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 Retreatment Failure
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, John A Khademi
From: Terry Pannkuk
Sent: Wednesday, 13 September 2006 8:02 AM
Subject: [roots] Retreatment Failure

This case was a mess; bridge with a caries washout. I pushed for implant replacement but the patient
and gp wanted to replace the bridge.  I usually donít get bullied into these cases but all the
disclaimers were in place.

To make a long story short, I retreated the first bi, treated the second. The cervical root was extremely
eroded but not particularly caries involved. I shuddered to think how the dentist was going to restore it.
I retreated the first bicuspid obturating the entire root canal system with MTA, then bonding up a
composite core. Yesterday was 1 Ĺ years later, the patient had been in a temporary splint for the entire
period (not a great situation with his caries index) The second bi has a questionable lateral radiolucency
but shows extensive periapical osseous regeneration.  The first bicuspid was failing with a PA radiolucency.

The patient was finally ready to have the new bridge started so I suggested an exploratory flap to clean up
the 1st bicuspid and make sure it was ok.  There was very little buccal bone but it wasnít hopeless.
I removed all PA granulation tissue and took sequence of pictures to show a blocked out accessory canal
filled with debis/gp and a 90 degree lateral canal offshoot that I had to sequentially bevel away without
disrupting the critical remaining buccal bone.  I took a pic at the end to show the lateral canal and
accessory canal beveled away leaving only the one large portal of exit filled solid with the MTA that
I had placed 1 Ĺ years ago.

The interesting thing about this case was the decision to ether prep the accessory and lateral canals for
a reverse filling with fresh MTA, or what I did, simply beveling these complexities out.  I figured that
apical prep and reverse-filling would have required further beveling of the root to gain access and
adequately seal these complex entities.   It seemed much better to use a very large carbide round bur and
have the depth of the ball bevel out the anatomy behind the wall of critical buccal bone. If this anatomy
had coursed more coronally I would have failed to adequately treat the case.

I still question the status of the second bi with the lateral lesion but wasnít going to go after it today
not knowing the position of the defect and if it was accessible.   This will require further discussion
with patient and dentist - Terry

Nice case Terry thanks what did you graft with? - Simon Bender I had a patient cancellation right afterwards so I put in some BioOss.- Terry
Hi Terry,, This case that you hate just came in for a 6morc today. She is fine. :-)) A sinus tract had persisted B #8 for years. Her GP was, well, Randy says be nice. We began treatment 11/2005 with a couple of CH changes, one of them blowing out the S/T. By Feb, the S/T had not healed so I moved on to a thru-and-thru. This case, I squirted, reflected a flap, and the lesion was over the lateral root surface pic3. There was tartar on the root end. We curretted the root end, and the curretted off the lesion, and began resecting the tooth. Pic5 shows the beginning of a lateral canal in the "bowling pin" shape of the resected GP. I discovered other lateral canals as well, that were filled, partially with GP and partially with sealer. I prepared them all (pic6) and filled every hole with MTA. Pic7 is two or three weeks PO. Pic8 is 6morc. Big Smile on her face. Getting braces now. :-))) John A Khademi
Well Hell, thatís one way to do it. - Terry John: hmmm....no grafting???.)) Just kidding man, this is a phenomenal case - ahmad Ahmad, I'm gonna pay for this post. :-))) I always worry in surgery about apical scarring, and that some clown will go back in and screw up the case. Therefore, for "prophylactic reasons only" I usually sprinkle, not jam pack, sprinkle, a little DFDBA in the crypt. I have no illusions about this "graft" or it's intended purpose. More than likely, the case would heal just fine with no scar without it, especially in a small lesion case. However, on average, the biologic price to pay, for such a small amount of material, a lot of which will be resorbed, that is not densely placed, does not occupy a large volumetric percentage of the blood filled crypt is low, even if the tooth is lost and an implant placed. It's a judgement call. I want the case obviously healed to the unsophisticated eye. I don't recall if she got a graft or not, but the answer is "probably" For $150 at most (material cost) Thanks. :-) - John
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