To save, or not to save? (Saving teeth, that is!) That is the question I have to answer most often.
Here’s Another Case Where I Focus on Saving Teeth
My periodontist brought this case to me to ask my thoughts and to see if I could help him try to save this 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, and now there was a huge gingival dehiscence on the buccal aspect of the tooth.
Here is what the CBCT looked like. You can see just how much bone he was missing distal to his canine!!!
He had no pain, just a big hole in his gums. I mean, I could see the root right from where I was standing.
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.
When I was evaluating him, I thought to myself, “I’m not sure this is going to work!” I had an open, honest discussion with my patient, but he was still adamant that I try. I can honestly say this case is THE case I attribute to changing my mindset about how things can heal, and I hope it does the same for you.
Back to My Evaluation…
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. However, I had to do it with the help of my periodontist friend.
Here was my protocol:
1. I started the re-treatment and removed all of the gutta percha.
2. I made sure I was at working length and REALLY patent. I intentionally went a bit long with a very small file.
3. I placed calcium hydroxide and allowed it to sit for a month.
4. In the meantime, the patient went to the periodontist and the surrounding bone was debrided, a bone graft and membrane was placed and the soft tissue was approximated. I needed some sort of root closure to feel comfortable that this was going to work.
5. I did a few soft tissue checks over several weeks and found that root closure was happening.
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…
A Waiting Game
I can tell you, I did not get complete root coverage by the soft tissue for about six months. But, it eventually DID close!!
So don’t be too quick to judge. The patient just recently came back for a recall after so many years and here is what he looks like now (and the recall).
Now I know you might be thinking, “There’s still a ‘lesion,’” but I’ll argue it’s healing pretty well.
So, if you were to hear this patient’s story and you found this “lesion,” don’t be so quick to judge the root canal as failing; it may be healing. Something like this will take years to fully regenerate.
The best part about it is that he looks back to normal.
Here’s the before and after…
What I’m hoping this case brings you is hope about saving teeth.
I want you to believe that, when you try and give teeth a chance, things can work out for the best.
Yes, this case looked bad at first, and there wasn’t a quick fix, but by going through a process with the periodontist, 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 in cases that look as bad as it gets, because you never know what you’re able to save.