Objectives

Endodontic microsurgery describes minimally invasive surgical procedures that address non‐resolving endodontic pathology when non‐surgical root canal therapy has been adequately performed.

Modern endodontic microsurgical techniques involve the use of a surgical operating microscope and specialised microsurgical instruments, together with contemporary root end filling materials, to result in a more precise and predictable outcome than traditional surgical techniques.

At the end of this case, the reader should understand the principles of endodontic microsurgical procedures and identify clinical situations in which these procedures would be appropriate.

Introduction

A 52‐year‐old male presents with a history of swelling and pain to pressure above his upper left central incisor.

Chief Complaint

The patient presented with the chief complaint ‘15 years ago I fell and hit my front teeth and they were messed up since then’. He reports that one month previously, he had swelling and pain above the upper left central incisor. His dentist prescribed a course of antibiotics, and he has been comfortable ever since.

The Medical History

The patient had a history of controlled hypertension, diabetes and joint prostheses of both hips.

Dental History

The patient received routine dental care from his general dentist and no significant issues were reported.

Clinical Examination

Extraoral examination was unremarkable. Intraoral examination revealed tenderness to palpation in the anterior buccal sulcus over tooth UL1. The tooth was tender to percussion, but exhibited no mobility and was non‐responsive to pulp sensibility testing. No evidence of caries, prior restorations or fractures was seen. Periodontal probing depths were within normal limits. All adjacent teeth exhibited no tenderness to percussion or palpation and tested within normal limits to pulp sensibility testing.

What do the periapical radiographs reveal?

A periapical radiographs of tooth UL1 revealed an 8.5 × 10.5 mm well‐defined, periapical radiolucency. The apical lesion was seen to extend towards, but did not encompass, the apex of tooth UL2 (Figure 5.3.1a, b).

Diagnosis and Treatment Planning

Diagnosis of tooth UL1 was pulpal necrosis with symptomatic apical periodontitis.

Treatment options discussed with the patient were:

• Non‐surgical root canal therapy
• Extraction
• No treatment (not advisable)

The patient was interested in saving the tooth and consented to non‐surgical root canal treatment.

Treatment

Non‐surgical root canal therapy of tooth UL1 was initiated. Local anaesthetic was delivered and the tooth was isolated with a dental dam. The canal was accessed and the pulp chamber and access opening were examined with the surgical operating microscope for any evidence of cracks, fractures or other compromise. As no compromise of the tooth structure was seen, the canal was debrided and disinfected. The canal was dried and calcium hydroxide was placed. The access opening was sealed with a temporary restoration.

The patient returned in two weeks and reported that his symptoms had subsided. The calcium hydroxide was removed and root canal treatment was completed (Figure 5.3.1c).

One year later, the patient returned to report that his symptoms had returned. Radiographic examination with periapical radiographs revealed that a 6.9 × 8.2 mm apical radiolucency persisted (Figure 5.3.2a).

Further imaging with cone beam computed tomography (CBCT) revealed a 8 × 9 × 7 mm apical radiolucency with perforation of the buccal cortical plate associated with tooth UL1 (Figure 5.3.2b).