Post and core case- need help..!

[deeyala]

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This is a case i am working on, right now.

Initially both first and second molars were planned for a custom-made post and core..
Upon caries excavation in the first molar, the floor of the pulp chamber was perforated
Since my school doesn't let under-grads do root hemisections, we extracted the first molar..


Now coming to the second molar, this pre-fabricated post isn't cemented yet.

Post space was prepared too long, ( leaving inadequate gutta percha for an hermetic apical seal, i suppose ) + remaining dentin thickness on the mesial aspect of the distal root is very thin + gutta percha filling is over-extended apically..

After extraction of the first molar, i thought of constructing a bridge replacing it, using the second molar (with a custom made post and core) along with the second pre-molar as abutments... But after this X-ray, i am doubtful of the prognosis...

I don't want to start reducing the second premolar, use it as an abutment , only to have a bridge failure a couple of years down the road..

So i thought of extracting the second molar, and constructing a long-span bridge replacing them (3rd molar, and 2 premolars as abutments)...

BUT...
I don't like long spans

Patient is female, 21 years old, and has good oral hygiene, no fillings or decay except for those two molars and two incisors that are endodontically -treated...

Help, everyone???

Suggestions of alternative lines of treatment are highly appreciated

 

[deeyala]

PS: for got to mention that, i had initially constructed two temporary crowns (after caries excavation in both), the temp fell off during the Christmas vacation - saw her 10 days after that..
And surprize, MORE CARIES established in 10 days??
soft caries,that is..
And i am quite sure i totally excavated it the first time

 

[aphistis]

1) It's hard to tell for sure without a probe or something to use for scale, but to my eye it looks like you've got the 4mm of gutta percha you need for a good apical seal on #18D. Like you said, the mesial root is overfilled.

2) On #18M, it looks to me like you're going to have a biologic width violation by the time you prep a crown cervically enough to get your finish line on sound tooth structure. It happens to everyone every once in a while, but it looks like you gouged your endo access pretty significantly.

3) Can't say for sure in this case since we can't see the distal half of 17 or the opposing arch, but in general third molars make crappy bridge abutments. If she's 21, she's going to be needing those teeth for a long time to come.

If this was my sister, I'd recommend extracting 17, 18, & 19 all at once, and then replace 18 & 19 with implants. Expensive, yes, but much less costly than replacing a 5-unit bridge every ten years for the rest of her life, not to mention that implants would be more functional and would save two perfectly healthy premolars from being cut down to retain the bridge.

 

[capisce?]

Do you have any supervision at your school????

This couldn't have gotten to this point in my dental school before an instructor stepped in.

Did you do that overfill or was it previously done?

I agree, ext and have implants placed.

 

[TempleDMD]

If you want my opinion I would :

1. Extract 1st molar like you said
2.. Perfrom the post and core on the second molar
3. Place temporary crown on 2nd molar
4. Begin preps for bridge on premolar and molar.

The reason why I think you will not be violating the biological width on the 2nd molar on the mesial is that after you extract the first molar you will get some bone recountoruing. Basically that mesial bone should receed some and give you space to make a good finish line. If it doesnt then she needs to go to grad perio for crown lengthining. I wouldnt go to such drastic measures and extract and place an implant. I always try and stay conservative as possible because when you dont then you get into bigger problems. The gutta percha going past the apex worries me a bit but if she is symptomless then just keep and eye on it. I think you should be ok with the bridge and possible crown lengthining on the mesial of the 2nd molar. Just my opinion.

 

[psiyung]

1) extract first molar

2) crown lengthening on 2nd molar.

3) Post and core on 2nd molar and prepare a bridge spanning 18-20

 

[deeyala]

Do you have any supervision at your school????

This couldn't have gotten to this point in my dental school before an instructor stepped in.

Did you do that overfill or was it previously done?
.

yeah, we have supervision. Are there any schools that has none ? 😱
Practically she arrived with temporary filling and a stainless-steel crown on the first molar (along with loads and loads of caries undermining the whole tooth structure)
and the second molar had a broken amalgam filling (class II) along with a partially broken tooth at the coronal portion..
Both were previously endodontically treated, the filling on the first molar was way too short, so i personally removed it for re-treatment (only to be later confronted by more caries)

Apparently some JERK of a student abandoned her midway through the treatment plan and she can't seem to find him..

 

[gryffindor]

If it was my mother....

1) After extracting #19, I would recommend an implant for #19
2) Go ahead and crown #18 as long as you can get some decent margins. Looks like the distal root has enough gutta percha for an apical seal. The overfill on the mesial doesn't bother me if she's been asymptomatic for years now. I would mention that tooth doesn't have the best prognosis and she will likely end up losing it in the future and need another implant there.
3) Leave #17 alone if she is keeping it clean.
4) Avoid mowing #20 down for a #18 - 20 bridge since it is healthy, assuming she goes for the implant treatment plan.

To me this treatment plan gives her a chance for a few years with #18; those few years can be between 1 and 10, who knows, teeth can be funny like that sometimes. When it does fail, then do the implant.

 

[capisce?]

For those suggesting the crowns/bridges, it's very important to consider this person's caries risk. With the current condition being a strong indication for future care, the shelf life of those crowns and fpds is going to be very short!

 

[toofache32]

Full mouth extraction. Then again, that's my treatment for everyone.

 

[psiyung]

For those suggesting the crowns/bridges, it's very important to consider this person's caries risk. With the current condition being a strong indication for future care, the shelf life of those crowns and fpds is going to be very short!

very good point actually. that definitely needs to be considered.

 

[gryffindor]

Patient is female, 21 years old, and has good oral hygiene, no fillings or decay except for those two molars and two incisors that are endodontically -treated...

Sounds like low caries risk to me.

 

[capisce?]

Sounds like low caries risk to me.

The fact that she had active decay on the 1st molar means she cannot be low risk. The timing of the endos would also have an effect.

 

[aphistis]

To me this treatment plan gives her a chance for a few years with #18; those few years can be between 1 and 10, who knows, teeth can be funny like that sometimes. When it does fail, then do the implant.

This is true. My only beef with doing it that way is that it's recommending the patient spend an awful lot of money on a tooth whose longevity we can't endorse at all. If it were a family member and I was doing it for free, maybe, but it feels like bad clinical advice & bad patient relations to tell her you want her to pay $3000 this year for endo+crown lengthening+build-up+crown and then maybe pay another $3000 next year for the implant that's eventually going to replace it all anyway. It's too expensive a band-aid for me to feel good about recommending.

 

[TempleDMD]

a

 

[Zanderale6]

Woah! SDN PBL!

If this is a vertically stacked learning group, I'll volunteer to be the first semester d-1 who has no idea what's going on ...

 

[DrJeff]

The fact that she had active decay on the 1st molar means she cannot be low risk. The timing of the endos would also have an effect.

Remember, she came in with a stainless steel crown on #19, and frankly there aren't too many long term stainless steel crowns in adults that don't have secondary decay around them.

Ideally, #19 extraction + implant, #18, you could try and nurse along for a few years, but more than likely that overfill will become an issue at some point, then you're looking at a endo retreat and a new crown which compared to the initial cost of an implant/crown isn't very cost effective. So Ideally, I'd also extract #18 and do a couple of implants/crowns for 18/19.

Plus, she's 21, implants long term are going to be much more financially conservative than the endo/crown root, and cutting down a virgin #20 for a bridge, you're going to br creating problems long term where you don't need to.

 

[gryffindor]

This is true. My only beef with doing it that way is that it's recommending the patient spend an awful lot of money on a tooth whose longevity we can't endorse at all. If it were a family member and I was doing it for free, maybe, but it feels like bad clinical advice & bad patient relations to tell her you want her to pay $3000 this year for endo+crown lengthening+build-up+crown and then maybe pay another $3000 next year for the implant that's eventually going to replace it all anyway. It's too expensive a band-aid for me to feel good about recommending.

OK. Then let's put an implant in #19, extract #18, and use the implant as absolute anchorage and some segmental ortho to drag #17 into the #18 spot.

Afterall, I am an orthogonnabe. 😀

 

[aphistis]

OK. Then let's put an implant in #19, extract #18, and use the implant as absolute anchorage and some segmental ortho to drag #17 into the #18 spot.

Afterall, I am an orthogonnabe. 😀

Best two out of three on paper/rock/scissors. You win, we sling #17 forward with ortho. I win, we extract #17 and autotransplant it anteriorly. Deal? 😉