Marshall’s Monday Mystery Case 55: Tough Choice
Patient: 78-year-old female
Referral: Evaluation for endo on #3
This patient was referred for pain on #3, possibly for a root canal. The PA doesn’t show the palatal root at all. The CBCT cross section clearly shows the palatal root and the fracture (green arrow). There’s also a small radiolucency (yellow arrow) at the apex of #5. Finding the problem was easy. Now what to do about it…
The treatment is the interesting question, given the patient’s age and 3-unit bridge between 3 and 5. Remove the bridge and place implants at 3 and 4 is one option. There’s 3.8mm of bone in #3 and less than 1mm of bone in #4 (orange arrow), making #4 a difficult implant site without a significant bone graft. If #3 were extracted and grafted and replaced with an implant, another 3-unit bridge has risks because there’s not much bone around #5 and it may be somewhat weakened by the ECT. An extraction of #3 and a removable partial covering 3 and 4 poses the fewest complications, but perhaps also the least desirable for the patient in terms of comfort and function. There are a lot of options here with no simple solution, making it worth considering.
Marshall’s Monday Mystery Case 54: Bad Tip
Patient: 38-year-old male
Referral: Evaluation for endo on #9
This patient was experiencing acute pain in #9 and was referred to evaluate for a straight-forward root canal. The PA (left) didn’t show anything remarkable. The cone beam CT cross sections revealed the issue: the apex is exposed (green arrows). These CBCT slices are at 0.2mm intervals. Notice the possible apex exposure in slice 20, compared to the clear exposure in slice 23 (just 0.6mm distal to slice 20) and the extremely obvious exposure in slice 27 (another 0.8mm distal). For endo or pathology cases, it’s very useful to slice your area of interest finely. A lot can hide between 1mm of bone or root. For endo CBCT cases we also recommend axial views. When examining the roots from the top-down, the lack of facial bone around the apex (green arrows) is again very clear.
So we know why the patient is in pain. What do we do? One option is to first debride and place calcium hydroxide. If this works, great. If not, endodontic treatment should relieve the pain. A second option would be to extract and place an implant. The logic being the bone loss is progressing lingually (see slice 27 above) and maintaining that tooth too long would result in less bone for a future implant placement. Better to place the implant now with more good bone than wait until there’s just a sliver left. Because this case presents two very different treatment options, I thought it was a fun one to begin the year.
Marshall’s Monday Mystery Case 53: Diagnosis Recall & Best of 2015
Patient: 31-year-old male
Referral: Evaluation of Fractured #9
For my last case of 2015, I’m recalling last week’s “diagnosis” to extract a thoroughly fractured #9 and replace it with an implant. If California can recall its governor and replace him with a Terminator, I can recall a Mystery Case diagnosis. With input from a knowledgeable endodontist and www.dentaltraumaguide.org, I learned this tooth might be saved with very minimal treatment: (1) Clean the area with saline or chlorhexidine. (2) Without using local anesthesia, simply move the tooth back into its proper position with gentle finger pressure. (3) Clean again with saline/chlorhexidine. (4) Stabilize the tooth with a flexible acrylic or wire splint. (4) Tell the patient soft foods for a week and diligent hygiene with a soft brush and 0.1% chlorhexidine rinse. (5) Remove the splint after four weeks, take a PA or CBCT scan to see if it held, and then check with an x-ray every few months to see if pulp necrosis develops and ECT is needed. The odds of keeping the tooth are good, and it’s a non-invasive, conservative, inexpensive approach before jumping to the extraction/implant.
If you’re just looking for interesting CBCT scans, here’s some of the best over the last year. Enjoy the interesting 3D perspectives and ask yourself how you would approach these cases. And to see these full Mystery Cases and many more, you can always go to our website or click here.
Marshall’s Monday Mystery Case 52: Obvious Hidden Fracture
Patient: 31-year-old male
Referral: Evaluation of #9
This patient was scanned for possible ECT on #9. There was nothing obvious in the PA (lower left), but the patient’s history trumped the benign x-ray: he had just been in a bike accident and landed on his front teeth. The cross section of the CT scan revealed the source of the pain (green arrows). Given the lingual nature of the fracture, it isn’t apparent on a pano or PA but it is very apparent in 3D. This is pretty straight forward… until you look at the axial (top-down) view. The lingual fracture should be easy to see in the axial slices, but it’s not. The fracture is visible if you know where to look (green arrows), but it’s not as glaring as we’d expect. Why? The answer has to do with angle and perspective. For all endo cases, we angle the axial slices to the canal (see below Axial Orientation). This makes viewing ECT cases much easier. However, in this case because the fracture is at an angle different to our orientation, the fracture is not as obvious in our axial slices. When we noticed this, we created a special orientation image to make the fracture more apparent from the axial (top-down) view. Regardless, the diagnosis is still the same: extraction and implant.
Marshall’s Monday Mystery Case 51: One retreat, two issues
Patient: 25 year-old male
Referral: Evaluate #3 for endo retreat
From the PA we can see the lesion (green arrow). As we look at the cross sectional slices, we see two distinct contributing factors. There’s a clear periapical lesion over the mesiobuccal root (green arrow), perhaps reacting to the floating gutta-percha. In addition the palatal bone has been resorbed (orange arrow), allowing open communication with the maxillary sinus. This missing bone becomes more prominent over the palatal root. From the axial (top-down) view we can see the extent of the buccal lesion (again, green arrow) and missing bone (orange arrow).
So what to do here… Even with a retreat, the bone loss will continue to be an issue. The most predictable course may be to extract and graft, putting the patient on antibiotics and using a collagen barrier at the sinus to help that area heal. The patient will eventually need a sinus graft prior to implant placement.
Marshall’s Monday Mystery Case 50: The Rock
Patient: 52 year-old male
Referral: Evaluate #19 for Implant
This patient was referred for an implant on #19, and we have a nice 7mm wide ridge and 11mm to the IAC. When the ridge isn’t level, we also measure how much bone needs to be reduce to get to the level area. In this case there’s a 2mm (orange measurement) protrusion. This looks like a normal, straight-forward implant case. The abnormality isn’t in the mandible; it’s the lingual mass floating in the soft tissue (green arrows).
You’ll probably recognize this as sialolithiasis, also known as salivary calculi or salivary stones. These are present in 1.2% of the population, though less than half of 1% of the population is symptomatic enough to seek treatment. Men age 30 to 60 are the most likely to develop sialolithiasis, probably resulting from some unadvisable behavior of ours. Most salivary stones cause swelling and pain, especially before and during meal times when the salivary gland is most active. Small stones can be expelled by the body through hydration, heat therapy, nonsteroidal anti-inflammatory drugs, and (apparently) having the patient suck on something bitter like a lemon to increase salivation. Stones this size must be removed surgically.
Marshall’s Monday Mystery Case 49: Jawbreaker (no, not the candy)
Patient: 12 year-old female
Referral: Examine left condyle
Today’s Monday Mystery isn’t so much in the diagnosis as the long-term treatment. This girl had suffered jaw pain after an accident playing. When she went to the dentist, the CT revealed that this is more than a simple occlusion or TMJ issue. The left condyle fractured (orange arrows) and the condylar head (green arrows) has completely separated, having moved out of the fossa and more anterior.
This patient was referred to a surgeon for reattachment. For several years post-op her TMJ mobility and occlusion will be closely monitored, as there’s a fair possibility that both will change as a result of this injury. Monitoring her occlusion is complicated by her age: all four of her permanent second bicuspids have yet to erupt. This may become a case of coordination between the GP, orthodontist, oral surgeon (she has all four wisdom teeth), and prosthodontist if the left condyle surgery isn’t fully restored in the idea position.
Marshall’s Monday Mystery Case 48: Post-Cyst Problems
Patient: 75 year-old female
Referral: Evaluate #10-11 area, ten month after excision of cyst
This cyst between 10 and 11 was excised ten months ago, and the follow-up scan shows its extent. Notice the erosion of the buccal plate (green arrows) and some perforations in the palatal plate (yellow arrows). I also looked at this axially (top-down). The “Axial Key” gives a good reference of these slices. The axial slices themselves show the extent of the cyst’s damage to the buccal bone (green arrows again) and how extensively it wrapped around #11 (yellow arrows).
So… what are we looking at? Nothing good. After ten months the bone should have grown back. The size of the void here suggests either the cyst has reformed or it’s something else entirely. Eventually this area will require extensive cleaning and grafting, but first we need to know what we’re dealing with and why the original cyst excision didn’t work. A biopsy would be a good start.
Marshall’s Monday Mystery Case 47: How Many to Keep
Patient: 50 year-old male
Referral: Evaluate radiolucency around #2 and #3
This patient was referred to assess the lesions around #2 and #3 for possible endo or extractions/implants. The pano shows this upper right issue. The axial (top-down) view indicates he also has similar problems with #8 and #9. The cross sections show he also has no bone protecting the root of #11, he barely has #7 in place and only a half millimeter of bone left around the root of #10. Now this is an interesting case. (Note the hole on #9, yellow arrow, is just the incisal canal.)
It looks like #2, #3, #8, and #9 are all destined for extraction and bone grafts. Without a lot of grafting and hope, #7 probably also need to go. In a year or two #10 and #11 will probably be in the same position, given the lack of bone and a negative trend in this patient’s mouth.
As for treatment options, after multiple extractions and bone grafts, the most conservative is to simply go with a partial denture and see how the remaining teeth fare over the next few years. Or you could place implants on #2, #7 and #10 and do two bridges (2-4 and 7-10). Or you could place implants on #2 and #3, and more on #7, #8, and #9. That would bring the maxilla to a total of eight implants, and don’t forget #10 and #11 may need to be replaced soon. In this case, it may be worth considering a full arch implant denture; you could avoid the sinus grafts and minimize the number of implants placed. There are a lot of options, which makes this a fun mystery case.
Marshall’s Monday Mystery Case 46: Tooth Hide-and-Seek
Patient: 8 year-old male
Referral: Evaluate for ortho treatment
From the pano this patient seems to be missing his second bicuspids. At first glance, that also appears to be the case in the CT scan… but you know nothing is as it appears in these cases, and we don’t stop at just one glance.
When I zoom in and filter out all but the teeth (thanks Anatomage software!), I can see #4 hiding back there. It was completely obscured in the pano by the crowd of teeth more buccaly positioned. When we look at the maxilla from the axial (underside) view, we see #13 is also hiding palataly. Below I also took a look at the left half of the maxilla from the buccal and lingual views, which gives another perspective on the position of #13, and on the ability to view everything in 3D.