For this article I am sharing a case from my Associate doctor. My Associate is such a badass and I love her passion for saving teeth. I really hit the jackpot finding her (well, she found me) and we couldn’t be more aligned with our core values. Check out this sick case that she just did, and she has some impressive follow-up. So this one is all about root perforations — do you know how to handle them?
I honestly thought when I first saw this preoperative radiograph that this tooth was toast. But, this girl went for it. Like I said, she doesn’t like to give up.
Let’s chat a bit about perforations, because the things that affect a perforation are TIME, SIZE and LOCATION.
The longer the perforation has been there, the worse the prognosis.
The larger the perforation, the worse the prognosis.
And the more coronal the perforation, the worse the prognosis.
Because anything that comes in contact with the sulcus bacteria will likely leak and break down and has already been contaminated. So, the more apical the perforation (free from bacteria) the better the prognosis.
So check out her case…
The tooth was previously treated and there was a sinus tract.
The diagnosis was Previously Treated and Chronic Apical Abscess #5. Since we always want to know the true etiology of failure, it’s standard for us to take a CBCT in our practice.
You can clearly see the path of the bone loss headed to the apex and the patient had a 9mm probing depth in that area. But, the axial view shows you the etiology!
There is a missed buccal canal and a possible root perforation! Who knows how long this perforation has been there, but it seems rather small and it is in the mid-root, so a fair prognosis.
The coronal image shows you the missed buccal canal a little bit better…
How many people thought this was cracked or that it was not savable for some reason or another? Leave a comment!
I am in the camp of “you just don’t know until you try!” My Associate retreated the tooth, found the missed buccal canal, repaired the perforation on the distal with MTA, and medicated the tooth for 2 months with calcium hydroxide. After two months, the probing was now at 6mm, and the bone was starting to fill back in! Fast forward a few months since the obturation, and this is the tooth…
The PDL is starting to restore itself and she is getting her bone back. If I do ONE thing in my life, it is to change the way people think about teeth and saving teeth. A case like this is not heroic and I wish it wasn’t standard for us.
How do we prevent this from happening and how do we know we can fix it after it happens? I hope that the stories that I share give you hope that many more teeth can be saved.
Until next week,
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