Molar bridge abutment
From: Terry Pannkuk
Sent: Monday, June 25, 2012 11:36 PM
Subject: [roots] 10 year heroic recall: molar bridge abutment
This 88 year old male patient came back needing treatment on a different tooth,
I had treated #31 very reluctantly and it was a battle to keep aseptic isolation after
removing all the caries (2002). He had the minimal circumferential ferrule, but using
this tooth as a distal bridge abutment was quite off the grid as far as risk assessment goes.
Heís had his bridge for 10 years and is very happy with it. Thereís slight gingival
inflammation but no clinical signs, radiographic, or CBCT signs of recurrent disease.
Note the small as practical or as Fred would say large as practical size of the apical POEís.
I have no real memory or notes about why I placed the post short but I suspect it didnít seat
fully as I was in the heat of battle trying to keep isolation everything together during the
build-up. If the crown margin was placed on circumferential dentin, it probably didnít matter.
Today I would have placed a bonded amalgam without a post on a case like this, if I would
treat a tooth like this at all!
The important issue is that this tooth is functioning, disease-free, with a stabile restoration.
Iíd call this a success. I treated one other tooth on this patient which I recalled as well.
That recall will follow in a subsequent email - Terry
The opinions within this web page are not ours.Authors have been credited for the individual posts
where they are. - www.rxroots.com photographs courtesy: Terry Pannkuk|
Wow!! What a great service for this patient! I hope he is grateful for your efforts - Fred
I guess he learned to be grateful after the tooth he had treated by someone else failed after
I busted my butt on the previous two. :):):)
He was super nice at the recall visit last week. - Terry
Fantastic save Terry!!
interesting isolation, did you place the clamp on the gum and then gingivectomy and Dycal+cavit
to seal? - Imran
Yep, I canít imagine ideally isolating a tooth like that any other way.. On all these types of
cases with no attached gingiva and miserable isolation, I donít even dream of trying to clamp
whatís left of the tooth because the clamp slides, slips and the isolation is not secure.
Clamping down deep on the gingiva may create a laceration, but the deeper you go the less likely
you are to create a gingival defect and the deep laceration will heal. Who cares? It may not
be elegant and could freak out a periodontist, but the goal is not to look pretty, itís to
accomplish the objectives and be successful - Terry
Amazing case ! I can't believe this kind of tooth still can be survived for over ten years.
In schools, almost 100% extraction will be tx planned by any of faculties :) Excellent endo and
prosth work and lucky pt!! Does he have real occlusion teeth on his maxillary arch ? Just be curious ;)
Yep, Itís his main functioning side. These cases come in periodically and I have a few that are over
20 years old.
It is very satisfying to have a CBCT machine so that recall validation of proper endo technique can show
the importance of classic principles leading to success. The litmus test is the long term recall
evaluation not the immediate post op radiograph showing curve management
Why did that compromised case I showed succeed for 10 years? Simply because:
1. I made sure it wasnít open to the oral environment when I treated it.
2. Spent a lot of time in the case recapitulating with hand files flushing with copious irrigant.
3. The cleaning and shaping phase of treatment had to be meticulous and complete or the gp cones
would not have been fit with proper tug back at the apical terminus of the prep, which meant I explored
the lateral walls and removed all irregularities so the cones would fit.
4. I used electrosurgery to insure the dentin margins were dry, caries control was complete and that
there was a clean circumferential ferrule on dentin not some crap build-up delegated to a less concerned,
less meticulous clinician.
5. and there was some luck (host defense, patientís occlusion, quality of follow-up restoration, and etc.).
In summary I controlled everything I was able to control in that case creating the best odds for success.
You might not be able to control everything in a case but if you control every phase of the treatment
you can without compromise, you will have many successful results which seem extraordinary to other
clinicians which really should be routine if we all just simply cared about giving the patient out best
effort on each case. Itís humbling when I extract teeth I treated because it basically highlights my worst
treatment results. I donítí get to see my best results cleared or shaved back for examination!
Hereís a patient I treated this morning: This patient had the 2nd molar treated by some unknown dentist
years ago. Radiographically, the root canal filling on the second molar looks like what most of us would
say is good. Unfortunately, there is a 10 mm mesial pocket, furcation bone loss and periapical
radiolucencies. I finished treating the first molar today. I spent a lot of time in the case I treated.
I donítí know for sure but would you guess that the clinican who treated the second molar was as diligent
about aseptic isolation with a dam, spent time copiously irrigating with disinfecting agents, or worried
about deep apical shape? Is it Thermafilth? Is it a case with a resin sealer having jacked up
radiopacifiers with cone passively floating in a septic space? J We knew the first molar needed treatment
because it was symptomatic with a degenerating pulp, but what do we do with #31? It seems like the
attachment around #31 has been a festering asymptomatic wound melting bone away for years. No one really
noticed for decades until now. The guy who treated it probably considers this type of result an
endodontic success and if it fails heíll consider it a periodontal failure.
Do you really believe this is the blurry way we should view endodontic treatment results? - Terry