WARNING: This case has GRAPHIC CONTENT

Have you ever had a lesion on the radiograph that is just enormous, and then it looks even bigger on the CBCT?  I feel like I am seeing them all the time these days! (Or maybe it’s just that I see them more often with my CBCT.) 

Here is a case that I treated with just that scenario. I wanted to share it with you and see how you would manage it.  I’m curious as to whether you would have done  the same thing that I did, or if your treatment plan would be completely different. (Please comment at the end and let me know!)

 

Big Lesion on the Radiograph (& Bigger on the CBCT)

 The patient presented with very little pain, but he had a bump/swelling under his tissue that would swell up from time to time for several years. He wasn’t very concerned about it since it never really got that bad and didn’t really hurt. The area was not swollen and there was not a sinus tract — rather, it felt like a 1cm firm ball under his tissue.  None of his teeth in the area responded to the cold test, and there was no pain to percussion. Here are his periapical radiographs:

  

lesion on the radiograph-1lesion on the radiograph - 2

 

 Since the lesion on the radiograph was too big to see in its entirety (it was bigger than the radiograph), I needed a CBCT.  This is what the imaging showed: 

lesion on the radiograph - 3

 

Holy lesion, Batman!! I mean, this was off the charts BIG! I am STILL dumbfounded at how this patient didn’t have any pain. 

Having seen how large the lesion on the radiograph was, and then looking further with my CBCT, it was clear: This would not heal from a root canal alone.  This patient needed root canal therapy and surgery.  And since this was a bit more extensive than what I like to do on my own, I teamed up with my periodontist, who rocks at this.  (We have done so many of these treatments together that he refers to them as the “Chopra Special” now.)

 

Digging into the Details

 I was able to diagnose the patient with Necrotic Pulps #9, 10 and 11, and Asymptomatic Apical Periodontitis #9, 10 and 11 (some may argue that this may be an Acute Apical Abscess).  Actually, I wasn’t convinced that tooth #11 was necrotic (even though it didn’t respond to cold), but I knew that, after surgery, that tooth would likely get devitalized, so I included it in the treatment plan.

 The way I sequence treatment in a case like this is to start the root canals first and get the bulk of the bacteria out of there.  I then place calcium hydroxide in the canals and let the teeth medicate throughout the surgery and during the healing period.

 

lesion on the radiograph - 4

 

Want to see what it looked like surgically? WARNING — GRAPHIC CONTENT.  Well, here you go….the buccal plate was completely gone.  

 

 And so was the lingual plate…

 

 

You could actually fit the entire periosteal elevator from the buccal to the lingual side….

 

 

Here is close up of the palatal bone….

 

 

A bone graft was placed…..

 

 

And since it was a through and through lesion, a membrane was placed, too….

 

 

This is what he looked like in the immediate postop…

 

 

 

And a few weeks later…

 

 

 

Once the tissue had the chance to heal, I completed the root canals and restored the access of each tooth with a composite restoration.  (Can you believe it after seeing that huge lesion on the radiograph… and then the images of what was really going on?!)

 

 

A Waiting Game

 Now it’s just a waiting game to see that bone fill back in.  Don’t get fooled by this postoperative radiograph — that’s just the bone graft that makes it look totally healed!

 This client is aware that this lesion could take several years to completely heal, so I asked him to be patient.  (Keep that in mind when you are treating cases like these. They can take up to 4 years to exhibit complete healing.)

 

The Enormous Lesion on the Radiograph (What Would You Have Done?)

 So, now that I have shown you this case, how many of you would have taken these teeth out?

 Or how many of you would have treated this case in the same way?

 How about a different way? Because I know my way is NOT the only way.

 I would love to hear from you.  What would YOU do if you saw such a big lesion on the radiograph?! How would you treat a case like this? Leave a comment and let me know.

-Sonia

 

 

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