From: Terry Pannkuk
To: ROOTS
Sent: Friday, April 24, 2009 8:42 PM
Subject: [roots] Yesterday's Rheology

No resins at all here. I finished this case yesterday.  The tooth was severly tipped to the lingual.
The patient had a huge tongue, gagged and threw up on me on Tuesday.  The anatomy was super complicated.
Her caries index is very high and there was no way I would consider resins in this case.
I'm worried the restorative dentist is going to have a tough time restoring it.
I gave him the best core I could (bonded amalgam of course) hoping it simplifies things on his end.
Resins have their limitations and complicated cases like this require an "old school" approach to minimize
technique sensitivity and the chance of future problems - Terry





Terry, that is a beautiful job, but I have to ask from a restorative aspect is there enough tooth structure
remaining to do an adequate reduction and establish a proper ferrule for long term success?  Obviously you
feel there is, but it looks like a close call from where I’m sitting. - gary

Excellent point. There was very adequate tooth structure everywhere except the mesial box which required crown
lengthening/electrosurg.   The biggest issue I have with the comprehensive treatment plan is the ortho.
This patient's teeth are in gross malocclusion, and I'm wondering what the end result of the plan is going to be.
You can see on the second molar a lesion as well. Throughout her mouth she has recurrent caries and problems.
I performed a full mouth endo exam and highlighted all the endo issues as well as some of the gross related
contributory concerns affecting tooth retention.  The questions regarding long term stability and function remain.
I felt comfortable being a part of this treatment team because everyone is trying to appropriately work out
priorities given the patient's economic restrictions and immediate needs. This tooth presented as an emergency.
A crown will likely be placed with the tooth having a very unusual/nonideal occlusion, but the alternative was
extraction, further posterior bite collapse, and a progression of bigger problems.  I view the referring dentist
as a very competent, thoughtful practioner; we are simply providing the best of the available options which are
clearly an unavoidable compromise of the unavailable ideal option (orthognathic surg, ortho, long term provisionals,
and full mouth reconstruction).  If we can eventually get her into some sort of stable clean-up plan, maybe this
tooth will be uprighted.  The photos are misleading, there was more of a ferrule than you think, but like you
I'm worried about the long-term prognosis given the bigger issues, primarily the unstable occlusion and propensity
for caries.  This tooth may not have a great prognosis, but I certainly don't want the endo or the build-up to
be one of the "weak link" prognosis factors - Terry

She obviously ain't the best patient on the planet.  If I'm not mistaken, there some pretty good caries on that
tipped 3rd molar, and perhaps the distal of the 2nd, among several others.  You can only do what they allow
you to do.  One miracle at a time, even in southern cal - gary

Excellent work Terry! - Sanjay Jamdade

CLAP CLAP CLAP CLAP!!! Great endo and restaurative work. GP must be very pleased to work with you.
As we say in Spain  Ni a Felipe II se las ponían así - Javier Pascual

Thanks Javier and Sanjay,

It was pretty dicey on Tuesday.  She started gagging when I had everything isolated with Dycal, I quickly thumbed
a Cavit in the access and she upchucked all over the op. I was very concerned about aspiration.  She was amazingly
appreciative considering the ordeal, complexity, and the length of time it took to treat this case.   I got her
back in yesterday to finish, Rx'd her Xanax and she did great.   I didn't want too much time to pass because
I was worried about the "quick Cavit stuff" not being a great seal.

The take home message is that it's never good to press things or panic.   This was one of the toughest cases
I've had all year, patient-management wise,  tooth positioning wise, and anatomically.

I didn't create the anatomy, I just discovered it, taking all the time necessary to clean, shape, and pack it.
A final post op radiograph that shows root canal preps having the same shape as the placed cone likely represents
uncleaned, untreated root canal system space.  We should strive to see our cases have the look of natural Hess anatomy,
not the shape of a symetric autofit gp cone.

Access with prudent convenience form ("SEE" access, or strategically extended endodontic access) is essential
for apical third management and control.  The flow of the obturating material represents the efficacy of the
previous essential treatment steps.  Constricting access and preventing direct line visualization, instrumentation,
and debris evacuation is a serious treatment error - Terry

Did she also have limited mouth opening and complained about isolation? ‘Cause that would be the perfect nightmare
described, patient wise J.

Good for her it ended up in your hands already in the first treatment attempt. I’m sure there won’t be need for a
second one. Great job. - Leo.

Terry I have read about this isolation with Dycal often here but I haven't seen a technic /  blow by blow account
how it is done. I attempted to discover it for myself but the Dycal set all over me and I had to give up.
Could you reeal some professional secrets here? - Sanjay Jamdade