Periodontal probe in pocket.

Hirschfeld points demonstrate bone loss to apex.

Clinical: In 1979, a healthy thirty-year old woman presented with a history of a chronic abscess on the labial of tooth # 27. She stated that the infection had been going on for four months, during which time she consulted with many dentists. Each dentist who examined her recommended that the tooth be removed. No one suggested to treat the canine.

Examination revealed a suppurating pocket to the apex on the labial of # 27. There was no history of pain to hot or cold, and no history of trauma. No tooth mobility was noted.

Tx:

1. Pulp Test = Vital
2. Flap surgery

During surgery, as noted in the photo below, the root was denuded of bone on the buccal and around both line angles to the middle of the interproximal areas. The bone loss extended beyond the apex of the tooth.

Treatment consisted of thorough root debridement, during which time the curette engaged the root apex. The area was irrigated with water, then the flap replaced. It is important to note that neither a bone graft nor a GTR membrane were used. It appears that bone has regenerated on the x-ray below (right). This is a nineteen year follow-up.

Flap reflected. Defect almost to apex.		Radiograph of # 27 nineteen years later.

Discussion: Remember the restorative options for replacing tooth # 27 in 1979? A fixed bridge certainly could have been used to replace this tooth. But the patient had a delicate, scalloped dentition, and esthetics would have been a challenge. A cantilevered canine extended from the premolars is not a great restoration, especially since tooth # 30 was already missing. Titanium threaded implants were not being done in those days; neither were Maryland bridges. Other options included a lingual pin-splint and a removable bridge.

Once the pulp tested vital, this suppurative defect to the apex of # 27 was viewed as a periodontal lesion rather than as one of endodontic origin. The assumption was that something had gotten caught in the pocket resulting in a reaction to a foreign body. If that was true, debriding the area and removing the foreign agent could reverse the breakdown, allowing healing to occur. As it turned out, that is what happened. The lesion healed and it appears that lost tissues were restored about the tooth. Nineteen years later, the tooth is still vital and no additional treatment has ever been necessary.

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