You ever have a lesion that is just humungous on the radiograph and even bigger on the CBCT?  Well, I feel like I am getting them all the time now. Or maybe it’s just that I see them more often with my CBCT.

Well, 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 — if you would do the same thing that I did, or if our treatment plans are way off from each other.  

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 kind of just brushed it off 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 firm ball under his tissue and was about 1cm in diameter. None of his teeth in the area responded to the cold test and there was no pain to percussion. Here are his periapical radiographs…..

Since the lesion was bigger than the radiograph, I needed a CBCT. Here is what the imaging showed….

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

I knew from the looks of it that this would not heal from a root canal alone.  This 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.

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.

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.  

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 patient 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.  

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 and see what you would do in a case like this.  So make sure to leave a comment!!



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