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

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.

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.

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

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.

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.

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.

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.

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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