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Orthognath case

From: Terry Pannkuk To: ROOTS Sent: Wednesday, February 24, 2010 1:42 PM Subject: [roots] Another Orthognath Case The pain etiology was a tough one to diagnose. 45 year old female patient had orthognathic surgery 14 years ago. I thought getting a CT scan was a good idea. One screw looks itís right on the MB root apex of #15 (close to the DB of #14 as well). Her cold thermal response was a bit equivocal but I suspect the pulp is vital. Most notably is the fact that she only has discomfort on biting and when I checked the occlusion she was only hitting on #18 and #15 (see photo). She reported some sensitivity to palpation above #12-13 area which corresponds to the hardware which I feel is a separate issue of nonobvious path. I was a bit worried about how #14 would look on the CT but that looks unremarkable (I treated it 9 years ago), maybe slight apical widening of the MB root apex PDL, but it looks like there has been demonstrable osseous regeneration from the 2001 post op radiograph. I donít think performing endo on #15 will solve the etiology which seems to be occlusal trauma at this point. Itís probably best to rule that out first and re-evaluate if necessary. Itís not out of the question that there could be subtle endo path about to develop from affected apical pulp circulation but I wouldnítí presume that at this point. The referring dentist adjusted the occlusion on #15 and 18 today. She was still uncomfortable and on anti-inflammatories. There is a push for me to do the endo, but Iím very hesitant feeling that there is a very good chance itís not endo and want to see how the occlusal adjustment works out first. If the pain persists I may end up doing the endo to rule it out, but I rarely like to do that. In this case it may make for sense to do the endo then have the oral surgeon remove the hardware if pain persists after the endo. If the hardware removal is done first and then endo removes the pain, everyone will be pissed at me presuming an unnecessary surgery. Which is worse an unnecessary surgery or an unnecessary endo? J This case has disaster written all over it. My worst nightmare would be: 1.Occlusal adjustment.patient waits in pain as we monitor. 2.Endo..patient still in pain, patient gets more frustrated 3 Hardware removal.patient still in pain 4.Graft removal patient still in pain 5 Referral to pain management program.patient put on drugs. This scenario is not good. I attached the series of PAís and below are some CT captures that show the screw/bracket proximities and no real evidence of endo path. The big wedge of mystery block graft doesnít look autogenous or to be an allograft, probably balsa wood. - Terry

Terry, Like your analysis. Just perfect. - August

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