DEC CASE OF THE MONTH - FRACTURES

This month's discussion centers around when to condemn a tooth that has a fracture (i.e. how deep does a fracture have to go before RCT and crown will still lead to non-healing and extraction?) This patient presented w/ throbbing pain LLQ. Tooth #18, Palpation (-), Percussion (+), Tooth sleuth (+), Cold (NR), Probing depths (WNL), No swelling, fracture line noted on the distal and lingual clinically, PARL. Tooth #19, Palpation (-), Percussion (-), Cold (WNL), Tooth sleuth (-), Probing depths (WNL), No swelling, fracture line noted - deep restoration - widened PDL. Tooth #17 WNL to cold and not sen to percussion or tooth sleuth.Dx was #18, pulpal necrosis, symptomatic apical periodontitis -fracture. On access there was a fracture line extending internally down the distal root to the canal orifice and not into the root. The fracture did not extend to the pulpal floor and communicated w/ a lingual fracture that did not go sub-g. In these cases, once RCT is completed, the prognosis is dependent on how deep the fracture is externally (which usually cannot be visualized until the crown prep is done). If the provider is able to get the margin of the crown below the fracture externally and the fracture does not go into the root internally, the prognosis is favorable. If is imperative to to have a well sealing coronal restoration and the pt must be informed that the prognosis is guarded. At times the patient may elect to have the tooth extracted if there is a potential of non-healing but clinically we find these cases to heal well and the patient is able to maintain their natural tooth.

NOVEMBER CASE

17 y.o female presented w/ continued pain from a pulpotomy. Case is to highlight the existence of multiple canals in molar teeth. With the aid of a surgical microscope, we are finding additional (untreated) canals in mandibular and maxillary molars. This case had 3 canals in the mesial root of #30. Routinely the addition canal in mandibular molars is located in the isthmus between the MB and ML canal. Ultrasonic unroofing of sclerotic dentin greatly aids in the finding of additional canals. With the aid of the operating scope, the finding of MB2's in maxillary molars is now more the norm and not the unusual. Unfortunately, many molars w/ RCT and a recurrent lesion ("failed" RCT) are being extracted for implants when the tooth can be easily "saved" with a retreatment and finding of the additional canal. Let us take a look at the tooth under the scope prior to condemning it!!