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July 2006 Sometimes Disassembly is Necessary

This 56 Year old male in good health was referred to me for treatment of the maxillary right central incisor. He had a history of NSRCT of maxillary right incisor with 1 year old post and core PBM crown restoration.  The referral said that there was a lesion of endodontic origin at the apex that had developed in the past 6 months.

Clinical examination showed:

  • Maxillary right central incisor – Crown margins appear to be encroaching on biologic width
  • Acute inflammatory reaction at gingival margin
  • Heavy bleeding on probing the labial gingiva, Compromised Aesthetics
  • Percussion mildly positive. Palpation negative
  • Questionable Crown margins ( red arrow in radiograph)
  • Mobility 1+.

Diagnosis: Persistent periradicular pathology with localized acute gingivitis

The options for the patient were:

  1. Disassembly Retreatment with post and core crown remake
  2. SRCT without remake of the crown

Because the patient was asymptomatic and not that much concerned with aesthetics, I would face a difficult time trying to explain to him that the tooth required disassembly and retreatment. There was also the problem of trying to convince the referring dentist that the gingival situation obviously was not normal and that encroachment on the biological width combined with poor patient hygiene and possible open crown margins were present. I would be under pressure to simply have the gingiva scaled or treated with hygiene procedures and then surgerize the tooth.

However, although my flap incision would be up in the attached gingiva, I felt that the periodontal condition was not adequate to risk surgery and that it is my firm policy to conventionally retreat all cases BEFORE going to surgery. A high percentage of these conventionally retreated cases heal without surgery. If the lesion persisted, I could confidently do the SRCT knowing that the canal had properly been cleaned by me. Removal and re-temporization of the crown would also deal with the open crown margins  and allow us to ensure that the contours produced a  periodontium that was now healthy.

In this situation, it is best to report the findings to the referral and let them tell the patient what is required. This can frequently involve crown remakes or procedures whose costs will have to be borne by the referring dentist rather than the patient (because the patient had only recently paid for the crown.)  My better referrals understand this and are quick to do what is necessary to provide optimal patient results, even though it may require them to eat the cost of retreatments.