AP on tooth # 21 - Courtesy ROOTS
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From: Marga Ree
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
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
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.
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