I think that poor prognosis of this case is the matter of loss of hard tissues. Broken instrument can be evacuated. The lession may heal, the resorption may stop, but... There is almost no ferrule. If it were me, i would take a risk, but demanding patient should be considered differently. I presume, that cost of both ways is similar. Ask patient: if he/she wants to take a risk and costs, claim signatures and struggle for it. If there's a shadow of a doubt in patient's decission - be radical.

Thanks for your comment. As a matter of fact i agree with you and perhaps the crucial point is the patient point of view. The ferrule effect is very important in term of prognosis even if i think it can not influence alone the decision making. From my point of view, unfortunately in france, there are too much extractions because more and more practionners easily earn money with dental implants whereas endodontic treatments require more time, special skills for this kind of clinical case and with a little remuneration. There are many parameters to consider the therapeutic option but basically, i think the honesty of the practionner is the key. Here is the result just after root canal retreatment but unfortunately i don't have the follow-up.

Very nice endo. My respect. I wish that all Your effort put into the treatment will be crowned with long-term success. I'm personally not a big fan of cast posts. Upper lateral incisors are tricky and i had to extract few of theese due to vertical root fracture. All with long, adequate metal posts. I've got less problems with glass fiber ones. I think the crucial thing is occlusion and proper crown's occlusal shape. I have many big lesions that heal by itself. It is very stimulating to see few-year recalls with our success.

One of examples: gangraena pulpae.

I have the same problem with GPs. I mostly make composite restoration with glass fiber posts and send to GP for making crown etc. The best situation is to talk to GPs, that are sending You patients. Endodontist, who did RCT should place a post. This is my opinion. Nice case BTW. I such cases (suspected VRF) i use methylene blue to seek for fracture line.

I do apicoectomy about three times a year. Reendo is very predictable. I agree with You, that perfect crowns with adequate posts should be treated surgically. I mostly do reendo because i rarely see perfect crowns with bad endo. Nice healing in Your cases. So You are making research about surfactants. I think it is great to improve rinsing. In my opinion this is very important factor. Maybe more important than mechanical preparation and shaping. I do research concerned with irrigation protocol. It is interesting that untill now there is no consensus.

Dear Both,

the decision making is a very lengthy and multifacett process.

Many aspects have to be considered beside the analysed beside ferrule.

Currently on top of writing this up as a book.

Liviu

Dear Frederic,

thank you very much. Much appreciated. No, I am not writing alone. There are two editors and multiple authors. You are cordially invited to coauthor if you are interested in. My private e-mail address is [email protected]. How about you contact me? Yes, work load is incredible! BTW you have clearly made the point with your statement: "each practitioner should accept to refer his patinet...." This decision needs to be performed based on the case difficulty assessment by the AAE.

One more point! How about you came and attend my lecture in London in march to this topic? Would be nice to meet and catch up while understanding the basis all has started. Thank you and kind regards.

Liviu

I'm waiting for that book. This is great idea. I see lots of speculations during implantology lectures. Book with many autors and critical point of view is the way to go. Congratulations.

About general practitioners: this is our role to educate them to know what can they do and what cases should they refer to endodontist.

Dear Wojciech,dear Frederic,

thank you for the kind words.

It is task of the book to give practioners an instrument in the hand to perform the decision making process in accordance to scientific evidence. A lot of bias is out there and misleading outcome studies although with high citation index as systematic reviews (while raising case studies to high level of evidence). The attempt of comparing RCT studies in general medicine (with thousands of cases) with those in dentistry (couple of dozens) leads to a fiasco. Common sense and knowledge throughout dentistry is therefor requested.

Yes, will attend the ESE meeting in Lisboa. Happy to meet up.

Let us know should help be required with your NaOCl research.

Kind regards

Liviu

I personally hate traumatic cases. In this situation (lack of data) i would probably make ortograde treatment of tooth 22 with MTA. MTA can stop resorption. I would only control the tooth 21 without treatment. Show it! Have You got recall?

Well, u didn't write that 21 was symptomatic. Very nice case. Long term follow-up. Good job. Did You make surgical approach directly after ortograde treatment or delayed. Didi You wait for few month before resection (or should i say apico-plasty?) ?

Nice case. Thank You for sharing.

Its a beautiful n important information of a trauma induced rct case..................thanks for sharing

I believe that Frédéric has brought all researchers and clinicians into very nice and motivating discussions......Really interesting.

- Since you also were discussing regarding the retrograde fillings, Is there anybody a fan of GIC as a retrograde filling material?.

Indeed, all the materials you have mentioned are widely accepted at the clinical and research levels. However with my experience with GIC as a retrograde filling, the healing pattern also is favorable, even with challenging cases

Ahmed et al. "Management and prognosis of teeth with trauma induced crown fractures and large periapical cyst like lesions following apical surgery with and without retrograde filling."

In addition, few years ago, some formulations of GICs has been introduced. Highly viscous fast set conventional GICs have solved some of the common drawbacks of GIC. Probably these formulations would bring GIC as a possible alternative, but at the end as you have mentioned, there is no ideal material!

Restorability (and all related issues), competence, skills, konwledge and expertise of the professional, technical equipment, dental iq of the patient, medical and dental history history, etc.....

Liviu steier

Biodentin is an excellent mta like material. We have just submitted a paper for publication in the iej dealing with biodentin. The use as a retrograde material is questionable based on our research i am afraid.

Liviu steier

This is in addition to the price. Despite being less expensive than MTA, but still much more expensive than other retrograde filling materials. I believe that the dramatic increase in price of such materials is not corrosponded with a dramatic enhancement of bio-materials used for similar applications.

My favourite material for perforations, open apices and retrograte filling, is Angelus MTA Grey. White MTA lacks biocompability and good setting of grey one. Angelus is grainy, which i like. I've made research in 2011 (printed in polish) with Biodentine vs MTA in real open apex cases (not simulated ones). It was a india ink based leakage study and MTA was a little bit superior. The most common mistake of in vitro studies concerned with MTA is the lack of simuated setting conditions. In my study i used fresh meat from eco-farm. Samples should have contact with physiological fluids during setting, and with BPBS within few days after setting. I saw a thin layer of white hydroxyapatite crystals growing on the surface of MTA (not on Biodentine).

Hi Wojciech,

Actually it is well documented in the literature that white MTA is a biocompatible material (Koulaouzidou et al. 2008, Lessa et al. 2010 and others). The main problem in preparing samples of MTA in body fluids is contamination, especially if you gonna prepare for a MTT assay via the indirect method (the samples usually are left for 24 hours at 37 degrees and then prepared for the extracts). Indeed, this may mask the actual biological profile of the material. I believe that comparing given bio-materials at similar conditions, even not exactly at similar conditions in vivo, would also reflect the biological properties of the materials.

Hello Frédéric, thanks to share interesting clinical cases. I like the term "honesty" of the practitioner is the key, In fact, skill and honesty go together. Microscope, improvements of endodontic instruments, biomaterials, and microsurgery led to a better teeth conservation and particularly in challenging cases.

Hany Ahmed, i agree that white MTA is biocompatible material. Nevertheless grey MTA is even superior. Frederic, You have got the point, that not every in vitro study is relevant to clinicians. Researches concerned with physical and chemical properties of the materials are very important. For example resilon seems to be as good or better than gutta-percha. Tay et al. made few studies about polycaprolactone matrix degradation with enzymes. I used resilon for couple of years and i see, that in some cases it doesn't work. During retreatment i see degradated resilon that look like gray-ish mud. In my humble opinion in vitro studies should be constructed to simulate clinical situation. Interaction within material and tissues/fluids. Nice discussion :-) All started with one case. Endo is fascinating.

Very nicely done! Congratulations!

Next treatment step:

- Root canal anchored core

- Cuspal coverage.

Open questions:

- Possible collagenolysis?

- Adequate force dissipation b directing occlusal forces!

Let us deliberate on the alternatives:

1. Extraction.

2. No treatment.

3. Removable prosthesis

4. Fixed bridge.

5. Internal or external sinus elevation and implant placement.

Afraid you have misunderstood my statement as such. Would have done the very same.

Was just offering the treatment options to start further deliberation for the readership.

Thank you for your reply. Happy all in best terms!

May we than return to the discussion please?

You say ( I start to argue to animate discussion and thoughts only!!!! ):

"Extraction : leads to an other issue...replace the tooth or not ?..."

Clinical experience shows that antagonist teeth may extrude and adjacent teeth may tilt, but do we really have any evidence to prove this?

"fixed bridge: what kind of bridge ? I'm against conventional bridge in this case (vital and intact adjacent teeth). Bonded and partial bridge...why not but depending on occlusion. I wanted to avoid touching the patient's adjacent teeth."

Adults tend to turn from anterior and canine guidance into group function with age.

Group function will lead to shear forces. Bonded restorations may fail with shear forces acting towards delamination.

et voila... here we are searching for evidence.... but we all clinicians have come across the fact numerous times...!

I am currently following the vitriolic dispute between the "Cochrane library adepts" and the "common sense professionals" in other dental dental issues (correlation between TMJ and occlusion). It is sadness that wraps my thoughts and disappointment in regards of credibility.

Tough case clincially to say restore or extract and implant. The ultimate decision if you are giving both to your patient is its up to the patient. There are risks and benefits to any procedure and you as the dentist have a ethical duty to present those to the patient. The fee to save v fee to extract,graft,place and restore are real issues for real life patients. The long term prognosis(5year) assuming healing goes well for both in my opinion is the dental implant. That opinion becomes even stronger if the patient is younger. That tooth as it stands now is mostly dental materials inside and out. There is no dental material that will outlast a young patient or that tooth outlasting a young patient. Just my thoughts hope it helps.

Yes, Frederik this will be the key to open the door for future professional decision making!

Complete a detailled diagnosis: endo, restorative, perio, etc.

Assess level of difficulty.

Deliberate if level of difficulty can be acomplished or requires referal.

Decision making protocol follows.

Well done. Great service to the patient.

We may slightly differ in regards of level of expertise but of course

opinion have to differ as perception is different and as a result

appreciation is different.

While i agree that iatrogenic damage does frequently occur, a wise old prosthodontist once said to me "dentistry has done more for my practice than mother nature ever could", there does come a time where treatments need to be discussed. Just because you can save it doesn't mean you necessarily should if the long term prognosis of that tooth is guarded to poor. That is where experience, training and knowledge come in. The problem with making a decision from patient to patient is you only know how that decision worked out and not the other options that may have been possible!!! No one is perfect that is why it is called the "practice of dentistry". It is also why we have dental specialist as well!!!

I prefer to do a root canal if the root is straight than a implant because sometime the patient do a allergic reaction witth the implant . For a smoker patient you can't do it i will be provoke so periodental problem.

+

Dear sir,

do you mind please quoting literature refernces for your statement.

Not quite sure i ever had a chance to read any paper in support of

allergic reactions and implants.

Very nice Fred. Well done!

Just to play devil s advocate - anyone having any particular idea in regards

of the origin of the disease?

Good morning from Spain.

I´m just graduated, so probably I haven´t the knowledge nor the experience to opine correctly on these topics... In addition, endo-periodontal pathology is one of the topics that make me doubt ... but here's my answer ...

I think, this case is a primary periodontal lesion with secondary endodontic problem.

The radiolucent area is wider coronally, because the pathogenic mechanism has launched these injuries is the deposition of plaque in the gingival sulcus, resulting in periodontal pocket; and I don´t distinguish pathology (caries, restorations ...) that may lead to a dental origin of the problem... Besides the type of mobility is important.

Moreover, apply unilateral forces or oscillating forces with periodontally healthy teeth fail to form packets or any insertion loss, so occlusal trauma isn´t destroyed periodontal tissue, but induces alveolar resorption, which can cause increased tooth mobility.

So the presence of periodontal pockets associated with plaque and subjected to occlusal trauma may increase the rate of destruction of the disease and the subsequent pulp involvement.

Is this patient with periodontal maintenance therapy?

Dear Cristina,

superb answer for a recent graduate! Congratulations! Very well done.

The malposition of the tooth (tilting - as a reslut of a gap which was not closed in time),

the elasticity modulus of the lover jaw, associated with the nocive force applied (see occlusal relief) have indeed initiated the disease as very correct described by yourself.

Thanks a lot Dr. Liviu Steier.

I'm learning a lot reading all the answers in the different topics.

Two years ago, I had this case at the university. A 35 years old woman who arrives in this condition. I raised several treatment options for both, the upper and the lower arch...

But I like to focus on the lower molar ... I extracted this tooth and I rehabilitated the lower arch with a removable partial denture (because the patient had economic´s problems and she couldn`t afford another treatment).

If conditions would be different, Do you attempt a endo-periodontal treatment?

Dear Cristina,

afraid not.

Clinical reasoning:

1.Tilted tooth = changed axial force dissipation direction.

2. Position of the tooth in ascendent part of ramus.

3. Cervical carious lesion.

4. Distal abutment / root canal treated of a however sorted restoration.

Conclusions: occlusal forces would not favor mid to long term expectations.

Hope this helps.

I neither would try ...

Thank you very much, it´s always helpful read your answers.

Have a good day.

Honoured and delighted.

Same best wishes to you!

Dear Dr Fred

Simply amazing outcome.

Thanks for posting its encouraging.

Dr I would like to know when the new permanent crown was restored, immediately after endo/perio surgery or later.

Finally one more request kindly publish this case report sir , such publications are much needed nowadays to preserve the sanctity of this profession.

Thanks a lot sir.

I moved to Montreal last august , unfortunate to miss your talk . Kindly let me know if you plan to Montreal in future.

I do completely agree with you . Since most of the present articles emphasize more on implant supported, immediate loading, The cases you posted motivates to explore the all possible options of preserving the available structure, which quite often ignored even for simple cases either for convenience or for compensation.

Sir,I would like to know your opinion about evidence based principles . Do EBP will be a panacea for deciding the treatment plan or proportion of intuition and scientific validity will be useful to treat such challenging cases, considering patient is cooperative and willing to save the teeth.

Gentlemen,

the debate sadly will lack EBD. One can hardly compare an implant to a natural tooth trying to answer the following questions:

- osseointegration versus PDL

- proprioception

- application of occlusal load

- periimplantitis versus perio diseases

- integration in restorative concepts

- etc.

It should not be forgotten that the discussion is lead by "big money" or the marketing departments of implant manufacturers...

You are cordially invited to visit my blog as this may enhance your decision making process:

http://drsteier-implantology.blogspot.de/

Thanks Dr Fred and Dr Livivu. I agree both of your views. Dr.Liviu the blog was simply superb.

Thank you.

Will do my very best in the future to expend and share more data.

Thank you sir.