Document 6523080

CLINICAL
Why (and when) I love Biodentine
Specialist Endodontist Peter Raftery explains how Biodentine can be the ideal
material for root canal procedures.
The appearance of narrow
canals and curvy roots
on a pre-op periapical
radiograph rightly alerts us
to the prospect of a tricky
root canal treatment.¹ Yet
I would argue that the
technical challenge posed
by cases at the other end of
the spectrum – those teeth
with wide, straight canals –
shouldn’t be underestimated.
At first glimpse, these ought
to be simple cases since
they are normally anterior
teeth and there is usually
little difficulty in negotiating
the canals to full length, but
controlling for length during
both the cleaning and filling
stages can be especially
difficult.
Cleaning
It is possible to clean the full
canal system only once the canal
length is determined. Electronic
length determination (apex locator
accuracy) is best when the canal
is relatively dry and when there is
snug contact between the file tip
and the apical canal walls. With a
wide canal this snugness of fit is
lost, which is why apex locators
working length determination are
less reliable in cases where the
apical foramen is enlarged.²
Since the 1980s we have known
that, on its own (ie without an
antibacterial irrigant), mechanical
debridement of infected canal
walls was insufficient to render
them bacteria free.³ Micro-CT
scans of extracted teeth show
that a significant proportion
of canal surfaces remain
uninstrumented following
preparation, with the shortcoming
most pronounced in wide canals
where up to 50% of the canal
remains untouched.4
Pre-op
Filling
Teeth with wide canals and
straight roots lack the usual
friction, taper and apical
constriction normally afforded
by the canal walls so that there
is little to stop the extrusion of
root-filling material through the
apex during vertically compacted
obturation. This is considered
a challenge since not only are
overfilled teeth associated with the
lowest endodontic success rates5
but various sensitive anatomical
structures are in harm’s way when
endodontic procedures are not
confined within the root canals.6
Post-op
Case study
Peter Raftery
Specialist endodontist based
in Portsmouth, having trained
in endodontics at the Eastman
Dental Hospital, London. Peter is
a member of the Royal College
of Surgeons in England (MRD) as
well as Edinburgh (MEndo).
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Denplan INSIGHT Magazine May 2014
The following case nicely shows
a successful outcome in a case
of wide canals and straight roots.
The patient, a 20-year-old female,
was referred by her dentist for
endodontic management of her
LR7 which had been associated
with a draining buccal sinus for
the preceding month.
Clinical examination revealed that
the LR7 had a large distal Class
II amalgam restoration. A draining
Six month review
sinus was noted bucally to the tooth which was Grade
II mobile but not associated with significantly increased
periodontal probing defects.
We reached and discussed
a diagnosis of chronic apical
periodontitis with suppuration LR7.
In light of her overall sound
periodontal state I felt that
the mobility and periodontal
destruction (as well as the
periapical lesion) would resolve
with successful management of the
endodontic infection.
On removal of the defective
restoration, the seal and
appearance was improved with
a Fuji IX glass ionomer cement
restoration. Following rubber
dam isolation, endodontic access
yielded three canal orifices. The
walls of the wide, straight canals
were debrided lightly with metal
files. Plenty of time was then
dedicated to thorough irrigation
of the canals with plentiful 5%
concentration sodium hypochlorite.
At the six month review the
patient had no complaints. The
sinus had resolved and the
mobility had returned to that of
her normal adjacent teeth. A
periapical radiograph confirmed
resolution of the radiolucency
both apically and periodontally.
The merits of a cast restoration
were reiterated.
Conclusions
Biodentine was the ideal material
for canal obturation, in this case
from time saving and biological
perspectives.
In my hands there weren’t enough
hours in the day or accessory
gp points in the practice to
have completed cold lateral
condensation. I was concerned
that any attempt at a warm
vertical obturation would have
resulted in significant extrusion –
possibly compromising the nearby
ID nerve.
The interface between the root
filling material and the periapical
tissues is normally small, but
when the apical foramen is
considerably widened (as was the
case here) a more biocompatible
filling material is desirable. The
biocompatibility of Biodentine is second to none
and the improved handling characteristics (12
minute setting time) made it the ideal choice.
CLINICAL
A sinus tracer radiograph tracked
the source of the discharge to
the root ends of LR7. The canals
appeared wide and the roots were
straight. Although radiolucency
was evident periapically, it was
not confined to a discreet apical
lesion; radiolucent bands were
seen extending up the mesial
and distal root surfaces. The
restoration – which extended into
the pulp chamber – had a marginal
discrepancy, possibly secondary
caries.
Although Biodentine served as the ideal root
filling material in this case, its use in so many
other applications makes it an essential part of
the dentist’s armamentarium. It is ideally suited
for use as a temporary enamel restoration,
permanent dentine restoration in deep or large
carious lesions, a material for pulp capping or
pulpotomy. It is suitable for repairing root and
furcation perforations, sealing internal/external
resorptions, for apexification and for retrograde
root-end fillings.
References
¹ www.rcseng.ac.uk/fds/publications-clinical- guidelines/
clinical_guidelines/documents/complexityassessment.pdf
² Stein TJ, Corcoran JF, Zillich RM (1990) Influence of the
major and minor foramen diameters on apical electronic probe
measurements. Journal of Endodontics 16, 520–2.
³ Byström A & Sundqvist G (1981). Bacteriologic evaluation
of the efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res. 1981 Aug;89(4):
321–8.
Hübscher Barbakow & Peters (2004) Root canal preparation
with Flexmaster: canal shapes analysed by micro-computed
tomography. International Endodontic Journal 36, 740–7.
4
Ng Y-L, Mann V, Rahbaran S, Lewsey J, Gulabivala K. 2008.
Outcome of primary root canal treatment: systematic review of
the literature – Part 2. Influence of clinical factors. International
Endodontic Journal, 41, 6–31.
5
Knowles KI, Jergenson MA, Howard JH (2003). Paresthesia
associated with endodontic treatment of mandibular
premolars. Journal of Endodontics, 29(11):768–70.
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Conventional electronic length
determination was likely to be
difficult because of the canal size
so an estimate was made from the
pre-operative radiograph. From
this estimate, the true canal length
was confirmed via the ‘paper-point
technique’ whereby a large paper
point is briefly inserted into a canal
before removal and inspection
of the tip. The working length is
reflected in the distance from the
coronal reference point to the
location of the wet-dry junction on
the paper point.
After disinfection, Biodentine
was mixed according to the
manufacturer’s instructions. Small
increments were placed into the
pulp chamber with a flat plastic
and then tamped down to full
working length using a measured,
large paper point. Once Biodentine
filled the canal to orifice level, I
packed a further increment of Fuji
IX into the access cavity.
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