Apicoectomy Case Study

Endodontic surgery, typically referred to as surgical root canal or apicoectomy, is used to treat apical periodontitis in cases that did not heal after nonsurgical re-treatment, or, in certain cases, primary root canal therapy with persistent intracanal infections after iatrogenic changes to the original canal anatomy,persistent microorganisms in the apical foramen, extra-radicular infection (including bacterial plaque on the apical root surface) or persistent bacteria within the lesion itself.

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This case pictured here is based on a 60 year old female who presented with a chief complaint of pressure sensitivity on teeth #7-#10 and a history of a draining sinus tract.

At the time of the visit, there was a fluctuant, palpable swelling in the maxillary buccal vestibule above teeth #8 and #9. The radiograph showed preexisting root canal treatments on #8 and #9 which had been completed within the last four years, and a large radiolucent lesion extending from teeth #8-#10. The treatment plan presented to the patient was surgical root canal therapy to eliminate the source of infection.

The procedure began with elevation of a full mucoperiosteal flap with one vertical releasing incision. This image above demonstrates the preexisting bone loss following elevation of the flap. A well-encased epithelial cyst was removed from the osseous crypt and sent for biopsy. Tooth #8 was resected at a 90 degree angle to ensure accurate elimination of bacteria harboring lateral canals most commonly found in the apical 1/3 of most canal systems. Staining and microsurgical inspection was completed to view for missed canals or fractures. The retro-prep was completed using ultrasonics and sealed with MTA retrofill. The site was grafted, a resorbable membrane was placed, and the flap closed.

Four weeks following apical surgery, the patient returned to her general dentist for restorations on Teeth #7-#10. At both her 3 and 6 month recalls the patient no longer presented with any clinical symptoms and radiographs revealed substantial maxillary bone fill.

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What the literature shows us today is…

For many years, traditional surgical root canal therapy involved utilizing surgical burs and amalgam as a root-end filling material. Today, modern techniques utilize a 90 degree apical root resection and incorporate the use of ultrasonic tips and more bio-compatible filling materials including IRM, SuperEBA and MTA. The use of microsurgical instruments, high-power magnification and illumination allows for greater accuracy than traditionally used methods. Despite these advancements, the traditional techniques are still being used in the oral and maxillofacial surgery community.

Source: Setzer FC, SHah SB, Kohli MR, Karabucak B, Kim S.  Outcome of Endodontic Surgery: A Meta-analysis of the Literature Part 1: Comparison of traditional root-end surgery and endodontic microsurgery.  J Endod 2010; 36:11:1757-65

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