This tooth had been retreated once, and was failing to heal. Over time, an increase in the radiolucent lesion around the MB root was detected. The patient was then presented the options:
1. Root canal surgery to treat the MB root
2. Extraction & tooth replacement
Since the crown was in good shape, the patient wanted to try and save the tooth. The patient was informed that we would surgically expose the tooth, evaluated the root end. If no fractures are found, then we would recontour the root end (apical resection) and then place a reverse filling (retrofilling) in the end of the root. Patient was also informed if a crack is found down the length of the root, we'll have to review other options.
After flap reflection and curretage and apical root resection. You can see that there is only a small bridge of bone across the buccal of the MB root.
A crack is seen on the palatal side of the MB root. The patient at this point is informed of the fractured root. He is given the option to stop and extract the tooth, or proceed with a root amputation.
Here you can see the MB root has been removed. The gutta percha is exposed. A retropreparation and retrofilling must still be completed to prevent coronal leakage into the canals system.
A root amputation is a great way to buy some time for this tooth. It allows the patient to retain the natural tooth, but I make sure the patient knows that if another root becomes fractured, they will have to remove this tooth.
Following the retropreparation. I have sometimes seen root amputations performed without doing a retropreparation and retrofill. That would be the same as doing a root canal without placing a permanent restoration. Bacteria will leak in and contaminate the root canal.
Retrofilling placed. In this case, it was a glass ionomer.
Final Film. After root amputation is completed. It is important to reduce the occlusion to make sure that all occlusal forces are directed over the remaining roots. While a root amputation is not the best call for all patients, we should be aware of this treatment option and the service that it can provide to our patients.
Nice job. The unfortunate thing with root amps is that in our attempt to maintain the existing crown, a food trap develops no matter how well we try to recontour the root trunk area.
ReplyDeleteThe long term prognosis tends to be guarded because of perio issues that potentially arise.
At least you've bought the tooth indefinite amounts of time though.
I read everyone of your posts, keep it up as they are all very interesting! We start Endodontics I next semester, so look out canals, here I come!
ReplyDeleteAmeloblast, good point. I always explain to a patient that a root amputation is not a permanent fix.
ReplyDeleteI also try to contour the underside of the crown to make it cleansable. I'll try to get some follow up films on the healing of this case. I expect a slight bone loss, with the loss of the buccal plate, which will also make the under side of the MB more cleansable.
Ben,
ReplyDeletethanks for your help getting this blog started. I'm glad you find it helpful
Jason
I am a 31 year old female that was referred to have #18 extracted. They have told me after a 5 min review of x-rays that I have a VRF. It was presented as an abscess. I had gone in three times to have the filling filled down, as it felt high. I am surprised after researching on line that extraction is not the only option! When is extraction the only option? I'm just trying to be an informed patient. Tara
ReplyDeleteThere are always options. Some have better prognosis than others, but you always have options.
ReplyDeleteYou might consider seeing an endodontist to evaluate the fracture.
Once you extract the tooth, there's no turning back!
how necessary is the socket graft in the resulting socket after the root is removed in order to preserve socket? Would there be significant bone resorption without socket graft EVEN for root amputation? In the future if the tooth cannot be saved and needs to be extracted and get implant done, i also want it still in a good shape for the implant. But if the bone loss will be insignificant in the root amputation case, i may want to skip it.
ReplyDeleteThanks!