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Lateral surgical treatment
From: Terry Pannkuk
Sent: Thursday, March 08, 2012 11:05 PM
Subject: [roots] Quiz 2 Treatment
When the patient came back on 2/24/2011 with continued symptoms/swelling,
I suspected a root fracture #9 and a possible problem with the previous
lateral surgical treatment figuring over the years the amalgam
corrodes and if the post wasnít placed aseptically (which they usually
are not), then a foreign body/microleakage sepsis of the encapsulation
may have occurred and become acute. The dual posts in #9
was certainly weird and the perio around #10 and 9 was inflamed.
I recommended removal of the crown on #10 since it was still the one
that was percussion sensitive although less than it had been the previous year.
I was thinking combined etiologies involving #9 being cracked or failing
retreatment, or #10 crack/biologic width problem. The occlusion had been
reduced so she wasnít hitting these teeth. The CBCT was only good for the
apex of these teeth and the scatter obliterated the cervical/midroot
areas of interest. I would have like the crowns off and posts out
so I could take another scan, but I was probably the only one who liked
that plan with the patient having each tooth heavily restored.
The dentist was not in the mood for anymore endo heroics after what she
had as a history of endo expenditures and failures.
In my mind Iím thinking there was a poor foundational framework layered
upon #9. The dentist was pushing for me to extract #10 because it was
the one that was percussion sensitive. He wanted me to extract both
and place two implants. I wanted to preserve bone and natural teeth
if possible. It was Get r done versus Get it Right with Get r done
beating down on Get it Right. I absolutely hate the shot gun
approach because I like to understand whatís happening then learn from
each experience so I donít keep making the same mistakes like everyone
else. Itís a big problem in dentistry when you just extract all
the problem teeth and think you can just place implants. No one learns
anything and the same shit keeps happening over and over again,
like in the movie Groundhog Dayí with Bill Murray.
I finally convinced the patient and dentist to let me flap the area
rather than just extract blindly guessing that these teeth were cracked.
This is my email report to the dentist after the flap procedure
(note I threw in a literature reference for more credibility and convincing.
I call it placebo lit to shut everyone up and keep them optimistic
while Iím trying to bust my ass to give these cases a chance, so we can
all learn something even if it fails)
2/25/2011: When I was giving anesthesia I sounded the needle around
the labial plate and the break was clearly around the area of the previous
lateral root reverse filling. Rather than take out a perfectly
good tooth, I laid a flap (submarginal incision with a single distal release)
curetted, drained the lesion, removed the corroded amalgam, irrigated with
aqueous tetracycline, submitted a portion of the tissue for
biopsy, and reverse-filled the prep with MTA. The root could be cracked
on the lingual but there was no clear sign of a crack from the labial access
and #10 looked perfectly fine with intact bone. Iím still perplexed why #10
was percussion sensitive but it made no sense to address that tooth until the
obvious area of infection was addressed which was clearly associated with
the distal #9 root area. Iím not absolutely confident #9 will make it but it
didnít make any sense go through the effort of a surgical exploratory and not
spend the extra few minutes taking out the alloy and reverse-filling it with MTA.
The amalgam was not loose at all and it was placed well. The research by
Moodnik and others show a 100 micron gap between amalgam and dentin and the
presentation was typical of eventual leakage and breakdown
we see with some of these cases over the years. She had an arduous
appointment mainly because I was flying by the seat of my pants and my staff
wasní't really set up to do an endo surgery, but it went very well.
I would at least expect the emergency problem to be resolved.
The perio around #10 was normal, but there was a 9mm pocket at the distolabial
line angle of #9 which was not associated with a crack. .
I suspect it was a simple transient blow out from the parulis and is likely
to heal. If the defect doesnít heal I would assume the root is likely fractured
on the lingual and the tooth should then be extracted.
it will be a better situation for xxxx (the oral surgeon)
if we at least get some initial healing. Have a great weekend!
Suture pic after immediately after the surgery (not pretty!....
tissues very friable and inflamed):
2/28/2011: I removed the sutures. The patient still had some symptoms
but reported that she was greatly improved. Soft tissue looked good.
3/2/2011: Soft tissue check, looked even better, slight symptoms even more improved.
3/15/2011: Patient had no symptoms and felt great. Tissues looked good
(pic below) Scheduled a 1 year recall which was today (3/7/12)
Recall 3/7/2012: All signs and symptoms were within normal limits, additional
images attached. Probably some bone fill in the lateral defect
but not complete on the PAís No clinical signs of disease though.