This case report describes the successful non-surgical treatment of external inflammatory root resorption in a replanted maxillary incisor tooth. A 22-year old patient presented with a fractured and previously avulsed tooth #21 that was replanted over 3 months prior without endodontic therapy. Clinical examination found tooth #21 tender to percussion with mobility. Radiographs showed radiolucencies along the apex, consistent with external inflammatory root resorption. The tooth was treated with root canal therapy and calcium hydroxide dressings. Over a 1 year follow up, the resorptive lesions healed with new hard tissue formation and the tooth remained asymptomatic.

1. Endodontic Case Reports– a review Presented by Dr. Syed.k.Aliuddin B.D.S,(M.Sc.D—Endodontics)

2. Retrieval of a foreign object from the palatal root canal ofa permanent maxillary first molar: Ujwal M, Nadkarni, MDSVAmilaMunshi, MDSVSatyawan G, Damie, MDS^/Riîesh R. Kalaskar, (Quintessence Int 2002:33:609-612)

3. Endodontic treatment in children can be a demanding task and, occasionally, a clinician may encounter bizarre situations that require both skill and patience. Many children are in the habit of placing various objects in the oral cavity. So this case report describes successful retrieval of a sewing needle that fractured within the palatal root canal of a permanent maxillary first molar followed by endodontic treatment and placement of a stainless steel crown.

4. A 12-year-old boy reported to the hospital with pain in the right maxilla. His intraoral examination revealed a large occlusalcavity in the tooth.(16) All permanent teeth except the maxillary and mandibular second molars had erupted. The dental history revealed that spontaneous pain, followed by swelling, had occurred in relation to the same tooth approximately 6 months earlier. The patient had visited a private dental clinic but was unable to recollect the exact treatment procedure that had been carried out.

5. Preoperative radiograph revealed the presence of an unusual radiopaque object in the palatal root canal of the permanent maxillary molar. When asked, the patient initially denied having inserted any object within the tooth. His mother was also unaware of any such occurrence. However, after detailed questioning, the patient admitted that he often placed a sewing needle in the tooth to relieve discomfort associated with it. When the needle eventually fractured inside the root canal, the patient did not disclose the incident to anyone.

6. The tooth did not respond to thermal stimuli (cold test) or electric pulp testing. It was decided that an attempt would be made to retrieve the foreign object and complete the endodontic treatment. After administration of L.A, and placing rubber dam.

7. It was observed that an attempt had been made, probably by the dentist who had been consulted earlier. Management: A conventional access cavity was prepared, and the pulp chamber was irrigated with normal saline. The foreign body was visible as a discolored object near tbe orifice of the palatal canal.

8. A thin, tapering, diamond fissure bur was used to slightly widen the orifice of the palatal canal and to facilitate access for instrumentation. Care was taken not -- remove too much internal tooth material --weaken the tooth, A No, 8 K-type file was slowly worked on the mesial and distal sides of the foreign body.This procedure was repeated 5 or 6 times with No, 10 and No, 15 K-type files. Copious irrigation with normal saline and 2.5% hypo was used to remove the debris around the foreign object to loosen it.

9. An attempt was made to engage the object with a No. 15 H-type file and remove it with a pull-back motion, but did not succeed. To check for loosening of the broken needle, an attempt was made to grasp the object with a tweezers that had long narrow beaks. Because it could be grasped adequately with the tweezers, the object was removed from the root canal with a slow, careful motion the retrieved foreign object was confirmed to be a fractured part of a sewing needle, which was discolored and measured 8 mm in length.

10. Conventionalroot canal treatment was then completed Because the maxillary second molar had not erupted, the tooth was restored with a stainless steel crown.

11. discussion In this case, a child used a sewing needle to relieve discomfort associated with a maxillary molar. The needle fractured within the palatal root canal and remained there, asymptomatic, for about 5 months. Several techniques for the retrieval of foreign objects from teeth. Fors and Berg‘ described a method that involved removal of a considerable amount of internal tooth structure prior to removal of foreign objects from the root canal. Roig-Greene‘ demonstrated a simple device, comprising a disposable 25-gauge dental needle, a thin segment of steel wire, and a small mosquito forceps, to remove broken silver cones.

12. Williams and BjorndaF used the Masseran kit to remove fractured posts from root canals. The ultrasonic scaler and the Cavi-Endo instrument have also been used to remove such objects from the root canal. McCullock suggested that a small amount of tooth structure be removed to improve access to the foreign object.. Therefore, in the present case, a thin, tapering diamond bur was used to widen the palatal root canai orifice slightly, to promote better visualization of the foreign object.

13. CONCLUSION The present case report also highlights the importance of both careful radiographic evaluation and the ability to manage unexpected situations.

14. Non-surgical root canal treatment of dens invaginatus 3 in a maxillary lateral incisor Saeed Moradi1* DDS, MS, Zakyeh Donyavi2 DDS, and Mohammad Esmaealzade3 DDS Dental School, Mashad University of Medical Sciences

15. Dens invaginatus also called dens in dente, dilated composed odontoma or gestantodontoma. developmental disturbance -- invagination of the enamel organ toward the dental papilla before mineralization; it may be limited to the tooth crown or invade the root to affect the periapical region. According to Pindborg---etiology—unknown But the followingexplanations have been proposed: (i) Delayed focal growth, (ii) stimulation in the area of the tooth bud (iii) abnormal pressure on tissues surrounding the dental organ

16. Mostly effect permanent dentition, especially maxillary lateral incisor. Clinical appearance: Thus, there may be greater buccolingual diameter peg-shaped or barrel-shaped teeth or a talon cusp. Mild invaginations exhibit only a lingual pit--- often clinically unnoticed

17. According to the extent of the invagination Oehlers proposed the following classification Type I)a small invagination limited to the crown not extending beyond the cej. Type II) line delineating enamel invagination invades the root, yet is limited to it as a ‘cul-desac’ configuration, without reaching the pdl . it may communicate with pulp

18. Type III)a severe form of invagination extending through the root andending at the apical region without direct communication with pulp Radiographically, the roots present smaller dimensions with presence of a radiopaque formation with density similar to that of enamel. ‘tooth within a tooth’

19. Histologically, the structure of dens invaginatus is composed of internal enamel, dentine, connective tissue nucleus and blood supply. The internal enamelhypo mineralized but dentine is uniformly mineralized . The purpose of the present article is to describe a case of apical periodontitis associated with a tooth containing a dens invaginatus healed successfully after non-surgical root canal treatment.

20. A 15-year-old girl was referred by her general dental practitioner. She reported throbbing pain and swelling from a week before, but at the time of examination, there were no symptoms. Clinical examination revealed the maxillary lateral incisor to be unusually greater buccolingual diameter.

21. Preoperative palatal inspection of maxillary lateral incisor confirmed the large enamel projection. There was no evidence of swelling or sinus tract; however the tooth was slightly tender to percussion. The tooth was not responsive to CO2 stimulation, whilst adjacent teeth respond normally. Periodontal probing was within normal limit.

22. Radiographic examination revealed an apical radiolucency of approximately 6 mm in diameter and an anomalous internal structure consistent with class III dens invaginatus.

23. The diagnosis was pulp necrosis with chronic apical periodontitis. The contralateral lateral incisor was also checked for clinical and radiographic sign of the same abnormality, but none was detected

24. The treatment presented was to perform RCT. After rubber dam isolation and gaining access into the pulp chamber, two distinctly separate areas of pulp tissue were found.

25. A central component was surrounded by internal hard tissue; the lateral component appeared to form a c-shaped extending from the mid labial towards the mesial and palatal surface.

26. determination of working length biomechanical preparation complemented by irrigation with 5.25% sodium hypochlorite, calcium hydroxide paste was applied. and temporarily sealed with Cavit

27. After one week, patient returned without any symptoms. At this appointment, the tooth was not tender to percussion and the soft tissue in the area was not tender to palpation. The canal was irrigated with 1% sodium hypochlorite and dried with paper point

28. The invagination was obturated by lateral condensation of gutta-percha and AH-26 primary root canal was obturated using an injection-mouldedthermoplasticizedguttapercha delivery system

29. At one-year follow up, the patient reported no symptoms, the tooth was not tender to percussion and the labial mucosa related to the area was not tender to palpation. The radiography showed reduction in size of the apical radiolucency

30. Discussion Clinicians should be aware of the incidence and methods for treating dens invaginatus. Failure to locate, debride and obturate complex root canal spaces will lead to failure in some cases. The etiology of the periapicalpathosis in this case was due to the infected primary root canal. However, it is not known how long the root canal had been infected prior to the patient developing symptoms.

31. Mechanical debridement of the primary root canal was difficult. The combination of chemomechanical instrumentation and the use of calcium hydroxide were sufficient without resorting to surgery. As calcium hydroxide has been reported to successfully eliminate bacteria and stimulate hard tissue repair , it was decided to treat the primary root canal with this medicament before obturating the root canal with gutta-percha. The use of a warm gutta-percha technique helped to obturate the root canal system,

32. Conclusion Despite complex anatomy and diagnosis of dens invaginatus, non-surgical root canal treatment was performed successfully

33. Management of cracked teeth - a case report NeelamMittal ,Vishal Sharma ,AnshuMinocha

34. INTRODUCTION Gibbs in 1954 was the first to describe cracked teeth using the term ‘Cuspal fracture odontalgia’. The term ‘cracked tooth syndrome’ was coined by Cameron in 1964. Cameron’s cracked tooth syndrome described fractures that were not easily visible but the teeth responded painfully to cold or pressure applications and became necrotic despite an apparent healthy pulp and periodontium.

35. The most common cause of an incomplete fracture is masticatory or accidental trauma. Unintentional biting with physiologic masticatory force on a small and very hard object may suddenly generate an excessive load that may cause the tooth to split. Other factors like extensive tooth preparation, unrestored deep carious lesions, teeth endodontic cells treated teeth, deep grooves or pronounced radicular grooves or bifurcation also make teeth susceptible to fracture. Overzealous condensation of amalgam, excessive lateral condensation of Guttapercha and placement of friction lock or self threading pins may also contribute to tooth fractures.

36. Mandibular molars (67%) were more prone to incomplete fractures than maxillary molars. Diagnosis is a difficult task, sharp pain on chewing hard substances is important diagnostic evidence. It is speculated that this short and sharp pain is generated by an alternating stretching and compressing of odontoblastic processes located in the crack. Magnifying glasses, transillumination, staining with methylene blue are useful in visualizing cracks. Now a days ultrasound imaging system is being used for crack detection

37. The use of radiographs to detect cracks is controversial. Radiographs may reveal the fracture line if it is in direct alignment with the central rays The primary goal is to splint and stabilize a cracked tooth to prevent further extension or complete fracture of the tooth.

38. A 35 years old female patient came to the faculty of Dental Sciences, Banaras Hindu University, Varanasi, India with the chief compliant of pain and sensitivity in right maxillary posterior region. The pain was sharp, intermittent in nature which increased on chewing hard substances. Noncontributing medical history. Dental history revealed that she had undergone RCT of the right maxillary first molar 1 year ago.

39. Clinical examination revealed fractured right maxillary first molar with the fracture line running buccolingually in the crown region. The tooth was not restored with a crown restoration after therapy and occlusal loading may be the cause of fracture. Radiographic examination revealed adequate root canal filling with no signs of periodontal involvement. A tooth slooth was used to confirm the diagnosis.

40. Orthodontic steel band was fabricated and cemented to the tooth and the tooth was disoccluded. After a month, the crack was reinforced with bonded composite restorative material and was finally restored with a full coverage metal crown restoration.

41. Tiny cracks are common and usually do not cause problems. Various treatment modalities are available and the choice depends on the location, direction and extent of the crack. Cracks may be superficial, affecting the cusp of a tooth or deep involving the root of the tooth. Some affect only the enamel; others may involve the dentin or the pulp. Before the treatment, reduction or elimination of occlusal contacts to avoid an overload of a split tooth is done. Erhmann and Tyas suggested the use of orthodontic steel bands for this purpose.

42. A high success rate has been reported when full-coverage acrylic provisional crowns were used to stabilize the compromised tooth after 2-4 wks the tooth should be examined and if symptoms of irreversible pulpitis are evident, endodontic treatment should be performed. About 20% of teeth with cracked tooth syndrome need root canal treatment. Permanent stabilization can be achieved with an adhesive intracoronal restoration

43. however,if the cusp is left unprotected, there is probably enough movement to allow microleakage and a continuation of symptoms. Some clinicians recommend the use of reinforced glass ionomer cement (GIC) to hold the cusps together. The bond strength of the GIC to hard tissue is inadequate to withstand the forces to which the tooth is subjected. Cracks extending subgingivally often require a gingivectomy to expose the margin, however, an unfavourable crown–root ratio may render the tooth unrestorable.

44. Where vertical cracks occur or where the crack extends through the pulpal floor or below the level of the alveolar bone, the prognosis is hopeless and the tooth should be extracted followed by replacement with an implant or a fixed bridge restoration. CONCLUSION Fractures are the third most common cause of tooth loss. Thus, it is of outstanding importance to avoid or eliminate risk factors which contribute to tooth fracture. The key factor is early diagnosis and treatment of the crack, However, a cracked tooth is a compromised tooth even with propertreatment.

45. Healing of external inflammatory root resorption Mithra N. Hegde ,Deepak Pardal

46. INTRODUCTION Facial trauma often results in the complete avulsion of a maxillary permanent incisor. These teeth may be replanted. It is well known that the fate of a replanted tooth can cover various healing categories such as; normal periodontal healing, surface resorption, inflammatory resorption and replacement Resorption.

47. When extensive damage occurs to the innermost layer of the periodontal ligament, competitive healing events take place Healing from the socket wall and healing from adjacent pdl occurs simultaneously. If less than 20% of the root surface is involved, a transient ankylosis may occur, which can later be resorbed due to functional stimuli, provided the tooth in the healing period. But if the trauma is extensive involving more than 20% of root surface, an abnormal attachment can occur after healing.

48. After the initial inflammatory response to remove debris resulting from the injury, a root surface devoid of cementum results. Cells in the vicinity of the denuded root now compete to repopulate it. Often cells that are precursors of bone will move across from the socket wall and populate the damaged root rather that slower moving periodontal ligament cells. Bone resorbs and reforms physiologically through out life. The osteoclasts in contact with the root resorb the dentin. In the reforming phase, osteoblasts lay down bone in the area that was previously root, eventually replacing it.

49. This progressive effect of ankylosis on the avulsed tooth is termed replacement resorption. A healthy 22-year-old patient visited the Department of Conservative Dentistry and Endodontics, A.B Shetty Memorial Institute of Dental Sciences, Mangalore, with a chief compliant of broken tooth in the right upper front region of the oral cavity. History revealed that the patient had a fall about three months back, following which avulsion of tooth number 21 and fracture of 22 occurred.

50. The patient visited a hospital where the avulsed tooth was replanted after an extra-oral time of more than 1 hour. During this period avulsed tooth was not stored in any suitable medium, instead was held in hand. The replanted tooth was then nonphysiologically splinted for a period of 15 days. No root canal therapy was done at this period. Although patient did not complain of any pain but on clinical examination it was found that tooth number 21 was tender on percussion and had mobility.

51. An intra-oral periapical radiograph revealed areas of radiolucency along the apical and lateral surface of root and surrounding bone with loss of lamina dura suggesting external root resorption in relation to 21. Tooth number 11 and 22 also showed periapicalradiolucency.

52. Electric and thermal pulp testing gave a negative response in relation to tooth number 11, 21 and 22. Access opening and a complete canal debridement was undertaken for all the three teeth. Tooth number 11 and 21 were filled with Vitapex and 22 was obturated(Gp) .

53. Tooth number 11 was obturated (GP)at 6 month recall.

54. It was only after a 12 month recall that the intra-oral periapical radiograph showed sufficient healing of external root resorption in relation to 21 with replacement resorption and so a permanent root canal filling in form of GP was placed There was no mobility and tenderness on percussion in relation to tooth number 21 at the 12 month recall.

55. DISCUSSION Unlike bone, which undergoes resorption and apposition as part of a continual remodeling process, the roots of permanent teeth are not normally resorbed. Only the resorption of deciduous teeth are considered physiological. In clinical studies, teeth replanted within 5 minutes after avulsion had the best prognosis. The avulsed tooth should be replanted immediately or should be stored in a suitable medium before replantation.

56. The replanted tooth should be splinted flexibly to the adjacent teeth for 7 to 10 days to enhance periodontal healing. If the tooth apex is closed or almost closed, prophylactic rct should be carried out on the day of splint removal to prevent the onset of inflammatory root resorption. Inflammatory resorption is a mechanism of eliminating infected calcified tissue from the body. osteoclasts acting as specialized macrophages actively participate in the healing process to repair traumatized tooth and bone.

57. It has been emphasized that endodontic therapy should be undertaken within 7-10 days after replantation so as to remove the necrotic pulp tissue which could get infected and initiate inflammatory root resorption. In this case with extensive external inflammatory root resorption on the first visit, long term calcium hydroxide Rx was planned using Vitapex.(viscous mix of caoH and iodoform) CaoH is one of the most effective materials for the Rx of external root resorption because of mainly two properties high calcium ion concentration and alkaline pH.

58. mechanism of action of calcium hydroxide One theory discusses its high alkaline pH, which is important in stimulating matrix formation by the formative cells. Another theory postulates that a high pH neutralizes the acidic products of the resorptive cells, creating an unfavorable environment for them. Seltzer and Bender stated that the presence of Ca2+ ions may activate ATPase, which may then enhance dental tissue remineralization

59. According to Andersen replacement resorption can take place once inflammatory resorption has been arrested by endodontic therapy. Though there is no treatment for replacement resorption, it is worth an effort to try slow down the resorption process and maintain the tooth as long as possible in the arch for esthetics, mastication, and natural space maintenance

60. Thank you