Apical surgery #14.
35 year old healthy woman presented for evaluation and treatment of tooth #19. She reported a swelling and pain on biting. My evaluation confirmed slight swelling and percussion tenderness on tooth #19. No perio probings more than 4mm. Radiographically, periapical radiolucency on the mesial and distal root, and a thin dentin wall mesial to the post were noted. After discussing treatment options, the decision was made to proceed with root end surgery. This patient was then prescribed a coarse of Clindamycin 300mg tabs and Peridex rinse, she was also given an Rx Motrin 800 and Vicoden for post-operative pain to use in a staggerred fashion and was reappointed for surgery.
I apologize for dark pre-op and intra-op photographs.
Bone graft was placed into the surgical crypt prior to closure.
One year recall shows complete periapical healing, tooth #19 is asymptomatic and functional.
Surgical Endodontics has been my passion for a while now!
In this post I will share several cases and highlight their individual challenges.
This women in her early forties had a root canal on tooth #14 over 5 years ago. Clinically, there is a 7mm perio probing with exudate on the buccal. Radiographically, there is a strip perforation on the distal aspect of the MB root.
Options: 1. extraction and tooth replacement 2. MB root amputation.
This patient wanted to retain the tooth if possible.
Since the majority of root amputation failures are due to fractures, case selection is extremely important. DB and P roots on this tooth are not distally inclined and are fairly vertical which minimizes the fulcrum effect during function and a fracture potential is minimal.
A full flap was raised, MB root was resected and removed, a retrograde glass ionomer filling was placed. Dynoblast bone graft was used along with the Biomed membrane.
2 year follow up shows complete healing. Tooth is functioning normally and tissues look healthy.
This gentlemen is a healthy 60 year old. Teeth #26 and 27 had recent root canals (#27 was retreated by a general dentist, #26 was done by me). He reports discomfort and slight swelling in the area. Perio probings are 4mm or less. Large periapical radiolucency is present radiographically. These teeth are also abutments for an existing lower partial.
The decision was made to perform apical surgery rather than lose these teeth.
In cases involving lower anteriors, the challenging part is three fold: 1. surgical access in people with prominent chin, 2. labial inclination of the crowns and therefor lingual positioning of root apecies, and 3. Tissue management (thin tissues).
Apical surgery was completed on both #26 and 27. MTA root end fillings were placed and calcium sulfate was placed into the surgical crypt as a barrier to prevent epithelial ingress.
One year follow up shows complete healing.
This women is in her fifties. Presented with discomfort on the buccal of tooth #30. Slight gingival swelling and an 8mm perio pocket on the buccal. Root canal was done years ago. Post perforation with furcal radiolucency is noted radiographically.
My recommendation to her was to remove the tooth and replace it with an implant. She refused to get an implant. We decided to open this up surgically and attempt a repair with guarded prognosis.
Photograph below shows several things:
1. Post was reduced back into the root
2. There is adequate root trunk for epithelial attachment
3. A three wall bony defect (conducive to healing if repair is adequate)
After the repair, Dynoblast bone graft and a Biomed membrane was used.
At four months, perio probings are 3mm, tissues are healthy, tooth is functioning normally and a radiograph shows signs of initial healing.
Patient is scheduled for a 1 year follow up.
These three very different cases illustrate the importance of case selection! All of the above teeth could have easily been extracted and replaced with implants! Instead, they live to bite another day!
In this post I really wanted to simply go through some of the concepts involved in apical surgery and to share my thought process when considering such procedures.
So, why do some root canals fail?
1. Intra-radicular infection.
2. Extra-radicular infection.
3. True periapical cyst.
Root canal failure in most cases can be attributed to at least one of three reasons listed above. When I get a patient with failing root canal, I prefer a non-surgical re-treatment when possible to save the natural tooth. Sometimes however, this option is not possible or practical. In this case, a decision must be made whether or not endodontic surgery is a viable option.
Indications for apical surgery:
1. Conventional re-treatment is not possible or practical.
2. Re-treatment has already been done.
3. Biopsy is necessary.
So, at this point in a treatment planning algorithm, a clinician must evaluate the tooth in question and together with the patient choose the course of treatment.
Is it just better to extract the tooth and place an implant? In many cases it is.
Case selection and surgical skills!!!!! These two are paramount when considering apical surgery!
Case selection, in my mind, simply involves patient factors (medical history etc.) and “tooth” factors. I will concentrate on “tooth” factors.
Here are some of the things I look at during evaluation for possible apical surgery:
1. Proximity of the apical lesion to vital anatomical structures. For example, if the apex of tooth #29 is “sitting” on a mental foramen, apical surgery is contraindicated and an implant, bridge or intentional replantation (to be discussed in future posts) should be considered.
2. If there are deep pockets or fractures – implant! I need crestal bone around the tooth to give me better prognosis.
3. How deep is the vestibule? Lets say on a lower molar, typically lower second molars, if there is a thick buccal plate and a shallow vestibule, I will typically recommend an extraction and an implant because the apical surgery will destroy lots of good bone and in a case like this, an implant will be less traumatic. Conversely, if the vestibule is deep, the surgical access is easier and I am more likely to choose apical surgery option.
4. Size of the lesion – the larger, the worse! There is no “cut and dry” rule here. We do know however that apical surgery performed on a lesion more than 5mm in diameter tend to have a lower chance for healing.
5. Existing restoration is to be considered and also intangibles.
Besides all the obvious, like basic principles of flap design and tissue handling, the following should be done during apical surgery:
1. Periapical granuloma/cyst should be removed.
2. Must resect the root(s), best completed at a 3mm level from the apex.
3. Must place root-end filling(s) and according to research best material for that appears to be MTA. It is desirable to make the root-end preparation and therefor a root-end filling as long as possible to prevent apical leakage.
4. If the root-end filling is not placed, failure will follow!
5. During the root-end preparation – isthmus (if present) between canals MUST be incorporated into the preparation and sealed. Often isthmus is present on MB root of an upper molar (between MB1 and MB2), lower anteriors, upper premolars and lower molars (between buccal and lingual canals)
6. In order to achieve best possible outcomes, surgical operating microscope and ultrasonic instrumentation should be used.
30 year old healthy male presented with the swelling around #13. Periapical area is present on the radiograph. Diagnosis #13 failing root canal with acute periapical abscess.
Options: re-treatment with the post removal and a new crown, implant supported crown or apical surgery.
In this case, my patient opted for apical surgery.
Full periosteal flap was raised and the periapical lesion was curretted out. Roots were then resected. In this case, untreated palatal root was discovered.
Both 2 year follow-up radiographs show complete periapical healing, tooth is asymptomatic and functional.
50 year old woman with controlled hypertension, reported persistent discomfort in the periapical area associated with tooth #7, previous root canal was done by an endodontist. Diagnosis #7 Previously treated root canal with chronic periapical periodontitis.
At the 3 year follow up, tooth is asymptomatic and functional, radiograph shows a complete healing with the classic “star burst” appearance of a periapical scar.
34 year old healthy male reported a “bubble” on his gum.
Diagnosis: #30 previously treated root canal with chronic periapical abscess.
Separated instrument is “peeking” out of the mesial root. Large periapical lesion.
No perio probings above 3mm, new crown placed 3 weeks ago.
Mesial and distal roots were resected and MTA root-end fillings were placed. Isthmus was also prepared and sealed between MB and ML canals.
At one year, tooth #30 is asymptomatic and functional. Radiograph shows complete periapical healing.
This is an example of palatal root surgery.
Tooth #14 was retreated 1 month prior to this film. Regretfully, I lost apical control of my obturation on the palatal root and this tooth was symptomatic (biting tenderness).