3 Years to Figure It Out!

In this long-term, three-year case journey, Dr. Bill Nudera shares one of the most fascinating and educational cases of his career—an evolving diagnostic and therapeutic puzzle involving a persistent osseous defect in the maxillary right premolar region.

What began as a seemingly straightforward diagnosis on the first premolar quickly shifted as CBCT imaging, follow-up evaluations, and unexpected clinical findings revealed a far more complex etiology involving both premolars. Despite well-performed root canal treatment, the lesion failed to heal over 6, 12, and 18-month follow-ups, ultimately requiring exploratory apical surgery, cyst enucleation, grafting, and close monitoring.

Dr. Nudera walks through each turning point in real time—failed healing, patient decision-making, surgical surprises, medical considerations for a patient on Plavix, flap design, root-end management, histology results, and the emotional roller coaster of improvements followed by relapse.

When symptoms reappeared more than three years after the initial consultation, the diagnostic focus shifted again. Dr. Nudera illustrates how strategic retreatment of the second premolar led to complete symptom resolution without requiring a second surgery—highlighting the value of patience, adaptability, and respecting how multifactorial these cases can be.