From: Marga Ree
To: ROOTS
Sent: Saturday, March 08, 2008 8:13 AM
Subject: [roots] 2 year follow-up of a trauma case

I have posted this case earlier and wanted to show the 2 year follow-up.

This 13 year old boy sustained a trauma on tooth 11. Unfortunately, the horizontal root fracture was treated by his
dentist by performing an endo in the 2 segments. Because of persistent complaints, the coronal segment was retreated by a
resident of the endo program, with gutta-percha and sealer. I question the choice of the root filling material, it's an
illusion to think that this could have been sealed with gutta-percha and sealer. However, his symptoms never went away,
tooth remained sensitive to percussion and had a grayish discoloration. He was recommended to have the tooth  extracted,
because everything that was possible had been done.

I performed a conventional retreatment till the fracture level, filled the coronal segment with MTA,  raised a flap and
removed the apical fragment in 2 parts, this was done in 1 treatment session. After removing the sutures, we applied
sodium perborate for a few days, and the access opening was filled was with composite.

Healing was amazing, after 2 months tooth was rock solid and patient was completely symptomfree, for the first time since
the trauma took place. The last rad is the 2 year follow-up  -  Marga









Dear Marga, just beautiful. What a great service for the patient. - Jörg

Marga, thanks for sharing this amazing case! It is a miracle of thought and fine skills.
One question however, did you only inspect the fracture line or did you preped coronal fragment to smooth the surface? Did
you do retrograde prep and obturation or just polished that MTA which you have orthogradly placed?   - Dmitri Ruzanov

Thanks Dmitri! I prepped the fracture site gently to smooth the surface and the orthogradely placed MTA. I didn't add
extra MTA after this procedure. - Marga

Marga:  Your treatments always stun me.  There are people like yourself, Jorg, John Levinje, Khademi, Rod Tataryn that I
dive into their emails when they post their work.  You all set the bar so high with your clinical treatments and your
wonderful documentations.
Bravo Marga.....you are a tremendous clinician.
This case surprised me that the tooth would hold......I didnt think it would. CLAP CLAP CLAP - Glenn

Marga, The apical fagment, which should never have been treated anyway, was
very poorly sealed based on what your beautiful photographs show.
Your result is fantastic. - Dan Shalkey

Thanks  Dan. As you said, the best treatment on a horizontal root fracture
is no treatment, except for splinting. The pulp in the coronal part remains
vital in the majority of cases. Sadly, many clinicians are not aware of
this. - Marga



Do  you routinely use white MTA in anterior teeth? - Andreea

Dear Marga, excellent result.  Could you share your osteotomy technique and instrumentation?

How did you remove what appears to be the palatal fractured segment of the coronal tooth (not the fractured apical
segment)? Thanks! - Tony

Hi Tony, For osteotomy I use an impact air handpiece with a Lindeman H 151 tapered bur.
The fracture is usually not a perpendicular one, but an oblique fracture, of which the most coronal fracture line is
located at the palatal side. This was also the case here. I sectioned the buccal fracture line perpendicular to the long
axis of the root, and removed it, first pic. Then there was a remaining segment, attached to the palatal mucosa, which was
the most difficult part to remove. I carefully severed it from the palatal mucosa with a scalpel blade and a sharp
excavator. In this way, you save as much of the root as possible. If you look at the last 2 pictures, you can see how the
2 segments were located in relation to each other.

The smallest, most coronal segment was located at the palatal side.  - Marga

Hi Marga, I had thought perhaps you used a special root elevator, etc, but it looks like a excavator worked well.  Thanks
for the explanation. - Tony

Beautiful healing marga, although I still question the long term prognosis of this case.  But at age 11, now 13, if you
can keep that tooth functional through the teenage years, it is a great service to the patient and better than the
prosthetic alternatives. - gary

Dear dr  Ree,
your case impressed me equally as a dentist(GP) and..as a mother:), who's child has finally received  the correct therapy!
Furthermore,  your images are brilliant, THANKS for sharing them so kindly...  Cristina Ghita

Dear Marga, excellent case as usual, but, why don't you use Leubke-Oschenbein flap tehnique, and 5-0 nailon , it doesn;t
leave any scar. - Sergiu Nicola