reconstruc-
dontically treated tooth. However, as regards the lat- tion of cores. Its use in young patients for the restora-
ter, certain biomechanical concepts must be taken into tion of endodontically treated posterior teeth, to avoid
consideration. As has already been stated, every in vi- a prosthetic solution before 20 years of age, has be-
vo 140 and in vitro 161 •208 test confirms that the conserva- en recommended by many authors 5•160 (Fig. 35.60).
tion of tooth structure is the best way of protecting the In these cases, the amalgam has enabled an extre-
endodontically treated tooth from fracture. Regarding mely compromised tooth to be saved and restored to
this aspect it is important to consider that crowns, li- proper occlusal function with maintenance of the in-

ke metal-ceramic ones, require a more aggressive pre- terdental space during somatic development of the
paration compared to some all-ceramic ones or those young patient until the age that allows definitive pro-
with ceramic baked onto electro deposited gold. sthetic rehabilitation. Its optimum quality/ price ratio
A finishing line with a knive' s edge is certainly mo- makes it even now a type of restoration that is wor-
re conservative than a shoulder or chamfer. A prepa- thwhile and valid in cases of reduced economic me-
ration differentiated by a buccal chamfer (for aesthe- ans (Fig. 35.61). Conservative restorations with this
tic reasons) and knive's edge margins in the interpro- material initially have a marginal gap of a few mi-
ximal and palatal zones allows the maximum saving cron which, after a few months, becomes saturated
of tooth structure. due to the corrosive products of the amalgam cre-
Regarding the finish lines, studies carried out to de- ating a valid seal that is maintained over time (Fig.
termine the area of stress accumulation have shown 35.62). 20
that a 90° shoulder preparation causes an unfavoura- The main disadvantages of using amalgam for post-
ble stress concentration compared to a bevelled pre- endodontic restorations are:
paration. 38 When it is necessary to protect an endo- -the lack of adhesion to the dental structures (passi-
dontically treated posterior tooth where there is no vity) 152 making it necessary to condense it into the co-
particular aesthetic requirement, a metal-ceramic or an ronal portion of the canals or to remove healthy den-
electro-galvanic crown with a metal margin can be tin to create retentive undercuts or retentive pins 181
used. In the case of anterior teeth or in the area whe- -its dimensional variation due to moisture contami-
re aesthetics is of great importance, a chamfer prepa- nation or mercuric expansion102·177 could cause a ro-
ration or rounded shoulder preparation for an all-cera- ot fracture
mic crown should be considered. 68 In this case a more -its poor aesthetic appearance.
conservative preparation of the core compensates for As a pre-prosthetic restorative material (Fig. 35.63) it
a poor biomechanical performance of the margin. The was used extensively, especially in the past, so much so
preparation for glass ceramic or high strength ceramic that a study by Morgano in 1994 144 identified it as the
crowns have the advantage of allowing preparations material most use by specialists in prosthodontics in the
to be juxta-gingival, eliminating the aesthetic problem USA. Its advantages as a preprosthetic material are:
due to the presence of a metal margin. This possibili- -excellent plastic adaptation
ty guarantees the maximum biological respect for the -easy preparation of the core
periodontal tisst!es (Fig. 35.38).
35 - Restoration Of The Endodontically Treated Tooth 1189

Fig. 35.58. A. Preoperative radiograph. The upper left fir~t premolar needs endodontic treatment due to deep caries, the second premolar needs to be extracted and
the first molar needs endodontic retreatment. B. Postoperative radiograph . C. After core reconstruction with carbon fibre posts and composite, surgical crown leng-
thening and tissue maturation time, the cores have been prepared for the definitive impression. D. The core preparations were done with attention to saving the to-
oth structure and not invading in any way the periodontal tissue. E. The zirconium framework (Lava 3M ESPE). F.The try in of the framework. G.The finished and bon-
ded bridge (Technician Paolo Vigiani). H. Radiographic recall. I. Clinical recall after one year.
1190 Endodontics

Fig. 35.59. A. Lower premolar restored in amalgam at the end of

the carving phase. 8. The same tooth after polishing the restora-
tion. C. At higher magnification one can appreciate the excellent
marginal integration of this material.

Fig. 35.60. A. Lower premolar of a young patient after endodontic treatment. 8. An overlay restoration in amalgam. C. A lateral view of the same tooth. D.Two year re-
:35 - Restoration Of The Encloclontically Treated Tooth 1191

Fig. 35.61. A. Radiograph of an upper molar of a young patient at the end of endodontic treatment. B. The tooth has extensive loss of the coronal structure. C.
Amalgam restoration of the tooth. D. The same tooth after polishing the restoration. E. The upper arch of the patient following conservative treatment. F. The lower
arch of the patient following conservative treatment. G, H. Ten year recall.
1192 Endodontics

Fig. 35.62. A. Amalgam overlay restorations of endodontically treated teeth. B. Four year recall. C. Eight year recall.

Fig. 35.63. A. Pre-prosthetic amalgam restoration of upper left second premolar and first molar treated endodontically. B. The core after polishing. One can apprecia-
te the finishing characteristics of this restorative material.

-the possibility of achieving an excellent finish. of a salt in the form of hydrated gel, which is the bin-
On the other hand the disadvantages as a core re- ding matrix between the nuclei of the glass particles.
storative material are: Developed by Wilson and Kent 231 in 1972, they ha-
-the passivity does not correspond to an increase ve undergone a tumultuous evolution over the years,
in core strength, rather the necessity to find retention so much so that the addition to the basic formulation
in the depths of the pulp chamber and the coronal of a series of substances has brought about the crea-
part of the canals, which in the case of a dimensional tion of a new group of materials that up are still dif-
change may provoke a root fracture ficult to classify. In fact, apart from the glass-ionomer
-the quite long setting time prevents the immediate cement (gic) traditionally selfcuring, other hybrid pro-
preparation of the core following reconstruction ducts have been introduced which, due to the addi-
-the amalgam dust spread by the handpiece during tion of methacrylate molecules, are able to be lightcu-
preparation of the prosthetic core could create a tatoo red. To combine the properties of gic and those of
with an intense colour, in the presence of a damaged, composite in the same material, the construction tech-
inflamed or post surgical periodontium. nology of both materials was combined in order to
The use of amalgam in recent years has been subject obtain a resin-composite with the addition of polya-
to a rapid decline due both to the improvement of al- cids, the so called compomers (hybridization of the
ternative materials and for legislative motives tied to words composite and glass-ionomer). The gic's set in
mercury pollution, but above all to the numerous in- two phases, 115 one rapid, in about five minutes and
formative campaigns claiming potential toxicity. the other slow of 24 hours during which water con-
tinues to be absorbed from the surrounding environ-
4b) Glass ionomer cements ment. The property of most interest with traditional
The term cement is derived from the fact that the- gic is its ability to release fluoride for a long period
se materials are formed from a reaction between an of time without breakdown (as opposed to old silica-
acid (polyalkenoic acid such as polyacrylic acid) and te cements) in sufficient quantities to locally develop
a base (fluoroaluminosilicate) with the formation an excellent caries resistance. 93 Other advantages are
35 - Restoration Of The Endodontically Treated Tooth 1193

a thermal coefficient similar to dentin (which is direct- by the development of materials that offer an excellent
ly proportional to micro leakage), a weak adhesion to performance both mechanically and aesthetically. All
dentin of around 6 Mp and the absence of polymeri- this has brought about a progressive decline of metallic
zation contraction. The defects of these materials that materials, like gold and amalgam. The use of the latter
limit their use as a material for the restoration of en- has undergone a brusque decline due to the presumed
dodontically treated teeth are: toxicity (even though there is no actual scientific
- their fragility and poor mechanical properties 212 proof 58), unsatisfying aesthetics, an issue patients are
- the difficulty of compacting it which often causes becoming all the more sensitive to, and ultimately the
the formation of air bubbles and voids more aggressive preparations compared to the adhesive
- the weak adhesion to dentin does not reinforce techniques. The indirect cast gold restorations, on the
the residual structure. other hand, also have an aesthetic impact which is
Thus their use in the restoration of endodontically becoming more difficult to find acceptance for and
treated teeth must be limited to the preprosthetic re- their use involves a significant loss of dental tissue and
construction of cores where there has been a limited difficult and expensive operative techniques.
loss of structure. The adhesive techniques used for the composite
The hybrid materials like gic-composite and compo- materials have become more and more sophisticated
mers should combine the best mechanical qualities of and reliable. Currently fourth generation adhesives are
composites, the reduced dependence on the presence being widely used. They were introduced at the be-
of an exact degree of moisture during the setting reac- ginning of the 90's 104 and make use of the simulta-
tion, with the typical advantage of fluoride release by neous pretreatment of the enamel and dentine with
the gic. 228 The mechanical characteristics of these ma- a strong acid that is successively removed with rin-
terials are however inferior to those of composites and sing (etch and rinse technique) to obtain the removal
therefore their use is only advisable for preprosthetic of the smear layer, the widening of the entrances to
restorations where there is a small or medium loss of the tubules and the exposure of a collagen network.
tooth structure. 227 In recent research, the fracture of all The successive infiltration by the hydrophylic primer,
ceramic prosthetic crowns was attributed to the hygro- spread by an alcohol or acetone solvent, of this colla-
scopic expansion of these materials. 185 gen network, brings about the formation of the so cal-
led hybrid layer, in part formed by resin and in part by
4c) Composite and the adhesive technique collagen fibres intimately attached to dentin and the
The origin of adhesive dentistry started in 1950- restorative material. Another group of adhesives invol-
1960 with the technique of acid etching the enamel ves the partial demineralization and modifying of the
and the formulation by Bowen 26 of the organic smear layer, which successively is used for the adhe-
matrix Bis-GMA (Bisphenol A with two molecules of sion. In this case the etching is not done with the tra-
Glycidil-Methacrylate). During the past years, the use ditional acid, but a selfetching primer is used which
of these materials for direct restorations of severely consists of a weaker acid that is not successively re-
compromised posterior teeth was not advisable due moved. Many of these systems, commonly known as
to the high number of failures after a short time. Apart self-etch, exhibit problems with adhesion to enamel
from the inadequate physical characteristics of the as well as sclerotic and sub-carious dentine, so much
materials used in the past, the cause of their failure so that the three-step etch-and-rinse systems are cur-
was their use in the incorrect clinical situations and the rently considered the 'gold standard'.49
application of techniques, which were everything but The most important advantage obtained from the
precise. In fact one of the weak points of this material use of composite materials applied using the adhesive
is the enormous variety of products and continuous technique on endodontically treated teeth is the saving
changes that they are subjected to and very often they of healthy dental tissue. 225 Furthermore this material is
do not correspond to an adequate scientific updating the only one able to reinforce 193 the dental structure
by the dentist. of this tooth which is more deformable and brittle.
In recent years, the use of composite materials The research 158 confirms that the level of adhesion
and the adhesive procedures in conservative and that could theoretically be achieved on moist dentin of
prosthetic dentist1y has undergone a rapid increase vital teeth is very high and has values similar to those
due to the improvement brought about by the achievable on enamel.
techniques of adhesion to the dentinal substrate and We know that to predictably achieve these results
1194 Endodontics

over the whole surface of the rest.oration is unrealistic. collagen reduces the availability of fibres for resinous
There are many factors that can negatively influence infiltration due to the preceding endodontic and resto-
a good adhesion: rative procedures; the first part of the tubules become
-dentin substrate changes with the age of the pa- contaminated with foreign substances that could in-
tient and because of the stimuli that it is subjected to terfere with the successive adhesive procedure. In re-
(like sclerotic dentin at the neck of the tooth or like gards, the substance most likely to be blamed for this
that under caries) presumed interference with the adhesive mechanism
-the large variety of adhesive systems available on is undoubtedly eugenol even though, as mentioned
the market have methods of use, time of application before, currently its role seems less important.
and an efficacy that differs one from the other Even at the ultrastructural level the dentin of
-the storage and handling of these materials influen- the endodontically treated tooth probably presents
ce their efficacy (eg. evaporation of the solvent becau- some changes compared to a vital one, which are
se the primer bottle is kept open too long) as yet not completely clear. The molecules of the
-the experience, ability and rigour of the operator in dentinal tropocollagen form polypeptide chains with
scrupulously applying the various adhesive steps me- a seconda1y structure of a counter-clockwise helical
thodically greatly influence the result (technique sen- type and are linked to each other in a clockwise
sitive). helical structure. The clockwise helical structure has
On the other hand, in endodontically treated teeth, a particularly long pitch for the limited flexibility of
the absence of tubular fluid makes the adhesive pro- the aminoacid sequence and is basically an extremely
cedure less sensitive and therefore more reliable. On compact structure. The type of intermolecular bonds
these teeth, even before the introduction of the tech- that become established in this complex structure are
nique which creates a hybrid layer, it was easy to ob- various and some are still uncertain in nature. They
tain a good level of anchorage simply by etching, rin- have ester bonds between the monomers, transverse
sing, drying and applying the bonding resin only. The and longitudinal intermolecular bonds and co-valent
retention that is obtained operating in this way is ve1y bonds that all together determine the characteristic
high due to the formation of resin tags at the entran- physical properties of mature collagen, which is rigidity
ce of the dentinal tubules which were enlarged by the as well as resistance against stretching and traction.
action of the orthophosphoric acid. 3 This web of resi- These bonds, which are so important for the physical
nous filaments in fact is able to provide a considerable characteristics of collagen, become modified with time
mechanical anchorage but without the formation of a and in certain conditions. We know with ce1tainty in
good intertubular hybrid layer, 135 the seal most proba- fact that co-valent bonds increase in number in adult
bly not being of much worth. However, with the pre- collagen compared to the immature collagen, which
prosthetic reconstruction of a core, this sealant de- with ageing increases its insolubility in a saline solution.
fect has no clinical importance, while the cement se- In a preliminary study Rivera 169 found that in the dentin
al of the prosthetic crown remains intact. However, in of endodontically treated teeth the intermolecular cross
the case of the conservative restoration of an endo- bonds were mostly of the immature type and this
dontically treated tooth it is essential to have the best could possibly be responsible for a reduced resistance
seal possible to avoid a dangerous coronal leakage. to traction. Currently the clinical impo1tance of this is
The problem of bacterial infiltration occurs especial- unknown and little is also known about the longevity in
ly if there is no enamel at the cervical margin of the time of the dentin-restoration bond. It is hypothesized
cavity. that in time, for some adhesive systems like the self-
The dentin of an endodontically treated tooth pre- etching one step system, they could show evidence of
sents some differences compared to that of a vital to- microinfiltration (nanoleakage) via the irregularities of
oth regarding the mechanism of adhesion. In this si- the bonding between resin and the collagen network
tuation, as has already been mentioned, the procedu- with successive hydrolytic degradation 201 of the
re is not disturbed by the tubular fluid that, in the vi- adhesive bonds by the enzymes like est.erase, protease,
tal tooth, exudes continually at a pressure of 30 mm metalase, etc. 157 This phenomenon of nanoleakage
Hg, 27 and hence there is no need to be concerned paves the way for successive bacterial infiltration that,
about pulp 'toxicity' due to the acid etch or various even though the retentive effect remains and prevents
other adhesive substances. On the contra1y, the pro- the restoration from dislodging, can cause secondary
longed digestive action of sodium hypochlorite on the caries at the cervical margin.
35 - Restoration Of The Endodontically Treated Tooth 1195

One of the general rules that should be remembe- materials having varying degrees of opacity, enabling
red for a post endodontic adhesive restoration is that a more natural reproduction of the difference between
it is necessa1y to cany out a slight finishing of the ca- enamel and dentine, and materials having the
vity to be restored to expose a 'fresh' dentin surface phenomena of fluorescence, 221 typical of dentin. 214 The
that is less contaminated for the successive exposition anatomical stratification of the dentine masses, more
to orthophosphoric acid. Although this does not me- opaque and fluorescent, with enamel masses having
an removal of new healthy dentin, because it is nor- va1ying degrees of transluscence allows the further
mally sufficient to finish removing the residue of old possibility of obtaining good aesthetic results (Fig. 35.
restorations, cany out a careful check of the surfaces 64). 57. 220. 222
for decay and do the necessary retouching of the pre- When carrying out a conservative restoration of an
paration for the successive restoration. The etching of anterior endodontically treated tooth, certain funda-
the dentin already has an excellent cleansing effect, as mental points must be taken into consideration. 57 Right
well as eliminating the smear layer (highly contamina- from the first phase of endodontic treatment procedu-
ted with bacteria) which was inevitably created with res that prevent the discolouration of the tooth must
all the previous instrument use. The action of the acid be used. In the case of an emergency pulpotomy, for
must be lengthened for an adequate time (30-60 sec.) example, attention must be given to prevent the ble-
to liberate new collagen fibres suitable for the creation eding of the pulp stump under the provisional resto-
of a good hybrid layer. The successive steps depend ration to avoid the haematic filling of the dentinal tu-
on the type of adhesive system used but must be used bules, which will cause a chromatic change of the to-
and handled scrupulously according to the manufac- oth. Every time that it is possible, it is best to carry
turers instructions. out a complete endodontic treatment at the same vi-
The composite materials can be used as a prepro- sit that the pulp chamber is opened. The endodontic
sthetic restorative material as well as for those cases treatment must be carried out with the abundant use
where a conservative restoration (direct or indirect) of of sodium hypochlorite which has a whitening action
the endodontically treated tooth can be done. as well as a digesting action of the organic substance.
The use of an endodontic sealer must be used in very
J) CON SERVA TIVE ANTERIOR ADHESIVE RESTORATIONS limited quantities and the contact with the internal co-
The use of these materials for direct restorations of ronal walls must be carefully avoided. The backfilling
endodontically treated anterior teeth has been consi- with guttapercha must be stopped 2 mm apical to the
dered largely successful for many years.75 ·190 ,205 ,206 The gingival limit of the clinical crown (Fig. 35. 65).
possibility of adhering to all surfaces allows one to In the successive phase of the restoration, the se-
avoid the use of auxiliary retention such as posts, 8 al of the canal entrance must be done with a material
the use of which is only for those cases where one (like zinc oxyphosphate) which in the case of retreat-
has no choice and where successively a prosthetic so- ment can be easily identified by colour and consisten-
lution is planned. 19 cy. The composite that should be used in the depths
For the restoration of anterior teeth, the most recent of the pulp chamber must have an excellent capaci-
generation composites highly filled with ultrafine or ty to flow and adapt (like composite flow) and must
nano-particles have shown to have both the best me- be cured for a longer period since the intensity of the
chanical properties as well as excellent surface and light of the curing unit decreases with the square of
chromatic characteristics. These materials are defined the distance. If the reconstructive phase was preceded
as universal composites because they can be used for by internal tooth bleaching, it is best to wait at least 2
direct as well as indirect restoration of both anterior weeks before proceeding with the restoration to avoid
and posterior teeth. that the oxygen liberated by the bleaching agent inter-
feres with the adhesive mechanism. If relapse of the
-Direct Restorations discoloration is expected it would probably be advisa-
For the restoration of anterior teeth it is thus possible ble to use glass ionomer cement for the restoration of
to use a single material for both the palatal side, the internal portion of the tooth so as to avoid, with
exposed to the stress of the anterior guidance, and the the adhesive procedure, the sealing of the entrances
buccal side, where the aesthetic characteristics of the to the dentinal tubules and therefore prevent a new
material are extremely important. 52 With regard to the bleaching procedure. 122 This type of material should
latter, a big step forward has been the availability of be used where there is sufficient good residual struc-
1196 Endodomics

Fig. 35.64. A. Coronal fracture of the upper left central incisor. 8. Silicone index made from diagnostic wax up. C. Reconstruction of the palatal wall and incisal margin
using an enamel composite. D.Stratification of the dentin mammellons and incisal masses. E. The finalized restoration. F. Clinical recall.

Fig. 35.65. A. Dischromic central incisor. 8. The incomplete access cavity of the previous endodontic treatment is the cause of the chromatic change of this central
incisor.(. The radiograph after endodontic retreatment. D. One of the phases of bleaching done with sodium perborate and water. E.The conservative restoration.F.
The finalized restoration with the reconstruction of the marginal crests. G. One year recall. H. Seven year recall. I. The palatal view at the seven year recall.
35 - Restoration Of The Endodontically Treated Tooth 1197

ture in view of its poor mechanical and low adhesi- indicated in the following situations:
ve qualities. - severe teracycline staining
An important biomechanical study 129 has shown -discolourations that are resistent to bleaching
that the concave lingual surface of the upper incisors -correction of conoids and other malformations
under load manifests a tensile stress and is protected -closure of diastemas
by the only reinforcing structures in this area which -incisal lengthening
are the cingulum and the mesial and distal marginal -extensive coronal fractures
crests. If the loss of dental structure in this area has in- -severe loss of enamel.
volved these important structures, then it is essential The use of these adhesive techniques have the un-
to reconstruct them in the restorative phase. 122 disputed advantage of limiting the removal of den-
When a significant amount of structure has been tal structure compared to the more traditional invasi-
lost, the easiest and most correct restorative procedu- ve techniques that require coverage with a full crown.
re involves a diagnostic waxup from which a silicone Thanks to excellent aesthetic qualities, the prepara-
index is made that acts as a guide for the reconstruc- tion of a veneer can furthermore be kept completely
tion of the palatal surface and incisal margin. 221·222 On supragingival (Fig. 35.69) with maximum respect for
this initial shell of enamel the dentin body, the mam- periodontal tissues. 123
melons, the opalescent incisal areas, the intensives,
possible characterization etc. can be easily construc- JI) CONSERVATIVE POSTERIOR A DHESIVE RESTORATIONS
ted. A lot of attention should be given to the creation As was previously stated, an endodontically treated
of the macro and micro texture of the surface, which posterior tooth manifests with an increase in deforma-
together create the natural effect of the restoration (Fig. bility and therefore fragility. In theory, its protection
35.66).218 could be carried out by either partial coverage with a
prosthetic crown or by reconnecting the walls with an
-Indirect restorations adhesive material that is able to reduce the deforma-
Amongst conservative and prosthetic procedures tion under load. Unfortunately, no material is curren-
there are indirect procedures, which by means of an tly available that will replace the strength that is lost,
impression and a laboratory phase produce a veneer, but the only one that gets close to the ideal goal is
more or less extensive, in composite or ceramic mate- composite placed using the adhesive technique. There
rial.133 In the case of the veneer in composite, the fact are many in vitro studies 59·97 ·121 ·147 · of teeth restored
that a reconstruction can be carried out on a stone die with composite and the adhesive system which de-
or silicone model allows complex cases or operations monstrate reduced cusp deformation under loading.
on very young patients to be approached with more The clinical confirmation was given by Hansen, 91who
ease. The complete polymerization of the material in in a retrospective study published in 1988 and another
an appropriate small oven 48 allows for a restoration successively in 199090 evaluated the cusp fracture fre-
which has improved mechanical and aesthetic charac- quency in endodontically treated premolars with MOD
teristics.133·217·219 The ceramic veneer (Fig. 35.67), although restorations in amalgam or composite. After three ye-
it has a higher cost, due to a more complex laborato- ars about one third of the teeth restored in amalgam
ry procedure, allows for more predictable aesthetic re- fractured, while no fractures were noted in those re-
sults that are longer lasting and once etched and ce- stored in composite and after ten years the survival of
mented attains the important biomechanical outcome the teeth restored in composite were
of reinstating rigidty and strength to the endodontical- definitely higher than those restored in amalgam.
ly treated anterior tooth (Fig. 35.68). 9·10•125 .1 26 .1 29 In the The authors concluded that in the light of these results
case of a discoloured, endodonticaly treated and ble- more consideration should be given to using adhesive
ached, anterior tooth, the use of a ceramic veneer has restorations in endodontically treated premolars (Fig.
the advantage, compared to a complete all ceramic 35.70). In 199644 Christensen, starting from the con-:
crown, that in case of relapse of the discoloration, the sideration that endodontically treated teeth have the
tooth can be treated from the palatal aspect with the same resistance to fracture as vital teeth reduced on-
usual bleaching techniques. These types of anterior ly by the amount of dental structure removed, recom-
adhesive restorations in ceramic can be carried out, mended that endodontically treated teeth which have
depending on the indications, with varied degrees of lost less than 50% of their coronal structure be resto-
extension. According to Magne and Belser, 123 these are red with a conservative adhesive restoration while a
1198 Endodontics

Fig. 35.66. A. The central incisor fractured in a car accident, with the old previous restoration. B. The diagnostic wax up of the fractured tooth. C. The preparation of
the tooth after removal of the previous restoration. D. A silicone index taken from the wax up allows an easy reconstruction of the palatal wall and incisal margin. E.
The palatal wall and incisal margin reconstructed with an enamel composite. F.The reconstruction of the dentinal body using dentin composite and incisal opale-
scence. (continued)
35 - Restoration Of The Endodontically Treated Tooth 1199

Fig. 35.66. (continued) G.The finalized reconstruction. Note the micro and macro characterization of the surface. H. One year recall.
1200 Endodontics

Fig. 35 .67. A. Coronal fractu re of the lower right central incisor. 8. The partial coronal preparation for a ceramic veneer. C. The feldspathic ceramic veneer (Technician
Paolo Vigiani). D.The cementation of the veneer under rubber dam. E. A finishing step once the veneer is cemented. (continued)
35 - Restoration Of The Endodontically Treated Tooth 1201

Fig. 35.67. (continued) F.The restored tooth immediately after removal of the rubber dam. G. Clinical recall.
1202 Endodontics

Fig. 35.68. A. Central incisors with severe loss of buccal enamel and alteration of extensive areas of dentin. B. The teeth after careful removal of the damaged dentin,
the sealing of the dentinal surface and the preparation for two ceramic veneers. C. The pressed ceramic veneers (Technician Paolo Vigiani). 0. The veneers after bon-
ding. E. Two year recall.
35 - Restoration Of The Endodontically Treated Tooth 1203

Fig. 35.69. A. Upper left central incisor endodontically treated with the previous defective coronal restoration. B.The smile of the patient: note the inverse line of the
incisal edge due to the excessive relative length of the canines and lateral incisors. C.The direct mock up carried out with composite to lengthen the central incisors.
The canines and lateral incisors have been marked with a black felt-tip pen to simulate shortening. A functional analysis of the occlusion excluded further shorte-
ning of the canines. D.The diagnostic wax-up carried out in the laboratory from an impression of the direct mock up. From the wax-up a silicone index and resin pro-
visional veneers will be made. E, F.The occlusal and labial silicone indices will guide the preparation of the incisors. G. The central incisors following the preparations
which were carried out completely supragingivally. H, I.The all ceramic veneers (IPS Empress Esthetic lvoclar Viva dent) (Technician Paolo Vigiani).J.The supragingival
preparation facilitates the placement of the rubber dam. K. Finishing during the adhesive bonding. L, M. Restorations following adhesive bonding. (continued)
1204 Endodontics

Fig.35.69. (continued) N, O.Two year recall .

35 - Restoration Of The Endodontically Treated Tooth 1205

Fig. 35.70. A. Upper left endodontically treated second premolar. B. Four year recall of the direct restora-
tion. Some cohesive defects of the surface are evident. C. Thirteen year recall. The composite restoration
has only been repolished. D. Twenty year recall. The first molar has been restored with a composite over-
lay (Technician Massimiliano Pisa).

prosthetic solution be used for the more compromised the use of a conservative restoration of this type. Those
teeth. Therefore the composite materials of the most teeth that are statistically less at risk, like lower premolars
recent formulation and the new adhesive techniques s9,9i,1 9o ( Fig. 35.74), could be more suitable. The type of

should most probably be considered in carefully se- occlusion that the patient has must be evaluated to veri-
lected cases as an alternative to the more destructive fy that the tooth is protected by an effective antero-lateral
traditional prosthetic techniques. guidance. On the contrary, those clinical situations where
The research carried out on type, shape, size and there are numerous and extensive wear faccettes on the
filler loading have shown that the latest generation of other posterior teeth due to parafunction with obvious
composites have reached a more than acceptable in signs of bruxism and/ or clenching must be excluded. It
vivo abrasion resistance 114.l 65 and that the amount of appears even more important in these cases that one mo-
wear tends to reduce in time and stabilize after 3 to 5 nitors the occlusion in the successive years to exclude
years. 229 Currently, however, there is a lack of scien- that the wear that occurs to the anterior guidance intro-
tific certainty with the new generation materials with duces traumatic interferences of the endodontically trea-
regards to the long term maintenance of the occlusal ted and conservatively restored teeth.
integrity and dentinal seal, so therefore for precautio-
nary reasons these restorations should be considered -Direct restoration
as long term provisionals. As has already been men- .With the direct restoration of an endodontically tre-
tioned, the decision to carry out a conservative adhe- ated posterior tooth certain specific operative precau-
sive restoration on an endodontically treated posterior tions should be noted. Above all, attention must be
tooth must take into consideration a number of para- paid to avoid that the stress due to polymerization
meters to remain within a margin of safety. 19 The first contraction is transferred to the already weakened
evaluation to make before doing a direct restoration walls. Therefore it is advisable to use material with a
on a posterior tooth is that of the cavity configura- low modulus of elasticity, like the flow type compo-
tion. All cavities with a type MOD configuration must site,56 which is placed between the adhesive surface
be excluded as they require protection with an over- and the restorative composite. The occlusal stability
lay restoration. In simple class one and two cavities an must be assured by a material like a highly filled mi-
adhesive inlay restoration can be done as long as the cro-hybrid composite with superior mechanical cha-
walls have adequate thickness (Fig. 35.71). For this re- racteristics which is able to ensure better durability
ason it is essential to carry out the correct measure- over time (Fig. 35 .75). The mechanical characteristics
ment, with calipers used for measuring metal at the can only be optimized by obtaining a high rate of
base of all the cusps (Figs. 35.72, 35.73 ). A thickness conversion of the material with a polimerization that
of less than 2.5 -3 mm, according to us, goes against is as complete as possible. Therefore small increments
1206 Endoclontics

Fig. 35.71. A. Upper right first premolar required endodontic treatment due to leakage of an old restoration. B. Post operative radiograph of the endodontic treat-
ment. C. The thickness and shape of the residual tissues indicated a direct restoration. D. The finished direct restoration in composite. E. The restored tooth after re-
moval of the rubber dam. F. Two year recall. G. Four year recall. H. Eight year recall.

Fig. 35.72. Incorrect (A) and correct (B) measurement of the thickness of the Fig. 35.73. The measurement of the wall thickness can be carried out with a
cusps. simple metal caliper.
35 - Restoration Of The Endodontically Treated Tooth 1207

Fig. 35.75. A. Upper endodontically treated molar. After careful examination of

Fig. 35.74. A. Lower left endodontically treated premolar. B. The construction the residual structure it was decided to do a direct composite restoration. B.
of the distal wall (sectional matrix band and G-Ring Composi-Tight Garrison Base lining with a composite type Flow. C. The completed restoration with a
Dental Solutions) during direct restoration. D. Clinical check. microhybrid composite. D. Clinical view.
1208 Endodontics

of material must be irradiated for the amount of time native to traditional prosthetic treatment could there-
that is adequate for the lamp intensity and for the spe- fore be the use of an overlay in composite or an all
cific features of the material. Once the restoration is ceramic material cemented adhesively. 19·113 •123 In those
completed, it is furthermore advisable to cover it with particular situations where the loss of dental structure
a glycerine gel and carry out a final extended irradia- has only involved some cusps and the marginal crest
tion. This brings about the complete polymerization that joins them, the coverage would be done only on
of the surface layer of the composite as well which these cusps (onlay) (Fig. 35.78). The adhesive appli-
brings about a reduction in wear over time. cation of the restoration, as it does not require macro-
retention, could avoid complete reconstruction of the
-Indirect restorations prosthetic core, making the use of a post absolutely
Until not long ago, the restoration of posterior teeth unnecessary. The practical consequence of this appro-
with extensive loss of structure necessitated a tradi- ach is essentially conservative. One could in fact avoid
tional treatment, 45 requiring the use of a post and full the removal of healthy dentin, both internally as oc-
crown coverage. A more modern approach (i.e. mi- curs when the post space is prepared, and external-
nimally invasive techniques 216) would be where the ly with preparation for the full crown. Furthermore, it
conservative adhesive techniques can be used with becomes totally unnecessary to protect the radicular
success, revolutionizing the old restorative standards. structure from the risk of structural failure, by way of
In a recent article Krejci et al. 109 subjected to testing a clinical crown lengthening either surgically and I or
in vitro endodontically treated teeth, using composite orthodontically (Fig. 35.79).
restorations of va1ying dimensions (with and without The conservative indirect type onlay I overlay re-
posts), with a control group of restored 'vital' teeth. storation of a posterior endodontically treated tooth
The authors, though noting the limits of the study, fa- with an extensive coronal destruction could be cor-

vour reflection on the univocity of the traditional ope- rectly used in the case of single teeth, providing it can
rative protocol for restoring endodontically treated te- be isolated with rubber dam and is in a situation of
eth. They assert that in many situations, with both ave- normal occlusion where the lateral and torsional loads
rage as well as extensive coronal destruction, the post are reduced to a minimum.
does not add anything in terms of retention to a good A conservative approach of this type, in fact, redu-
adhesive restoration and that in conditions of normal ces the amount of sound dental structure to be remo-
occlusion an adhesive inlay would be the first opera- ved, the number of procedures needed and has a no-
tive choice. From this point of view then the adhesive table advantage of operative simplicity as well as an
technique, mainly the indirect type, allows the endo- excellent aesthetic result (Fig. 35.80). Other advanta-
dontically treated tooth to be restored with the same ges of this procedure are:
standard as a vital one, with the same amount of struc- - both the buildup and adhesive cementation
tural loss (Fig. 35.76). 44 As has already been mentio- reinforce the residual structure
ned, the traditional therapy of a posterior endodontical- - maximum periodontal respect (supragingival
ly treated tooth with extensive coronal structural loss of- preparation)
ten indicates the use of one or more posts for the recon- - restoration of teeth with short clinical crowns
stmction of the core. Furthermore, the situation in which - better crown - root ratio, avoiding clinical crown
there is no adequate ferrule effect, a clinical crown leng- lengthening
thening with orthodontic and/ or periodontal treatment - in cases where surgical crown lengthening is
becomes essential before finalizing prosthetic restora- necessary, the procedure is less invasive
tion (Fig. 35.77). The latter treatment, as mentioned be- - better endodontic seal because the removal of
fore, complicates the therapeutic procedure, increasing gutta percha from the canal is avoided
the operative time, discomfort and cost for the patient as - endodontic retreatment is easier
well as many other inconveniences. An indirect adhesive - ideal procedure for young patients (interceptive
restoration that does not require a post for its retention restoration)
could avoid the necessity of these procedures. - lower cost.
The criteria for defining the biomechanical impor- In regards to the clinical procedure, having follo-
tance of the type of structural loss that an endodonti- wed the completion of the endodontic treatment, ei-
cally treated tooth is subjected to have already been ther at the same appointment or sucessively, the cavi-
mentioned. 19 ·67 ·113 In these selected cases, a valid alter- ty preparation and build-up are completed, the shade
35 - Restoration Of The Endodontically Treated Tooth 1209

Fig. 35.76. A. Old restorations of upper molar and premolar showing leakage.
B. After removal of the old restorations it was found that the teeth, especial-
ly the premolar, were severely compromised structurally. C. Once the ca-ries
was removed it was decided to do indirect composite restorations. In the ca-
se of the premolar an alternative treatment could have been endodontic tre-
atment, clinical crown lengthening, post and core reconstruction and covera-
ge with a full crown. D.The composite on lay (molar) and overlay (premolar) on
laboratory master cast (Technician Massimiliano Pisa). E. The teeth have been
isolated with rubber dam for bonding. F. The on lay/overlay immediately after
bonding. G. Clinical view following rubber dam removal. H. Four year follow-
up. I. A buccal view of the restorations at the four year recall.
1210 Endodontics

Fig. 35.77. A. Drawing of an endodontically treated and severely compromi- Fig. 35.78. A. On this upper molar, after endodontic treatment, the cusps wi-
sed molar. B. Removal of the weak and unsupported walls for a post and co- thout adequate support were reduced and a composite build-up was done.
re restoration. C. Clinical crown lengthening. D. Restoration with post and full B. The bonding of the composite on lay under rubber dam (Technician Paolo
crown. Vigiani). C. Occlusal view.
35 - Restoration Of The Endodontically Treated Tooth 1211

Fig. 35.79. A. Drawing of an endodontically treated and severely compromised molar. B. Preparation for an adhesive overlay. As much sound structure as possible is
kept. C. Adhesive composite build-up. D. Bonding of the adhesive overlay.

Fig. 35.80. A. Upper first and second premolars endodontically treated and prepared for partial coronal adhesive restorations. B. The indirect composite restorations
(Technician Massimiliano Pisa). C. Rubber dam isolation of the teeth for bonding. D. The restorations after bonding.
1212 Endodontics

is selected and the impression taken. Du.ring the cavi- open contact point) directly at the chairside. Instead
ty preparation phase the guidelines regarding the ma- an overlay in etchable ceramic has the advantage of
ximum conservation of dental tissue must be respec- having a higher rigidity compared to composite and
ted but the 'at risk' cusps must be reduced. 67 therefore has better biomechanical behaviour with
The internal build-up must be carried out with a sta- less deformation under loading. 124 In the areas of in-
ble material 132 such as a microhybrid composite and creased aesthetic importance (such as the buccal sur-
will have the function of: faces of upper premolars) the ceramic inlay permits a
- filling in the undercuts to save dental structure superior aesthetic result which is longer lasting (Fig.
during the preparation phase 35.82). Periodic radiographic and occlusal checks al-
- reinforcing the residual structure low the monitoring of the integrity of the marginal se-
- enabling the production of a restoration with al over time and so there is no abnormal occlusal lo-
homogenous thickness ading. One of the factors that needs further study in
- facilitating the correct placement in the cementation the future is the maintenance of the adhesive seal in
and light-curing phases. time 50,199 under functional loading.
At a second visit the prosthetic restoration in com-
posite or all ceramic is tried on and consequently ce- JJI) PRE-PROSTHETIC COMPOSITE RESTORATIONS
mented adhesively (Fig. 35.81). In the case of an inlay
in composite, 55 •132 the contraction due to polymeriza- It has already been stated that composite be used
tion will be limited to a thin layer of composite used for the construction of the base (build up) for inlays
for the cementation while the mechanical characteri- and it is definitely the material of choice for recon-
stics of the material are optimized by the complete po- structing the prosthetic core because of the many ad-
lymerization in the laboratory with heat and light, car- vantages it offers:
ried out in the appropriate oven. The adhesion at the - adhesion to the tooth allows the saving of more
cervical margin, especially when there is no enamel, tissue compared to a passive material like amalgam
is more reliable than with a direct restoration becau- - the reduction of the deformation of the residual
se the negative effect of the polymerization shrinkage walls thereby lowering the fragility
of the whole restoration is not felt. 54 The big advan- - the modulus of elasticity, being similar to that of
tage of the composite restoration is the possibility to dentin, is able to restorations with better biomechanical
be able to carry out any required corrections (like an characteristics

Fig. 35.81. A. Endodonticaly treated upper right first molar of a young patient. B. Removal of the fragile walls in preparation for an interceptive indirect restoration. C.
Composite build-up. D. The indirect restoration (Technician Massimiliano Pisa). E. The adhesive cementation of the on lay. F. Two year recall.
35 - Restoration Of The Encloclontically Treated Tooth 1213

Fig. 35.82. A. Endodontically treated upper right premolars and first molar fol-
lowing extensive caries. B. In the same patient the upper left second premolar
was endodontically treated for the same reason. C. The right second premolar
was restored with a build-up in composite before doing an overlay. The right
first premolar has both buccal and palatal walls with sufficient thickness and
will be prepared for an inlay.D.The left second premolar has severely compro-
mised walls and will be prepared for an overlay. E. Silicone impression of the
preparations.Two fragments of retraction cord remained beyond the prepara-
tion margins of the premolar. F. Laboratory master cast with the preparations
of the various teeth. G. The restorations on the laboratory model. Composite
inlay for the first premolar and ceramic overlays for the others.(continued)
1214 Endodontics

Fig. 35.82. (continued) H. A view of the restorations (Technician Paolo Vigiani).

I.The teeth ready for bonding.J.The finalized adhesive bonding. K, L. Few days
after bonding the restorations appear well aesthetically integrated.M.Occlusal
view. N. Four year recall.
35 - Restoration Of The Endodontically Treated Tooth 1215

- the diametral compression and traction strength of - the rapid setting allows for core preparation
some micro-filled composites is similar if not immediately after finishing the restoration
superior to amalgam 41 - its excellent aesthetic properties make it the material
- they do not have the risk (typical of amalgam ) of of choice in the case of all ceramic crowns.
delayed expansion, responsible for the start offractures The reconstruction of a prosthetic core can be carri-
- they do not create a tatoo of the mucosa during ed out with composite only or in combination with a
preparation post (Fig. 35.83). The latter is used only in those

Fig.35.83. A. Patient's smile. B. Orthodontic treatment.(Dr. Francesco Pedetta) C. A severely compromised upper left lateral incisor. D. A quartz fibre post is used for
the restoration. E. The composite used to build up the core is light cured .F. The restoration immediately after completion. G. The alumina copings (Procera Crown
Alumina) for the cores of the three endodontically treated teeth and try- in of the silicone index obtained from an impression of the provisional crowns (Technician
Stefano Inglese). H.The ceramic stratification (Technician Stefano Inglese). (continued)
1216 Endodontics

Fig. 35.83. (continued)!. All ceramic crowns and veneers. J. The cores ready
for cementation. K. The try-in of the ceramic crowns. L .The cementation of
the alumina crowns ( Procera Crowns Alumina) with a self- adhesive cement
(Relyx Unicem 3M ESPE). M. The veneers are cemented after rubber dam iso-
lation. N. The veneer on the lateral incisor immediately after cementation .0.
Clinical evaluation. (continued)
35 - Restoration Of The Endodontically Treated Tooth 1217

Fig. 35.83. (continued) P. Patient's smile. Q. Lateral view of the patient's smile.
1218 Endodontics

cases where the coronal structure is so reduced that can be previsualized with the use of a transparent mask
it does not permit the adequate retention of the re- made from a diagnostic waxup (Fig. 35.85).
constructive material. One must therefore previsualize The composite material used for the preprosthetic re-
the amount of dental tissue that remains after the co- storation can be either self curing or lightcured.
re preparation. The amount of dental structure that is - Self curing: the self curing composite has the ad-
removed depends on: vantage of being a material that one rapidly applies to
- the type of material used for the prosthesis the tooth when a matrix can be easily placed. It has
- aesthetic requirements the undisputed advantage of having low polymeriza-
- asymmetric preparations necessary to parallel the tion stress due to the reduced dynamics of reaching the
cores to each other gel phase (Fig. 35.86). On the other hand, its manipula-
- asymmetric preparation to modify the inclination tion and application can more easily cause air bubbles
of the core. and voids inside the material. With these materials at-
To evaluate the type of preprosthetic restoration to tention must be paid to the choice of adhesive, becau-
be carried out, one could proceed with the core pre- se some of these,34 if they have a pH that is too low,
paration before reconstruction, so as to have the exact are not compatible with self curing composites, as they
perception of the residual thicknesses or one could me- sta1t an acid-base reaction along the composite adhesi-
asure the thickness of the walls with a calipers and ve interface that compromises adhesion here.
then, subtracting the amount of material destined for - Light curing: with light cured composite one has
the prosthetic crown, evaluate whether to place a post the undeniable advantage of being able to apply the
(Fig.35. 84). Should it be necessary to carry out any material even without the need for a matrix and wi-
shape correction of the core or change the angle of the thout the material polymerizing during manipulation
axis, the maximum amount of dentin to be removed (Fig. 35.87). Thf reconstruction of an endodontically

Fig. 35.84. A. Measurement with a caliper of the thickness of the residual tooth structure of an upper left
central incisor. The adhesive bonding of a transluscent quartz fibre post. C. The core restored with a tran-
sluscent post and composite. D. Occlusal view of the same tooth.

Fig. 35.85.The use of a transparent index, made from the diagnostic waxup, could give an indication of the
amount of dental structure to be removed during preparation. In this case a periodontal probe is placed
in guide holes, made in the index, at various points on the preparation.
35 - Restoration Of The Endodontically Treated Tooth 1219

Fig. 35.86. A. Cores reconstructed with a carbon fibre post and self curing composite. B. Laboratory master cast with prosthetic abutments. C. Ceramo metal bridge
cemented on the same cores (Technician Paolo Vigiani).

Fig. 35.87.A.These upper premolars require new restorations after previous prosthetic failure (see. Fig. 35.20). B. The suture removal following surgical lengthening of
the clinical crown (Surgery by Dr.Stefano Gori). C.Two months after surgery. O. Isolation of teeth with rubber dam. E. Restorations with quartz fibre posts. F. The co-
res restored with quartz fibre posts and lightcure composite. G. A buccal view of the cores, with supra gingival preparations. H. A clinical view after cementation of
the all ceramic crowns (IPS e.max Press lvoclar Viva dent) (Technician Paolo Vigiani). I. Two year recall.
1220 Endodontics

treated tooth often requires the use of a large amount the core in the inter-radicular zone (barrelling-in), if
of composite and a lot of attention must be given not actually separation, with or without removal, of
to controlling the stress due to polymerization shrin- one or more roots (root resection). This requires pre-
kage to avoid having cracks in the residual walls. To ventive endodontic treatment to be able to perform
avoid this happening it could be useful to 'paint' the the successive phases of the complex treatment plan.
internal walls of the cavity and surfaces of any posts Once the endodontic treatment has been completed,
with a flowable composite which has a low modulus the reconstructions must be completed rapidly befo-
of elasticity, to take advantage of the stress-breaking re passing to the successive surgical phase. The re-
function. Particular attention must be given to cavi- storation of endodontically treated teeth must be car-
ties with an unfavourable configuration (many oppo- ried out very soon after the endodontic treatment to
sing and deep walls) especially in the presence of fi- avoid danger of coronal leakage as well as to make
bre posts. With these cases it is best to place small the preparation of the cores easier for the produc-
increments of material before light curing, because tion of the first temporary restoration. This is not true
the contraction of a large mass of material that has when a crown-root fracture or an extensive subgingi-
contact with both post and wall at the same time val decay prevent the correct use of the rubber dam.
could provoke an extended crack of the latter. The In these situations the risk of coronal leakage is ve-
lamp used must have a high power of light emission, ry high because of the long time required for therapy
which is important to periodically check with a ra- and consequently for the frequent decementation of
diometer, so that complete conversion of the compo- the provisional restorations.
site material is achieved. It is also important to have This complex treatment plan often subjects the co-
the possibility to regulate the power and curing time, res to a notable sacrifice of tissue:
to be able to utilize the light curing techniques 32 that the periodontal treatment exposes portions of the
reduce the polymerization shrinkage. root where the diameter is reduced in an apical di-
Once the core preparation is completed a careful rection. The consequent preparation of the root cau-
check must be made to ensure that no material re- ses further loss of dental tissue
mains bonded to the tooth surface along the margin the lengthening of the crown or the separation of
of closure of the future crown the roots makes the axises more divergent and the
to avoid the risk of certain leakage. Even here an need to make them more parallel requires more ag-
adequate amount of healthy cicumferential dentin gressive preparations (this aspect is accentuated with
(see ferrule effect), coronal to the crown margin of those roots , like the mesial of first molars, which ha-
closure, guarantees better results : ve a concave surface).
All this makes these cores extremely fragile with a
SEVERELY PERIODONTALLY COMPROMISED high risk of fracture and, therefore, it is imperative
TEETH to proceed with treatment aimed at saving dental
tissue. For endodontic treatment it is good practice
Teeth with severely compromised periodontal to use techniques and instruments, like nichel-
support, especially in the posterior segment, necessitate titanium rotary instruments, which reduce the
an extremely complex multidisciplinary treatment sacrifice of dentin. For the reconstruction of the
that includes endodontic, reconstructive, surgical cores it is preferable to use materials and adhesive
and prosthetic procedures (Fig. 35.88). Generally we techniques that do not require undercuts, pins etc.
refer to extremely sophisticated and expensive perio- for retention. The use of posts is often absolutely
prosthetic treatment, which if each step is not carried useless as, following surgery, the extended length
out with absolute rigor (including the selection of of the clinical crown makes its use superfluous. In
patients who are suitable for this treatment), has a high many cases their use (especially the metallic type) is
percentage of failure. 172 •173 Currently, implant therapy · not indicated, because they could interfere with root
has become more predictable and consequently the separation or core preparation. As was mentioned,
number of cases which need this type of treatment the reconstructed teeth are subjected to an initial
has been reduced. preparation for making the provisionals in resin
In the case of multi-rooted teeth, following fur- and a final preparation, following surgery, once the
cation involvement because of periodontal disease, gingival tissues have completely healed and matured.
it is necessary to carry out a deep preparation of Seeing that following periodontal surge1y the axises
35 - Restoration Of The Endodontically Treated Tooth 1221

of the teeth often change and in the second phase of the centric contacts in the fossae, marginal crests and
preparation need to, once again, be paralleled with centric cusps , eliminating those on the cuspal incline
further dental tissue sacrifice, it is essential that in the plane and those contacts that occur with eccentric
first preparative phase to be more conservative than mandibular movements.47 This occlusal scheme must
usual. A precise occlusal check must follow all the be followed during all the therapeutic phases so as to
phases of the long treatment course of these teeth, optimize it and eventually copy it accurately with the
which almost always present an unfavourable lever definitive prosthesis. The monitoring over time, at
due to the altered crown-root ratio. These checks checkups, avoids dangerous functional overloading
must start at the provisional phase, maintaining only of extremely compromised teeth.

Fig. 35.88. A. Pre-operative radiograph of upper left first and second molars with severe periodontal involvement. B. Radiograph following endodontic treatment. C.
After the periodontal surgery and the separation of the roots one has to wait for the complete maturation of the tissues before proceeding with the finalization of
the case. D. The cores were restored using self curing composite without the use of posts. E. Laboratory master cast. F. Palatal view of the tissue after finalization of
the case (Technician Paolo Vigiani). G. Attention must be given to the cleanability of the prosthesis so that the patient is able to carry out hygiene maintenance. H.
The interdental spaces must be designed to guide the interproximal brushes with correct cleaning action. I. One year recall. J. Palatal view at the ten year follow-up.
1222 Endodontics

Conclusion: perio-prosthetic treatment of teeth approach.171 It is still a treatment that is valid where
with reduced periodontal support and inter-radicular implant therapy is refused or where there are
involvement is an extremely sophisticated type of anatomical difficulties (Fig. 35.89).
treatment, requiring a very rigorous multi-disciplinary

Fig. 35.89. A. Severe periodontal disease of the right quadrants. The patient also presents an evident alte-
ration of the occlusal plain. 8. Acetate index made from the diagnostic wax up will guide the preliminary
preparation of the teeth for fitting the first resin provisionals. C. The resin provisionals must re-establish
the correct occlusal plain. D. Post surgical tissues maturation. E. At higher magnification the extremely ag-
gressive preparation following separation of the roots is quite evident. F. The delicate residual cores re-
constructed with self cure composite without the use of posts. G.The need to have the cores parallel to
each other requires very aggressive preparations. H. Laboratory master cast. I. Occlusal view of the labora-
tory master cast.J. Occlusal view of the ceramo metal prosthesis cemented on the abutments (Technician
Paolo Vigiani). K. Buccal view after prosthetic finalization. L. Four year recall. M. Palatal view at the five ye-
ar recall.
35 - Restoration Of The Endodontically Treated Tooth 1223


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