Doug Kase
|
 HIS
MONTH I will start “Tales” with an interesting case. A patient presented
with a fistula associated with tooth # 3. This tooth had quite an active
history, which included prior endodontic treatment approximately one and
one-half years ago and a subsequent PFM crown. Nine months later the case
failed, and the patient had an apicoectomy on the mesiobuccal and distobuccal
roots, leaving the palatal root untouched. This now brings us to the present
situation (Figure 1) with an actively draining fistula, which seemed to
be associated with the mesiobuccal root and a periapical radiolucency at
the palatal apex. Well, we all like to think of ourselves as heroes, so—being
the hero that I am—I initiated an endodontic retreatment of the tooth with
the goal of finding an MB2 canal and retreating the palatal endo.
Eureka! I found the MB2 and retreated the palatal root as planned
(Figure 2). I prescribed clindamycin 150 mg TID and dismissed the patient
with the expectation of a closed fistula on the checkup visit in two weeks.
To my great dismay the fistula was still present and draining in all its
glory.
Frustrated but nontheless very determined, I decided
to retreat the entire tooth. Using the apex locator, I was able to remove
the existing gutta percha and re-instrument the canals with the retrograde
amalgam seals without dislodging them. Once again victory was in
sight as I re-obturated the canals (Figure 3) and told the patient that
all was well. Needless to say, my patient returned, as did the fistula.
It was time to take out the big guns! Extraction and replacement
was not an option, so an apicoectomy was scheduled.
After two carpules of Septocaine, an incision was
made in attached gingival from the mesial of # 2 to the mesial of # 4,
where a vertical release incision was done to achieve greater access without
stressing the tissue on reflection of the flap. It was apparent when
the flap was raised that there was a fenestration in the buccal plate over
the MB root. Using a # 4 surgical round bur, I opened a window over
this area to discover that the DB root was involved as well. Using
a 557 surgical length bur, I beveled the MB and DB roots back, removing
the old retrogrades. On the MB root, I identified both the MB and
MB2 canals, which I then prepared for retrograde amalgam seals, using my
Newton Ultrasonic unit and retrograde prep tip that is integrated into
our DentalEZ chair side units.
Now when I beveled back the DB root, that’s when
things got a bit interesting. As I beveled, I identified the DB canal,
but 3 to 4 mm palatal to that I saw another “vein” of gutta percha in this
dumb-bell shaped root. I thought, “Could this possibly be the palatal
root?” How could the great God of endodontics be so good to me?
Sure enough it was the palatal root, for this was a great example of fusion
of the distobuccal and palatal root anatomy and explained why this radiolucency
actually involved all three roots. The DB and palatal were prepped
and sealed and the surgical site closed (Figure 4). Clindamycin and NSAID
analgesics were again prescribed, and the patient returned one week later
for suture removal without any post-operative complications. Persistence
paid off, the fistula has not returned, and the patient is healing well.
A happy ending for all!
July-September 2005
|
FIGURE 1: An actively draining
fistula associated with tooth # 3.
FIGURE 2: Following retreatment
of the palatal root.
FIGURE 3: After retreatment
of the entire tooth.
FIGURE 4: Showing the DB
and palatal roots sealed—persistence pays!
|
