here is an interresting question I got on a recent examination:

first have the X-ray

IMG_3837 copy.jpg



question is : WHAT IS YOU ATTITUDE in this situation.

(P.S.:I want you to tell me what do You decide if your patient presented this kind of lesions then i'll discuss it with you this will be far more interactive ).µ

السلام عليكم..
شكراً لك أخي Bassam AlRihawi على هذه الحالة السريرية..
من خلال الصورة الشعاعية يتضح أن هناك امتصاصاً خارجياً حصل جذر الثنية وخاصة في الأنسي، وحتى الرباعية حدث فيها امتصاص، والامتصاص الخارجي له أسباب عديدة من أهمها الرض على السن، ونلاحظ أن المريض يضع جهازاً تقويمياً على أسنانه، لذلك فالسبب المرجَّح هنا لامتصاص الجذر هو القوة التقويمية الراضة المطبَّقة على الأسنان، ويؤكد ذلك غياب الاستمرارية في طبقة اللامينادورا حول الجذر، وهو للأسف بسبب عدم دراسة دقيقة لمقدار القوة الواجب تطبيقها على الأسنان، لذلك فيجب فوراً إزالة الجهاز التقويمي، وإعادة دراسة القوى المطلوب تطبيقها، فالقوة الشديدة المستمرة لن تحرك الأسنان كما نريد، بل ستسبب امتصاص الأسنان نفسها..
طبعاً يجب عدم المباشرة بوضع جهاز تقويمي آخر حتى تستقر الحالة، حيث يجب مراقبتها، وإذا احتاج الأمر يمكن ترميم الجزء الممتص الأنسي للثنية إذا كان مكشوفاً على الوسط الفموي وأصبح خطراً لتجمع الجراثيم كي لا يحدث نخر فيه، كما يجب أن نرمم النخر الوحشي على الثنية..
هذا هو تقييمي للحالة.. وشكراً لك ثانية..، بانتظار إفادتك وإغنائك للموضوع..

أنا أوافق عبد الحليم تماماً في كلامه أن الحالة هي عبارة عن iatrogenic external resporption لكن أعتقد أن الثنية تبدي أيضاً Cervical external resorption وليس هو مجرد نخر سني ، نحتاج للمعطيات السريرية ..

التدبير .. نزع الجهاز التقويمي فوراً ، يجب وضع الحالة تحت المراقبة ، مع احتمال قوي لقلع الثنية ، اما الرباعية فيمكن إجراء المعالجة اللبية لها ثم إجراء Retrograde filling بعد الـ Apicectomy وذلك إذا كانت حيويتها سلبية ، أو ضعها تحت المراقبة في حال كانت استجابتها للـ Pulp VitalityTests طبيعية..

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ملاحظة أخرى حول الرباعية أن القناة مغلقة تماماً ، رربما معالجة سابقاً لبياً بأقماع الـ Resin أو أن اللب متراجع بشدة حتى أدى لانغلاق شبه تام في قناتها كاستجابة للقوى التقويمية ربما أو لأسباب مجهولة ..

Thnk you for your answers i am glad to see this case interrested you.

we had no other clinical informations so i can't supply them to you, sorry for that.

In fact the 11 show an inflammatory cervical resorption and an external replacement resorption (ankylosis) in the distal radiculaire region.
for the treatement you gived nearly all the éléments.

the problem is removing the 11 must not be done without being sur of what doing after that so the best treatement is to do an exploration flap to remove all necrotic tissus at nesial 11 them repair with GI, this gives us more time to decide how to replace 11 (inflammatory resortion has a much faster progression than repalcement resorption)

For the 12 after vitality testing if not responding TRY the ondodontic treatement.

Anyway if orthograde treatement is impossible because of the root canals being closed, retrograde filling is not possible and not recommended (never retrograde without orthograde) so extraction may be an option in the futur here too.

interesting case, thanks mate, and waiting for more
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my treatment plan is to extract 11 and insert a bone graft into the socket after extraxtion thence complete or modify the orthodontic treatment to correct the relationships between the teeth with taking into consideration the saving of the central insicor space and the midline in order to be replaced with an implant in the near future after releasing the orthodontic fixing braces.. that might be the best treatment choice..

Wesam in this case if the implant is chosen :

better to keep the tooth in place and make a one time Extraction-Implantation because this preserves the bone

A bone graft is a good idea but the problem with anterior maxillary implants is the vestibular resorption when the bone is not stimulated so if you really want to be sure not to loose the vestibular wall an immediate implantation is the way to go.

if a vestibular resorption has already reduced the bone not likely to be the case here because the bone is stimulated by occlusion and the orthodontic treatment) we need to put some osteosynthesis material associated to a membrane or an osteosynthesis screw

Anyway a new case is coming

a new case is coming soon so keep on!....

thanks Bassam, ok, according to what u mentined above, I got a question hee, is it possible to complete the orthodontic treatment here with braces on the central incisor, or it's advisable to exclude the central from the ortho treatment which is in progress and maintain it for the immediate immplantation??

I mean ; could such a tooth respond to the forces applied via the ortho movement or not?

Well it depends on the type of orthodontic treatment

if it is only done for aesthetic reasons,in this case it is iatrogenic and has to be stopped then resumed after the implant is osseointegrated and in function and the 12 is stable, to harmonize the teeth (this seems to be the case here because 11 ans 12 have brackets over them

it it is done for other reasons (correction of inverted occlusion or rotations,etc) we can after negotiation with the orthodontist remove brackets of 11 and 12 without stopping the treatement, then after the implant is done and if the 12 is stabilized (no additional rhisalyse) the 12 can be integrated into the treatment again (not the implant because implants DO NOT RESPOND to orthodontic or orthopedic forces
).
hope i answered your question and thank you for your interest

yes that's all, but we must not insert the implant unless the ortho treatment is done in order to prevent the wrong relationships between it and the rest tof the teeth, is it right??

We can't insert it during the ortho proccess, therefore, we can discuss the orthodontist about completing the treatment with exclusion of 11 from it , and after finishing the ortho, we can extarct 11 an do an immediate implantation .

All in all, it was an enthusiastic case..thanks

well after reading myself i feel that i did not express myself clearly
to resume in this case there are brackets over 11 and 12 and there are iatrogenic lesions caused bu the orthodontic treatement so 11 and 12 HAVE to be excluded.
i do not think any orthodontist will appreciate the idea of excluding TWO incisors from his treatement s
because they are the most important elements in the estheic function, this is in case it is an esthetic treatements (anterior teeth alignement).
in other treatements they can be excluded and treatement continued (really depends on case)