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The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. -

Lateral surgical treatment

From: Terry Pannkuk
To: roots
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.

Lateral surgical treatment

Lateral surgical treatment 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) Lateral surgical treatment

Lateral surgical treatment 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): Lateral surgical treatment 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) Lateral surgical treatment 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. Lateral surgical treatment

Anastomosing Laterals
Calcified canals
Pulp chamber
Calcified molar
Ominous Lesion
Instrumenting MB2
Buccal caries
Recent recall
Cast post cores
Severe pain
Perio pocket
Not much calcified
Hess anatomy
3 palatal POE
Crap endo
Implant algorithm
Long term recall
Nerve proximity
Tooth #15
Psicologic condition
Fractured central
Radicular root
Wave lower molar
ECIR recall
Stainless steel band
Microscope dentistry
Complex root canal
Upper premolar
Scope bracket
Thermafilth abuse
Retreatment failure
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