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Retreatment, surgery or implant?

From: Marga Ree To: "ROOTS" 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 apico. 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. - René. 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? - Jonathan Thanks Jonathan. 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
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