Diagnostic Case II:
Exploratory Surgery: Repairing Incomplete Fracture
Keivan Zoufan, Takashi Komabayashi, and Qiang Zhu
Chief Complaint
“I had a root canal re-done on my front tooth, but there’s still a bump there. My dentist said maybe it’s fractured and sent me to you. By the way, my front teeth are sensitive to cold as well.”
Medical History
The patient (Pt) was a 70-year-old female. Vital signs were as follows: Blood pressure (BP) 129/85 mmHg right arm seated (RAS), pulse 63 beats per minute (BPM) and regular, respiratory rate (RR) 16 breaths per minute. No known drug allergies (NKDA). A complete review of systems was conducted. The Pt had controlled seasonal allergies and hypertension and was taking Clarinex® (5 mg daily) for seasonal allergy relief and Zestoretic® (10 mg daily) for high blood pressure treatment.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class II.
Dental History
The Pt had a history (Hx) of routine dental care. Her oral hygiene was good. Numerous restorations were present. Tooth #7 had been endodontically treated with silver point more than twenty years ago. A sinus tract presented approximately four months ago and a non-surgical retreatment was completed on tooth #7. However, the sinus tract was still present. Pt’s general dentist believed that she had a vertical root fracture on tooth #7 and Pt was referred for further evaluation. Two radiographs were provided by her general dentist; one showed tooth #7 had been endodontically treated with silver point and had a normal apex (Figure 3.1). The second one showed tooth #7 had been retreated and the root canal obturation looked adequate (Figure 3.2).
Figure 3.1 Radiograph taken by patient’s general dentist 4 months prior to the Pt coming to the office. Tooth #7 had been endodontically treated with silver point.
Figure 3.2 Tooth #7 was retreated and the root canal obturation looks adequate.
Clinical Evaluation: (Diagnostic Procedures)
Examinations
Pt was alert, normally developed, and was not stressed.
Extra-oral Examination (EOE)
EOE revealed no lymphadenopathy, swelling or sinus tract of the submandibular and neck areas. Soft tissue appeared healthy. Temporomandibular joint (TMJ) was within normal limits (WNL).
Intra-oral Examination (IOE)
A sinus tract was located in the attached gingiva of the labial area between teeth #7 and #8 (Figure 3.3). Periodontal probing depths of teeth #6, #7, #9, and #10 were < 4 mm; however, tooth #8 showed increased pocket depth and bleeding upon probing on middle buccal surface. There had been multiple restorations. Tooth #7 was restored with composite; tooth #8 had distal (D) amalgam restoration and discolored BML composite restoration. Discolored ML composite restoration with evidence of recurrent caries was noted on tooth #9. All teeth had normal physiological mobility. Transillumination revealed no cracks or fractures. Placement of Endo Ice® on tooth #8 produced sharp and short sensitivity without lingering pain.
Figure 3.3 Sinus tract was seen in the apical area between teeth #7 and #8.
Diagnostic Tests
| Tooth | #6 | #7 | #8 | #9 |
| Percussion | – | – | – | – |
| Palpation | – | – | – | – |
| Endo Ice® | + | N/A | Sensitivity, no lingering pain | + |
| EPT | + | N/A | + | + |
EPT: Electric pulp test; +: Normal response to Endo Ice® or EPT; –: Normal response to percussion or palpation; N/A: Not applicable
Selective Anesthesia after Diagnostic Tests
Probing on tooth #8 was very painful. Therefore, to assess the exact measurement, local anesthesia using 36 mg lidocaine with 0.018 mg (1:100,000) epinephrine was administered. An 8 mm isolated probing was noted in middle buccal (B) of tooth #8. All other probing depths were <4 mm.
Radiographic Findings
Preoperative radiograph showed teeth #5 and #6 had three surface fillings and normal apical status. Tooth #7 had previous root canal treatment (RCT) and was restored with core build-up. The root filling appeared to be adequate. Normal periradicular structure of teeth #7 and #8 was noted (Figure 3.4). Gutta-percha (GP) tracing of the sinus tract on B mucosa pointed to D and apical aspect of the root of tooth #8 (Figure 3.5). A GP tracing radiograph showed tooth #8 had mesial (M) and D fillings. A 2 mm × 4 mm lateral lesion extending from 2 mm coronal of the radiographic apex to 6 mm below the alveolar crest was seen on the D surface of tooth #8 (Figure 3.6). The sinus track came from the lesion extending from 2 mm coronal of the radiographic apex to 6 mm below the alveolar crest.
Figure 3.4 Preoperative radiograph shows teeth #7 and #8 have normal apex.
Figure 3.5 Gutta percha traces sinus tract.
Figure 3.6 Gutta-percha tracing radiograph shows a 2 mm × 4 mm lateral lesion on tooth #8, with the distal surface extending from 2 mm coronal of the radiographic apex to 6 mm below the alveolar crest.
An M restoration of tooth #9 was partially viewed. Also, evidence of recurrent caries was noted (Figure 3.6).
Pretreatment Diagnosis
Pulpal
Reversible Pulpitis, tooth #8
Apical
Normal Apical Tissues, tooth #8
Treatment Plan
Recommended
Emergency:No treatment
Definitive:Exploratory surgery of tooth #8. Repairing root crack line (observed in exploratory surgery), and non-surgical root canal treatment (NSRCT) due to the possibility of devitalizing pulp by the crack line repairing procedure.
Alternative
Extraction of tooth #8 or no treatment
Restorative
Core build-up and full coverage restoration
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Exploratory surgery of tooth #8: medical history was reviewed. BP: 129/85 mmHg RAS, pulse 70 BPM. Explained the procedures to the Pt and obtained informed consent. Confirmed with the Pt’s physician over phone that for pain control, Tylenol® was more appropriate than ibuprofen because of the beta-blocker drugs that the Pt took for controlling BP. The Pt was concerned about urinary incontinence; assured the Pt that she would be free to go to restroom as needed and that the dental procedure would be as atraumatic as possible. Pt was asked to rinse with 0.12% chlorhexidine. Local anesthesia was administered with two capsules of 2% lidocaine with 1:100,000 epinephrine. A full-thickness sulcular flap from M side of tooth #4 to D side of tooth #10 with a releasing incision M to tooth #4 was elevated. A bony defect in the B side of tooth #8 was noted. The defect perforated the B plate. Also, the interdental alveolar bone was lost on the the B side of tooth #8. Granulation tissue was enucleated and was sent for biopsy. The B surface of tooth #8 was stained with methylene blue and examined at high magnification. A crack line was observed (Figure 3.7). Tooth #7 was fully covered by bone. Because the root apex of tooth #8 was fully surrounded by bone the without the apical lesion seen on PA, and the B lesion did not extend to the root apex, it was decided to repair the crack line. The B crack line was prepared with ultrasonic tips ProUltra® Surgical Endo Tip Size 1 (Dentsply Sirona, Ballaigues, Switzerland) under the operative microscope (Global Surgical Corporation, St. Louis, MO, USA) and the prepared groove cavity was filled with Geristore® (DenMat, Lompoc, CA, USA) (Figure 3.8). The flap was well irrigated with 10 ml of 0.9% sodium chloride (NaCl). The wound was closed with 5-0 nylon suture (Nurolon® Suture, Ethicon US LLC, Somerville, NJ, USA). Due to the possibility of devitalizing pulp during the repair procedure, a NSRCT was recommended. The Pt agreed with the recommendation. A rubber dam (RD) and clamp were placed over tooth #8. Restorations were removed with high-speed burs. Access was completed. When the canal was located, the pulp was vital and hyperemic. No evidence of a fracture was noted inside the tooth. A working length (WL) was established and confirmed with a radiograph (Figure 3.9). Instrumentation was performed with Sequence series 0.04 taper rotary files (EndoSequence®, Brasseler USA, Savannah, GA, USA) using a crown-down technique. The canal was irrigated with 5 ml of 0.5% sodium hypochlorite (NaOCl) and dried with paper points. A master cone was then placed to length with AH Plus® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany). The canal was obturated by System BTM (Kerr, Orange, CA, USA) and back-filled using Calamus® Dual (Dentsply Sirona, Johnson City, TN, USA). The access cavity was filled with CavitTM (3M, Two Harbors, MN, USA) and Fuji IX GP® (GC America Inc., Alsip, IL, USA). The RD was removed. Post-operative (PO) vital signs were within normal limit. Post-operative instructions (POI) were given: PeridexTM 0.12% (3M, Two Harbors, MN, USA) rinse two times daily (BID), beginning the second day after surgery for one week. The Pt was instructed to take one tablet Tylenol® 500mg three times daily (TID) as needed (PRN) for pain. Ice pack and gauze were applied. A PO radiograph was made (Figure 3.10).
Figure 3.7 A crack line was observed in the root of tooth #8.
Figure 3.8 The crack line was repaired.
Figure 3.9 Working-length radiograph of tooth #8. Root canal treatment was initiated due to the possibility of devitalizing pulp by the crack-line repairing procedure.
Figure 3.10 Obturation radiograph of tooth #8.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size | Obturation Materials and Techniques |
| Single | 24.0 mm | 45 | GP, AH Plus® sealer, Vertical condensation |
Second visit (Day 6): Suture removal and biopsy report. RMHX was conducted and vital signs examined. Pt had no swelling and the healing of the surgical wound was uneventful. All sutures were removed. Biopsy reported a cyst lined by hyperplastic unkeratinized stratified squamous epithelium. The wall displayed mild to moderate inflammatory reaction (Figure 3.11). A request was made to Pt’s general dentist for a full coverage restoration without a post on tooth #8, as well as caries excavation on tooth #9. A follow-up appointment was scheduled.
Figure 3.11 Histologic slides of the biopsy tissue revealed a cyst lined by hyperplastic unkeratinized stratified squamous epithelium. The wall contains mild to moderate inflammatory reaction. A: Original magnification ×4; B: Original magnification ×40.
Histopathologic Diagnosis
Periapical Cyst (biopsy report)
Diagnosis (Post-Treatment)
The cystic lesion was most likely a lateral periodontal cyst considering the cyst was located in the lateral periodontium of tooth #8, and the tooth was vital with normal apex.
Post-Treatment Evaluations
Third visit (1-year follow-up): Pt failed the six-month recall appointment. RMHX. Tooth #8 was asymptomatic and restored with composite core (Filtek™ Supreme Ultra A2B, 3M ESPE, Two Harbors, MN, USA) by her general dentist. The tooth was non-tender to percussion and palpation. A follow-up radiograph was made and it revealed healing of the bony defect (Figure 3.12). The general dentist had performed a RCT on tooth #9 and restored with composite core build-up. Gingiva was normal. Probing depth was <3 mm and mobility was normal. A full-coverage restoration was recommended on teeth #7, #8 and #9. A follow-up appointment was scheduled.
Figure 3.12 One-year follow-up radiograph reveals healing of the lateral lesion on the distal side of tooth #8.
Fourth visit (3-year follow-up): RMHX. Tooth #8 was asymptomatic and non-tender to percussion and palpation. Mobility was normal. Gingiva shape and texture looked normal (Figure 3.13). Probing depth was <3 mm and no bleeding upon probing was noted (Figure 3.14). Apex appeared normal in the periapical (PA) radiograph (Figure 3.15). The Pt was urged to pursue full coverage restoration as soon as possible. Prognosis was favorable.
Figure 3.13 Three-year follow-up clinical photograph. Gingiva looks normal.
Figure 3.14 Three-year follow-up clinical photograph. No bleeding upon probing.
Figure 3.15 Three-year follow-up radiograph shows normal apex of teeth #7 and #8 and healing of the lateral lesion on the distal side of tooth #8.
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