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Molars |  Bicuspids |  Canals

Lingual bleeding and inflammation - 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
To: ROOTS
Sent: Friday, March 19, 2010 12:16 PM
Subject: RE: [roots] Today's Meet 'n Treat

Itís simple; treat and do no harm. If the risk of harm is great refer to where the risk is much
less or at least accepted as being the best that can be done.

Hereís a patient I saw yesterday on consultation.  The patient was a very pretty 23 year old woman
with a wide attractive smile.  I would have loved to have treated a caries exposure molar endo on her,
but thatís not what she came in for.  In this womanís case she fell off her moped and nailed this tooth
a few years ago (#8).  She had a beautiful veneer on it that looked great from the facial but was
periodontally a mess at the distolingual line angle.  Her previous dentist told her it needed to come
out and she should have an implant.  She changed dentists probably because that scared her and she didnít
understand why a tooth that felt great and looked great needed to be taken out.  I showed her the pictures
and explained that her soft tissues (gums and papilla) needed hard tissue support (natural root surface/
attachment apparatus and bone) to continue looking as nice and esthetic as it currently does.   I showed
her the lingual bleeding and inflammation explaining that she was in the process of losing this bone and
support due to a periodontal infection.   Sheís between a rock and a hard place:  If she keeps the tooth
she is going to continue to lose essential supportive bone/attachment and crown lengthening would be terrible.
There is virtually no root length to super erupt maintaining a reasonable crown-root ratio (maybe supererupt
temporarily just to bring up some lost native bone).    Her new dentist wanted me to assess the endo prognosis
and I did: terrible.  He likes to work with me on implants and Iíve placed several for him.  She then asked me
about the implant prognosis knowing I do both endo and implants.  I explained that an implant would integrate
just fine, function just fine, but it might not end up looking as nice as her natural tooth with the high
knife edge gingiva.    Her contacts points are not broad and the proximal tooth contours are very curved
so making a tooth with a board contact to prevent a dark triangle would look terrible.

Do you think I offered to do the implant for her? Öeven though I could have?   Hell no!   Iím not sure I could
make her happy at all.   I explained what types of implants cases I select and my role as an endodontist.
I explained that there was an implantologist who has done many of these types of cases that are esthetically
high risk. Sheís being referred out to a periodontist who does these types of cases all the time.  Quite frankly
Iíve never seen an implant placed with this type of gingival architecture that would look as good as the natural
tooth on  a later recall. Sometimes they look really nice immediately post op, but not 5 years down the road.
She can go to the periodontist, he has the experience and chips in the bank to deal with this risk. If he fails
itís the best that can be done.  If I tried this and it failed Iíd be a clown.

I select implant cases like I wish general dentists would select endo cases.

Lead by example not words right?  - Terry.


Protaper flaring
6 yr old Empress
Cvek pulpotomy
Middle mesial
Endo misdiagnosis
MTA retrofill
Resin core
BW importance
Bicuspid tooth

Necrotic #8 treatment
Finding MB2 / MB3
Deep in a canal
Broken file retrieval
Molar cases
Pushed over apex
MB2 and palatal canal
Long lower third
Veneer cases
CT Implant surgury

Weird Anatomy
Apical trifurcation
Canal and Ultrasonics
Cotton stuffed chamber
Pulp floor sandblasting
Silver point removal
Difficult acute curve
Marked swelling
5 canaled premolar

Sealer overextension
Complex anatomy
Secondary caries
Zygomatic arch
Confluent mesials
LL 1st molar (#19)
Shaping vs Cleaning
First bicuspid
In Vivo mesial view
Inaccesible canals

Premolar 45
Ortho and implant
Radioluscency
Lateral incisor
Obturation
Churning irrigant
Cold lateral
Tipped to lingual
Acute pulpitis images

Middle distal canal
Silver point
Crown preparation
Epiphany healing
Weird anatomy
Dual Xenon
Looking for MB2
Upper molar resorption
Acute apical abcess
Finding MB2

Gingival inflammation
Irreversible pulpitis
AG BU ortho band
TF Files
using TF files
Broken bur
Warm technique
Restorative prognosis
Tooth # 20 and #30

Apical third
3 canal premolar
Severe curvature
Interesting anatomy
Chamber floor
Zirconia crown
Dycal matrix
Cracked tooth
Tooth structure loss
Multiplanar curves