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2 year follow-up of a trauma case - Courtesy ROOTS

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. Photos courtesy Marga Ree - ROOTS

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

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