AP on tooth # 21 - Courtesy ROOTS

The opinions within this web page are not ours. Authors have been credited for the individual posts and images where they are.

From: Marga Ree
To: ROOTS
Sent: Thursday, February 10, 2005 1:14 AM
Subject: [roots] Sad treatment outcome of a nice apical closure

I have posted this case before, a 26 year old woman with an AP on tooth # 21. Maybe some of you remember
that I showed this case in my Gattling Gun presentation last year in SLC.

I retreated this case with calcium sulphate, MTA, resilon and composite. It looked pretty nice on the
rad, but the 6 months follow-up showed that the lesion had increased in size. At that time the patient
was without signs and symptoms, so I decided to monitor the case for a couple of months.

After 8 months the lesion was even bigger, and there was a probing depth at the palatal side of > 10 mm.
The tooth was very sensitive to percussion and palpation, and there was a fluctuant swelling at the
buccal side, from which drainage was obtained after an incision. I suspected a root fracture, did a
diagnostic flap, and yes, there it was, at the palatal side, the fracture was partly filled with resilon.
For me that was an indication that the fracture was already present at the time I did the retreatment.
What do you think?

We decided to refer her for an implant, and my husband made a resin retained bridge as a temporary
restoration. He used some ribbond with composite to connect the tooth to the adjacent teeth. The
implantologist will see her within a few days. - Marga

















Marga, Outstanding work and photography!  Even if it did not work.
Nice provisionalization also.  Any thought to a bone graft before closing the ext site? - Arturo

Thanks, Arturo

We discussed this with our implantologist, and he adviced to postpone the bone graft procedure.
According to his experience, it is often difficult to close the flap if you do a bone graft before
closing the ext site, because you can have problems with mobilization of the soft tissues.

He will see her within a few days and re-evaluate the situation
What is your experience with bone graft before closing the ext. site? - Marga

I like to do it the same day.  If I can't get primary closure by mobilizing the flaps I will use a
membrane barrier. Suture closed and let heal.  Later on I will come back to refine the provisional
pontic site if necessary.  If I do a direct bond pontic I will cut the ribbon and then rebond it
after I am done with the pontic site.

I like to take advantage of the bone healing time to develop the pontic site soft tissue contours
for the implant.  If the ridge is short of where I would like it for the emergence profile and if
it will show or cause a hygiene problem I will go back in with a CTG (connective tissue graft) to
plump out the pontic area (future implant area) and try to develop and support the papilla so that
when the implant goes in the sift tissue architecture is already there and stable.  That's assuming
there is enough bone to support the tissue.  Some times more bone has to be added before
the CTG graft - Arturo

Arturo, Thanks for your explanation, I can imagine that you like to do it the same day, since
I assume that you do the whole procedure yourself, so you can plan and execute the whole treatment
as efficient as possible. As far as I understood, our implantologist is planning the same procedure,
but only a few weeks later. Do you think that postponement of the bone graft procedure might
compromize the final outcome? - Marga

Probably not.  I'm sure he will carefully degranulate the site to make sure the graft goes right on
bone.  The only problems I see are patient convenience (sometimes that can't be avoided) and
resugeryzing the same site within a few weeks of the original surgery.   The tissues are starting
to heal and they will have already contracted somewhat.  It may make the soft tissue aspect a
little more difficult, but he's obviously comfortable with that approach.

Marga, you are such a wonderful technician and do such meticulous cases that I know you have the
skills and abilities to do the bone graft.  They are not difficult- the hardest part is getting the
tooth out and closing the flaps.  Both of which you did well.  Try it out.  The only thing you need
to know is what is going into or onto the site after the graft and that will determine the type of
graft and you may have to use a resorbable membrane if you can't get primary closure. In an area
where a titanium single tooth implant will be placed allograft is preferred.  Grafton makes a nice
product that is easy to place and work with.   - Arturo

I would 2nd that.  I love grafton and use it by the ton.  Regenaform is another excellent product,
but requires reconstitution in a heated water bath. Carl misch’s group claims their studies show
better bone fill with grafton than any of the other allografts tested. - gary

Thanks for your input Arturo ! I was already thinking for a while of taking some courses in
implantology, you  gave me a push in the right direction. - Marga

You gave it your best, that's all you can do.  and your management of the situation is beautiful.
I agree that the undetected fracture was the problem from the outset.   nicely done. - gary

I am sorry about the result. Happened to me too and it hurts. My was a apexification case. I suspect
you are correct about the fracture - if there is Resilon in there it was there when you filled
the canal. Excellent documentation as allways and very nice work over all.
How did the patient take it ? - Thomas

Thanks Thomas,  The patient was already prepared that there was a chance that she would loose the
tooth, so it was not really a surprise, but it is always difficult to face such a fait accompli.
She was very relieved that she could have her own tooth as a temporary restoration, she told me
that it almost looked  like nothing had changed. - Marga

I agree that the fracture must have been there at the time of treatment. What I find quite
interesting is the fact that there is a cohesive fracture of the Resilon/Epihany. So it looks like
adhesion works in the root canal. We always learn a lot from unfavorable outcomes. - Winfried

Marga, putting aside the fact, that the root is fractured, I still  think that its a beauty in the
xray, congratulation for your excellent work - Hans