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What happens when a gutta percha is extruded and broken beyond the apex?

Dr. Joel Fransen, Endodontist in Richmond BC, responded to a question submitted by a general dentist.

Q: What happens when a gutta percha is extruded and broken beyond the apex?

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11 comments

  1. The composite will not allow one growth over it, will it?
    Why not use MTA in that case? Thanx for posting

  2. Composite can and is used as a retro-preparation material. The hard (bone) and soft tissue (PDL) may abut up against it with little or no scar tissue. Some studies show better results than others. However, the bioactive marterials such as MTA do have better results when samples are examined under the microscope. The bioactive materials may also have a higher clinical success rate too. However, it is difficult to prove this. Composite was used rather than MTA in the coronal perforation for a few a few reasons:

    1) The preparation on the lateral surface was non-retentive, I am relying on the bond to keep the composite in place. MTA sits passively and I did not want to over-prep the tooth to accommodate the material.

    2) The coronal portion of the lateral prep may, in the future, communicate with the sulcus of the tooth. MTA is best when it is encased in bone ans it can ‘wash out’ if exposed to gingival crevicular fluid.

    3) Even white MTA can poorly affect the aesthetics of thin overlying soft tissue.

    4) The perforation site is close the apical portion of the post. I am worried that the seal of the MTA could be adversely affected by occlusal forces being transferred apically and laterally down the tooth and its post. I thought a bonded composite material would better resist the forces even in a shallow preparation.

    In summary, I was concerned the MTA could wash out, the prep was not retentive enough, there a possible forces that could disturb its seal, and the material can be unaesthetic when the overyling tissue is thin.

    Your question is great and got me thinking. Yeah, why did I do that again?

  3. When contemplating treatment, one must consider the following first…What is the long-term survivability? The first case brings the following into question. Did anyone think about the horizontally impacted 48 and its contribution to the long-term prognosis? Providing surgical retreatment on a tooth that is compromised from a periodontal and restorative perspective is, in my opinion, ill advised before those contributing factors are addressed.

    If tooth 47 is currently asymptomatic and a strategic tooth, then tooth 48 can be removed and tooth 47 restored with a proper fitting provisional crown. Only after the area has healed and proven to be stable from a restorative and periodontal perspective, can a decision be made on surgical endodontic retreatment that is not without risk.

    In hindsight, consideration should have been given to the presence of tooth 48 long ago. It is a contributing factor to the decay at the distal of tooth 47, resulting in the placement of a composite resin filling, not the ideal restorative material in this situation, that in all likelihood led to the need for endodontic therapy in the first place. Of course I am just guessing here.

    The over-extension of Gutta Percha in this case is way down on the list of what needs to be addressed. Further, we do not need fancy 3D computer imaging to come to this conclusion.

    Several of the other cases show restorations with “technical limitations” that may well contribute to the ingress of bacteria with subsequent endodontic failure, with or without surgical retreatment.

    The above not withstanding, Dr. Joel Fransen does demonstrate excellent surgical skills.

    • There is no shortage of cases where there are compromises, extenuating circumstances, and complicating factors relating to both the teeth in question, the patient, and the patient’s ability to pursue idealized treatment. Real-life dentistry for the average person usually does not involve implants, etc. and thus I greatly appreciated this presentation and the real-life nature of it that the average dentist and endodontist can relate to.

    • Thank Dr. Belzycki for your thorough commentary. The 47 is asymptomatic and functional. The referring dentist sent the PA to me for comment only. I typically require a CBCT prior to endodontic microsurgery in the posterior of the mandible. Surgery was mentioned as it is a possible option to consider. In reviewing a number of options it can appear we are running before we are walking. This is not a case I would jump in to do surgery on lightly.
      Your comments regarding the 48 are duly noted and delve into subjects that are worthwhile. I agree the impacted 8 is a complicating factor and is a liability for the 7 not an asset. However, I tried to restrict the presentation to the extrusion issue.
      All the best,
      Joel

      • Dear Joel,
        Thanks for your reply.
        Thankfully, your last comment to me restores my faith in you.

        I maintain a solo practice in Toronto since graduating in 1979. The demographics of my patients run the spectrum from affluent to working class. Today, we have a on overabundance of adjectives tacked onto Dentistry…Family, Cosmetic, Laser, Holistic, Wellness, Patient Centred (was posted on Oasis), just to name a few.
        Now I read “Real-Life” dentistry.

        It is my opinion that there are only 2 types of Dentistry. Good and Bad.
        Good dentistry endeavours to maintain a dentition for a patient that is in harmony with their physiology, psycho-social demands as well as financial constraints. Of course, we must do this with good technical skills.

        To do otherwise is Bad Dentistry and not in a patient’s interest.

        My initial comments were made to draw attention to the basic “meat and potatoes” issue of the first case. Nowhere in my comments did I mention implants. In fact, I did post a presentation on maintaining “Less Than Ideal” teeth on Oasis some months back.

        So often. I see patients from other offices in pain, having recently had a composite resin filling placed deep into a sulcus between upper molars. Even as far down as the fluting of the roots in the distal furcation. Exactly who is going to see a silver filling here? Does cosmetic concerns now override the benefits that amalgam has in these situations where composite resin is so susceptible to moisture control?

        Let us not even address the less than stellar contacts one achieves in these instances. I suspect someone will post a comment that they always get perfect seal and contacts using a new super-duper resin or technique. Forget it. You can not go against the laws of polymer chemistry.

        Your first case bought all this to my mind. I have heard that some dentists have “thrown away” their amalgamator. Why? Patients don’t like silver fillings? Okay, silver is unacceptable in teeth, but a huge silver bar-bell through the tongue, or lip or nasal septum is a fashion statement? I say this to patients when I get into an argument over what restorative material I will place. It is up to me to guide them in the right direction. I refuse to take the path of least resistance. If they insist on a “white” filling where I know it is not indicated, they are asked to seek treatment elsewhere. They are welcome back for the endo and crown when it fails.

        And that my Oasis friends is my version of “Real-Life” dentistry.
        Take it or leave it.

        Again Joel, thank you for your last comments to me.
        I do preform root-end surgery as well and know how difficult it is to take good photos while holding back lips, cheeks and blood. Well done.

        I fully realize, as a specialist, you are brought in to “save the day” in situations not of your own making, and for that you are to be commended.

  4. Dr. Vasant Ramlaggan

    Thanks for your great presentation!

  5. Your radiograph reveals sealer material beyond the apex not g.p. If the canal system is well cleaned/disinfected, then clinical studies reveal healing proceeds normally in the vast majority of cases where g.p has been extruded. If a ‘large’ extrusion of g.p. occurs surgical retrieval is occasionally required to help facilitate healing in an already existing apical lesions. – sincerely, Gerald McAndrews DDS, endodontist, Calgary AB.

    • Yes some cases show extruded sealer and some show extruded GP points. More often than not extruded sealer will not require further treatment and to a lesser extent the same holds true for extruded GP points. As with all cases it is best to have a firm diagnosis before treatment. If in the presentation it appears I advocating treatment then I would like to ensure you and others that is not the case.
      If GP or sealer is extruded it does not equate that the canals are cleaned adequately. Thus, retreatment is a viable option to consider too. The art and science of endo is complex and never boring. Thank you for your comments Dr. McAndrews.
      Regards,
      Joel

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