September 2010

What does the Sign of constant discomfort in perfectly obturated root canal denote?

R.Sathyanarayanan

pre op x ray 1

This patient was treated four years back with single visit root canal therapy of vital 44 and 45, followed with long span bridge from 44 -48.

One year follow up history revealed patient is experiencing occasional discomfort in relation to root treated 45. Radiograph revealed the satisfactory obturation in 45 with questionable periapical changes in relation to 45.

 The tooth was kept under observation and the patient was recalled after 6 months. But the patient reported after 4 years, with gingival abscess in relation to 45. since the bridge was intact and in a satisfactory condition, it was decided to proceed with conventional retreatment in 45. Root canal was reentered and attempts were made to remove the gutta percha through mechanical method with the help of protaper retreatment rotary files.

pre op x ray 2

It was not possible to remove the apical third of the guttapercha, probablly because of good lateral condensation. Cleaning and shaping was re accomplished and calcium hydroxide, Apex cal was placed for a period of 2 weeks. Since there was no improvement in the status of the tooth and the gingival abscess was not resolving, exploratory surgical intervention was planned. The treatment plan included periapical curretage, root end preparation and restoration followed with bone grafting if necessary.

 operative 1

 

Upon reflecting the flap, vertical fracture of premolar with bone loss of buccal plate was observed.

 operative 2

 

 

The treatment plan was revised with removal of the root fragment and the same was carried out successfully. The gingival abscess along with well obturated root canal should have prompted the differential diagnosis of root fracture in this case. Even though the out come of the treatment would have been the same, the patient would have been mentally prepared for this. Upon visualising, the root fracture, the reason for this and the time of occurrence were the questions to be answered for the complete understanding of the case.

 operative 3

operative 4

 

 

 

operative 5

 

 

Examination of the fracture segments revealed lot of granulation tissue along the side of fracture and near the apical third region. Hence it was rationale to think that this fracture could have not occurred during the retreatment and it has to be much before that. Either it could have caused because of occlusal trauma as the patient was good eater and used the masticatory to its full extent!!, or it could have been caused during the lateral condensation of guttapercha. It is not possible to pin point the exact reason at this stage. However, this case could be an eye opener for diagnosis of root fracture for patient reporting with similar condition.