Figure 6: Radiographic evidence of healing at six-month recall
Discussion
This case presents a difficult situation for the dentist. While the outcome remains successful, the other options for treatment would also have been reasonable. The most significant factor in including the option for re-treatment and repair was the absence of a narrow periodontal pocket. This is a significant differentiating factor in making a diagnosis of a perforation versus a fracture. The radiograph often looks the same in both instances, but in the case of a vertical fracture, the narrow pocket is somewhat diagnostic. The implication is that a perforation can be considered a closed lesion without communication to the sulcus. The use of MTA to repair the perforation was based on its ability to promote cementum repair and predictable sealing capabilities.1,2 Certainly, a large perforation may also have caused a communicating periodontal defect, and this would have created a hopeless prognosis much like a fracture.
In addition, saving the crown was a significant factor in the treatment planning process. If the crown had been ill-fitting or had fractured during the procedure, the case for extraction would have been stronger. There may also have been financial considerations, and tooth replacement with an implant-
supported crown would have been a predictable option. Some patients would not be willing to pursue such a perceived heroic measure to save the tooth. The patient treated in this case was highly motivated to save her tooth and was aware of its guarded prognosis. This case demonstrates the possibilities for saving teeth with the correct diagnosis, plan, and treatment.
References
1. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod. 1997;23(4):225-228. doi:10.1016/S0099-2399(97)80051-9.
2. Fischer EJ, Arens DE, Miller CH. Bacterial leakage of mineral trioxide aggregate as compared with zinc-free amalgam, intermediate restorative, and Super-EBA as a root-end filling material. J Endod. 1998;24(3):176-179. doi:10.1016/S0099-2399(98)80178-7.
Editor’s note: This article originally appeared in Breakthrough Clinical, a clinical specialties newsletter from Dental Economics and DentistryIQ. To subscribe, visit dentistryiq.com/subscribe.
Michael Zuroff, DDS, DABE, is a graduate of the University of Detroit School of Dentistry. He completed one year of general practice residency at Sinai Hospital in Detroit and attended New York University for his postgraduate training in endodontics. He is a graduate and fellow at the Misch International Implant Institute and a diplomate of the American Board of Endodontics. Dr. Zuroff has a special interest in bone grafting and implant surgery, and he lectures extensively on endodontics and implants.