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Nice Recall in a hopeless case! - Courtesy ROOTS |
| The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. Photos courtesy Jörg Schröder - ROOTS |
From: Jörg Schröder To: ROOTS Sent: Tuesday, January 15, 2008 3:44 AM Subject: [roots] Nice Recall in a hopeless case! Pt. has been treated with bisphosphonate . # 26 showed a large periapical lesion with a draining sinus in march 2007. I discussed the problem of surgery/extraction under the medication with bisphosphonate with the Pt. Finally we started the endo-adventure in may 2007. After access was prepared there has been a supracrestal perforation near to the furcation which I closed with a flowable composite. I left the CaOH2 a matrix and placed the composite. MB and P joined in a c-shape manner and ended in one foramen. After C&S the MB and the P I placed CaOH2 as a medication and used composite as a temporary filling. In 8/2007 the draining sinus has closed and we reentered the tooth. Due to the large apical lesion I used collagen as a periapical matrix to avoid a massive extrusion of MTA. For estethic reasons I am not happy with the small amount of MTA beyond th eapex ;((. But as the 7 month recall shows: Healing takes place. Will post the case again, when the healing is complete. Unbelievable what nature can do! - Jörg SchröderCongratulations Jörg!!!! Excellent management of a difficult and challenging case. Thanks for sharing!!!! BTW, how did you retrieve those gp points from PA tissues? - Carlos I used a Microopener (you can prebend it , if necessary to get around "corners") and a lot of patience ;))) - Jörg Great case! What adhesive do you use to place composite against the CaOH2? Do you etch? What do you use to seal rubber dam? - Roman Bakowicz Yes, I did etch with phosphoric acid, then placed Syntac Classic (2 bottle) , then Heliobond and finally Tetric Flow. I had to do the etching/bonding 2 or 3 times until the CaOH2 covered the perforation and no bleding took place. For sealing I am using Opaldam. - Jörg What a great case Jorg....thanks for sharing......amazing documentation and clinical case. CLAP CLAP CLAP - Glenn Unbeliable work performed too !!! And superb documentacion, this case deserves to be edited on video and published as a case report for more details. CaOH2 used as matrix to repair perforation is powder alone, homemade paste, brand new paste as Ultracal XS?. How do you put in place?. I haven´t heard about this technique before, and when you flush the etch is seem difficult not to dislodge CaOH2 and provoke new bleeding. Is the repair of perf with flow definitive? or only for bleeding control purpose during the procedure? What about irrigation protocols used? How long did CaOH2 paste I guess stay in place? 3 moths (May to August)? Did you ex-change sometimes? When did you expect/observe fistula closing? And about Composite as Temporary filling interappointments, did you put just over CaOH2 paste, previous etch/bond? Did you fill definitively the root canal system with a plug of MTA + gutapercha/Resilon or only MTA? And finally, did you delay the guta/resilon or the definitive buildup with composite in order to achieve MTA setting? How many appointments? How many time (doc even add time consuming)? ... It is worth definitively, but it should be planed/protocolised, and even consider what to do if it do´not heal ...Nuria Campo Thank you, Nuria. I will try my very best to answer all your questions. After removal of the post I could see a little bleeding point. The ELM showed apex, so I was sure to look at a small perforation in the furcation. The NaOCl irrigation stopped the bleeding for some seconds. I used this to gently dry the area with air and then placed Dycal. It contains 50% CaOH2 . It sets very qickly if it gets exposed to moisture. his has been the "initial" sealing of this perforation. A then etched and bonded the area and used the flow as a permanent repair, as the defect has been above bone level. I am using 5%-NaOCl as main disinfection solution. If I am working on wide foramina/perforations/ I use 0,2% CHX for flushing debris , GP , parts of CaOH2, out of the canal, or even out of the periapical area. Because the CHX is below 1% there are almost no staining reactions. The time delay between placement of the CaOH2 and the obturation has been caused by the patient. She did not want to visit us again for buisiness reasons. The fistula was closed about 2 weeks later, as far as I remember. Sure it would have been better to change the medication; in this case I have been lucky that the bugs did not party their revival.;) When I use composite as a temporary seal for the access-cavity I always place a small sponge over the medication, then use a small amount of Cavit to fix and cover he sponge. After doing that in all canals I also cover the pulp floor (if existing) with cavit. Then I etch and bond and place the composite of choice. Sure , there is some work to do, when you reenter the case, but on the other hand I feel better regarding coronal leakage. I only used MTA to fill the root canal. As I am using the Angelus MTA I waited for setting (about 15 minutes and then placed composite. All in all we had 4 appointments: 1. PreOp Xray and discussion about therapy options 2. removal of GP, C&S and medication. 3. I had a look on the tooth/gingiva, if the fistula had disaapeared. 4. obturation and build-up. I gues it took me about 7 hours in total (4 appointments) We started the treatment like some german soccer-coaches use to say when they are asked, what will be the tactics for the rest of the season: " We are thinking from game to game". To be honest: I never dreamed of a result like this, but there has been hope. ;))) We had nothing to loose. But I will always tell patients with similar teeth, that there might be a chance, but... If this would not be a pt on bisphosphonates I would have recommened extractio, because of the predictability of the result. Puuh, I hope I did not forget any of your questions - Jörg Jörg, I am exceedingly grateful to you. I abuse on your experience a bit more. Angelus MTA is only Grey version or White too as ProRoot MTA? In any case, do Angelus MTA stains dental tissues like ProRoot Grey & White? Do you have any article about Angelous MTA? I´m far to be an expert on implants, but my 1st impression is that it is not the best prognosis case for implants even in the case that bifosfonates weren´t been taken, done the periapical lesión, the near sinus location ... thanks to your effords the Natural Implant = The tooth wons this time. - Nuria Hello Nuria, sorry, I don't have articles about MTA Angelus. As far as I can tell, there is no staining, but I can only report about a period of 2 years. You can get Angelus in grey and in white, but I prefer the grey one. - Jörg
