Patient: 65 year old male in excellent health (1997)

Chief Complaint: Slight pressure sensitivity and sensitivity when pressing around the tooth with the finger (tooth #28 area)

Dental History: A long span bridge had been made utilizing tooth #28 as a single mesial abutment an unknown number of years previously. The periapical radiolucency was noted in 1996 (1 year prior to the initial exam by the author). The referring dentist had attempted to remove the bridge unsuccessfully and decided to monitor until symptoms developed. One year later (1997) the patient developed symptoms and was referred to the author.

Significant Findings: The patient presented with slight palpation sensitivity, slight percussion sensitivity, and normal periodontal findings. The radiograph exam revealed a periapical radiolucency about the tooth #28 apex measuring 6 ½ mm in greatest diameter. The bridge was loose on the mesial with a compromised tooth #28 margin.

Pulp and Periradicular Diagnosis (tooth #28): Necrotic Pulp with Acute Periradicular Periodontitis

Treatment Prognosis (tooth #28): Good

Treatment Plan: Nonsurgical endodontic treatment (tooth #28)

Special Considerations of Performed Treatment:

Initial access through the tooth #28 bridge abutment revealed a compromised margin and the pontic and mesial portion of the bridge were sectioned and removed. Endodontic treatment was performed in one visit and a post space was left with cotton pellet spacer and Cavit temporary filling sealing the access cavity preparation.

The patient was referred back to his referring dentist who placed a metal post/core and remade the bridge.

Recall:

The patient returned 7 years later (2004) for a recall examination which demonstrated complete healing. The distal abutment molars were tilted mesially and the forces were judged to be unfavorable with nonworking contacts and hyperocclusion.

The patient returned for examination of the mandibular right second molar (previous distal bridge abutment) which had developed a degenerating pulp and required endodontic treatment. Tooth #28 had been extracted and replaced with an implant and an implant had also been placed in the molar-bicuspid edentulous space.

Tooth #28 had been extracted due to fracture according to the patient.

Key Learning Points:

1. Maloccluded tilted bridge abutments create unfavorable forces prone to failure. In this case, the bridge design utilizing a first bicuspid as a single mesial long span abutment was destined for failure.

2. Orthodontic uprighting of the abutment teeth would have led to a more favorable restorative result.

3. Many failures involving endodontically treated teeth are related to poor restorative planning and execution, not recurrent endodontic disease.