Deconstruction of an Apicoectomy.
Surgery April 4th, 2008
I usually retreat cases like this (access the crown, remove the post, redo the root canal work), but the patient was sure the crown would come off without the post in the tooth, so fine, we decided to do the surgery instead. For those who understand what I’m talking about so far, if the crown is at risk of falling off without the post (during the temporization period), the crown is likely not fitting the tooth as well as it should and is probably leaking. Surgery in situations like that ends up being a short-term solution.
The surgery went fairly smoothly, and I got a decent shot of the root end after I’d resected and filled it. The largest amount of granulation tissue was on the buccal root surface near the apical/middle third junction. The culprit turned out to be a lateral canal. I filled the lateral canal and two main canals with white MTA. The apical bevel looks much sharper in the photo than it really is.
All the bright red is blood-covered jawbone. Here’s the key to the numbers in the picture:
- Crown of tooth
- Lateral canal
- Buccal canal
- Isthmus between canals
- Palatal canal
There is also a sinus perforation that doesn’t show well on the clinical photo.
April 4th, 2008 at 1:22 pm
Wow. Anyone who can identify those things from the picture on the right and relate them to the picture on the left… is a genius. I bow down to you Peri
Also, thanks for agreeing to show my face on your blog again ;P
fragileheart’s last blog post..Diving in head first
April 4th, 2008 at 2:10 pm
I have my textbooks open when I work. It’s much easier to figure these things out then…
You’re welcome. Your entrecard picture shows us 2 things: you’ve got at least four fingers and two eyes. Don’t know if you’re hiding something behind the camera though.
April 4th, 2008 at 6:47 pm
Yep, I understood every single word of that.
It made me wonder…, have you ever in your career had a moment where you had to step away from a patient for a couple of minutes because the blood was getting to you?
It’s never happened to me personally, but it has happened to The Boss a time or two. I’m a toughie.
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April 4th, 2008 at 7:14 pm
wow! that’s so cool!
just out of curiosity, what is the prognosis of the tooth following retrograde endo tx?
April 5th, 2008 at 11:33 am
Lin: If there’s that much blood, something’s wrong and stepping away from the patient isn’t a good idea
. Seriously though, there are really only 2 reasons why I have stepped away for a couple of minutes and then returned: I get really gaggy when people have stuff stuck between their teeth that I have to pick out (especially those with partial dentures). Like pubic hair; like last night’s salad. I usually put it on the bracket table in full view and then leave for a bit to recover myself. Oh, I guess vomit bothers me too.
The second reason is frustration. It’s rare, but some cases frustrate the hell out of me. Rather than throwing an instrument at my assistant, I just get up, walk out and then come back after a breather. It’s often behaviour management issues, but one case I remember had the rubber dam clamp flying off the tooth every couple of minutes. The last straw was when it flew off and hit the window in the room. I excused myself and left for bit. Amazing how once I came back and fiddled around a bit with the clamp, things stayed on just fine.
When things go wrong, my mind shouts out the F word really, really loud. I actually do hear it. As a professional though, it’s my job to make it as right as possible. Shit happens, how you deal with it is why patients come to see us.
April 5th, 2008 at 11:57 am
Pubic hair?! ROFLMAO!!!
The Boss gets really frustrated when he can’t get a clamp to sit still when preparing for a filling etc, and I can tell when he’s throwing F-Bombs in his mind ‘cuz his head jerks for a second, then he looks over at me.
He’ll get up and walk out for a minute when patients keep moving, shifting positions in the chair, try to talk while we’re working etc. Or patients with very strong tongues that we’re fighting to keep out of the way of the drill. Argh!
Patients…Do NOT move or shift positions when the Doctor has a high speed drill in your mouth!
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April 5th, 2008 at 12:38 pm
And don’t bite down…Had one patient a couple of weeks ago bite down while I was drilling.
April 5th, 2008 at 3:14 pm
Jeanie: Such a simple question, but a very complicated and somewhat controversial answer. Some recent research (Kim et al) shows the prognosis of surgery at the mid 90% range, older studies vary quite markedly (from as low as 45%, 65%, and up). This variation is complicated to explain, but has to do with followup periods, classification of healing, surgical techniques, and case selection.
The general consensus is that the prognosis is dependent upon case selection (quality of pre-existing endodontic treatment, location of tooth, presence of a lesion, fractures/perforations). Surgical technique likely plays a huge role in the success as well (ie. microsurgery with ultrasonics vs the old fashioned way with heavy bevels and high speed burs). Chronically infected cases with coronal leakage do more poorly with any sort of therapy, non-surgical or otherwise. However, when you consider that with surgery you are trying to trap bacteria inside a tooth and not allow them out, versus retreatment where you are trying to kill the bacteria inside a tooth, which do you think would be more successful?
Retreatment is generally more predictable (decent prognosis with a more narrow variance) than surgery but again is dependent upon the case (fractured instruments, very large posts, etc).
Bacteria that are locked inside of a tooth often find other ways out via lateral canals or again through the apex after chronically challenging the apical filling. Also don’t forget about the porosity of dentinal tubules.
The absolute best way to manage a failing endo is to retreat and do surgery, but most of the time this is overkill.
Why retreat and surgery? Because endodontic treatment or retreatment best instruments and disinfects areas coronal to the apical 1/3. Any bacteria left behind at the apex are then taken care of with an apical resection.
This is an important topic in endodontics and I’ve tried to make my answer as brief as possible, but prognosis is a huge part of any endo programme and yet there are no clear answers. Every endo grad comes out of their individual program with a certain bias for or against surgery (versus retreatment).
April 5th, 2008 at 7:01 pm
wow- i didnt know surgery was meant to trap bacteria in the tooth. i always assumed it was coz you couldn’t get access to retreat.
thanks for the on the spot endo lecture!
i hope it all works out.
(i’m actually doing a minor reseach porject on EALs as part of my final year at the moment so i feel more connected to the endo society!)
and omg, if i found a pubic hair in someone who wears dentures i’d probably throw up into my mask right there!
April 5th, 2008 at 11:48 pm
I think I need to expound a bit on some generalizations that I made in my attempt to be brief. Apical surgery with a retrofill is designed to trap bacteria inside a tooth, however apical endodontic surgery itself can consist of one or two procedures: Apical resection with or without retrofill. The apical resection prepares a root end for a retrofill but does provide the added bonus of removing potentially the largest reservoir for bacteria within the root (the apical aspect). There are also the largest number of accessory canals in this area.
If the practitioner suspects that the problem they are treating (usually bacterial contamination) is limited to the root end (as might be the case with an apically broken instrument in a previously infected root), an apical resection without retrofill should suffice to solve the problem if the entire instrument fragment is removed with the root end. No attempt to trap bacteria inside the canal is done here because the assumption is that there aren’t any above the level of the broken instrument.
The more common reason for apical surgery, however, is when retreatment is deemed risky for a tooth, such as in cases with huge posts. Bacteria are often trapped throughout the canal in these cases. Apical resection without retrofill will not solve the problem because bacteria will still be able to leak out of the apex. A retrofilling helps to minimise this.
So you’re right, surgery is done because the practioner feels that retreatment isn’t possible or a viable option. But you need to remember why the retreatment is needed in the first place.
Oh, I almost forgot. There’s also apical surgery where you can do a retrograde retreatment. You resect the root end and do canal instrumentation from that direction. This surgery is not done often because it’s tough to gain that kind of canal access from that direction. I don’t know the prognosis of this type of apical surgery…
April 6th, 2008 at 11:41 am
i hate those kinds of posts, the titanium, serrated, screw-type posts. i do know that they can increase the stresses on the tooth and deem it more prone to fracture, as they don’t fit as passively.
there’s always a risk of the crown falling off when any kind of endo re-treatment treatment is done on a crowned tooth. but if the crown fits well and has no caries or perio problems, what about retro-fitting a cast post to the existing crown? i have successfully done it before (i have a very good lab that can do it well) and you can verify the final fit with a bitewing, periapical and very fine explorer. if it doesn’t fit, then a new crown has to be made. that’s a risk that has to be explained to the patient, but either spend the money now on a new crown and post, or spend it later on extraction and implant when the surgery fails.
April 7th, 2008 at 7:28 pm
lol I like to keep people guessing Peri ;P
hahaha I just got this image of me sitting in the dentist’s chair and the Peri is working away, and all of a sudden I just hear “F@$*!” hahahaha I am never going to the dentist again (not that I was going before this conversation).
hehe
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April 7th, 2008 at 10:07 pm
Person: What’s wrong with a non-cast post for the retrofit? If you’ve got your mind set on a cast post, I don’t see a problem really. With a decent impression of the post space you should be fine. But you’ve got the restorative expertise, not me…Is your blog really dead by the way?
Jeanie: I forgot to ask you what you’re investigating with respect to apex locators…Do the dials go the other way Down Under?
fragile: In my office if you hear that it’s because either the internet is down or one of my staff just lost at online poker. I’m the only one that does work around there.
April 8th, 2008 at 8:07 am
i haven’t decided whether or not to kill or revive the blog. i feel like i’ve been gone for so long and i have so much to update that i just don’t have the time to update it. facebook also sucks up all my time. funny, i rarely even check my e-mail anymore, as all my friends are on it and that’s how we keep in touch.
besides, you’re the only one who would read it now, and you already know everything that’s going on anyway – the good, the bad, and the hormonal. but i’m not quite ready to let go just yet.
April 8th, 2008 at 8:14 am
it’s much easier for the lab to create an accurate retro-fit with a cast post than it is for me to recreate the interior fit of the crown with composite resin core material. i do tend to favor cast posts in general because of the more passive and accurate fit, esp for particularly wide or ribbon-shaped canals.
April 8th, 2008 at 1:31 pm
Sure, sure… any ploy to get me in your chair
fragileheart’s last blog post..No catchy titles here, new year’s resolutions are tough to keep.
April 9th, 2008 at 5:12 am
Hey PA, you’ve got to repost a year from now and tell me if the tooth is still in. RE case selection – on you’re preop film there is RL to the D of the post in the apical 1/3 which I would normally dx as a root fracture (rooth seperting from the post). It isn’t present in the post-op film though. Did you see something else clinicially taht made you rule out the fx? Also, from the pic it looks like S-EBA that you used. Any reason you did’t use MTA (could be you just work a lot cleaner than me and it is MTA). I’ve stopped using it when there “moisture” in the field.
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April 9th, 2008 at 5:59 am
Ian: A root fracture would produce a more periradicular lesion, if this lesion is from a root defect it would be a perforation from the post. There was also no clinical probing — which helps to rule out the possibility of a fracture. The lateral root lesion probably doesn’t show up on the post op film because of minor angulation differences and the fact that it became part of the overall osteotomy. That lesion was because of the lateral canal. As I said in the post, the retrofilling is MTA. I don’t know if I still have any EBA in the office. MTA sets much better in a wet environment than any other filling material. I think this was mentioned to you on the Endo Blog…
fragile: I’d much rather meet people outside of the office than in.
person: Your blog would save you time having to type the same long life updates to each of your friends. Instead you could do a post and facebook can pick it up as a note. I know I like to read my facebook friends’ notes and blogs. Maybe I’m too nosy but a blog is more personal experience than I find facebook to be these days.
April 9th, 2008 at 12:17 pm
Fair enough, but don’t you like in the boonies?
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April 9th, 2008 at 1:04 pm
live? Yeah, we live in the boonies. I didn’t say that I want to meet people, just that if I had to I’d rather outside of work.
April 9th, 2008 at 6:09 pm
Dentist scare me…
And that picture gave me the willies.
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April 9th, 2008 at 7:34 pm
You don’t know scared until you actually see my ugly mug.
I hope the picture took your mind off that racist Tech guy for a second or two. Your gravatar is underexposed also BTW.
April 10th, 2008 at 3:56 pm
lol oh ok…
I understand then ;D
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February 22nd, 2010 at 6:48 am
Grosss!!! i feel a bit wick after seeing tht second image x
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