From: Terry Pannkuk
To: ROOTS
Sent: Thursday, February 04, 2010 1:13 AM
Subject: RE: [roots] Consult Puzzle.

I just treated #20 and had all the temps off.  #18 looks very questionable and probably not restorable by the
dentist who sent her (no supragingival coronal tooth structure except a mm high thin wall at the distal).
#19 was much deeper than expected, probably needs endo just for retention. #21 looks like it won't need endo.
New plan:  extract #18, probable endo #19, monitor and probably leave #21 alone.

It's starting to become clearer.  I fixed all the potholes that were leaking in the temps.   The occlusion had
some  contacts on the molars, no contacts on #20 and a small contact in the mesial pit of #21.  Heavy contacts
on #22.   The bicuspids were splinted separately and the molars were splinted separately.  When #18 is extracted,
#19 will then have an ill-fitting single crown temp, hopefully it will be remade.  If not, I'll probably make
it myself when she comes back for the probable endo.

We know how this case is going,  how should it have gone?  From my perspective it should have probably gone as
follows (any alternate ideas?)......

1. The dentist discovers 4 heavily restored teeth in need of  crowns.  Impressions study models and a
comprehensive plan is developed, analyzing the occlusion, and full mouth for all areas to make sure this
quadrant is a reasonable place to start after sequencing priorities, right?

it could work well going this way

2......maybe the dentist decides to take #18's restorations apart, finds it's not restorable and sends the patient
to the oral surgeon for extraction

3.......the dentist removes the restorations on the two bicuspids, leaving the posterior support on the first molar.
#20 acts up due to a pulpitis/exposure.  I get referred #20 for treatment #20 and 21 have properly fitting temp crowns.
#19 hasn't been invaded and supports the posterior occlusion.

4.......After doing the endo, all symptoms go away, #20 and 21 crowns are performed without having screwed up the
vertical dimension.

5.......Tooth #19 is taken apart either found to be exposed and in need of endo in which case it is sent to me
before the crown, or simply the crown is made without the need for endo.

If you were a patient would you want all this crap torn apart at the same time?   Whether #18 was treated first or
the bicuspids treated first, by doing this in segments the complicated crisis could have been avoided, right?
I like the idea of maintaining posterior support throughout the process - Terry



Terry, just a thought - is all that necessary to place a crown on second molar??? From what i have been doing for
last three years, i would have elected onlay-type restoration, and if it lacks any determined macromechanical
retention features, then it should be bonded ceramic onlay (e.max in my hands).... why mess around with crowns on
vital, non-cracked molars?.... nevermind.

In this case and it's state right now... would you consider any kind of perio surgery to get more sound coronal
tooth structe to prepare a definitive margin? Why go with rather aggressive Tx like extraction immediately?- Dmitri

P.S. and, oh yes, i like the endo of course :-))

Terry, what do the other quadrants look like... is there severe wear?

One of the things that happens too often is that us restorative dentists get excited to start the big case and get
moving on it without fully diagnosing the case.  Prepping the teeth is really simple.  Make great money doing it.
Looks like this GP forgot to really look at the perio and pulpal health.  While it seems over the top for some,
I have made it a routine to have my local endodontist evaluate all the teeth if I'm going to start a case like this.
We still might run into a few surprises, but at least I've already got the patient forwarned about the possibility.
- Craig Harder

Good point.  Here's my email to the referral below.  I'm an admitted kiss-ass and certainly try to be congenial
not making the dentist feel bad for doing something I wouldn't have done.  In my opinion what this dentist did was
average care not below average.  I don't like average care but feel it is not my place to blow the whistle on every
case set up I don't personally like.  Average care is crap care in dentistry these days so we have to accept it as
the standard of care until it improves.

Regarding the extraction suggestion, I was factoring in patient management.  She is terrible to access posteriorly,
isolation will be a problem, but probably doable.  I feel that I can do the endo and the buildup but can it be
restored by her dentist?  Is it going to be a good service for the patient if I struggle and bully the patient
to get an ideal endo result with perfect buildup only to have the follow-up restoration fail?

I don't really know what you mean by an onlay and what type of value that would offer.  Onlay over an exposed pulp
and bond it on?  How long is that going to last without internal retention? - Terry

Hi xxxxx,

I took the temps off, treated #20, relined a few holes and evaluated the other teeth.  I think that #21 will probably
be fine, but we'll want to monitor it while the dust settles.  #19 looked deeper than I thought on the radiograph,
it should also be monitored.   #18 looks very questionable restoratively.  How do you feel about it?  A resin bonded
composite build up would likely fatigue, the bonds hydrolyze, and it would eventually fail.  An amalgam build-up
would provide more strength and better marginal integrity but the risk of root fracture due to minimal remaining
coronal dentin is probably quite high without crown lengthening possibly with some osseous reduction.  If you feel
confident getting a solid circumferential margin on this tooth after endo, crown lengthening, and a bonded amalgam
build up, then saving it may be reasonable, otherwise I view extraction as the best option.  She also has limited
jaw opening and it might be difficult for her to go through the procedure as I would need to keep the area isolated
and maintain asepsis with some difficult clamping and dam sealing with Dycal.  I prepared her for extraction but
she also understands I was going to talk to you first before setting up the next step.

I'll be happy to extract #18  if you would like me to.  Also let me know your thoughts on #19, if you need internal
retention and the endo done; I'll set her up for that as well. - Terry

Terry, Since you mention me,  I'll tell you what I'll do in case like that one. Although it is hard to judge based on
radiographs only, I would probably do endo on all these teeth to save a patient lot of pain and unpleasant moments in
near future. Explaining this to patient surely will be like trying to negotiate nuclear disarmament :-))).
You are lucky :-) you have not been the one who prepared these teeth for crowns this way - Valeri

You are probably right about 3 of the teeth.  I still think that since #19 was left off the referral slip, it was the
one that wasn't exposed.   I wouldn't jump to retreat that one. :):):) - Terry

hey, do the whole quadrant.  make sure you don't miss the offending one. :) - gary