Right Central Incisor hurts - Courtesy ROOTS
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From: Javier Pascual
Sent: Wednesday, March 30, 2011 12:36 AM
Subject: [roots] HELP WITH A PLANIFICATION CASE
This patient was referred to me by oral surgeon on March 2011
Chief complaint: My right central incisor hurts
Dental History (patient version): At the age of 10 dental trauma.
Endo was done five or six years ago because tooth was yellow
(an internal bleaching was offered to the patient to solve discoloration)
Pain History:Patient feels like a beating pain related to the
apical part of tooth 1.1
Clinical exploration: Vertical percussion normal, Horizontal
percussion some discomfort but not painful, Buccal probing under
anestesia reveals a deeper point of 5 min in central position.
I took periapical radiographs and ask patient to bring me a CBCT
that previously was taken by oral surgeon.
What do you think about this treatment plan? First of all I´ll
acces through the crown remove guttaperha, search for canal,
cleaning and shaping procedure and Ca(OH)2 medication for
2-4 weeks. After that I´ll pack canal with guttapercha.
Then I have to treat perforation. What do you think about
this perforation? Is this subcretal? paracrestal? or above
bone level? If it´s subcrestal I´ll seal it orto via with MTA.
But I´m afraid this is paracrestal and maybe I´ll need to raise
a flap and seal it surgically. What do you think after seeing
CBCT? I´ll take better periapicals and post intraoral pictures
Any comment will be of help!! Thank you very much - Javier!!
That's a nice case to deal with! I think the best option will be
to raise a flap after you do the orthograde endo and seal the
perforation with MTA. After raising the flap you will see what
is going on indeed and you can correct if needed the MTA seal
and prepare perfectly the root surface. Please keep us informed!
After obturating the canal, I would seal the perforation with
glass ionomer instead of MTA. Since it seems to be paracrestal
indeed and the risk is that the MTA will be washed away.
Afterwards I would raise a minimal flap and finish the glass
ionomer. - Rafaël
Thank you Rafäel and Bojidar. I also think I will have to raise
a flap. If deffect is paracrestal I think MTA is not a good idea
because it can´t be polished. What about a componer like Dyract
or Geristore? For the surgery maybe just sulcular incision
without vertical incisions? - Javier
Javier, You need to check the presence of a periodontal pocket.
In this case it is more important than the CBCT. Use your perio
probe to do that. If you find a normal depth, go to ortograde
seal with White MTA. During retreatment, if you find a small and
rounded perforation, instead of MTA you can seal the perforation
with a guta percha master cone and endodontic sealer as a "second"
canal. If you find a perio pocket, go to surgical repair with
resin to avoid aesthetic problems. Resin it's easy to be polished,
I don't like the polish quality of GICs, specially under microscope
view. Choose by papilae preservation flap design without releases.
Thanks for you advices Lendro!! They´re of great help. Yes there
is a perio deffect, 5 mm pocket and gingival retraction
(central-buccal) Next visit I´ll take pictures of soft tissue
before starting treatment. - Javier
Hi Javier, I think it's a good idea to plug the hole with resin.
Would be great to make a flap intrasurcular and if the defect does
not invade the periodontal bone mesiodistal bone, preserving the
taste. It can help with 212 for isolating the adhesive technique,
if the defect permit. - Ivan Garrido
Thank you Iván!!! I´ll phone you this evening to discuss the case.
Nice to read you here!! - Javier
Hi Javier, im interested which CBCT was used for imaging in this
case. like the quality of the image - M.J.
Hi Michael. CBCT: Morita Accuitomo 80 Visualization Software:
Kodak Kdis - Javier Pascual