Periapical Surgery Case I:
Maxillary Premolar
Pejman Parsa
Chief Complaint
“I had a root canal re-done on this tooth and I am still having pain when I chew with it.”
Medical History
The patient (Pt) was a 26-year-old Caucasian male. He had no known drug allergies (NKDA). Vital signs were: blood pressure (BP) 122/84 mmHg right arm seated (RAS), respiratory rate (RR) 18 breaths per minute and regular, pulse 72 beats per minute (BPM) and regular.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
The Pt had tooth #12 treated with root canal therapy (RCT) and restorative composite 5–7 years prior. The tooth became symptomatic and it was re-treated. After re-treatment, the Pt experienced postoperative pain for a few weeks and it was decided that apical microsurgery should be performed.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
Clinical examination revealed no lymphadenopathy of the submandibular and neck areas. Perioral and intra-oral soft tissue appeared normal. Extra-oral soft tissues appeared satisfactory in color and texture. The temporomandibular joint showed no popping/clicking or deviation on opening and was otherwise asymptomatic (ASX).
Intra-oral Examination (IOE)
The intra-oral soft tissue examination had normal appearance, but the root apex had tenderness upon palpation and percussion tenderness was noted (Figure 19.1).
Figure 19.1 Preoperative photograph of tooth #12.
Diagnostic Tests
| Tooth | #11 | #12 | #13 |
| Percussion | – | ++ | – |
| Palpation | – | ++ | – |
| Endo Ice® | + | – | + |
| EPT | + | – | + |
EPT: Electric pulp test; ++: Severe response; +: Normal response; –: Lack of response
Radiographic Findings
Tooth #12 showed dense root canal obturation with possible extrusion of gutta-percha (GP)/sealer into the periapical (PA) tissues. No final crown was present, but adequate composite restoration and glass ionomer material were placed within access and cavosurface. Tooth #11 was clinically intact without any restorations. Tooth #13 had a mesial-occlusal composite. Tooth #14 had previous RCT with incomplete root filling, but no PA pathosis was noted (Figure 19.3).
Figure 19.3 Root end inspection and visualization of obturation material with dental operating microscope (DOM)
Pretreatment Diagnosis:
Pulpal
Previously treated, tooth #12
Apical
Symptomatic Apical Periodontitis, tooth #12
Treatment Plan
Recommended
Emergency:NoneDefinitive:PA surgery to tooth #12 with Root End Filling.
Alternative
Extraction and dental implant, fixed partial denture, or no treatment
Restorative
Composite or amalgam build up with either onlay or full crown coverage
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): The medical history was reviewed (RMHX). Vital signs were as follows: BP 122/84 mmHg RAS; pulse 72 BPM and regular; RR 18 breaths per minute. The root tip was assessed based on previous measurements using an electronic apex locator (EAL)(Root ZX® II, J. Morita Kyoto, Japan) from the buccal cusp tip. This helped with creating a precise and conservative osteotomy during surgery. The Tx options were reviewed with the Pt including extraction and no treatment. The Pt elected for apical surgery and informed consent was obtained. The Pt was informed that vertical root fracture might be present. No concerns for anatomic structures were present. The Pt was scheduled for surgery in two months.
Second visit (2 months): RMHX. Vital signs were: BP 118/78 mmHg, pulse 72 BPM and regular. The Pt’s mouth was rinsed with 0.12% chlorhexidine for 30 seconds. Anesthesia: two carpules of 2% lidocaine (lido) with 1:50,000 epinephrine (epi) were administered for infiltration, and palatal injections were made to tooth #12 and surrounding tissues. A full thickness mucoperiosteal flap was reflected using an intrasulcular incision from the mesial (M) of tooth #11 to the distal (D) of tooth #13. No apical lesion was present. Based on EAL measurements, a bony crypt was opened 19 mm apically from the alveolar crest using a #4 round bur with sterile saline irrigation. Once the root end was approximated and visualized (Figures 19.4 and 19.5), excess root filling was noted and removed during root resection.
Figure 19.4 Surgical inspection with dental operating microscope (DOM).
Figure 19.5 Ultrasonic instrumentation (KiS 3 tip, Spartan/ObturaTM) in parallel to long axis of root surface and into canal.
Approximately 3 mm of the root apex was resected using a #171L bur with sterile saline irrigation. The tissue/root end was enucleated from the site. A biopsy was taken and sent to an oral pathologist for review. Hemostasis was achieved using epi pellets within the crypt. Then retropreparations of 3 mm in depth were made into the resected canal using ultrasonic instrumentation with copious amounts of water to prevent overheating and potential microfractures of the root surface (KiS 3 tip, Spartan/ObturaTM Figure 19.6). The preparation was dried with paper points. White mineral trioxide aggregate (ProRoot® MTA; Dentsply Sirona, Johnson City, TN, USA) Endodontics, Tulsa, OK, USA) cement root-end filling was placed in the root-end preparation and was condensed (Figure 19.7). The surgical site was rinsed with sterile saline. A periapical radiograph was taken to confirm the quality of the root-end filling (Figure 19.8). The wound site was closed with five 5-0 silk sutures (Figure 19.9). Postoperative instructions were given along with the following prescriptions: Peridex™ 0.12% (3M, Two Harbors, MN, USA), rinse twice daily, beginning the second day after surgery for one week. The Pt was also advised to take Motrin® 800 mg four times daily for pain.
Figure 19.6 Root end sealed with MTA.
Figure 19.7 Postoperative radiograph of tooth #12 with MTA retrofill.
Figure 19.8 Immediate postsurgical appearance, with sutures.
Figure 19.9 Fourteen-day postoperative check.
Post-Treatment Evaluation
Third visit (1-day follow-up): A follow-up call was made and mild soreness was reported. The Pt is on Motrin. No other complications.
Fourth visit (1-week follow-up): The report from the histopathologic exam was received. The diagnosis was: Granulation tissue and foreign material. RMHX. BP 125/79 mmHg, pulse 82 BPM and regular. The five sutures were intact and removed without complications. The soft tissue appeared to be healing well. The Pt experienced minimal discomfort.
Fifth visit (14-day follow-up): The Pt reported to be ASX. Soft tissue was healing without complications. There was no percussion tenderness but mild palpation tenderness was noted over root apex (Figure 19.9).
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