الحالة السريرية (2) : آفة لبية نسج داعمية

- تم إحالة مريضة -34 سنة- من قبل طبيب أسنانها ..

- الشكوى الرئيسية كانت وجود تورم على الناحية اللسانية للسن رقم 19
- الأمراض العامة : لا تشكو المريضة من أي مشكلة جهازية.
- سنياً : إن السن رقم 19 عليه تاج كامل وعلى الناحية اللسانية من السن يوجد جيب عميق قابل للسبر مع ملاحظة وجود تصريف قيحي في المنطقة .
- شعاعياً : إن السن رقم 19 قد أجريت له سابقاً معالجة لبية منذ 5 سنوات .
ملاحظة وجود شفوفية شعاعية في منقطة مفترق الجذور .
تم متابعة أصل الجيب بوضع قمع كوتابيركا ، حيث تبين شعاعياً أنه ينتهي إلى الجذر الوحشي.

CASE17_P 1.jpg

- التشخيص : تم وضع التشخيص بأن الآفة هي : أفة لبية بدئية مع آفة نسج داعمية ثانوية .
- الإجراءات العلاجية : أخذ القرار بإعادة معالجة قناة الجذر الوحشي ، تم إزالة التاج ثم تم إعادة معالجة قناة الجذر الوحشي ليتم حشيها بماءات الكالسيوم لمدة أسبوع. بالإضافة للمعالجة اللبية : تم تجريف الجيب الموجود عميقاً وإروائه بشكل جيد.

CASE17_P 2.jpg

- متابعة العلاج : بعد حوالي أسبوع ، تمت ملاحظة شفاء الجيب الموجود لسانياً .
تم إعادة حشي القناة الوحشية بالكوتابيركا ، ثم ختم منطقة مفترق الجذور بالــ MTA .
- متابعة الحالة : تم استدعاء المريض بعد شهرين ، حيث تبين أنه خلال هذه الفترة لم يلاحظ أي دليل على تشكل خراج لساني الجذر الوحشي ، كما أن الشفوفية الشعاعية في منطقة مفترق الجذور ظهرت بأنها تشفى .

CASE17_P 3.jpg

- نهاية المعالجة : إن المريض والطبيب كانا راضيين عن المعالجة ، لذلك تم إعادة إحالة المريضة لطبيبها الأسنان من أجل ترميم السن والتعويض ..

هاي وسامو

ممكن سؤال : كيف تراجعت الشفوفية الشعاعية وعادت الظلالية ؟ مع العلم أنه غالبا لايمكن تكون عظم جديد بدون طعوم عظمية ؟

تحياتي

هلا تميمو ..
أود أن أجيب على سؤالك بسؤال : هل يصبح هناك تجدد عظمي في منطقة التجريف العظمي بعد عملية قطع الذروة ..؟؟

بالتأكيد : نعم ، لأن الدم المتشكل في المنطقة سيحرض الـ Fibroblasts لتتحول إلى Osteoblasts بالإضافة لوجود الخلايا الــ UMC في النسيج الرباطي والتي قادرة على الهجرة والتمايز لأي نوع من أنواع الخلايا ، النمط التجددي للعظم وارد بما أن العيب (أو الجيب العظمي ) غير كبير وبإزالة السبب يمكن التجدد أن يتم بعد السيطرة على الصحة الفموية والمعالجة اللبية الناجحة ..

لاحظ أيضاً أن إصابة مفترق الجذور هنا من الـ Grade II وليست Through and Through (الامتصاص في الجهة اللسانية فقط) ، ونمط الامتصاص زاوي ، ولو لم تتراجع عودة العظم في منطقة مفترق الجذور لكنا فكرنا ربما بطرق أخرى مثل الـ Tunnel Technique (ربماأو غيرها) .. عموماً هذا رأيي ، لأنو مو أنا اللي اشتغل الحالة السريرية

I missed that one
really a great clinical case and a good work.

One comment
you should try to match color between photos before posting because sometimes there are surprises.
you can do that easily by using the ADOBE photoshop match color feature
(in Images/Adjustements/match color you have to open the 2 pics in photoshop then in the match color window just chose the photo you want the colors to be matched to and clic ok)

look what this gives me on the radios.

CASE17_P 1.jpg
CASE17_P 2.jpg
CASE17_P 3.jpg

now you can see much more clearly the evolution.

Bone can regenerate but this takes some time and in such case (infectious environment) this takes more than 2 month for sur,
on matched color pics you clearly see there is a small impovement but no magic as you can think by looking at original pics (the improvement is certainly due to the MTA usage which adds density to the X rays
so always try to match the pics.

Dear Bassam, Thanks for matching the Pics

I Beleive that we could gain more bone with less time if we used bone grafts and GTR is this case, but the re-assessment should be done and outcomes considered only after at least 6 monts of the operation..

المشاركة الأصلية بواسطة Wesambassout

Dear Bassam, Thanks for matching the Pics

I Beleive that we could gain more bone with less time if we used bone grafts and GTR is this case, but the re-assessment should be done and outcomes considered only after at least 6 monts of the operation..

I agree with you but as I know bone grafts and GTR are used where bone is NEEDED in this case you will never employ these technics.
bone takes 3 months for its structuring (and this takes much more time in an infectious environment)and even more time for its maturation so the 6 month delay is quit justified.

an apical lesion puts a lot of time to heal after an endodontical treatment and globaly the assessemnt is done a year after.

المشاركة الأصلية بواسطة Bassam AlRihawi

I agree with you but as I know bone grafts and GTR are used where bone is NEEDED in this case you will never employ these technics.
bone takes 3 months for its structuring (and this takes much more time in an infectious environment)and even more time for its maturation so the 6 month delay is quit justified.

an apical lesion puts a lot of time to heal after an endodontical treatment and globaly the assessemnt is done a year after.

OK, I agree, but we got no contraindications for using them,

also do you think there is a deference between the (infectious environment) of a periodontal pocket after a lesion of a non-vital tooth (endo perio) which forms class II furcation involvement, and the periodontal pocket periodontal origin of a vital tooth that leads to bone loss to furcation area to form class II, I think both of them need the same time of healing, and the 6 months re-evaluation is fare enough for the assessment of both cases.. And the use of bone grafts is very favourable and time saving in the furcation region...

What do you think??

Ciao

Well
II know that in periodontology lost bone never come back (donno what you think about that) but thankfully bone never regenerates beyond the limits and it stops at a medium level.
bone reagenerates when surrouunded by bone this is the idea behind grafts : you put two bones in contact so they try communicate and form a new bone.

after this consideration if you want to go further in treatement the good answer i think is GTR (to guide the bone in its rstructuring to go further) i do not see how a bone graft can be helpfull in such a small space

for the bacterial difference i do not think there is a substential difference but i'm not sur at all

--------------
by the way in the clinical case after looking more closely i do not see why they decided to do the endodontic retreatement of the root the problem is purely periodontic because of the CROWN that was not correctly adjusted.
i do not see and they didn't tell us why they thought there is a trouble with the endodontic treatement of the teeth?

what do you think about that???
--------------
[left]

المشاركة الأصلية بواسطة Bassam AlRihawi

Well
II know that in periodontology lost bone never come back (donno what you think about that)

after this consideration if you want to go further in treatement the good answer i think is GTR (to guide the bone in its rstructuring to go further) i do not see how a bone graft can be helpfull in such a small space

for the bacterial difference i do not think there is a substential difference but i'm not sur at all

--------------
by the way in the clinical case after looking more closely i do not see why they decided to do the endodontic retreatement of the root the problem is purely periodontic because of the CROWN that was not correctly adjusted.
i do not see and they didn't tell us why they thought there is a trouble with the endodontic treatement of the teeth?

what do you think about that???
--------------
[left]

Good observation mate, but you missed that there could be lateral or accessory canals which are not filled, and which are very common at the furcation region, and after tracing of the fistula it led to the distal root and we have a furcation bone loss, I'm sure it's not of periodontal origin, and it's contributing to an improper endo treatment, and after re-treatment and sealing the furcation area with MTA, the situation has changed, and no more progression of lesion. Is it right??

If we use GTR only, I think this is the best choice, because the pocket is narrow, we got a deal mate!!

But bone could be gained again after vertical loss even in Periodontology or in Mathematics, and there's always need for grafts and/or GTR or GBR with 3 or 2 walls defects which might favour the prognosis...

Ciao..

but you missed that there could be lateral or accessory canals which are not filled, and which are very common at the furcation region
MTA did tat job of filling any communication in the furcation aerea not endodontic treatement (can be replaced by CaOH² for economical reason)

after tracing of the fistula it led to the distal root
they didn' t trace a fistula it is clearly said they put the gutta in the periodontal pocket not a fistula
تم متابعة أصل الجيب بوضع قمع كوتابيركا ، حيث تبين شعاعياً أنه ينتهي إلى الجذر الوحش

finally look at the radio the mesial root situation is really worse that it was in the distal one, look at the DAL space thicker for the mesial root
i asked around at the clinic and our periodontics big bos told me that in the BIG (95%) majorityoif assiciated endo-periodontic pathologies the LAD is thickier than normal which isn't the case here.

all this to say it is always good to do a retreatement when there is a periodontic problem, but why they have not carry ou a full retreatement in that cas?

another argument for the periodontic origin is that they didn't put back the crown this proves it was badly adjusted.

anyway somthing that we can learn is how important are the contact points . at the furcation level the situation es better but at distal and mesial of the tooth [u]we are clearly loosing bone[/U this has to be restored]
.