Periapical Surgery Case III:
“I have a pimple in my gum from which pus comes out from time to time. So far the area has swelled up a few times but after the swelling goes away I have minimal pain.”
The patient (Pt) was a 53-year-old Caucasian male. His vital signs were as follows: blood pressure (BP) 128/72 mmHg left arm seated (LAS); pulse 71 beats per minute (BPM)/Regular. A complete review of systems was conducted. Pt reported mild seasonal allergies for which usually no medication was required. Pt had no known drug allergies (NKDA).
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class II.
The Pt showed an extensive dental restorative history including several composite and amalgam fillings, root canal treatments (RCT), and crown/bridge restorations. His general dentist referred him to see an endodontist for tooth #14 since it had RCT previously and the Pt had occasional discomfort along with swelling in the area. The Pt mentioned that the RCT was done few years ago and he remembered that surgery was done on that area as well but did not remember exactly at what location and whether an endodontist or a general dentist performed the procedure. He experienced mild pain only when swelling appeared. The Pt was interested in saving the tooth.
Extra-oral Examination (EOE)
No edema, lymphadenopathy or asymmetry was present. Temporomandibular joints showed no popping/clicking or deviation on opening and the Pt was asymptomatic (ASX).
Intra-oral Examination (IOE)
The Pt had good oral hygiene with mild staining. In the upper left quadrant (ULQ), distoocclusal (DO) composite on tooth #12, crown restorations on teeth #13 and #14, and occlusal (O) composite on tooth #15 were present. There was a non-patent sinus tract on apical of mesio-buccal (MB) root of tooth #14 with no isolated pocket. The rest of the oral mucosa appeared to be normal with no swelling. Probing depths were 2–3 mm in ULQ except mesiolingual (ML) and distolingual (DL) of teeth #14 and #15 which were 4 mm. No abnormal mobility on teeth noted in ULQ.
|Cold||Normal||Normal||No response||No response||Normal|
Tooth #13 had RCT with post/crown restoration. Tooth #14 had previous RCT showing four filled canals and a large/long off-angled post in the palatal canal. Palatal apex looked blunted with wide root filler indicating possible previous apicoectomy or treated wide apex. Apical radiolucency was associated with both MB and distobuccal (DB) roots. The RCT looked acceptable radiographically (Figure 21.1).
Previously Treated, tooth #14
Chronic Apical Abscess, tooth #14
Emergency:No emergency treatment indicated
Definitive:Periradicular Surgery, Apicoectomy, and Root-end Fillings
Extraction of tooth #14 or no treatment
No further restorative treatment required for surgical root canal treatment option
First visit (Day 1): The Pt presented for consultation regarding Tx on tooth #14. BP 128/72 mmHg LAS; Pulse 71 BPM/regular. Examinations and diagnostic tests were performed (Figure 21.1) and a diagnosis was made. The Pt was Informed of Tx options. The Pt was told that the RCT on MB and DB roots appeared to be failing. Since no radiolucency was associated with the palatal root with presence of a large, long, and off-angled post, the plan was to explore only the B area surgically. If no fracture was present, apicoectomy on B roots would be the Tx of choice. However, follow-up was recommended on the palatal root. The Pt was scheduled to receive surgical Tx on B roots at next appointment.
Second visit (5 weeks): The Pt presented for planned periradicular surgery/apicoectomy on MB and DB roots of tooth #14. BP 129/80 mmHg LAS; Pulse 60 BPM/regular; Temperature: 98.9° F; Respiratory rate 24 breaths per minute. The surgical procedure, prognosis, and postoperative instructions (POI) were reviewed with the Pt and consent was signed. Anesthesia was administered with 54 mg 2% lidocaine (lido), 1:100,000 epinephrine (epi), 36 mg lido 2%, 1:50,000 epi, B infiltration, left posterior superior alveolar nerve (PSA), and greater palatine blocks. A sulcular incision was made from mesial (M) of tooth #13 to M of tooth #15. A vertical releasing incision was made at M of tooth #13 with a #15 blade. A full thickness mucoperiosteal flap was reflected. Upon reflection of the flap, the periradicular area of MB and DB roots were exposed, showing fenestrations over the apical third of both B roots. The fenestrations were enlarged with a high-speed round bur under sterile water spray. Granulomatous tissue was removed using a spoon currette. The apical region of MB and DB roots were exposed. No fracture was detected by using methylene blue and an operatory microscope. Approximately 3 mm of MB and DB root apices were resected using a #171L bur. After resection, lack of seal and presence of fin in both roots were observed. No exposure or perforation of Schneiderian membrane occurred after enucleation of all granulomatous tissue in periradicular area. Root-end preparations made using a diamond ultrasonic tip. The surgical site was irrigated with sterile saline. Local hemostasis was achieved by using three epi-pellets in the crypt and root-end preparations were dried with paper points. White ProRoot® MTA (Mineral trioxide aggregate) root repair material (Dentsply Sirona, Johnson City, TN, USA) was placed at preparation sites and condensed. Epi-pellets were removed and the crypt was filled with demineralized cortical bone graft. The flap was replaced and digital pressure applied for 2–3 minutes. The flap was secured with 4.0 Nylon interrupted sutures. Good hemostasis was achieved. A final radiograph was taken (Figure 21.2). POI were reviewed and an ice pack applied. Favorable prognosis was expected. An appointment was made for suture removal. A prescription was given for Peridex™ 0.12% (3M, Two Harbors MN, USA) with instructions to rinse twice daily beginning the second day after surgery for ten days and to use ibuprofen 600 mg three times daily as needed for pain.
1-day follow-up call: Pt had minimal swelling and discomfort. He was on ibuprofen 600 mg.
Third visit (1-week follow-up): Pt had no complaint of symptoms. Sutures were removed and hydrogen peroxide (H2O2) applied to clean the area. The surgical site was healing well without evidence of edema and exudate. Instructions concerning oral hygiene were reinforced.
Fourth visit (5-week follow-up): Pt was ASX. Periodontal probings were 3–4 mm. No abnormal mobility, sensitivity to percussion or palpation on tooth #14 were present. The radiograph showed healing in progress (Figure 21.3).
Fifth visit (25-month follow-up): Pt remained ASX. Upon clinical examination no swelling or sinus tract was detected. The probing depths were 3–4 mm. Follow-up radiographs showed evidence of apical healing associated with both B roots. No apical pathosis was detected on palatal root (Figure 21.4).