Post Placement and Occlusion Affect Prognosis

A 59 year old male patient was referred to me for consultation regarding symptoms associated with tooth #14.  The tooth had been endodontically treated and restored some years earlier. The tooth was restored with a 2 post retained crown and crown. The patient’s current complaint was a low grade sensitivity to chewing and soreness in the gingival area.

Clinical examination showed porcelain bonded to metal crown with some gingival redness along the distal marginal gingiva. Buccal Palpation was WNL. Percussion and chewing were positive.

Examination of the periodontium revealed a 10 mm probing depth along the distal side of the root.

Radiographic examination of the BW and PA images was revealing.

Firstly, I noticed that tooth #46 had been fairly recently extracted since there was still an outline of the root in the mandibular bone. Secondly, I noted that the patient’s maxillary posterior dentition was intact. Both first and second molars were present and although were minimally restored. The supporting Periodontium in these teeth appears to be quite good, However, due to loss of the mandibular first and second molars, these teeth were unopposed.

Examination of the occlusal plane showed slight supra eruption of the crown in #14, which appeared to lock into the area between #44 and #45. I surmised that the supra-eruption had occurred partly because of the distal drifting of #45 and open contact that was occurring between #s 44 and 45.

Periapical radiography of  #14 showed a crack in the dentin , running from the most apical portion of the post placement, apically. There was an associated lateral radiolucent finding that was consistent with the 10 mm D pocketing.

 A diagnosis of cracked root was made and the patient was told that the tooth required extraction and prosthetic replacement. We emphasized that the lack of first molar occlusion in the mandible may have contributed to loss of this premolar and recommended that both #14 and 46 be replaced prosthetically ( preferably with implants.)

Although the endodontic treatment of #14 appeared to be good, the method of reconstruction ( using 2 posts rather than a single post), the supra-eruption of the tooth and the lack of posterior occlusion probably all contributed to loss of the tooth. 

Endodontic failures can occur,  even with good endodontic technique. The clinician endodontically treating the tooth will always depend on proper treatment planning, occlusion and reconstructive techniques if we are to ensure that the endodontic investment is preserved in the long term. Violation of sound restorative principles, ignoring occlusion,  and placing teeth under abnormal stress can only contribute to physical failure of the tooth and ultimate loss of even the best Endo-treated cases.

Failing Anterior NSRCT needs SRCT

A 68 year old female patient in good health was referred to my office for consideration of tooth #21. The patient’s current complaint was a history of previous intermittent swelling in the buccal vestibule and sensitivity to percussion. The patient had the problem for approximately two weeks and had been seen by her regular dentist, who made endodontic access of the tooth.

Pulp tests performed on the adjacent lateral incisor showed positive responses, indicating normal pulp vitality.  #11 had been previously endo treated and apparently had internal bleaching procedures performed without proper sealing of the coronal part of the  canal, which was still unfilled. #11 was still discolored ( and chipped) and the patient was unhappy with the clinical appearance.  Perio findings in #s 11, 21 and 22 were WNL but buccal palpation sensitivity over #21 was confirmed.

Treatment of #21 was initiated. The canal was cleaned, shaped and medicated with Ca(OH)2. The medication would be left until the patient was asymptomatic and the canal could be adequately dried.   The canal was subsequently obturated and closed with a matching palatal composite.

For reasons that were unclear to me,  the patient eventually ended up in another Dentist’s office. ( From the Spanish notation above the image, this may have been on vacation or “Dental Tourism”.)  In any case, the Dentist probably saw the radiolucent area and assumed that it was coming from #22. ( Had he performed a pulp test, he would have found the pulp to be responsive and normal.) Therefore, the tooth was treated unnecessarily and the endo treatment was not therapeutic for the patient.

cbCT imaging showed that the periapical radiolucent area involved the apices of BOTH #21 and 22. So, if were were to perform apical surgical procedures on #21, (surgically enucleating the entire lesion) it  would have also likely required  elective endodontic treatment of #22. Otherwise, there was a high likelihood that removal of the tissue would have severed the apical vasculature supply to #22, requiring subsequent NSRCT.  In situations such as this, it is sometimes preferable to do elective NSRCT of the adjacent tooth BEFORE the surgery to prevent possible necrotic pulp products  in #22 from compromising healing of the area. In this case, treatment of #22 had already been performed.
cbCT imaging also showed that the radiolucent finding did NOT involve the palatal plate and therefore was not a true “thru and thru”. The chances of healing without the need for GTR or barrier placement were excellent because of this finding.

BU flap with elevation and exposure of the roots of #22 and 21.  The lesion was enucleated in its entirelty and placed in Formalin for biopsy analysis.

Removal of the lesion allowed for excellent hemostasis and access to the root ends. No”Apical Plaque” was visible and the roots were resected to the level of the adjacent normal bone, retro-prepared with ultrasonics and filled with MTA putty.

The area was sutured with 6/0 Proline with an effort made to keep the knots OFF the suture line.  It has been my experience that this results in better, quicker healing.

Biopsy Report returned with a finding of Periapical Granuloma.

4 day postop suture removal. The patient’s post op care and hygiene have resulted in excellent soft tissue healing.