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Retreatment, surgery or implant?
From: Marga Ree
Sent: Monday, May 18, 2009 7:09 PM
Subject: retreatment, surgery or implant?
This patient wanted to have the crowns replaced on her 4 max.
incisors. 12 is symptomatic, apico was done several years ago.
What would you suggest?
Would anybody consider surgery here? Or would retreatment be
your first choice? Or a combination of retreatment and surgery?
Or an implant? - Marga
symptomatic how? I see no lesion - Dan Shalkey
She is always aware of this tooth, and painful to percussion
and palpation - Marga
Pappilla based flap, some Crown lengthening on te 11 21 22 and
a look and see on the 12 with probably an re-treatment of the
Rationelle: surgery is needed for C.L. so at least take a
look at the 12. - René Stevens
René, Why would you consider crown lengthening?
She hates the recession on 12 - Marga
Ok....you asked for it. :):):)
No surgery, no implants. The tissues have been beat up enough
from the slicing and dicing and the esthetics are showing it.
More surg-more problems.
I would dismantle both, place CH maybe even some Ledermix first,
then after intial healing pack with MTA and bond with a thick
fiberpost, NO Shoulder preps on the crown!
The lateral would be an interesting nonsurgical amalgam removal
case, taking out the resin and alloy. Silver points are usually
soft and I'm sure you can eventually slide a large Hedstrom
along side it and yank it out - Terry
Sounds like a good plan.............:-)) - Marga
The suggestions for esthetic corrective surgery are well founded,
but only after the endo path is eliminated. Endo surgery
would be a mistake - Terry
Agreed - Marga
You definetly need some surgery or the crowns would suck big
time! Either way you take ,implant or re-treatment.
If he wants to change the crowns he does not like the tissues
around them as the color is not that bad.
So if you want predictability you better trie first to get
the tissue stabilized around those teeth so retreat and perio
surgery. Then, new lovely festpaldic crowns.
If those were my teeth that;s the the way i do it!
if 1.2. is fractured the answer would be obvious so i assume
it is not! Can you show us the clinical pic without the crowns!
It would help a lot in diagnosis! :) - Bogdan
Why would surgery be beneficial for future new crowns? - Marga
the 11 21 22 are a bit square sized and need a bit of added
length and symmetry for an better looking result, the difference
with the gingival margin of the 12 will be improved also.
P.s. I would like to see a bit better what is going on with the
11 apically. And knowing you i could be totally wrong here ,-)
hi marga, it is tricky! we have to see every site by its own.
from endodontist and periodontist point of view. i guess first
is to realize customers confession to see which god we have to
pray to. secondly in my eyes we should give the patient a
success. he (?) wants new crowns and he doesnt like the
recession, did he? so lets look to the gingiva situation first.
if you would connect 13 through 23 the apicla point of 12 and
22 should be slightly higher and 11 and 21 direct on the line
((young- women a little bit mor apical) . how to get this:
site 12 has recesssion miller class III i guess. so you need
a graft procedure you could place a connective tissue graft
and cover it by a lateral rotated flap from site 13. coronal
positioned flap on 12 seems not a good idea due to the scary
tissue apically. 11 should get a coronal positioned flap or
semilunar flap. the gingiva 21 seems to place a little morr
apical - depends on the pocket depth there if you should
perform a gingivectomie, apical positionesd flap or only by
placing exact provis. 22 seems on the right position it would
be perfect to get the same hight on 12. provis - no question
about- should be placed on correct legth. in the regeneration
time i would do orthograde retreatment. long time later you
could perfore endo surgery if neccessary included aesthetic
change of the colored and scary tissue apical, but i guess
you dont need. to do endodontic surgery first is no option
cause it will fail and you will have more recession and fall
in to class IV with no chance of regeneration. placing
implants w/o any mucogingival surgery will lead to the same
estehtic problems you have today, so it is no successful
option. so implants would stand for a long time healing
period with removable prothesis. and a high level surgery
with long time healing period. my 02 cents - Dennhardt H
Dear Marga, Again, a challenging case! I would go for the
non-surgical retreatment because there is no way that i can
assure that the canal is bacteria-free. Only when the
obturation of the canal is as good as possible (and the
microbial load as low as possible), healing will occur
(furthermore, during the retreat, possible cracks and other
problems can be detected) and even the best surgery in the
world cannot clean the entire root canal. If I'm really
sure that i did the most i can with my non-surgical
approach and still, the tooth is symptomatic, i would go
for the surgery - Bart
Bart, I fully agree, and guess what, it was a bit of a
trick question....yes, I am pretty mean.....:-).., in that
sense that I already knew the outcome before I posted this
case. Funnely enough, only you and Terry focused on carrying
out a retreatment first, without taking out the knife.
Exactly my treatment approach.
This is the whole story:
Believe it or not....this patient was referred to me by an
implantologist. Unsighty scar tissue, high smile line,
recession of gingiva, thin periodontal biotype ... He didn't
want to burn his fingers on this highly demanding female
patient...:-)) I asked him to make a temporary construction,
to assess the remaining tooth structure.
I prepared the patient for surgery, but I was able to remove
the remnant of a silver point and the old retrofil in the
lateral by an orthograde approach, and packed it with MTA.
The silver point in the central was a challenge, but I was
lucky, it came out with the hedstrom and hemostat trick.
MTA again and placement of fiber posts in both incisors.
I used the temporary restoration as a mould to make a
BU of composite.
I 'll post the prosthetic follow-up in a few months - Marga
selective hearing or reading can be a blessing :-) )
What a hell of a job to remove all this silverwork! Actually,
seen the quality of this work, I'm quite sure you will not
need the surgery. Love those mean tricky cases! - Bart
Implants are a little tricky especially in the esthetic zone
and lower anteriors. I have a lower anterior case I wish
I had tried a little harder before going to an implant.
I like the decision your implantologist made.
Do you think there is any buccal bone over the lateral that
has the recession? A sub-epithelial connective tissue graft
should give some root coverage prior to the new crowns - Dan
Hello Marga, can you enlighten me on what the trick with
hedstrom and hemostat is? - Rafaël
Hi Rafaël, The trick with the hedstrom and hemostat is simple:
Flood the canal with choroform. Bypass the silver cone with
small files, # 08, 10, 15, 20. Of course the first file may
take some time, I prefer to use C+files for these prcedures,
they are more stiff than regulare files.
Engage the silver cone with a hedstrom file # 20, 25, or 30
by turning it clockwise while bypassing the cone
Clip a curved hemostat (I used a straight one here, but a
curved one is easier) to the shank of the H-file under the
handle and find a mesial or distal adjacent tooth as a
fulcrum, to enlarge the force. Rock the hemostat against
this fulcrum, and use it as a crowbar, to launch the cone.
There is a video clip on the Website of Steve Buchanan to
show this technique: http://www.endobuchanan.com
I think you have to register first, and then go to Media
showcase, technique clips, carrier removal - Marga
hi marga , any concerns about recessions and change of the
esthetic of gingiva margins? - Dennhardt H
Marga, wonderful work! Could you please describe your
technique for removing the retrofill from an orthograde
approach - do you just use ultrasonics to break it up?
Well, you already guessed it, I used ultrasonic tips to
break it up, and irrigation solutions to flush the remnants
out of the canal. I have got some prebend explorers in
my drawer, to fish out the pieces. This was superEBA, so
not as difficult as amalgam. You can follow this approach
with amalgam as well, I did some cases in the past
successfully. Terry has a very nice description on this
procedure, maybe he can chime and comment - Marga
The more implants I do, the more I like to save teeth
whenever possible! Great discussion - Dan Shalkey