Wednesday, April 25, 2012


Occasionally, we see cases that have had previous treatment, retreatment, and apicoectomy, often times many decades ago, and now require intervention.  The prognosis on these cases is often guarded at best, and it is great that we have dental implants as an option.  If a tooth has a fractured root or is in poor restorative or periodontal condition, I generally recommend a dental implant.

However, there are some select cases, and select patients, where there are some alternatives.  I have a few such cases where I have elected to retreat a case with previous apicoectomy, and have had success without redoing the apicoectomy.  This is usually necessary where the entire canal system or chamber is contaminated, or there are missed canals that can be addressed.  In fact, a missed canals, or a leaking restoration are the most common reasons for apicoectomy failure.  I will save those cases for a future post, and instead show a couple cases where it was decided to "re-apico" the tooth.

This first patient suffered a traumatic sports injury 30 years ago to her anterior teeth.  The original root canal treatment was done at that time.  The teeth had apicoectomies within a few years.  The crowns on the teeth were recently redone, and a sinus tract was noticed soon after.  As an aside, the appearance of apical pathology on a previously treated tooth only following a new restoration is a common trend.  The most likely explanation is a lack of proper isolation during restorative care and a lack of seal in an old root canal treatment.  

There was heavy amalgam tatooing of the buccal mucosa, but the patient was happy with the esthetics of her new crowns after many years of having crowns she considered ugly.  I discussed treatment options at length, and ultimately referred her to a periodontist for implant consult and to learn about the alternative treatment.  After discussing the option of implants with her periodontist, she came back to me to take a chance on redoing the apicoectomy.  The sinus tract was only associated with #9, but upon access, a granuloma perforating the B plate of #8 was noted, and a decision was made to treat both teeth.

Preop #9

Preop #8

Intraoperative, note the extreme bevels already present.
A submarginal scalloped rectangular flap was selected due to an abundance of attached gingiva.  (pic is flipped)
Post op.  MTA retrofil.
1 month recall, no sinus tract.

The 6 month recall will be coming up soon.  

Case Two is similar and more recent.  This was an extremely challenging case.
This patient presented with two sinus tracts, each tracing to #9 and #10.  The crowns on 8-9 and 10 were all recently redone within the past three months.  The post on #9 is out the end, and crown to root ratio is poor.  I recommended ideally extracting #9.  A case could be made to retreat #10, and that would be my usual preference.  The patient understandably was averse to extracting #9, and so an alternate plan of apicoectomy of both #9 and #10 was suggested.  Tooth #9 was already splinted to #8, so mobility is unlikely.  I likened the desired final result to a cantilever bridge, with a little bit of support.  I cautioned the patient that the prognosis was guarded at best, and the patient again wished to proceed with treatment.  

Preop radiograph.
Dual sinus tract tracing.

Upon access, a complete lack of buccal cortical plate on #9 was noted, and is obviously not ideal.  (pic is flipped)
  A papilla-base preservation flap was selected due to a lack of attached gingiva for a  submarginal.
Hemostasis was a major challenge with this patient.
I was able to resect some of the post, retroprep the GP on the palatal aspect of it, and pack it with MTA.
(flipped pic)  I also apologize, the color balance is off on some of these last few photos.
The MTA retrofil on #10. (flipped pic)
Closure with interrupted sutures. (flipped pic)

Post op radiograph.

I was very pleased with the final result of this case.  Only time will tell if we can have sustained success.  I'll be recalling this case is the coming months.

These two cases turned out as well as I could have expected, but I always appreciate any feedback. I always have more to learn about endodontic surgery, since my preferred approach is retreatment for an overwhelming majority of cases, and I don't have some of the experience in surgery that some other clinicians have.  If you would have selected a different flap design, let me know! I'm open to suggestions.

Both cases posted here could certainly have been treatment planned as dental implants.  However, both patients were in the unique situation of very recently having invested in new crowns.  With careful patient selection and expectation management, I believe we can offer patients these types of treatments to preserve their natural teeth, even if for only for a few more years.  

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Javier Pascual Irigoyen said...

Thanks for share Dr. Parente. I would like to ask you a question. When I perform upper anterior PA surgeries patients usually experience pain during lesion curettage. How can I solve this problem? I usually perform buccal infiltrations with lido 1:50 and nasopalatine nerve blockage. Should I peform troncular blockage? Have you experienced this problem and how can be solved? Thank you ver much. Kind regards

Javier Pascual

Justin M. Parente, DMD said...

Hey Javier,

The cause for this sensation during treatment is most likely insufficient palatal anesthesia. A NP block alone may not be enough. For a case like this, I started with something similar to you, although using mostly 1:100k epi and supplementing with a final dose with 1:50k epi for hemostasis. The only difference is I administer additional palatal anesthesia supraosseous to the osteotomy sites.

If you find that your patients are still feeling it during curettage, you can administer anesthetic directly into the lesion or crypt, or add it back again supraosseous on the palatal.

Hope that makes sense and helps. Each case is a little unique and, of course, be sure to observe all precautions with lidocaine and epinephrine dosages with respect to the patient's health history.

Best of luck,


Marielaina Perrone DDS said...

Thank you for sharing. Very nice work.

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