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Tooth severly tipped to the lingual - 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: 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
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