Doug Kase
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 OMETIMES
a patient may present to your office with a problem (related to dentistry,
of course) that after a careful clinical and radiographic exam makes you
kind of say to yourself . . . why bother? Sometimes taking a shot
at treatment might be well worth the result, ultimately saving the patient
from a surgical procedure or an extraction and the eventual replacement
of that lost tooth.
This story starts out more than twenty years ago,
when a patient had endodontic therapy performed on tooth #3. The
tooth was obturated using silver points and ultimately restored.
Years later, it was found to have developed a periapical radiolucency over
the distobuccal root, and the patient was subsequently referred to an oral
surgeon for an apicoectomy. The procedure was completed, and our
patient was expected to live happily ever after, which he did for a number
of years.
The Plot Thickens!
THE PATIENT described above became my patient when he developed a fistula
traceable to the distobuccal root where the apicoectomy was performed.
There was quite a large retrograde filling, the root had been shortened
quite a bit, and—adding insult to injury—the palatal root also had a periapical
area (Figure 1). There now were treatment alternatives to discuss,
such as extraction, another apicoectomy, root amputation or resection,
or retreatment. The patient wanted to save the tooth and did not
want a bridge or to have to go through an implant procedure. Because
the root was so short, any other surgical procedure would have to be very
conservative to preserve as much root as possible. Performing an
apicoectomy on the palatal root could have been much more complicated and
could have involved the maxillary sinus as well. The alternatives
of root amputation and root resection also would not have addressed the
problem of the failing palatal root.
An interesting question is why did the original
apico fail? The reasons could be that it did not seal the apex, eventually
leaked, or there were lateral canals that eventually reinfected the case
from the original silver point obturation. Whatever the cause, I
decided to retreat the case and try to create a better internal seal on
the distobuccal root and the other roots as well.
It is always better to remove a crown if possible
when attempting to remove silver points. With the crown off, you
have much greater access to grab the point rather than attempting it through
a smaller access opening in the crown. The crown was removed with
no damage and, using very fine hemostats, the points were lifted out of
the canal with little effort. There was evidence of breakdown within
the tooth. (You know . . . schmutz!) Measurement control was
achieved with an apex locator, and the canals were re-instrumented using
the EZ-Fill® technique until clean filings were seen on the instruments.
Care was taken on the distobuccal canal not to dislodge the retrograde
seal. The canals were obturated with EZ-Fill Cement and single point
gutta-percha cones. It is important to note in Figure 2 the extrusion
of sealer around the retrograde filling, which completely sealed the canal
and ultimately resulted in closure of the fistula. The core was rebuilt,
and the crown was recemented permanently with Ketac cement (Figure 3).
The patient returned recently for a follow-up radiograph
(Figure 4). He remains symptom-free.
Sometimes the easy way may not be the best way for
our patients. Remember: never give up, never surrender!
September-October 2001
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FIGURE 1: Large retrograde
filling, shortened root, and (arrow) fistula traceable to the distobuccal
root.
FIGURE 2: Extrusion of sealer
around retrograde filling (arrow), completely sealing the canal and closing
the fistula.
FIGURE 3: The core rebuilt
and the crown recemented permanently with Ketac cement.
FIGURE 4: Three-month recall
radiograph.
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