From: Terry Pannkuk
To: ROOTS
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?
.....no way!

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.