Endo tips    Better Endo    New additions    Endo abstracts    Back to home page    Endo discussions

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

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 it’s 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 don’t think performing endo on #15 will solve the etiology which seems to be occlusal trauma at this point.
It’s probably best to rule that out first and re-evaluate if necessary. It’s not out of the question that there
could be subtle endo path about to develop from affected apical pulp circulation but I wouldn’t’ 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 I’m very hesitant feeling that there is
a very good chance it’s 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 PA’s 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 doesn’t look autogenous or to be an allograft, probably
balsa wood. - Terry





Terry, Like your analysis. Just perfect. - August