Patient: 78 years-old with noncontributory medical history (5/22/1995)

Chief Complaint: Biting sensitivity localized to the maxillary right second molar (initial presentation in 1995)

Dental History (maxillary right second molar, tooth #2):

The patient presented with a history of having had a full gold crown placed 3 months prior to being examined by the author on 5/22/1995). The referring dentist reported a history of a crown fracture which was the reason for placement of the crown. Symptoms persisted and the patient was referred to the author for an endodontic evaluation.

Significant Findings (Tooth #2):

The patient presented with sensitivity to biting, very slight percussion sensitivity, and bleeding upon probing. There was no response to cold thermal stimulation and generalized gingival inflammation. Significant sulcular probing depths were measured 5mm at the MB and 6mm at the DL line angles. The periapical radiograph demonstrated a radiolucency circumscribing the palatal root apex measuring 4mm in its greatest diameter.

Pulp and Periradicular Diagnosis (Tooth #2): Necrotic pulp with an acute periradicular periodontitis

Treatment Prognosis(Tooth #2): Poor to Guarded

Treatment Plan(Tooth #2): Extraction was initially recommended but exploratory access was agreed upon after consulting with the referring dentist.

Special Considerations of Performed Treatment:

Interestingly extraction was recommended by the author but because the new crown had been recently placed both the referring dentist and patient wished to be heroic and at least perform initial endodontic exploratory access. The initial access was performed on 6/7/1995 and as the author had predicted, a crown-root fracture was discovered extending through the pulp chamber floor. It was again recommended to have the tooth extracted but the patient and dentist urged the author to complete nonsurgical endodontic therapy which was performed uneventfully and completed on 6/27/1995. The author discussed that the prognosis was poor and that a long term successful result as unlikely.

Recall:

On 10/21/2015 the patient returned for examination of a different tooth. Surprisingly, tooth #2 was still present without reported symptoms. A recall examination was performed. All periodontal findings and clinical tests were observed to be within normal limits. Periapical and bitewing (horizontal) radiographs were taken and the original periapical radiolucency about the palatal root was not evident. The findings suggested complete osseous regeneration and healing of the attachment apparatus.

Key Learning Points:

1. Never presume that a patient nearing 80 years old might not require an intact healthy dentition for an additional two decades. In this instance a 78 year old patient returned for a 20 year recall examination.

2. Although root fractures are one of the most common reasons an endodontically treated tooth is lost, proper root canal retreatment with appropriate restoration can save these teeth for a patient’s lifetime.

3. Gold has very favorable physical properties, specifically an ideal modulus of elasticity which minimizes stresses and prevents crack propagation.

4. Often cracks are not definitively explored prior to tooth restoration. Definitive exploration of a crown fracture allows a needed endodontic procedure to be performed before placement of the restoration and minimizes patient morbidity.

5. The full extent of a crown-root fracture is better assessed after endodontic exploratory access and canal orifice widening.