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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Contention case

The opinions within this web page are not ours. Authors have been credited
for the individual posts and images where they are. photographs courtesy: Terry Pannkuk

From: Terry Pannkuk
To: ROOTS
Sent: Friday, October 28, 2005 6:46 AM
Subject: [roots] Cyclone of Contention CaseAnother

I saw this patient for tooth #13 in 2001 and treated it. She came back 
with a cracked #12 two week ago and we thought there was a good chance 
it was going to be an extraction/immediate implant placement.  We planned 
it out but while she was on an interim trip to Chicago she sheared off 
the lingual cusp.  She came in this morning for the exploration and
probable extraction.  We had the extraction and implant setup ready to 
go, but after looking at the fracture, electrosurgically removing the 
tissue on the lingual, I decided it would be better off with endo and 
a crown.  I put the implant crap away and did the endo and build up.  
The only reason I got this case referred to me was because I do implants.
The referral was comfortable with my deciding either way, but I’m sure 
this would have been extracted if the case had landed in a periodontist 
or oral surgeon’s office.

You can argue about the likelihood of fracture after the crown is placed, 
but my personal impression is that the odds are low.  I sandblasted the 
chamber with a microetcher before bonding the fiber post and core.

Target practice is now in session……you guys like the messy electrosurg 
versus laser?  Is it worse than a lingual releasing incision?  Worried 
about the interdental papilla and dark triangles?  - Terry

Dear Dr. Terry, I guess your tooth Numbering is all wrong there? would you take a second look? - Vipin 12: left maxillary first bicuspid (treated last week) 13: left maxillary second bicuspid (treated in 2001, recall) - Terry Neat case, now the key is to obtain 2mm of ferrule and 3mm of Biologic Width.....not easy in my opinion. Endo is done beautifully, core buildup is done. Not gonna be easy for anyone to do a good crown there........ Chronic inflammation for sure I would have done the implant....but then again what the heck do I know Your work is beautiful Terry, where she goes from here to the GP using 2 power loupes or nothing at all is the question. - Glenn Glenn, That’s a very good point and equals my concerns, but I believe with some very slight ortho extrusion or some slight osseous reduction on the palatal aspect, this tooth is fairly simple to restore. I communicated this to the referral and always worry that even the routine cases will be restored properly. The problem with implant mania is that it has given free reign to expeditious mediocre dentistry. Any “savable” tooth that requires even just a little bit of extra effort to restore is being yanked and screwed. I think this is a crime and disservice to the patient Attached is a case I performed a recall on Friday (short term recall from my perspective). I treated the case in Feb, 2003 and saw her Friday to check the status. Bicuspidization isn’t a popular treatment anymore but it seemed indicated after the CAT scan assessment and discussion of options with this patient No one gets cookie cutter treatment in my practice. Randy and Gregori may take issue with my personality style and sarcasm, but my responses come from a passionate distaste for the attitudes they represent and their protection of substandard efforts and minimalist thinking. Ayn Rand would accurately categorize them as collectivists No one cares about irrelevant releasing incisions in the attached gingiva of an implant case. This is more about battle lines drawn dividing those who have fragile, vulnerable, non-intuitive, commercially driven paradigms and those who will bluntly expose all ideas giving no safe harbor to anyone’s protected self-interests. Don’t you think? - Terry Hehehe nice Terry, very nice! I always look forward to seeing your excellent care and documentation - Stephen Terry, You changed your rubber colour, it looks better. Did you use any form of matrix for the build up? - Bill This tooth is not a lower second molar. Less likely to cut the lingual nerve here, eh? Nice case handling. The Jab at your colleagues could diminish the person but not the case or care given. You are almost as good as the reflection you see. :-) - Alan Cady I have no issues with your treatment decision nor the use of an electrosurg to expose the lingual root nor the use of fiber posts in the two canals. my only suggestion would have been to make the incision differently
I believe you made your incision at the green line. which will make healing more uncomfortable on the palate and alter the soft tissue architecture for the crown. If you made the incision at the blue line this would have openned the sulcus up to expose the root and allow you to place the post plus create a better form for a healed site. another suggestion would have been to over build the lingual contour from what you have so that after healing the restorative dds could prepare it for a crown and not have the tissue impinging on the lingual tooth Take the suggestions for what they are worth with an open mind or not your choice. arent we ALL here to learn? - Gregori M. Kurtzman Anatomical Quiz Question: What percentage of the time does the lingual nerve course through the lingual attached gingiva opposite a mandibular second molar? Answer: Never, Gregori and Randy are full of crap and wouldn’t know their rectal nerves from their lingual nerves which cause them to fart and talk at the same time - Terry Terry Unsure why your blasting Randy and me regarding lingual nerves. in this string I don't remember commenting about a lingual nerve. But if your talking the prior string where you critized making lingual releasing incisions then yes there is possibility of severing a nerve running in the lingual flap at the 2nd and third molar that's probably why oral surgeons and those lecturing on mandibular molar extractions advocate not making lingual releasing incisions and carefully reflecting that flap as the nerves and vessels lay between the periosteum and the connective tissue and are elevated in the flap. But your post as usually comes across as unprofessional, childish and petulent. But then again that's what we have come to expect from you. Its obvious that this goes beyond meer critizisim of fellow dds and seems to show deep down your just not a happy person in life and chose to direct that unhappiness to those you encounter. i wish you luck with that life plan - Gregori M. Kurtzman this may help clarify what i ment in the previous post. I would suggest making the incision at the blue line - Gregori M. Kurtzman A flap bunches up and impedes apical placement of the butterfly clamp beak; whereas the wide swipe with the electrosurg loop mows down the height and allows easy clamp placement. Of course within reason, it doesn’t matter what you do to the palatal tissue. You can mangle the Hell out of it and palatal tissue is so tough and resistant it grows back just the way it was. You’re better off taking a big bite out of it to simplify the impression-taking for the restorative dentist. Hopefully he’ll get the patient in soon before it grows back - Terry here you go Terry this illustration indicates nerve distribution as viewed from the mandibular lingual, these are the nerves laying in the soft tissue - Gregori M. Kurtzman Where’s Waldo? P.S. i.e. lingual nerve in the attached gingiva? There is no major nerve structure in the attached gingiva on the alveolar ridge between first and third mandibular molars - Terry if that's true whats the structure colored in yellow? I made it easy for you Terry I labelled the structures. And so that even you Terry can understand it heres where your incisions would be (green) so what appears to be in the flap? - Gregori M Kurtzman

from Gray's Anatomy, the Bible of Human anatomy, here is origin, insertion and the path of Mylohyoid nerve:The mylohyoid nerve (n. mylohyoideus) is derived from the inferior alveolar just before it enters the mandibular foramen. It descends in a groove on the deep surface of the ramus of the mandible, and reaching the under surface of the Mylohyoideus supplies this muscle and the anterior belly of the Digastrics.. - Ahmed Tehrani Actually the anatomy portion is taught by a phd in anatomy at the school, I taught the implant surgery portion along with lee silverstein a periodontist from atlanta. according to the anatomist a branch of the mylohyoid nerve has been shown in a percentage of the population to send a branch off as it splits from the IAN that runs in the lingual soft tissue around the 1st and 2nd mandibular molars inervating the tissue there and may provide some sensory innervation to the first molar. this can be a cause of difficulty achieving anesthesia on lower first molars. the image you posted may be what the majority of the population shows but anatomy doesn't always follow the norm plus that image is very old the image i posted was a more recent image and one that the anatomist used in his lecture - Gregori M. Kurtzman Actually what I was concerned about and still am is the LINGUAL nerve. It is kind of high in that area and at times may be right at the MGJ. A scalpel can get it easy. In fact a poorly operated elevator can damage it also. The mylohyoid is most a nuisance in IAB with the lower 1st molar. I am simply not as skilled as Terry is to even take the chance of dissection IN HALF the lingual Whoever printed the diagram miss marked the areas. Greg, you might want to point that out to the PhD. :-) Alan not an expert at anything - Alan Cady Actually what I was concerned about and still am is the LINGUAL nerve. It is kind of high in that area and at times may be right at the MGJ. A scalpel can get it easy. In fact a poorly operated elevator can damage it also. The mylohyoid is most a nuisance in IAB with the lower 1st molar. I am simply not as skilled as Terry is to even take the chance of dissection IN HALF the lingual Those are terminal axon branches that can be cut without any problem because the peripheral branches reinervate just like the terminal branches of the long buccal that innervate the buccal attached gingiva. This is purely a nonissue unless you go deep into the lingual tissue and cut a major branch - Terry So just to clarify this your stating that its ok to cut the mylohyoid nerve branch (seen in some pts as illustrated in the pic i had posted) or other nerves that may be running in the lingual flap when a vertical releasing incision is made because they will reinervate? do you have any lit ref to support this? not sure if in a court when your being questioned about this and the pt has an area of parathesia if they are going to accept your reasoning - Gregori M. Kurtzman I believe the diagram was illustrated by Frank Netter who was one of the foremost medical illustrators. I placed the labeling based on how things were identified by the anatomist will check with him to make sure i have not mislabled. but none the less even if i got the labels wrong its still a nerve in the labial flap - Gregori M. Kurtzman

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