Doug Kase
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 ELLO
AGAIN, and welcome to the summer edition of Tales. A patient
presented with a history of trauma to a maxillary right central
incisor. Clinically, there was some color change to the tooth as
compared to the contra-lateral central, but other than that the tooth
was asymptomatic. The routine set of radiographs provided the
clue that something was amiss. After taking a look at the
periapical film (Figure 1) it was apparent that the tooth had undergone
internal resorption.
Internal resorption is the resorption of dentin; it
starts in the pulpal cavity either in the pulpal chamber or in the root
canal. There are many etiological factors, but its most frequent
cause is infection or trauma, which can initiate an inflammatory
response in the pulpal tissue. What generally happens in response
to these stimuli is that granulation tissue is formed in the pulp; this
tissue ultimately produces odontoclasts, which are similar to
osteoclasts, and hence the resorptive process begins. Usually,
the resorption process is diagnosed either from routine radiographs,
due to its asymptomatic nature, or from the fact that it has become so
extensive that it actually perforates through the crown or root.
The resorption process can proceed rapidly, or it can proceed at a slow
pace, even going unnoticed for many years. After diagnosis,
endodontic treatment is essential in all forms of internal resorption,
the object obviously being to remove the offending tissue and obturate
the space. Treatment modalities can differ depending on the
extent and location of the destruction. If canal perforation is
present which directly affects the prognosis, then additional internal
sealing with MTA is appropriate in addition to gutta percha
obturation. Surgical intervention also may be an option if the
first two treatment modalities are not enough.
In the case presented, the first thing to determine
was whether this pathology was purely internal, had perforated the
root, or was a case of external resorption. Looking at the
initial radiograph, I saw that the resorptive area clearly obliterated
the canal. Very often when a case of external resorption presents
on a radiograph, a ghosting of the canal passes through the
radiolucency. Additionally, an angled radiograph will shift the
canal and radiolucent area away from each other. In this case,
the canal and radiolucent area shifted together. Access was
attained, and the calcified coronal section was negotiated with a # 10
reamer. Using an apex locator is most important. An
inability to gain an accurate reading would indicate a perforation and
a change in treatment modality. In our case, the reading was typical of
a normal canal, and an apical measurement was attained and duplicated
throughout the procedure. The canal was instrumented apically to
a # 60 and back stepped to a # 90 in .5 mm increments to create some
taper. The coronal aspect of the canal was opened with a Peeso
reamer and ultrasonic cpr3 tip. Sodium hypochlorite was used
copiously throughout the procedure. I placed a 45-degree bend on
a black Broach to check for any trapped remaining tissue or debris
within the resorptive area. The canal was irrigated with EDTA to
remove the smear layer and then finally irrigated with chlorhexidine
and dried. A master # 60 point was fitted with tug back (Figure
2) and then EZ-Fill® cement was expressed into the canal with an
EZ-Fill spiral (Figure 3). Note that sealer was not expressed out
the apex due to the design of the bi-directional spiral. The master
cone was then seated to the apical measurement coated with EZ-Fill
cement (Figure 4). Then using a combination of lateral
condensation and vertical packing with heat the gutta percha was
condensed into the remaining canal and resorptive defect (Figure
5). It is important to recall resorptive cases on a regular basis
for up to a year.
July - August 2007
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FIGURE 1: Periapical film reveals that the tooth has undergone internal resorption.
FIGURE 2: Showing a # 60 gutta percha point in the canal.
FIGURE 3: After EZ-Fill sealer was expressed into the canal with an EZ-Fill spiral.
FIGURE 4: Showing the gutta percha condensed into the remaining canal and resorptive defect.
FIGURE 5: Showing the gutta percha condensed into the remaining canal and resorptive defect.
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