Crazy Internal Resorption.
Resorption June 6th, 2007
Internal resorption cases that are as advanced as this are difficult to manage, especially if they are more coronal and compromise the integrity of the clinical crown.
The complication with this case was that the resorption had perforated the root. Every time I tried to regain the true canal beyond the level of the defect, my instruments would slip out the perforation. Because of this I decided to limit obturation to the level of the defect.
The prognosis of the case is fair at best and could require surgery to address the apical area and perforation better. Surgery isn’t a great option either though because if I end up having to resect the root to the coronal aspect of the defect, the tooth might become very unstable.
June 6th, 2007 at 4:07 pm
u say the tooth may become unstable? i think if i had ur job, i would become unstable! i admire u, man. in my opinion, ur the best endodontist in the world! if i ever need an RCT (and i pray i never do), im flying over to see u!
June 6th, 2007 at 7:32 pm
hmmm….i say extraction and implant. you did a great job with what you had, though.
are those open margins on that crown? tsk, tsk
June 6th, 2007 at 8:17 pm
Anon: I just do what I can. Thanks for the comments, but I’m sure there are better endodontists than me.
Dr. Mom: Yup, deficient margins. But as I always say, “What can *I* do about that?”
Extraction is a little premature right now. There’s a decent (fair) chance that things will be good indefinitely. A couple of days ago I had an almost rude awakening when I was reminded that implants in the premaxilla don’t necessarily have a good prognosis. The bone is less dense, there can be angulation issues, and if the tooth is infected, there might be a dehiscence…not good things for an implant.
June 7th, 2007 at 8:30 am
question – i’m assuming this was a vital case, how do you thoroughly clean out debris and pulp tissue in a defect like that when the defect is so far apical? it must be near-impossible to instrument thoroughly. do you use ultrasonics?
as for the implant discussion, while the maxilla defninitely has a more guarded prognosis than the mandible and poses greater challenges, there is still around a 90% average success rate in the area (but you’re right, when these cases tank, they tank well, remember the implant i pulled out two months ago???). i wasn’t saying to just automatically extract the tooth and forgoe endodontic treatment (at least that was not my intent). but there have been cases where it’s a 50-50 toss up and that from a restorative and perio perspective the tooth may have a guarded prognosis. if you feel confident of the success of this treatment, even better for the patient. i can’t wait to see the recall pictures!
perhaps my perspective is a little skewed at the moment. one case that i just refered to the endodontist the other day is a re-treatment of 11, 21. this patient had root canals completed in china when she was about 9 years old so the canals were HUGE (i’m thinking an *initial* K file size of at least a 90) i think apexification may have been attempted, because the roots are quite short. the fills are deficient and two enormous screw posts were wedged into the canals and the whole mess was finally topped with a heap of acrylic/composite/whatever that spills over the lingual margins and onto her palatal gingiva. she “doeesn’t like the way they look” and there’s recurrent caries. my first instinct was re-treat and crowns but my concern was how weak these teeth might be after those metal posts were wedged in there for so long. there’s a significant risk of root fracture down the line. she needs cast posts and crowns, treatment costing about $1500 per tooth on my end alone (and also not counting that her laterals also need re-treatment and crowns). in my opinion, i don’t know if its worth it to pour all of that money into something that may or may not last more than 5 years when you can spend the same amount on something that has a more preditcable outcome like a bridge of implant (because lets face it, finances are always a huge mitigating factor when it comes to situations like this). i sent her anyway and i’ll see what he thinks, but not until the patient and i had a thorough conversation about all of her treatment options. i would rather that it came from me, the restoring dentist, than the specialist. there have been one or two cases that i’ve refered thinking re-treatment was a great option and he says, not worth it, extract and implant, and i take a second look and i’m like, “yeah, i can see that…”
i wonder what the referring dentist had to say about it. the good news is that at least this patient already has a crown and doesn’t have to plunk down so much for extensive restorative treatment.
June 7th, 2007 at 4:46 pm
The case was infected prior to treatment. Infected or not, in situations like this we rely more on chemical rather than mechanical disinfection and debridement. That involves copious irrigation and a medicated phase of calcium hydroxide. Calcium hydroxide has been shown to necrotize tissue which can then be irrigated out.
The case was done over 2 appts using CaOH. A pre-existing sinus tract closed during the medication period so we’ve at least got some short term signs of healing.
The prognosis of the tooth is currently fair. Not good, or poor. This in my mind is reason enough to leave it alone and monitor for now. Also the patient is 17 (I should have mentioned this before). I’m not an expert on jaw growth, but if there’s potential for growth, the positioning of the implant might be a problem at this age.
The referring dentist relies on my judgement, so doesn’t really have much to say about the tooth. We knew that a perforation was very probable in the defect from the time I saw the pt for a consult.
March 5th, 2008 at 5:50 pm
[...] a month and a half recall film of the internal resorption case I did a short time ago. I just finished a retreatment of 11. Looks like healing is progressing [...]