After nearly 25 years in Dentistry, I’ve learned that “herodontics” is often an exercise in futility. But, one of the things I love about being a dentist is the creative problem-solving aspect. My assistant has called me “McGyver” for many years.
Today’s patient is a 28 y.o. woman. She has a number of problems stemming from neglect and procrastination. Money is not an issue. She came to my office for a comprehensive examination and treatment plan. Her top priority was a tooth (#5) that was “broken.” Her biggest concern was that she’d end up with a “hole in her smile.” Case photos and technique after the jump…
Where did the tooth (#5) go?
Tooth #5 was severely compromised. The only thing left standing was the wisp of a facial cusp. Treatment options included extraction and an implant vs. saving the tooth. She preferred to save it, if possible. The question was: Is it possible? Is it savable? The x-ray images were not conclusive in that regard. Well, I’m sure some would argue that the tooth is unrestorable based on the x-ray alone. The only way to be sure was to get a good look at it by cleaning it up. She was OK with an “exploratory” approach.
Pre-op x-ray from previous dentist.
Pre-op BWX from previous dentist.
I placed an Optragate retractor for easy access and limited isolation. I used a diode laser (Picasso Lite) to clean up the hyperplastic tissue on the palatal side. I was surprised to find fairly solid tooth structure hiding under there. The pulp was exposed without me even touching the tooth. But surprisingly, it was still vital! At this point, I explained to the patient that I thought we could save the tooth, while I could not guarantee any long-term results. She was fine with that.
Tooth is exposed and cleaned up.
This x-ray was taken after I cleaned things up.
I cleaned up the tooth and the canal orifices. There was no way to clamp the tooth for a rubber dam. So, it was “McGyver time!” With the Optragate still in place, I did some initial instrumentation and shaping of the canals. (Edit: I did that using ONLY rotary files connected to a handpiece.) Then I temporarily placed a couple of gutta percha points in the canals and filled the rest of the “chamber” with cotton. This was followed by placing a core build-up around the gutta percha.
Two gutta percha points temporarily placed in the canals.
Core build-up placed around the gutta percha.
Now I could place a rubber dam and have the canal system isolated from any contamination. I removed the gutta percha and cotton and had perfect access to the canals.
Now I can place a rubber dam and proceed with endodontic treatment!
Rubber dam placed and easy access to canals!
I got as far as instrumenting to the apex with hand files to a #20 file. At this point, the patient had enough, and I was pretty tired, myself! I dried the canals, placed a dry cotton pellet and Cavit temp. My patient was happy to get a break and made an appointment to continue treatment.
And, that’s how I spent my morning! 🙂 Now… should I grow a “mullet?”
Update: Here is a pic of the prep. (Sorry the image isn’t well-focused.)
UPDATE #2: Here’s a pic of the prep the day we delivered the crown.
I’ll post a post-op photo of the final restoration when I see the patient back. Oh… by the way, this is the case I was working on (finishing the endo) while I was being filmed by CNBC for their one-hour special on the AR-15.
I would have to agree with your assistant! MacGyer!! Great job Mike!
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You r crazy!
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LOL! Thank you, master of the obvious!
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Nicely done. I would’ve given my inner MacGyver the day off and sent her off for the implant. But hey, if it works……
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Great photos and documentation for this case. Definitely herodontics. In your other posts you mention that you don’t charge for simple troughing. Most dentists I know don’t either if they use the laser to facilitate a better impression. Did you charge out for the use of the laser in this case? If so did you use the gingivectomy code?
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Hi Nicholas! Thanks for checking in and for your comments.
In this case, I charged for an “exploratory” procedure (which assumed / included the gingivectomy)… I made up a code for it. I don’t have to worry much about which “code” I use, since so few of my patients have any benefit plan (“insurance”).
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Nice work. love the GP to help with the initial buildup. So this gets crown lengthening and a crown?
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Hi Daniel! Don’t know about crown lengthening, yet. Will sound to bone at next visit to determine biologic width.
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Nice job Mike. From my experience, I can never get enough of a ferrule around the tooth. The patient usually ends up back at my office with the crown off and the build up left inside. I have learned to punt these immediately. Good luck 🙂
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Hi Cole. Yeah… I’d like beautiful ferrule 360-degrees around the tooth, too. However, some patients really want to keep their tooth if at all possible. Is it a success or failure if it lasts 5 years? 10 years? 15 years? More? This patient knows that this is a “Hail Mary.”
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Just in case you’re subscribed to this post, Cole…
I’ve updated it to include a photo of the prep.
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I can’t believe no one has encouraged you to grow the mullet!
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Really smart by putting the GP points in first before building up the composite!
I was just wondering how did you restore it after the root canal was completed? I have a similar case and was wondering what was the best long term solution for it. Thanks!
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Hi Lily,
I later did a post / core and prepped for a crown. It’s still in a provisional while we do some other restorative. Will take final impression of everything at once. Once I finish, I’ll post some final photos and films here.
Thanks for your comments!
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sir this is upper 1st premolar not second
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Hi Dr. Ashu,
Of course, you are quite correct. But, I never called it a 2nd premolar. I did, however, properly call it #5.
I suspect you are not in the U.S.
Here in the U.S. this is tooth #5. We use #’s 1 – 32. #1 is upper right 3rd molar and that goes around to #16 as the upper left 3rd molar. Then we drop down to #17 (the lower left 3rd molar) and work our way around to #32 (the lower right 3rd molar).
Yep… we are the only crazy country to use this numbering system. 🙂 The funny part is that it’s called the “universal” tooth numbering system. But, we’re the only ones who use it.
If I’m not mistaken, this would be a #1-4 in the rest of the world.
Thanks for reading and commenting. I hope you’ll find the blog interesting!
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Long-time follower, first time commenter. Just curious about the post/buildup combo you used here… and how is this holding up one year later?
-JJ
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Hi Jordan,
Thanks for commenting on my blog. This restoration is still going strong. I’ll see if I can get an x-ray and photo of it at her next recall.
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