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Volume 9 Number 2

CASE STUDY

the oral environment for 2 weeks, resulting in pulp necrosis (Figures 4-5). Tooth No. 9 responded positively to pulp tests, and the mobility was within normal limits. There was reasonable doubt about the reliability of the pulp test in tooth No. 9, and we suspected that the radiolucency associated with No. 9 was a sign of pulp necrosis (Figure 6). The preoperative diagnosis was a complicated crown-root fracture and apical periodontitis of tooth No. 8, and an extrusive luxation of No. 9. Treatment plan was root canal treatment in tooth No. 8 and highly likely in also in tooth No. 9, followed by restorative treatment with adhesive composite restorations. Local anesthesia was administered, and the teeth were isolated with a rubber dam. After working length determination with LightSpeed™ instruments (Figure 7) (marketed in its current form by Kerr Corporation, Orange, California), and mechanical and chemical debridement with 6% sodium hypochlorite (Vista Dental Products, Racine, Wisconsin), an interappointment dressing of calcium hydroxide (UltraCal® XS; Ultradent, South Jordan, Utah) was applied, and the tooth was temporized (Figure 8). Three weeks later, a composite core (LuxaCore; DMG, Hamburg, Germany; DMG America, Englewood, New Jersey) was placed in tooth No. 8, while preserving the endodontic access cavity. Because the palatal outline of the fracture site was located deep under the gingiva, a gingivectomy was performed using an electrosurge. After application of retraction paste (3M, St. Paul, Minnesota), a dry work field was created, and a core form (Kuraray Noritake Dental Inc., Okayama, Japan) was applied, acting as a matrix. A pulp test in tooth No. 9 yielded a negative response, and the radiolucency associated with tooth No. 9 had increased in size. Root canal treatment was started, and the diagnosis apical periodontitis of tooth No. 9 was confirmed. After mechanical and chemical debridement of tooth No. 9, an interappointment dressing of calcium hydroxide was applied, and the tooth was temporized (Figure 9). Four weeks later, the patient returned for finishing treatment. He was completely asymptomatic. After removing the calcium hydroxide by alternating 6% sodium hypochlorite (Vista Dental Products, Racine, Wisconsin) and 17% EDTA (Vista Dental Products, Racine, Wisconsin) ultrasonically activated, working length determination was repeated using LightSpeed instruments. The author follows a rule of thumb that if an apical foramen is equal or larger than a hand file or LightSpeed instrument No. 70 (= 0.70 mm), a hydrophilic

Figure 4: After removal of the splint, the extent of the fractures is clearly visible

Figure 6: Radiolucency associated with tooth No. 9 in conjunction with a positive pulp test

Figure 5: A complicated crown-root fracture has been exposed to the oral environment for 2 weeks and has resulted in pulp necrosis

Figure 7: A LightSpeed instrument is used to determine working length

Figure 8: Interappointment dressing of calcium hydroxide and a temporary restoration

calcium silicate-based sealer in conjunction with gutta percha is to be preferred. Traditional obturation methods do not provide an effective seal. They may shrink on setting, have little or no adhesion to dentin, and are not dimensionally stable when they come in contact with moisture, leading to dissolution and leakage over time. In recent years, new materials have been developed that overcome some of these shortcomings. Since 2008, three premixed Figure 9: Both central incisors are Figure 10: Gauging the apical forabioceramic products have been dressed with calcium hydroxide men with LightSpeed instruments ® available: EndoSequence BC Sealer™, EndoSequence® Root Repair Material™ (RRM) Paste, and Root oxide, tantalum oxide, calcium phosphate Repair Material™ (RRM) Putty (Brasseler monobasic, and fillers) have excellent USA®, Savannah, Georgia). Recently, these mechanical and biological properties, and materials have also been marketed under good handling properties. They are hydrothe name of TotalFill® (FKG Dentaire SA, La philic, insoluble, radiopaque, aluminum free, Chaux-de-Fonds, Switzerland). and high pH, and require moisture to harden. The manufacturer states that the three The working time is more than 30 minutes, forms of bioceramics are similar in chemical and the setting time is 4 hours in normal composition (calcium silicates, zirconium conditions, depending of the amount of Endodontic practice 17

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Endodontic Practice - Summer 2016 Vol 9 No 2  

Endodontic Practice - Summer 2016 Vol 9 No 2  

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