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Persisting endodontic lesion- compound odontomes and residual cyst: clinical case report; |Dr vineet vinayak

ABSTRACT
Odontomas and residual cysts are the most common type of persisting lesions encountered and generally are asymptomatic. This paper describes cases of compound odontomas and residual cysts. in both cases, the surgical excision of the lesions was performed. The results achieved indicate that the early diagnosis of these persisting lesions allows the adoption of a less complex and expensive treatment and ensures better prognosis.

INTRODUCTION
The periapical cyst is a common sequela of periapical granuloma originating as a result of bacterial infection and necrosis of dental pulp. The majorities of cases of periapical cyst are asymptomatic and present no clinical evidence of their presence. The tooth is seldom painful or even sensitive to percussion. This type of cyst is infrequently of such size that it destroys much bone, and even rarely produces expansion of cortical plates. But if neglected for long time may undergo acute exacerbation of inflammatory process and may develop into large residual cyst or an odontoma. A residual dental (or radicular) cyst arises from epithelial remnants stimulated to proliferate by an inflammatory process originating from pulpal necrosis of a non-vital tooth that is no longer present. The natural history begins with a non-vital tooth which remains in situ long enough to develop chronic periapical pathosis such as a dental (radicular) cyst. Eventually the tooth is extracted with little regard to the periapical pathosis which remains within the jaw bone as a residual dental cyst. Over the years, the cyst may regress, remain static or grow in size. Odontomas are considered to be developmental anomalies resulting from the growth of completely differentiated epithelial and mesenchymal cells that give rise to ameloblasts and odontoblasts. These tumors are basically formed of enamel and dentin but they can also have variable amounts of cementum and pulp tissue. During the development of the tumor, enamel and dentin can be deposited in such a way that the resulting structures show an anatomic similarity to normal teeth, in which case the lesion is classified as a compound odontoma. However, when the dental tissues form a simple irregular mass occurring in a disorderly pattern, it is described as a complex odontoma. Compound odontomas appear more frequently than complex odontomas.This paper discusses two case reports for management of persisting lesions.

CASE REPORT 1
A 28 year old female was referred to the department of endodontics by a general practitioner. The patient came with a big swelling on the palatal aspect. (Fig A) Patient had trauma 4 years back and had undergone acrylic crown placement for discolored tooth 21.

Preoperative photo showing large palatal swelling

Fig A: Preoperative photo showing large palatal swelling

Preoperative OPGPeriapical radiolucency was observed to be extending from 21 to 25. Pulp vitality tests using an electric pulp tester were done irt #21, 22, 23, 24, 25. All the teeth were non vital. Routine endodontic procedure was done from 21 to 25.

Fig B: Preoperative OPG

Fig B: Preoperative OPG

Purulent exudate was coming out only from 21 and dramatically swelling subsided after access opening in relation to 21, subsequently swelling developed after obturation. Surgery was performed after endodontic procedure. During surgery under local anesthesia flap reflection was performed. The lesion was found to be extending well enough on labial side that was not diagnosed initially. Biopsy report confirmed the diagnosis of residual cyst.

Fig C: Extent Of Lesion

Fig C: Extent Of Lesion

The granulation tissue was removed using curettes (API). Removal of cystic lesion was done.(Fig D) The flap was repositioned and sutured using sling suture technique. Patient reported back asymptomatic after 3 months.

Fig D: Residual Cyst RemovedFig D: Residual Cyst Removed

Fig D: Residual Cyst Removed

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Achieveing Ideal Endoesthetic- Restorative Continuum; Dr Vineet Vinayak

INTRODUCTION
Preserving the pulp vitality is the main aim of present day dentistry. However due to a myriad of conditions, the use of posts may have to be considered as the last therapeutic option. Generally, endodontically treated teeth have already undergone significant coronal destruction and a pertinent loss of radicular dentine. In such a condition the non metallic posts help to bring the concept of an endoesthetic restorative continuum closer to reality by providing an esthetic post, a composite core and an automixed resin luting cement , thus formulating a monobloc that ensures not only high quality esthetics but is also safe , durable and easy to use for the clinician.

CLINICAL APPLICATION OF GLASS FIBER POSTS
The step by step protocol is easy to follow as given below;1.Evaluate a successfully treated root canal tooth by confirming radiographically the intact apical seal2.Remove the gutta percha such that 3-4 mm of intact apical seal is retained3.Insert the glass fiber post after adequate canal preparation4.Lute the post in place using flowable composite5.Build up a composite core6.Take a final impression for crown placementIt is important to note that a post that can be bonded to tooth structure improves its ability to retain the entire foundation.Hence it is imperative to select a post that provides maximum retention while at the same time removing as little tooth structure as possible.

DISCUSSION
The glass fiber post is a clear resin post that is designed to refract and transmit natural tooth colors .It is placed passively in prepared canal and is available in different sizes and diameters. Advantages offered by the resin post over metallic posts includes increased bond strength, lesser chairside work for clinician and forming an esthetic tooth composite monobloc. Other secondary advantages are its ability to distribute stress, capability to maintain intraradicular rehabilitation and ease of retreivability.The root length, shape and amount of tooth structure lost as well as the periodontal status and final root canal treatment quality are important aspects in deciding the success or failure of post endodontic restoration. Post placement should be as long as possible for better stress distribution and increased retention. Placing a long post in a short root may cause disruption of root canal seal at the apex and eventually may lead to root fracture also.Resin fibre glass posts are also easy to retrieve as compared to metal posts, that may compromise the remaining dentine while being removed from the radicular tooth structure. In case of glass fiber posts,the use of gates glidden drill through the existing post can safely act as a vertical guide making the post removal rapid and predictableTrial post placement ,before saeting post in place,is a must, to see the proper placement, position and length of post in dentin.After post placement and before curing initiation, the excess flashes of composite should be removed by microbrush to aid in better post placement. Curing of composite at minimum of 40 sec is advocated, but this variable depends on the type of composite cement used and the manufacturers instructions. Shade matching should be accomplished and keeping the variables of hue, chroma and value in mind, so that the core composite material is of the same shade, as the final crown for an esthetic result.

CONCLUSION
Modern day endodontics demands clinically convenient and esthetic post and core systems to help restore lost tooth structure. Recent developments in use of esthetically viable non metallic posts have served to provide an ideal endoesthetic-restorative continiuum comprising of an esthetic non metallic post, a composite core and an automixed resin luting cement.

REFERNCES
1.Brett C, Mark P ,Ira N, Allen DS, Cyclic fatigue testing of five endodontic post designs supported by four core materials. J Prosth Dent 1997; 78 (5);458-64.12. David A and Colin G .Biomechanical considerations in restoring endodontically treated teeth .J. Prosth Dent.1994; 71(6); 565-567.3. David RN, Vistasp KM, physical behaviors of fiber reinforcement as supplied to tooth stabilization. DCNA 1999; 1 (43); 7-34.4. Francesco M, Martyn S, Timothy WF. Three-point bending test of fiber posts. J Endodontics.2001; 27(12); 758-761.5. Gordon CJ. Posts and cores; State of the art. JADA 1998; 129 ;96-98.6. Giovanni SE, Paul KA and Derrick SJ. An in vitro evaluation of a carbon fiber based post and core system. J Prosth Dent 1997;78 (1); 5-9.7. John S. Stanley LF . An endodontic- prosthodontic approach to internal tooth reinforcement. J Prosth Dent 1981;45(2); 164-174.8.John SA, James MT.Intracoranal reinforcement and coronal coverage; A study of endodontically treated teeth. J Prosth Dent 1984; 51 (6);780-784.

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Influence of Ultrasonic Irrigation and Chloroform on cleaniness of Dentinal Tubules during endodontic retreatment- an invitro SEM study |Dr. Vineet Vinayak

ABSTRACT
Background:
Ultrasonic irrigation has been proved for its remarkable cleaning efficiency in the field of endodontics. But its role in endodontic re-treatment has been understated. There is not much data available to understand the effect of ultrasonic irrigation for the evaluation of cleanliness of dentinal tubules when it is used with or without chloroform, a gutta percha solvent during endodontic retreatment.

Aim:
To compare the influence of ultrasonic irrigation with syringe irrigation on cleanliness of dentinal tubules after gutta perch removal for endodontic retreatment with or without the use of chloroform a gutta percha solvent using scanning electron microscope (SEM).

Materials and Methods:
Freshly extracted 45 human mandibular premolar teeth for periodontal and orthodontic reasons were taken and were occlusally adjusted to a working length of 19 mm. The root canals of all teeth were prepared chemo mechanically to a master apical file size 40 and were divided in various groups. In Group 1 (n = 5; control group), the canals remained unfilled. In Groups 2 and 3 (n = 20 each), the canals were filled using lateral compaction with gutta-percha and AH plus sealer, removal of root fillings was undertaken after 2 weeks using Gates Glidden drills and H files without chloroform in Group 2 and with chloroform in group 3. The specimen of Group 2 and 3 were further divided into two subgroups I and II (n=10). In subgroup I, irrigation was done using side vented needles and sodium hypochlorite. In subgroup II irrigation was done using passive ultrasonic irrigation with sodium hypochlorite. Thereafter, the roots were split and the sections were observed under SEM. The number of occluded dentinal tubules /total number of dentinal tubules were calculated for the coronal, middle and apical third of each root half. Statistical analysis was performed using one-way ANOVA followed by Tukey’s test using standardized technique.

Result:
Results indicated that the cleanest dentinal tubules were found in the control group (Group 1 where the canals were unfilled) followed by the non chloroform group with ultrasonic irrigation (Group 3 subdivision II) followed by chloroform group with ultrasonic irrigation (Group 2 subdivision II), the non chloroform group with syringe irrigation (Group 3 subdivision I) and least cleanliness was found in the chloroform group with syringe irrigation (Group 2 subdivision I).

Conclusion:
Under the limitations of this study it could be concluded that both ultrasonic and syringe irrigation showed cleaner canals when chloroform was not used. Irrigation when done with ultrasonics leads to cleaner tubules than syringe irrigation. Hence, mechanical methods of retrieval in conjunction with use of passive ultrasonic irrigation should be a part of retreatment protocol.

Scanning Electron Microscope (SEM) analysis of specimen
Estimated mean, standard deviation (SD), standard error (SE), of the ratio evaluated in SEM (number of occluded dentinal tubules/total dentinal tubules) analysis and number of evaluated images (N)CCl3=chloroform US=ultrasonic
canals and canal curvature angles varying between 0–10° as given by Schneider [5] were selected, after radiographic evaluation. All teeth were stored in 10% ethyl alcohol solution. Access cavity preparations were done and the incisal edges were adjusted, so that the final working length of each tooth was 19.5 mm. The working length was confirmed by radiographs. Radiographs were taken to confirm that the distance of file from the apical foramen remained between 0.5-1mm in all the specimens.

Canal preparation-
All the roots were instrumented using K- type file (Dentsply, Maillefer, Ballaigues, Switzerland). The apical enlargement was done up to size 40 using K file at the working length by using the files in sequence according to increasing order of their tip diameter size (size 15-40 K file). Frequent recapitulation was done by using number 15 K file. A step back technique was followed for cleaning and shaping of the canal. K files of sizes 45,50,55 were used in progressing order at file lengths 1 mm short of the preceeding file. (i.e. at 18.5mm,17.5mm and 16.5mm for K file 45,50 and 55 respectively). K file size 40 was used for recapitulation to prevent iatrogenic ledge formation. Using side vented needles (canal clean), 3% sodium hypochlorite was delivered in the root canals each time before using instrument of larger diameter. Finally, the root canals were rinsed for 1 minute using EDTA, followed by 3% NaOCl (10 ml) for final rinse. A 28-gauge side vented irrigation needle, inserted 1–2 mm short of the working length was used for irrigation. All root canals were dried with paper points.

Obturation-
All samples were randomly divided into three groups. Group 1: (Control Group, n = 5) The roots remained unobturated and it served as a baseline parameter for comparison. The root canal of each tooth in experimental Groups 2 and 3 were obturated using lateral compaction. The roots were radiographed in buccolingual and mesio-distal directions in order to confirm the adequacy of the obturation. The access cavities were filled temporarily by Cavit (3M ESPE). All teeth were stored in a humid or for two weeks in 100% humidity to allow complete setting of the sealer.

Retreatment technique-
In Groups 2 and 3, from the coronal 5 mm of the root canal of each specimen the obturating material was removed using Gates Glidden drills of sizes 2, 3 and 4 in sequential increasing order of their size. In the middle and apical part of the canal, Hedstrom files sizes 15-40 (Dentsply, Maillefer, Ballaigues, Switzerland) were used in order to remove gutta-percha and sealer from the canal. In Group 2, chloroform (Rankem, Ranbaxy), a gutta percha solvent was used along with H files to ease the removal of gutta percha. In Group 3 also gutta-percha removal was done by using H files without using chloroform. In Group-2 chloroform was deposited for 15 sec into the reservoir created by Gates Glidden drill. The gutta-percha was removed with Hedstrom files sizes 40–15 (in descending order) to the working length using a push and pull action. Once the working length had been reached with a size 15 file, sizes 20, 25, 30, 35, 40 were instrumented to the working length. When no gutta-percha could be seen on the flutes of the file, radiographic confirmation was done and the gutta-percha removal was ceased. After gutta-percha removal, specimens from both the groups were divided in two sub groups. In subgroup I (n=10), the canals were irrigated with 3% NaOCl (10ml) for one minute using side vented needles 1-2mm short of working length. In subgroup II (n=10), canals were subjected to passive ultra sonic irrigation by ultrasonic file along with 3% sodium hypochlorite for one minute. Finally, all canals were dried with paper points (Dentsply, Maillefer, Ballaigues, Switzerland).

Evaluation-
The teeth were grooved with a diamond saw and split longitudinally using chisel and mallet. For the SEM analysis, the specimens were dehydrated with ascending concentrations of ethyl alcohol (30-100%) and then sputtered with gold. The root halves were examined using a SEM at 10–15 kV and at a standard magnification of 2000 X. Each root half was evaluated by an observer who was blinded to which technique was used for the removal of the gutta-percha. Evaluation was done for three different locations i.e. coronal, middle and apical third. For statistical analysis, the total number of dentinal tubules and the number of dentinal tubules either completely or partially occluded with obturating material were recorded.

STATISTICAL ANALYSIS
A one-way ANOVA test was performed to calculate the mean value and standard error in each group for each third of canal for occluded tubules over total tubules. Normality of error terms can be assumed. In the analysis, all observations were included distinguishing between the coronal, middle and apical third. The group effect was calculated and the p-values for the pair wise comparisons were adjusted using Tukey’s test. Significance was established at 1% (p< 0.01).

RESULTS
After combining the mean values of occluded tubules/total number of dentinal tubules of all thirds of the canal, the cleanest dentinal tubules was found in following order: Group 1> Group 3 subdivision II> Group 2 subdivision II> Group 3 subdivision I> Group 2 subdivsion I [Table/Fig-1,2]. [Table/Fig-3a-e] shows representative SEM images from all groups.

DISCUSSION
The most important factor associated with endodontic failure is the persistence of microbial infection in the root canal system and/or the periradicular area. Bacteria located in areas such as isthmuses, ramifications, delta’s, irregularities and dentinal tubules may be seldom not affected by endodontic disinfection procedures . In such anatomical regions, bacteria entombed by the root filling usually die or are prevented from gaining access to the periradicular tissues. If the root canal filling fails to provide a complete seal, seepage of tissue fluids can provide substrate for bacterial growth. In such cases the endodontic treatment often fails and requires retreatment. To prevent failure, it is necessary that disinfectant and delivery system is chosen wisely to ensure its availability and wettability in the uninstrumented areas. To improve the wettability of irrigant, various agitation techniques have been developed, like manual brushes, rotary brushes, ultrasonic and sonic devices and pressure alternating devices . However, using hand held syringe needle (both open ended and side vented) irrigation may show more cases of unsuccessful root canal treatment due to weak mechanical flushing of debris . According to a survey by Ravanshad S. despite of introduction of various newer techniques the most commonly used protocol by majority of dentists in endodontic therapy is use of hand files for instrumentation, use of sodium hypochlorite as chief irrigant, use of syringe for delivery of irrigant and use of cold lateral condensation technique for obturation . Dunter reported that passive ultrasonic irrigation is used as second most commonly used irrigation system after syringe irrigation in USA as per a survey done in the year 2011 . Due to the above reasons, the study incorporated cold lateral condensation as an obturation technique and compared passive ultrasonic irrigation against syringe irrigation for their efficacy in retreatment.Previous data suggests that further studies should be conducted to evaluate the effect of ultrasonic irrigation on the cleanliness of dentinal tubules during endodontic retreatment . Therefore,Depicting ratio of occluded/total number of dentinal tubules of all specimens.

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