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…
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.
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.
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.
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!
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.