0099-2399/86/1206--0257/$02.00/0 JOURNAL OF ENDODONTICS Copyright �9 1986 by The Amencan Association of Endodontists

Printed in U.S.A. VOL. 12, NO. 6, JUNE 1986

CASE REPORTS

Trauma: Mismanagement and Resolution

Irving H. Sinai, DDS

In this case report the misdiagnosis and misman- agement of four mandibular incisors, including sur- gical intervention, are presented. The subsequent retreatment of this case, indicating the manner of problem management is discussed. Finally, a 9-yr evaluation suggests that the problems have re- solved with a long-term favorable prognosis for the retention of these teeth.

As mentioned in an earlier report (1), "Trauma involving incisors is an unfortunate occasional occurrence in childhood. 'By the age of seven years, 28% of girls and 32% of boys have suffered a traumatic dental injury to the primary dentition. In the permenant dentition a marked increase is seen for boys aged 8 to 10 . . . . ' (2). The most common sequelae of this event are avulsion, partial avulsion, or subluxation, and coronal or radicular fracture."

A proper evaluation of the consequences of a trau- matic episode is essential for its correct management. This is particularly important in trauma involving the dentition, as this most frequently effects children. The diagnostic conclusions and treatment regimen can af- fect the child for the remainder of his/her life. If the individual providing treatment is careless, the results can be tragic. In the case report that follows, it was possible to overcome most of the ill effects produced by misdiagnosis and mismanagement.

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A young boy, age 91/2, suffered an injury to his mandibular incisors as a result of an accident on Oc- tober 10, 1975. He was seen by an orthodontist, who splinted his lower incisors due to their mobility. This would probably have been adequate immediate treat- ment, as will be seen later. However, he was then seen by an oral surgeon in the emergency room of a hospital. The surgeon indicated the need for further treatment, perhaps without doing any pulp testing. In any case, testing would be of limited value immediately following

trauma, as often there is no pulpal response (3, 4). Preferably, following trauma and splinting, a waiting period with repeated testing would be the recom- mended approach. The operator, however, gained ac- cess to the pulp chambers in all four mandibular inci- sors. Following access, and possibly instrumentation of the canals, a single gutta-percha cone was placed into each tooth. The butt end of the gutta-percha cone formed the "occlusal seal." The oral surgeon then ap- parently approached the teeth surgically and ran a bur across the labial root surfaces approximately one third of the way toward the occlusal surface from the apex.

FIG 1. Initial examination radiograph taken on December 13, 1975 indicating bur cut (BC) and poor root canal treatment.

CASE REPORT

258 Sinai Journal of Endodontics

dure for so young a child. The boy was a model patient, quite cooperative at all times. The treatment of the four incisors was completed on March 11, 1976 (Fig. 3). Unfortunately, although there was a taper to the root canals, they were quite large and it was not possible to create stops. There was some extrusion of filling ma- terial beyond the root canals into the area of the per- forations. Healing was expected to occur, nonetheless, as the canals were apparently well sealed, the apical pulp tissue was vital, and the surgical damage was quite a distance from the gingival sulcus (5-7).

It was possible, fortunately, to follow this case over a 9-yr period, with some interesting results and findings. The patient was seen again on September 10, 1976 for a 6-month recall. The patient had been completely asymptomatic during this time. The teeth were com- fortable to percussion and the labial alveolus to palpa- tion. The radiograph indicated little change in the mid- root lesions when compared with the original film. This delay in healing was undoubtedly due to the extrusion of filling material. Of considerable interest was the continued absence of any apical lesion (Fig. 4).

The patient was seen again on April 13, 1979 for a 3-yr recall. He continued to be asymptomatic and his

FIG 2. Measurement of mandibular left central incisor indicating per- foration (P) at level of bur cut.

The patient was referred by the family's dentist on December 12, 1975. This was 2 months after the previous treatment. Upon careful evaluation of the ra- diographs the following tentative conclusions were reached (Fig. 1):

1. The apical pulpal tissues were probably vital as there was no indication of periapical pathosis.

2. The root outline was still intact and therefore there was still integrity on the lingual halves of the roots.

3. The surgeon had probably cut until the gutta- percha was visible and therefore each root had been perforated to the root canal. This was borne out by the measuring instrument radiograph (Fig. 2).

4. Root development had been completed and there- fore the root canals had an apical taper. This would permit management of the canals by routine endodontic therapy.

The treatment plan approach consisted of determin- ing the points of perforation, instrumentation of the canals to that point, and then sealing the canals to that point. It was felt that if the pulp in the apical portion of the canals was vital, the portion of the roots apical to the bur cuts could be left in place, maintaining root length as well as avoiding an additional surgical proce-

FJG 3. Completion of the root canal treatment to the levels of perfo- ration March 11, 1976. Right lateral incisor (RL) noted.

Vol. 12, No. 6, June 1986 Trauma 259

buccal cortical plate over the root of the lower right lateral incisor. The radiograph taken at this time clearly indicated that the mid-root lesion of this tooth had expanded in size. The remaining mandibular incisors continued to be negative radiographically in both the apical area of the root and in the area of the surgery (Fig. 8).

The possibility of retreating this tooth using Ca(OH)2 to effect an apical closure and then resealing the canal with gutta-percha was discussed with the patient. He did not wish to become involved with a procedure that would extend over many months and would require multiple visits. The alternative of a surgical approach was offered. This was far more acceptable to the patient. The surgical procedure was performed on March 29, 1985. Consistent with the belief that the apical pulp was vital and that the lingual portion of the root was intact, the surgical plan was to curette the lesion, prepare the portion of the root that had been previously perforated, and then seal the apical end of the filled portion of the canal with amalgam, thereby

FIG 4. Six-month recall September 10, 1976. Notice slight enlarge- ment of radiolucency at the region of the bur cut of the right lateral incisor (RL). The apical tips manifest no pathosis.

teeth were comfortable to percussion and palpation. At this time it was possible to note the continued absence of any apical lesion on the radiograph, substantiating the probability that the pulps were vital at the time that initial "endodontic" treatment was rendered. In addition, the mid-root lesions of three of the four teeth had apparently completely resolved. The mid-root lesion of the mandibular right lateral incisor persisted, although it seemed to be reduced somewhat (Fig. 5).

The patient was seen periodically over the years. The mandibular right central and left central and lateral incisors continued to remain negative. The mid-root lesion of the right lateral incisor persisted, with no indication of resolution or enlargement, except possibly at the 5-yr recall, which seemed to indicate a possible enlargement. During all of this time the patient was asymptomatic (Figs. 6 and 7).

The patient was next seen on February 7, 1985, which was 9 yr after our treatment of the lower incisors. The patient had been asymptomatic all of this time. However, there was a palpable firm expansion of the

FIG 5. Three-year recall April 13, 1979. Notice repair occurring at all mid-root lesions except the right lateral incisor (RL). The apical regions continue to be normal.

260 Sinai Journal of Endodontics

FIG 6. Four-year recall, May 1, 1980. Note persisting and enlarging lesion mid-root of the right lateral incisor (RL). The apices continue to appear normal.

FiG 8. Nine-year recall, February 7, 1985. The mid-root perforation of three teeth, and the apices of all four teeth continue to appear normal. The mid-root perforation lesion of the right lateral incisor (RL) contin- ues to expand.

F~G 7. Six-year recall, June 4, 1982. Note persisting and enlarging lesion mid-root of the right lateral incisor (RL). The apices continue to appear normal.

FiG 9. The immediate postsurgical radiograph of the right lateral incisor (RL), March 29, 1985. Note amalgam (A) seal. The postsurg- ical lesion (L) is quite large.

leaving the root length intact as well as not disturbing the apical pulpal tissue. In exposing the previously surgerized area of the mandibular right lateral incisor, the above assumptions proved to be correct and the surgical procedure was executed as planned (Fig. 9).

No bioposy was performed. The tissue appeared to be granulomatous upon removal. The etiology of this failing to heal might have been due to an inadequate seal, extrusion of more material than could be tolerated, or debris in the exposed portion of the canal between the

Vol. 12, No. 6, June 1986

FIG 10. Six-month recall, September 20, 1985. The lesion (L) in the region of the surgery has reduced considerably compared with the postsurgical lesion in Fig. 9.

Trauma 261

intact apical and coronal portions of the root. Not being certain of the etiology of the failure, the apical portion of the filled root canal and the exposed portion of the root canal were prepared and sealed with amalgam. The intact apical portion of the root, with vital tissue, was left undisturbed. Postsurgical healing was unevent- ful.

The patient was seen again on September 20, 1985 for a 6-month recall following the surgery. The patient was completely asymptomatic during these 6 months. The buccal expansion was no longer palpable. As can be seen the lesion has reduced considerably, with every anticipation of a complete resolution (Fig. 10).

Dr. Sinai is professor and chairman, Department of Endodontology, School of Dentistry, Temple University, Philadelphia, PA.

References

1. Sinai IH. The management of an anterior radicular fracture. J Endodon 1981 ;10:327-9.

2. Andreason JO. Traumatic injuries of the teeth. 2rid ed. Copenhagen: Munksgaard, 1981:42.

3. Cohen S, Burns R. Pathways of the pulp. 3rd ed. St. Louis: CV Mosby, 1984:496.

4. Ingle J, Taintor J. Endodontics. 3rd ed. Philadelphia: Lea & Febiger, 1985:712.

5. Seltzer S, Sinai, IH, August D. Periodontal effects of root perforations before and during endodontic procedures. J Dent Rest 1970:49:332-9.

6. Jew R, Weine F, Keene J, Smulson MH. A histologic evaluation of periodontal tissues adjacent to root perforations filled with Cavit. Oral Surg 1982;54:124-35.

7. Sinai I. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc 1971:95:90-5.