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Renovo Endodontic Studio
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HOPELESS PROGNOSIS?:

Based on the pre-operative PA, many dentists would suggest to their patients that this tooth has a poor or hopeless prognosis. Clinically it had a 12 mm probing to the apex and radiographically it has a large apical lesion that was confirmed to extend around the entire MB root on CBCT. Even more concerning was that the lesion was not well centered around the root apex and was localized around the lateral root surface. Frequently patients like this are told "This tooth is fractured, it has to come out" without even attempting endodontic treatment. This case presents a great example of what root canal therapy can achieve and with less effort, time, and cost than a dental implant. The final PA is a 1 year recall.
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3 reasons why we have teeth:

1) Esthetics
2) Function: allows you to speak and eat
3) Stability: keeps other teeth from moving around.

Bottom line? When you can't save the tooth...replace it...
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INTENTIONAL REPLANTATION:

This is a great example of how a treatment approach that is not 'in vogue' in the implant era can still have a fantastic outcome. Root canal therapy was completed by this patient's restorative dentist and the mesial root was not able to be negotiated due to moderate curvature. CBCT shows that the canals had been transported and ledged to the buccal and lingual but the patient wished to attempt retreatment. Unfortunately, the ledge/transportation could not be corrected during retreatment. In preparing this patient for a possible implant, intentional replantation was discussed as an alternative if we could remove the tooth atraumatically. As can be seen in the one year recall, this patient is happy to be out of pain and have the infection completely resolved!
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FIXING COMPROMISED CASES:
This 50 y.o. healthy male presents with pain associated with the support tooth of his bridge. We have noted a 6 unit FPD with #5 and #6 used as pier abutments. We have diagnosed a recurrent infection associated with #6 secondary to a misplaced post causing a perforation on the disto-palatal aspect. As all potential options involving removal of the FPD would be very costly to replace, we made the decision to perform surgical repair of the perforated post. Root end preparation and retrofill was also done to seal off all potential communications from the canal system to the extraradicular space. We are looking forward to favorable recall appointments in the future. Yeah....saving teeth, one case at a time. 😉
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INSTRUMENT REMOVAL – This patient presented to our office with a previously initiated RCT #19 with a separated retained instrument in the ML canal. Information regarding “pathophysiology” of instrument separation, risk-benefit ratio of removing the retained instrument, alternative options if instrument removal cannot be achieved (i.e. bypass and/or apicoectomy), and prognosis were reviewed with the patient. The patient was motivated to save his tooth at all costs. Upon access, the retained instrument was visualized in the ML canal. The instrument was successfully removed using ultrasonics and hedstrom files. The patient was pleased with the final result.
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TRANSIENT APICAL BREAKDOWN: Here we present a case of a young healthy male who sustained facial trauma involving monkey bars and affecting tooth #9. He had subsequently had a splint placed at the ER to rectify a subluxation injury and was referred to our office for follow-up and necessary treatment. Upon initial evaluation, the tooth was still slightl symptomatic and tested negatively to pulp vitality testing. Additionally, there appeared to be a lesion on radiograph. As the traumatic incident was recent, we recommended that the tooth be re-evaluated at a future date (in this case 3 months) and instructed the parents on signs/symptoms in which to be aware that would warrant treatment. Upon 3 month evaluation, the patient was asymptomatic and showed no clinical signs of pathology. Moreover, the tooth now was responsive to pulp vitality testing. Lastly, the radiograph showed what appears to be spontaneous resolution of the lesion. This process is known as transient apical breakdown. It is important not to get caught up in the results of pulp vitality testing particularly when done immediately after a traumatic incident. Teeth such as this one may not be responsive for up to 2-3 months. Recall is imperative. We were glad that no treatment was necessary here.
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COMPROMISED CASES: Here we present a case where both restorative dentist and periodontist were a little unsure as to what could be done here with regards to the large resorption defect on the mesio-palatal aspect. Periodontal surgery was initially in the plan should the tooth be deemed restorable. We deconstructed the case via complete canal instrumentation, degranulation of the resorption defect, and medication with Ca[OH]2. On the second visit, we completed the root canal and repaired the defect with Brasseler Root Repair Material and sealed it with a dual cured core composite. At 8 weeks between treatment initiation and completion, the soft tissue response was excellent where there was once a soft tissue abscess. Additionally, we see bony healing as well. Restoratively, we have recommend a 3/4 crown with a supragingival termination on the palatal aspect. This case will be followed closely in the coming months.
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OROANTRAL COMMUNICATION CAUSED BY ODONTOGENIC PATHOLOGY–
This patient presented for evaluation of tooth #3. His chief complaint was a painful swelling of gum that would sometimes bleed in the area of tooth #3. The patient reported RCT #3 was completed over 20 years ago by an Endodontist. The patient stated that he is congenitally missing teeth #4, 5, 12, and 13. The patient denies wearing an RPD.
The patient’s chief complaint was consistent with a sinus tract located mesial to tooth #3 at the level of the alveolar crest. The sinus tract was traced with gutta-percha. Tooth #3 had an intact PFM crown, ++ percussion, ++ palpation (buccal aspect), 12mm isolated probing depth along the MB root, mobility WNL.
CBCT evaluation demonstrated previously RCT treated #3 with large j-shape PARL wrapping around the MB root. The j-shape PARL of the MB root is notable in that the lesion involves BOTH the maxillary sinus floor as well as the alveolar crest—oroantral communication. Furthermore, there is also a significant mucosal thickening of the maxillary sinus.
These findings are consistent with the possibility of root fracture. The patient was informed that the prognosis is unfavorable. Extraction and discussion of tooth replacement options with his restorative dentist was recommended.
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