Although I’m perfect, not everything that I do is. And if you believe that, well…well you’re welcome as a guest in my house anytime!

Here is a case that is about 12 months old. The right central incisor had a history of trauma and at the consultation appointment there were clinical signs of infection (chronic apical abscess).

By the time I saw the child for treatment, the apical lesion had enlarged. The plan for treatment was endodontic therapy, of course, but I was unsure if apexification would be necessary. I assumed it would be, but decided to play things by eye.

Once I got into the tooth I found pus in the coronal third of the canal but as I worked my way further up the canal, hyperemia developed. The apically vital pulp was likely the reason that I found an apical stop.

The apical vitality and stop allowed me to complete the case, rather than medicate it therapeutically against infection or for apexification purposes. I was a little overzealous with my obturation (warm lateral condensation for this case) and squished out a heavy amount of sealer.

To show you that presence of infection is really the only factor that affects apical healing, I took the third film as a recall this year. The left central incisor has completed apical maturation. The sealer outside the right central is still there but the periapical radiolucent area has practically disappeared. Clinical examination found no signs of infection and our patient reports no issues with the tooth.

This is a healed case.

The goal of my therapy is not to squish sealer out the apex, but to create a favorable environment for osseous healing. I did both of those things here. Extra-radicular material will increase post operative inflammation and will cause a foreign body reaction which can result in a fibrous connective tissue scar. The scar can look like a persistent lesion over time and complicate future diagnosis.

Histology of the periapex (yes, that’s my name) of this tooth would probably show fibrous encapsulation of the sealer, but in this case the capsule is thin enough that it does not show radiographically.

Hey, I’m not perfect and not everything I do works out the way it is supposed to. Fortunately for our patient this case did. Seeing how a substantial Ellis II fracture line is now obvious on the left central, I might see this guy again at some point in the future for work on that tooth.

And lest I forget, one more thing: When you get your cases back from an endodontist and they say that the tooth has been temporized with a cotton pellet and Cavit, please remove the cotton pellet from under the Cavit before you place your permanent filling.