Please refer back to the original entry – Riddle me this DDS….These exchanges go on daily on so many treatment discussion forums world wide….what a joy it would be to see this happen at Oral Health….
There is nothing wrong with removing tooth #3.7 and placing and implant, which may be where this ends up regardless. These were the points of discussion before electing to do the resorption repair surgery.
Extra Pretreatment Considerations:
1. First of all there was no reason to up the ante and redo the endo, which showed no obvious signs of recurrent disease even though I suspect it was treated slightly short and maybe has a widened PDL, not enough of a case for retreatment, especially given the complexity of treating the resorption. 2. The patient was highly motivated to save the tooth and did not want an implant. She was receiving ideal care from a great dentist so the follow-up restoration is not going to be a weak link in the outcome. 3. She accepted all the disclaimers and realized that if treatment failed she wasn’t’ going to get a refund. Her dentist also promised me he wouldn’t be pissed if my treatment failed. In other words I prepared everyone for failure so I could be calm and give this my best effort without personal anxiety. 4. I was very worried about controlling the placement of the root repair material in this posterior position due to isolation challenges would predispose debonding/dislodging of the Geristore. I went back and forth with her dentist about this and we finally decided that we didn’t want to bury the crown margin on the mesial with a deep osseous recontouring procedure taking away too much bone and finally decided on having the crown margin rest on Geristore creating a more natural interproximal contour, removing tissue and letting the bone healing end up where it may. Attached (Page3.jpg) is the final radiograph after the procedure with the red outline showing the ideal crown margin plan (chamfer). Hopefully occlusal forces won’t cause eventful debonding of the Geristore (but it might).
Treatment:
1. Envelope flap (buccal and lingual with no releases). 2. The entire interproximal “col” was removed down to bone along with all granulation tissue associated with the resorption defect. No attempt was made to close the buccal and lingual margins of the flap at the end. Wound healing is secondary intention by design. This greatly simplified control of the prep and hemostasis during matrix placement. 3. The gingival margin was identified and a small amount of bone was cleared away to create identifiable smooth prep margins. A few retentive dots were placed with a Munce bur and long ultrasonic tip into the corners of the prep for a little bit of extra mechanical retention. 4. Trichloracetic acid was placed with paper points along the prep margin treating the adjacent bone/tissue. 5. A “floating” Striptease matrix was cut and adapted to the prep and Dycal injected to secure it tightly against the margins. 6. The prep was etched with phosphoric acid and the Geristore placed. 7. The matrix was removed, the prep finished down so that the temporary would fit. 8. A Collagen pad was cut and placed at the base of the interproximal floor of bone as a wound dressing. 9. The temporary crown was recemented with Zone, the cement cleaned up. 10. The collagen pad kept the temporary cement from going deep. I removed the collagen pad and replaced it with a fresh one. 11. One suture was placed simply to keep the collagen pad in to cover the exposed interproximal bone.
I plan to remove the suture on Thursday and inspect the healing. In two weeks she can have the crown re-prepped and a new temporary made. That will be the next decision point. If the Geristore falls out we have to decide whether we want to try again or just extract the tooth and place an implant. I’m prepared to do either. So is the patient and the referring dentist.
This is a very unique case and this treatment decision is not for everyone or every presentation that may look the same.
Terry Pannkuk, Santa Barbara, CA – double click images
