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Skiing accident - 2004 - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: Terry Pannkuk
To: ROOTS
Sent: Thursday, April 08, 2010 10:03 AM
Subject: [roots] Skiing Accident 2004

Hereís a chronology of a 15 year old who had a skiing accident 
in 2005 mangling his maxilla and all four maxillary incisors.
I included the emergency CT scan data from the MDís at Boise, 
ID where he was airlifted before coming back to Santa Barbara
and being eventually seen by me.

The focus was on his maxillary fixation instead of his teeth 
so he got treated outside the ideal 7-10 pulp extirpation window,
2 months later.  As expected with these types of cases where a 
child is traumatized the parents are super involved and
hyper-involved in the treatment so itís exhausting and very 
energy draining.  I wrote countless letters and reports to
satisfy eveyroneís concerns, rightfully so.  Itís a big deal. 
This teenager was a great kid.  I gave him my max effort
to keep these teeth as long as we could, but I only changed the 
calcium hydroxide twice and did not add a cocktail of
Ledermix like I probably would today.  Itís hard to say if 
the outcome would have been different but I was surprised
to see the resorption rapidly develop within a couple of years. 
Clearly these teeth must have been severely dislodged/intruded 
in the sockets and they were doomed.  The two central incisors 
were extracted 7/31/2007 and the two laterals were used 
provisionally to support a Maryland Bridge while the 
grafting/socket healed. The patient is now age 20.  
(the facial pics show an interesting transformation of a pimple 
faced kid with braces at age 15 to a man at age 20).  
Teeth 7 and 10 had to come out 4 months ago and the implants 
were placed. When I recalled him a couple days ago the labial 
bone of #11 was blown away and he has severe recession.
The endo on #11 was fine and implantologist who placed the 
implants is going to perform a gingival graft.

Interesting take home points/questions:

1.  Would the outcome had been different if I had kept him 
    in CH indefinitely/used Ledermix?

2.  Was the resultant resorption due to the delayed pulp 
    extirpation and placement of intracanal CH?

3.  Was the delay of extracting #7 and 10 related to gingival 
    inflammation that progressed and cause the #11 labial blow out, 
	or close implant proximity to #11?

4.  Am I smart to not consider taking on high risk implant 
    cases like this?  (I know Robís opinion )

These cases are learning experiences - Terry


Patient: xxxx  Date of Birth: xx xx 1990

AccessionNo RequestID Report's Date&Time Status Organ  
1625771 .. 2004.12.20 15:30:00.000 SIGNED NEURO

DATE:     12/20/2004

FACIAL CT WITHOUT IV CONTRAST WITH REFORMATIONS

CLINICAL DATA:  Skiing injury.

COMPARISON EXAM:  Head CT 12/20/04.

PROCEDURE:  Helical noncontrast axial scans were obtained 
through the facial bones with 2.5-mm axial scans
and coronal reformations performed

FINDINGS:  A fractured anterior nasal septum with 6 mm of 
left to right deviation is present. There is a faint lucency 
at the right nasomaxillary junction which may represent a 
nondisplaced fracture or vascular impression.

Some additional nasal lucency is probably vascular in 
sutural markings although I could not exclude
nondisplaced fractures.  Soft tissue swelling is seen 
over the nose and both maxillary sinuses.
A small buckle fracture of the medial left maxillary 
antrum is present.  The supermedial wall of the
left maxillary antrum appears to be displaced medially 
over the inferior turbinate.  This is probably
a developmental variant although might

represent a left anteromedial wall fracture.  Disruption 
and displacement of maxillary orthodontia or hardware with 
loosening of the medial incisors, left lateral incisors 
and left canine are present. There is marked displacement 
and rotation of the left medial incisor.  There is subtotal 
opacification of the left maxillary antrum consistent with 
a combination of posttraumatic hemorrhage and sinusitis.
Soft tissue density fields may

partially obstruct the left osteomeatal unit.  These results 
called to Dr. xxxxx  at 2:20 p.m. on 12/20/04.

CONCLUSION:  1) There is a fracture of the anterior nasal 
septum with 6 mm of left to right midline shift,
a small buckle fracture in the medial left anterior 
antral wall, possible nasal and left medial maxillary wall
fractures, and dislocated/loosened maxillary teeth described above.

2) Subtotal opacification of the left maxillary antrum 
consistent with a combination of posttraumatic hemorrhage
and possible preexisting allergic or

inflammatory change. ELECTRONICALLY AUTHENTICATED xxx M.D.   
Dec 20 2004  3:30P Boise xxx

- Terrell F. Pannkuk, DDS, MScD

Protaper flaring
6 yr old Empress
Cvek pulpotomy
Middle mesial
Endo misdiagnosis
MTA retrofill
Resin core
BW importance
Bicuspid tooth

Necrotic #8 treatment
Finding MB2 / MB3
Deep in a canal
Broken file retrieval
Molar cases
Pushed over apex
MB2 and palatal canal
Long lower third
Veneer cases
CT Implant surgury

Weird Anatomy
Apical trifurcation
Canal and Ultrasonics
Cotton stuffed chamber
Pulp floor sandblasting
Silver point removal
Difficult acute curve
Marked swelling
5 canaled premolar

Sealer overextension
Complex anatomy
Secondary caries
Zygomatic arch
Confluent mesials
LL 1st molar (#19)
Shaping vs Cleaning
First bicuspid
In Vivo mesial view
Inaccesible canals

Premolar 45
Ortho and implant
Radioluscency
Lateral incisor
Obturation
Churning irrigant
Cold lateral
Tipped to lingual
Acute pulpitis images

Middle distal canal
Silver point
Crown preparation
Epiphany healing
Weird anatomy
Dual Xenon
Looking for MB2
Upper molar resorption
Acute apical abcess
Finding MB2

Gingival inflammation
Irreversible pulpitis
AG BU ortho band
TF Files
using TF files
Broken bur
Warm technique
Restorative prognosis
Tooth # 20 and #30

Apical third
3 canal premolar
Severe curvature
Interesting anatomy
Chamber floor
Zirconia crown
Dycal matrix
Cracked tooth
Tooth structure loss
Multiplanar curves