Combination Nonsurgical Surgical Resorption Repair Endo Tx - Courtesy ROOTS
The opinions and photographs within this web page are not ours.
Authors have been|
credited for the individual posts where they are - www.rxroots.com
From: Terry Pannkuk
Sent: Sunday, December 13, 2009 3:57 AM
Subject: [roots] Combination Nonsurg/Surg/Resorption Repair Endo Tx
This was a very time-consuming case requiring a grand total of
11 treatment hours according to my timer that records all time
from the consultation, anesthetic time, to discussion and the
patient leaving the chair.
The patient presented with palatal root resorption last summer.
He was highly motivated to save the tooth. The implant alternative
did not look particularly favorable with the pneumatized sinus,
especially when viewed on the ICAT scan later. At the initial
consultation we were talking about extraction, but after
viewing the ICAT we changed our mind and decided to go heroic.
The MB root had some internal-external apical root end inflammatory
resorption. I treated the root canal systems internally with
trichloracetic acid on the first visit, cleaned, shaped, and placed
calcium hydroxide. I had spent and extraordinary amount of time
recapitulating with hand files due to the intracanal irregularities,
wanting to debride and remove as much granulation tissue/circulatory
elements as possible. The second visit it was nice and dry when
I opened back into the chamber. I filled the DB and P canal systems
with gutta percha and sealer (The external resorption defect had been
pretreated basically by stuffing it with Cavit internally and
externally on the first visit). The MB systems were obturated with MTA.
Yesterday (third visit), I flapped both the buccal and the palatal,
apically resecting the the MB root, then prepping and restoring
the palatal defect with Geristore. The surgery was very challenging
because the patient and physician would not let me use a vasoconstrictor
and I had to use plain Citanest. Hemostasis was very poor but manageable
after waiting patiently for bleeding points to subside.
This patient will be interesting to scan with the Kodak when he comes
back on recall. I'll charge him for the Kodak scan in one year but do
one for free on Monday when I take out the sutures. It seems only fair
to comp him on the one Monday since he had to pay for the ICAT scan at
the beginning of treatment.
Very few patients would be willing to go through all this to save a tooth.
His motivation level and dental IQ was very high considering all the
treatment challenges - Terry
Terry very nice case (endo/implant diagnosis, surgical and non surgical
approach...). Just one question. Did you pack the MTA in the MB root via
orthograde? Why did you flap buccal and remove the root tip of MB root?
do you think this was absolutely necessary? Thanks for share these
extreme cases - Javier
Terry, This beyond my scope of treatment modality's, i am very interested
how you gauge the prognosis in these sort of cases. My greatest concern
would be(if i could do the same quality of treatment as you did) how the
peridontium would react and how long before, due to peridontical problems,
i have to remove this molar.
Great work thnx for showing it. - René Stevens
I don't like leaving loose ends. Leaving a short-filled MB root to the
point of resorption isn't a definitive result. Packing it with MTA orthograde
and apically resecting it flush to set MTA is. The one weak link I did
leave was the untreated isthmus between the MB1-MB2. The patient had a
cardiovascular disease history; I was forced to use plain Citanest and not
take him off his baby aspirin, so the hemostasis was poor. I stained it
with methylene blue dye and there wasn't much of an isthmus stained blue
so I didn't prep it out. I figured that it would be more of a problem
prepping it out, opening it up and not sealing it properly in a
poorly controlled environment than it would be leaving it alone.
Tough decision. I was actually hoping the patient would elect to extract
then I could pass the buck to the oral surgeon who would have the graft the
inadequate alveolar bone, but no one else wanted to touch him.
Tag! I was it. :(
I assessed the prognosis as fair. 60-70% chance it will be around on a
long term recall without path. That's probably conservative. These
Geristore repairs usually heal with junctional epithelial attachment
and this one didn't wrap around interproximally. It was easy to repair
and get good sealed margins, once the bleeding stopped briefly - Terry
Excellent case Terry, Why you left upper portion of canal uninstrumented
and unfilled ? Was access to it closed with Geristore only or you placed
MTA first ? Done this way upper portion of canal/nerve has no any
blood supply or am I missing something ... ? - Valeri Stefanov
The tooth was lingually inclined and the idea of making a nonsurgical
coronal access and repairing the resorption defect was judged to weaken
the tooth too much. The coronal pulp is entombed and unlikely to
communicate septically with the periodontium; why bother treating it?
Prior to the Geristore repair
I packed some Cavit up toward the pulp chamber. It's hard to believe
that space was worth dealing with. - Terry
In my humble opinion there is a risk that this necrotic pulp tissue left
coronally can possibly leak under Cavit and RMGIC - Geristore. This would
compromise the final result in time. Of course it is fully possible
and most probably that will be the final outcome - this old lady will
not have problems until she is alive.
I, however would have removed this necrotic pulp. In my humble opinion
a conservative access to coronal pulp is possible with quantities of
sound tooth tissues seen on RX.
Your approach to this case somewhat contradicts with all you have written
up to now about need for total necrotic tissues removal and achieving a
"perfect" seal ? - Valeri
What is written in the scriptures of endodontic literature isn't the word
of God (aka Gary Carr if one is a TDOr). :):):):):)
.....cmon Valeri let's get real. a coronally blocked out pulp chamber with
a stuffed Cavit base then restored over with Gerstore? Do you really think
any minuscule crap left in this coronal portion blocked out miles
away from the periodontium ever has a chance to see the light of day on
this 90 year old woman? - Terry
If by some miracle a significant bacterial titer percolates through the Cavit
and through the coronal Geristore margin: where is it going? ....into the root
PDL with the coronal Geristore margin being supragingival?
Shouldn't I be a lot more worried about the quality of the Geristore seal that
is subgingival preventing coronoapical leakage than the irrelevant entombed pulp
chamber space that would have required significant effort and additional removal
of coronal tooth structure? Every treatment requires a balance of risks and
rewards. You cannot adequately clean and fill a blind sac unless there is patency
to assure clearing and debris removal; that is why short-filled blocked endo is so
crappy. Just look at the distance a pulp chamber pathogen would have to travel;
i.e. through the Cavit and across a very long space of filled Geristore already
having externally worrisome margins mesially, distall, and gingivally. Can one
really common sensically concern themselves with preventing something that requires
additional tooth weakening effort in order to prevent something that is such
a nonissue? The pulp chamber debris might cause some slight tooth discoloration
over time, but at age 90 with this tooth not showing as she smiles, do you think
she really cares?
We really need to think these things out and make sure what we do has a reason
other than esoteric theoretical endodontic scripture extrapolation. There are
exceptions to every rule and rules were meant to be broken and creatively
reworked to fit unique presentations.
If this case fails it will be because of the mesial, distal, and gingival Geristore
margins and not because of the pulp chamber space. I would bet the bank on that - Terry.