Tuesday, June 3, 2014

Episode 400/500: Extraction or Retreatment - Traumatized Maxillary Incisor

A 50 year old male presented a few weeks ago with a fistula draining from between teeth #'s 8 and 9 (11/21).

CC:  I have this pimple on my gums and it comes and goes - over the past few weeks.
History:  I fell on the ice many years ago, had a root canal and crown - and haven't had any problems since.  (It happened 30 years ago)
Med:  No meds, no medical conditions, non smoker (BP 124/79 P 66)
CE:  Intra oral:  No swelling, pain, erythema.  Fistula (draining slightly btn #7/8)

            Probing        Mobility             Cold                 EPT
#6       <3mm           Miller 1       ++ fleeting              80
#7       <3mm           Miller 1       No response            80
#8       <3mm           Miller 1       No response            80
#9        <3mm           Miller 1       No response            80
#10      <3mm           Miller 1       ++ fleeting              80
#11       <3mm           Miller 1       ++ fleeting              80

Now, the problem was trying to figure out the reason for the lateral radiolucency on #8.  Why was it coming from this tooth in the first place?  The patient had been asymptomatic for 30 years and why all of a sudden was this tooth causing a problem now?  Was it the poor obturation or the position of the post?  I talked with several colleagues and we determined that a possible reason for this presentation is a root fracture.


#7:  Necrotic pulp w/ asymptomatic apical periodontitis
#8:  Previously treated w/ chronic apical (lateral) abscess - also - Non restorable due to fracture
#9:  Necrotic pulp w/ asymptomatic apical periodontitis

#8 Deductions in thinking:
1.  Previous history of trauma.  There is always a possibility of root fracture fol trauma.  It's interesting that #7 has significant calicification and #8 has a very wide pulp chamber/canal.
2.  Location of post.  The most apical extent of the post is at the lateral RL (radiolucency).  Careful though - when you look at the fracture pictures, it appears it may be coincidence that the post is at the same level as the RL as the fracture is vertical.
3.Location of the RL.   Although there is an undefined apical extent of a RL lesion on the 3 teeth in question, the lateral position of the RL on #8 gives us some clues about the nature of the problem.  Look at the lateral bone destruction as outlined in red on #8.  This was on the palatal portion of #8.

I discussed treatment options with the patient and he elected to continue treatment with an FDP from #11-22 (7-10).  For implant treatment, he will require significant osseous augmentation (block graft) and significant soft tissue augmentation.

Extraction of #8 was uneventful.  I stained it with methylene blue dye to aid in visualizing the crack.  I always find it interesting when I can't probe anything >3mm and you find out it after extraction the tooth is cracked/fractured.

So, keep this diagnosis in your back pocket when you see those atypical lateral RL's.  When associated with an endodontically treated tooth, it may require something other than a retreatment.
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Root fracture, endodontics, allthingsdentistry

cracked tooth, root fracture, allthingsdentistry