Conservative approach of the dental surgeon to unusual cases of daily practice

In our daily practice, there are cases in which it is difficult to make a definite decision about the treatment approach. I would like to present to your attention two such clinical cases. As for the first, at first glance the temptation is to perform surgery to preserve the tooth. Moreover, at the moment in our country we use the so-called "guided tissue regeneration" - a method with a proven effect, which I have been practicing for more than 20 years and which is almost a routine surgical intervention almost anywhere in the world. In the second, we usually do an apical osteotomy (cystectomy). I chose a conservative approach and got impressive results.



It is about a 16-year-old girl in good general condition. A year ago, a dentist obstructed the lower right sixth tooth. Immediately after this manipulation, she felt pain from cold and pressure. The dentist told her that the complaints were normal and that the pain would gradually go away. After about 2-3 months, the pain really subsided and the patient calmed down. For several days, however, the tooth began to ache from heat and eating and became unstable. The patient turned to the same dentist, who found from the X-ray that the tooth was definitely for extraction. She sought a second and third opinion from other dentists - everyone was adamant that the tooth was for extraction. When she came to me during the examination, I did not find any extra oral changes. Intraorally there was a large obstruction at 46, slight pain with vertical and horizontal percussion and pathological mobility I degree. The lining around the tooth was slightly red. Radiologically - aп interradicularly cystic image, reaching the bifurcation and surrounding the apexes.

Diagnosis: Gangraena clausa, Periodontitis chronica granulomatosa progressive sine fistula.



I removed the obstruction from the amalgam and treated the canals by the method of cold lateral condensation, as there was no exudation from the canals. As we can see on diagnostic radiography, the canals are wide and do not pose a particular difficulty for endodontic treatment. On the control radiograph (Fig. 2), we can see well-filled and compacted root canals. The next day the patient had no complaints, the percussion pain had turned into a "feeling" of tapping in her words. I did a pin construction and for 6 days, I performed laser therapy to stimulate bone regeneration (output power 15 mW, time 1.5 min., Frequency 0 Hz). The patient ate without worrying about the tooth. With the appointment to see each other in 4 months, we parted.


On the control radiograph after this time (Fig. 3) we can see bone regeneration from the apexes to the bifurcation, reaching 2/3 of the length of the roots, still showing the border of the former pathological process. The bone still has an unformed structure different from the structure of the surrounding healthy bone and has an uneven border at the top. The patient had no subjective complaints. I applied a second course of laser therapy. The patient did not appear for a follow-up radiograph after another 4 months.

On Figure 4, 11 months after treatment, we can see a bone that is structurally identical to the surrounding healthy bone. At a height relative to the roots of the tooth, it reaches ¾ of their length. We cannot see the boundary of the former pathological process. The most interesting thing is, and it is clear in a definite way, that there is already the so-called „Linea albuginea“, an X-ray image of the compact of the interradicularly septum. On Fig. 5, we can see a calm crown around the tooth. The tooth is to be dressed in a metal-ceramic crown, as the walls of the tooth are quite thin due to too much carious destruction.



The final result after 1 year:



On the X-ray, we can see the complete healing of the lesion.


Here is the other case

A 34-year-old woman in good general condition. She urgently visited another dentist, not the attending dentist, for inflammation of the lower left sage, which had partially erupted. The dentist extracted the wisdom tooth, but the X-ray taken on this occasion revealed a "cyst" covering the sixth and seventh teeth on the same side. The sixth tooth was killed in the past, and the seventh - completely healthy. The dentist (polyvalent specialist) referred the patient to me for surgery. 



Objectively - extra orally - without peculiarities. Intraorally - 36 tooth with a huge obturation of amalgam, painless on percussion. The gingiva around him - calm. 37 tooth - vital (EOD - 18 mA). Radiologically, we observe an extraction wound of 38, unsuccessful endodontic treatment of 36 tooth and a cystic formation that covers the apexes of 36, fills its interradicularly space and spreads around the medial root of 37 tooth (Fig. 6).

Diagnosis: Periodontitis chronica granulomatosa progressiva s. radicular cyst 36.

For the correctness of the relationship, I sent the patient to her dentist, who turned out to be an endodontist, with a request for endodontic treatment, refraining from surgery. On Fig.7, we can see the exact endodontic treatment. I applied 6 sessions of laser therapy. Three months later (Fig. 8) the pathological process has almost disappeared, the patient has no subjective complaints, but we still do not see complete bone regeneration. After another month (Fig. 9), we observe a normal bone around the medial root of 37 and almost regenerated bone around and in the interradicularly space of 36. In the control, EOD 37 the tooth has preserved vitality. I made a metal-ceramic crown on 36 teeth.



Conclusion
Modern endodontic treatment methods are very effective. The low-intensity lasers with a wavelength of 630-650 nm, used in dentistry, definitely have a bone regenerating effect. Therefore, we must assess each clinical case specifically, in no case resort to radical treatment (extraction) and not rush with surgery, which we can always apply when we run out of other options as a final stage of treatment.