ENDODONTIC RETREATMENT WITH

PERIAPICAL ABSCESS WITH FISTULA

RESULTING FROM FAILURE OF FIXED
ORTHODONTIC APPLIANCE : A CASE
REPORT

U SS I*,
I*,Trimurni
TrimurniAbidin**
Abidin**
SU
Resident at Conservative
Conservative Dentistry
Specialist
Program
**Resident
Dentistry
Specialist
Program
**Lecturer
Lecturer at
Department
**
at Conservative
ConservativeDentistry
Dentistry
Department
13-14 NOVEMBER 2015, SINI II COSMOS - GRAND CLARION MAKASSAR - INDONESIA

13-14 NOVEMBER 2015, SINI II COSMOS - GRAND CLARION MAKASSAR INDONESIA

PENDAHULUAN

Pra perawatan
Diagnosis
Seleksi kasus
Prognosis yang buruk
Selama perawatan
Preparasi akses
Kesalahan preparasi
Pengisian saluran akar

13-14 Nopember 2015

kegagalan
perawatan

Pasca perawatan
Desain restorasi yang
buruk,
kerusakan restorasi,
Trauma dan fraktur yang bukan
karena perawatan
endodontik. Asgeir, 2009

Introduction

Pre-operative treatment.
Diagnosis
Case selection
Poor prognosis
During operative treatment.
Access preparation,
Root canal preparation
Obturation

13-14 Nopember 2015

The
failure of
endodonti
c
treatment

Post-operative treatment.
Restoration design
Restoration damage,
Trauma and fracture caused by
non-endodontic treatment.
Asgeir, 2009

 Kegagalan
perawatan
saluran akar
akibat trauma

Sameshima GT, Sinclair PM,

2010.

13-14 Nopember 2015

Kesalahan perawatan
orthodonti Pergerakan
gigi Tekanan >>

kelalaian atau
pengetahuan operator
yang kurang.
Pasien yang tidak ko operatif.

Endodontic treatment
failure caused by
trauma

Orthodontic treatment
failure .Tooth movement
pressure >>

Sameshima GT, Sinclair PM,

2010.

negligence or lack of
knowledge of the operator.
Uncooperative patients.

13-14 Nopember 2015

Aim this case

Laporan kasus Perawatan ulang

saluran akar gigi insisivus lateral
kanan maksila Non vital dengan
abses periapeks disertai fistula
Trauma dari perawatan orthodonti
cekat.

Aim of this case

report
Accident

Endodontic re-treatment of a non vital tooth on

right maxillary lateral incisor with periapical
abcess and fistula

Trauma from excessive force by

fixed orthodontic appliance.

Case
Report

Patient

22 y.o

RSGM, Conservative Dentistry FKG USU

Keluhan
Utama

Pasien Sakit & bengkak pada gingiva bagian

labial gigi # 12 4 tahun yang lalu, pernah dirawat
saluran akar
Gigi 21, 22 pernah mengalami avulsi pada saat
berusia 12 tahun.

Riwayat
medis
13-14 Nopember 2015

Pasien tidak ada masalah.

8

Case
Report

Patient

22 y.o

RSGM, Conservative Dentistry FKG USU

Main
Complai
nts

Medical
history
13-14 Nopember 2015

# 12 Severe pain and upper labial gingival

swelling, which had been treated four years ago.
The patient also informed that at the age of 12
years old she had an accident and the teeth of 21,
22 had avulsed.

Noncontributory
9

Pemeriksaan klinis dan Pemeriksaan

Objektif
Pemeriksaan
klinis
Fistula pada bagian labial gigi # 12
Pasien sedang mejalani perawatan orthodonti.

Pemeriksaan Objektif

Tes sondasi (-), Tes termal (-), Perkusi (+), Mobiliti (2).

13-14 Nopember 2015

10

Clinical & Objective

Examination
Clinical
Examination
Fistula on labial gingival surface of the right
maxillary lateral incisor.
Patient is currently undergoing orthodontic
treatment.
Objective
Examination

# 12 :
- Response to thermal test (-)
-Percussion & palpation (+)
- 2st grade Mobility
13-14 Nopember 2015

11

Pemeriksaan Radiografis

Gambar.1 a. Panoramik sebelum perawatan. b. Radiografi sebelum Perawatan.

Gigi #12 :Pergerakan gigi 12 tilting, Lesi periapikal, dan Gigi telah
dirawat saluran akar dengan hermetis.

13-14 Nopember 2015

12

Gambar.1 a. Panoramik sebelum perawatan. b. Radiografi sebelum Perawatan.

Root tilting of # 21 teeth, and previously treated with hermetic

obturation.

13-14 Nopember 2015

13

PENATALAKSANAAN KASUS

Diagnosa # 12
endodontik.

: Abses apikal akut + fistula post perawatan

Rencana Perawatan Pulpa : Retreatment

Restorasi akhir

13-14 Nopember 2015

: build - up Resin komposit mahkota gigi

14

#12 : Acute apical abscess and fistula post endodontic

treatment.

Pulpal Treatment : Endodontic re-treatment .

Final restoration: Crown composite build - up

KUNJUNGAN PERTAMA :
-BAP

-Remove GP Solvent + deobturation files

- penilaian ulang kanal

- Irigasi (NaoCl 2, 5% ,EDTA 17% & CHX 2%)
- Panjang kerja radiograpi.
- pembersihan & pembentukanRotary protaper
insruments
Hybrid technique
- ditutup dengan Ledermix+Tumpatan sementara
3 minggu

First Visit :

-Proper access opening

-Remove GP Solvent + deobturation files

- Negotiation of canals
- Irrigation (NaCl 2, 5% ,EDTA 17% & CHX 2%)
- Working radiograph length.
- Cleaning & shaping Rotary protaper insruments

Hybrid technique
- Dressing with Ledermix+Temporary cements 3
weeks

At 2nd, 3rd, 4th & 5th

visit Dressing
Ca(OH)2
during 6 Months
Radiographic
lesion reduction
at 5th visit.

Follow-up
Kunjungan ke tiga

Follow-up
Kunjungan ke enam
13-14 Nopember 2015

Follow-up
Kunjungan ke empat

Follow-up
Kunjungan ke lima
18

-Pre-obturation examination:
Pain : (-)
Palpation : (-)
Percussion : (-)
-Intracanal Dressing removed
-Root canals were dried with
paper points master cone
fitted
-Obturation Lateral
condensation technique

MAC:

Evaluasi sebelum dan tiga bulan setelah

perawatan

Gbr.1 Sebelum perawatan

13-14 Nopember 2015

Gbr.1 Sesudah perawatan

20

FINAL VISIT

Gbr.1 Pre-operative treatment.

13-14 Nopember 2015

Gbr.1 Post-operative treatment.

21

Discussion
Tekanan yang diberikan alat orthodonti akan menekan
membran periodontal yang terletak diantara gigi dan tulang
alveolus.
Schwarz, 1932 tekanan yang diberikan dalam perawatan
orthodonti tidak boleh melebihi tekanan darah kapiler (20-25
g/cm2)
bila tekanan yang diberikan melampaui ambang batas
fisiologis dapat mengakibatkan terputusnya ligament
periodontal dan terjadi kerusakan sel-sel pada tulang
sehingga terjadi resorpsi tulang alveolar
Cobourne MT, DiBiase AT, 2009

13-14 Nopember 2015

22

Discussion
Pressure that given by orthodontic equipment will push
periodontal membrane which is located between tooth and
alveoar bone.
Schwarz, 1932. pressure that given in orthodontic treatment
shouldnt exceed capillary blood pressure (20-25 g/cm2)
Pressure exceeds physiologic treshold may lead to
periodontal ligament tear and damage the cells in the bone
resulting alveolar bone resorption
Cobourne MT, DiBiase AT, 2009

13-14 Nopember 2015

23

Teori teori terjadinya resorpsi

1. Pressure Tension Theory , Schwarz (1932)
Gigi Gaya orthodonti = Tekanan dan Rengangan.
Daerah tekanan Gigi bergerak mendekat dan daerah tarikan
Gigi bergerak menjauh.
Daerah tekanan akan mengalami resorbsi tulang sedangkan
daerah tarikan akan mengalami deposisi tulang.

Gambar 6. Skema pergerakan gigi (a) gaya eksternal diaplikasikan, (b) daerah aposisi serat yang
merengang (c) setelah aplikasi gaya yang lebih lama terlihat pembentukan tulang oleh osteoblas
pada sisi aposisi dan resorbsi tulang oleh osteoklas pada sisi repososi. (Hanneman, 2008)

13-14 Nopember 2015

Balajhi. SI, Iyyer BS AT, 2006

24

Teori teori terjadinya resorpsi

1. Pressure Tension Theory , Schwarz (1932)

Dental Orthodontic force = Pressure and Strain.
Pressurized area Teeth moving closer and strained area
Teeth move away.
Pressurized area will experience bone resorption while
strained area will experience bone deposition.

Gambar 6. Skema pergerakan gigi (a) gaya eksternal diaplikasikan, (b) daerah aposisi serat yang
merengang (c) setelah aplikasi gaya yang lebih lama terlihat pembentukan tulang oleh osteoblas
pada sisi aposisi dan resorbsi tulang oleh osteoklas pada sisi repososi. (Hanneman, 2008)

13-14 Nopember 2015

Balajhi. SI, Iyyer BS AT, 2006

25

2. Bone Bending and Piezoelectric Theory

(Farrar , 1988)
Pada saat gigi diberi tekanan, tulang alveolar disekitarnya akan
mengalami bengkokan.
Daerah cekung Arus negatif Deposisi tulang .
Cembung Arus poisitif Resorbsi tulang

Cobourne MT, 2009

13-14 Nopember 2015

26

2. Bone Bending and Piezoelectric Theory

(Farrar , 1988)
When the tooth is pressurized, alveolar bone around it will bend
Concave area negative flow Bone deposition.
Convex area positive flows bone resorption

Cobourne MT, 2009

13-14 Nopember 2015

27

3. Blood Flow Theory / Fluid dynamic theory, (Bien , 1966)

Pergerakan gigi timbul karena gerakan cairan yang dinamis
dalam ligamen periodontal.
Balajhi. SI, Iyyer BS, 2006

Pada laporan kasus diatas untuk mencegah terjadinya resorpsi yang

berkelanjutan pada gigi 12 , maka dilakukan perawatan endodontik
ulang.

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28

3. Blood Flow Theory / Fluid dynamic theory, (Bien , 1966)

Tooth movement caused by movement of fluid dynamic in the
periodontal ligament.

Balajhi. SI, Iyyer BS, 2006

In above case reports, to prevent sustained tooth resorption on 12th

tooth, repeated endodontic treatment is done.

13-14 Nopember 2015

29

America Association of Endodontist Glossary of Terms

Perawatan endodontik ulang adalah suatu prosedur yang
mencakup pembuangan material pengisi saluran akar, serta
pengisi saluran akar.

Tujuanya adalah untuk mengembalikan dan menjaga fungsi gigi di

dalam lingkungan yang bebas dari inflamasi dan patosis, sehingga
pasien mempunyai kesempatan untuk mempertahankan giginya
lebih lama di dalam mulut.

Rhodes J ,2006
Johnson WT, 2002

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30

America Association of Endodontist Glossary of Terms Re

endodontic treatment is a procedure that includes root canal
filling material disposal, as well as root canal filling.

The goal is to restore and maintain the function of the tooth

in an inflammation free and pathosis free environment, so
that patients have the opportunity to retain their teeth for
longer time in the mouth.

Rhodes J ,2006
Johnson WT, 2002

13-14 Nopember 2015

31

Pertimbanganperawatan
perawatanulang
ulang
Pertimbangan
saluranakar
akar
saluran

Sisa jaringan
gigi

Kebutuha
n restorasi

13-14 Nopember 2015

Kooperative
pasien

Keadaan
periodont
al

Hargreaves K, Cohen S, 2011

32

Repeated root canal treatment

Pertimbangan perawatan ulang
consideration saluran akar
Residual
tooth tissue

Restoratio
n needs

13-14 Nopember 2015

Cooperative
patients

Periodontal
condition

Hargreaves K, Cohen S, 2011

33

Perawatan konvensional
(ortograd) Perawatan ulang
saluran akar konvensional
dilakukan dengan mengulang
perawatan melalui akses
mahkota

Ekstraksi hal ini

dilakukan apabila
perawatan bedah tidak
memungkinkan lagi

13-14 Nopember 2015

Bedah (retrograd)
Menutup rapat saluran
akar pada apeks gigi.

Pilihan
perawatan

Hargreaves K, Cohen S, 2011

34

Conventional treatment
(orthograde) conventional
root canal treatment done by
repeating the treatment
through access of the crown

Extraction This is
done when surgical
treatment is not
possible anymore

13-14 Nopember 2015

Surgical (retrograde)
Tightly close the root
canal of tooth apex

Treatment
options

Hargreaves K, Cohen S, 2011

35

Keberhasilan perawatan saluran akar pada kasus gigi # 12, juga

dipengaruhi oleh pemilihan dan penggunaan bahan irigasi dan
medikasi yang tepat,
Bahan irigasi yang digunakan adalah:
NaOCL (Sodium hipoklorit) Bahan yang mempunyai daya
antibakteri yang luas, dan mampu melarutkan jaringan organik.
EDTA Mampu melarutkan smear-layer.
Chlorhexidine Merupakan bahan irigasi yang efektif tehadap
bakteri Enterococcus faecalis yang merupakan bakteri utama
penyebab infeksi sekunder pada kegagalan perawatan saluran
akar.

13-14 Nopember 2015

Taneja , Kumari , & Parkash. 2010

Bansal , dkk. 2013

36

The success of root canal treatment in cases of tooth # 12,

also influenced by the selection and use of irrigation and
proper medication,
Irrigation materials used are::
NaCl (Sodium hypochlorite) materials that have broad
antibacterial capacity, and capable of dissolving organic
tissue.
EDTA Capable of dissolving smear-layer.
Chlorhexidine irrigation material that is effective
against Enterococcus faecalis bacteria which is the main
bacterial cause of secondary infection in the root canal
treatment failure.

13-14 Nopember 2015

Taneja , Kumari , & Parkash. 2010

Bansal , dkk. 2013

37

Bahan medikamen yang digunakan pada kasus gigi # 12 yaitu

menggunakan Ledermix dan kalsium hidroksida.
Pasta Ledermix
Pasta Ledermix merupakan kortikosteroid yang dapat
mengontrol rasa nyeri dan inflamasi serta demeclocycline pada
pasta Ledermix mengandung antibiotik yang efektif untuk
melawan bakteri.

Berkitten , Okar , Berkitten . 2000

Cwikla . 2000
13-14 Nopember 2015

38

Medicaments materials used in the case of tooth # 12 are

Ledermix and calcium hydroxide.
Ledermix Paste
Ledermix Paste is a corticosteroid which can control pain
and inflammation, and demeclocycline on Ledermix
paste containing antibiotics effective against bacteria.

Berkitten , Okar , Berkitten . 2000

Cwikla . 2000
13-14 Nopember 2015

39

Kalsium hidroksida
Mekanisme antimikroba kalsium hidroksida terjadi dengan
pemisahan ion calcium (Ca2+) dan hydroxyl (OH) .
Ion calcium (Ca2+) bereaksi dalam enzimatik pada bakteri dan
jaringan, menginhibisi replikasi DNA serta bertindak sebagai
barrier dalam mencegah masuknya bakteri dalam sistem
saluran akar.
Difusi ion hydroxil (OH) menyebabkan lingkungan alkaline
sehingga tidak kondutif bagi pertahanan bakteri dalam saluran
akar, serta mengadakan difusi ke dalam tubulus dentin .
Berkitten , Okar , Berkitten . 2000
Cwikla . 2000
13-14 Nopember 2015

40

calcium hydroxide
The antimicrobial mechanism of calcium hydroxide
occurs with separation of calcium ions (Ca2 +) and
hydroxyl (OH).
Calcium ions (Ca2 +) reacts in the enzymatic reaction
of bacteria and tissue, inhibits DNA replication and acts
as a barrier to prevent the bacteria from entering the
root canal system.
Hydroxyl ion (OH) diffusion cause an alkaline
environment that is not conducive to the defense of
bacteria in the root canal, and diffuses into dentinal
tubules.
Berkitten , Okar , Berkitten . 2000
Cwikla . 2000
13-14 Nopember 2015

41

KESIMPULAN

Hubungan yang komprehensif antara ortodontis dan

endodontis merupakan hal yang penting untuk
memastikan hasil yang baik ketika gigi yang telah
dirawat endodontik terlibat dalam perawatan ortodontik
sehingga dapat dikontrol bagaimana kondisi dari gigi
tersebut.

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42

KESIMPULAN

Comprehensive relationship between the

orthodontist and endodontist is important to
ensure good results when endodontic-treated
teeth involved in orthodontic treatment so the
condition of the tooth can be controlled.

13-14 Nopember 2015

43

Daftar Pustaka
1.Asgeir Sugurdsson.Evaluation of Success and Failure.Dalam: Walton
RE,Torabinejad M (ed).Principles and Practice of Endodontics 3rd
,Philadelphia:WB Saunders.2002:331-344.
2.Dumsha TC, Gutmann JL; Clinicians Endodontic Handbook.2000 .LexiComp.Ohio.P 140-3, 213-9.
3.Thilander B, Rygh P, Reitan K. Tissue Reactions in Othodontics. In: Graber
TM, Vanarsdall RL, Vig KWL, editors. Orthodontics. Current Principles and
Technique. St. Louis: Elsevier Inc; 2000.p. 203-11
4.Sameshima GT, Sinclair PM. Predicting and preventing root resorption:
Part II. Diagnostic Factors. Am J Orthod Dentofacial Orthop 2001; 119:50510
5.Siqueira J F, Rocas IN, Favieri A, & Lima KC: Chemomecanical reduction of
the bacterial population in the root canal after instrumentation and
irrigation with 1%, 2,5%, and 5,25% Sodium Hypochlorite, J Endod 2000;
26 : 331-334
6.Siqueira J F, Rocas IN, Sauto R, Uzeda M, & Colombo, AP: Actinomyces
Spesies, Streptococci, And Enterococcus faecalis in primary root Canal
Infection, J Endod 2002; 31 : 312-317
13-14 Nopember
2015
7.Balajhi.
SI, Iyyer
BS. Biology in Tooth Movement. In: Orhodontic The Art

44

THANK

YOU