To save, or not to save? (Saving teeth, that is!) That is the question I have to answer most often. Tiny spoiler alert: we’re talking chronic apical abscesses today.
Here’s Another Case Where I Focus on what I love best: Saving Teeth!
My periodontist brought this case to me and asked if I could help him try to save one particular tooth. They had recently tried to place an implant distal to the canine, but it had failed. The patient was adamant about not losing any more teeth and did not want to lose tooth #27.
The previous root canal in this case was done by an endodontist, but now there was a huge gingival dehiscence on the buccal aspect of the tooth. Not good.
Here is what the CBCT looked like. And wow, you can see just how much bone this patient was missing distal to his canine!
Here’s the thing: He had no pain, just a big hole in his gums. I mean, I could see the root very clear right from where I was standing with my naked eye.
Based on my findings, I was able to diagnose him as having a Previously Treated Tooth with Chronic Apical Abscess. My job now was to try to regenerate his bone the natural way.
I have to admit, during the evaluation I had my doubts. Is this really going to work? When that happens, I take it as an opportunity to have an honest discussion with my patient. But of course, I was still very adamant that I was going to try my darndest to save this tooth.
I can honestly say this case is THE case I attribute to changing my mindset about how things can heal, and I hope it inspires you the same way it inspired me.
Back to My Evaluation of #27 – Previously Treated with Chronic Apical Abscess…
I looked at his radiograph to see what could be the contributing factor, and the only thing I could speculate was that the obturation was about 2-3mm short. My gut told me to re-treat the area over one month, and place some calcium hydroxide. I needed to do all this with the help of my periodontist friend.
Here was my protocol for saving this tooth:
1. I started the re-treatment and removed all of the gutta percha.
2. I made sure I was at working length and really, I mean REALLY patent. I intentionally went a bit long with a very small file.
3. I placed calcium hydroxide and allowed it to sit for one month.
4. In the meantime, the patient spent some more time with the periodontist and the surrounding bone was debrided, a bone graft and membrane was placed, and the soft tissue was approximated. It was important for me to have some sort of root closure to feel confident that this might work.
5. I did a few soft tissue checks over several weeks and found that root closure was happening. Yes!
6. At the 4- to 6-week mark, his tissue was still a bit open, but the dehiscence had shrunk to the size of a normal sinus tract. I thought that, with that much bone loss it was going to take so much longer to heal, so I felt good about obturating and finishing the case.
Here is my conefit radiograph…
And my post-op…
Next Up: The Waiting Game
I did not get complete root coverage by the soft tissue for about six months. When I said this case required patience I was not joking. But, it did eventually close!! Heck yes!
So here’s a bit of wisdom I’m going to share: don’t be too quick to judge.
This patient came back for a recall after a few years and here is what he looked like when he came back (and the recall).
OK, so now I know you might be thinking, “There’s still a ‘lesion’” but given the chronic apical abscess we were dealing with and just how much we came up against in this case: I’d say at this point it was healing pretty darn well.
So, if you run into a case like this and you find a lesion. Please don’t be so quick to judge that the root canal is failing! It may be healing. Some cases, like this one, have a lot to do with patience.
Because here’s the thing: something like this will take years to fully regenerate.
The best part about it is that these days he looks back to normal!
Here’s the before and after…
What’s the lesson here? Hope and patience.
I want you to believe that when you give teeth a chance, when you look at a case with clear eyes and the determination to try your best, things can and do work out.
Yes, this case looked pretty bad at first. And no, there wasn’t a quick fix. But by going through a step-by-step process with the periodontist and exercising a whole lot of patience, we were able to make it work without having to resort to the most drastic measures.
We all can learn to be patient and treat even the cases that look as bad as it can possibly get.
After all, you never know what you’re able to save until you try!
So tell me in the comments what YOUR big takeaway is from this tooth story!