From: Javier Pascual
To: ROOTS
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 next visit.

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!
- Bojidar

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.   -  Leandro

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