Clinical Case Reports

Advanced Endodontics of Westchester, PLLC is creating an archive of clinical cases studies for your perusal. Our current cases are displayed below.

Case Report #1: Re-infected Apicoectomy. 

Case Report #2:  Apicoectomy with Silver Point Filling

Case Report #1: Re-infected Apicoectomy.

History:
A 48 yr. old Caucasian female presented with pain and swelling in the muco-buccal fold next to her lower right first molar. The tooth was restored with a full crown and had undergone root canal therapy and apicoectomy with amalgam retrofillings, one year previously.

Clinical Examination:
Intra-oral examination revealed a small, well-localized, firm swelling in the muco-buccal fold adjacent to the mesial root of tooth #30. Periodontal probing was normal and the margins of the crown were excellent. Tooth #29 tested vital.

Radiographic examination revealed a periapical radiolucency around the mesial root of tooth #30 (Fig. 1). Previous endodontic treatment and apicoectomy with amalgam retrofillings had been performed. The distance between the mesial retrofillings indicated that a long bevel had been placed. A preformed post was present in the distal root.

Diagnosis and Treatment:
A diagnosis was made of acute apical abscess as a result of recurrent endodontic infection. After discussing treatment options with the patient, it was decided to retreat the mesial canals through the crown and assess for possible apical microsurgery if healing was incomplete.

Using the operating microscope, a conservative access opening was made. Profuse purulent drainage was obtained via the mesial canals. Despite courses of Augmentin and Clindamycin the drainage persisted. After raising a full thickness buccal flap followed by apical curettage (Fig. 2), the canals were filled with gutta percha using the Microseal technique. This was followed by apicoectomy and retrofilling of the buccal and lingual canals and the connecting isthmus using ProRoot MTA (Fig. 3 & 4). A 3-month follow-up showed complete healing (Fig. 5).

Comments:
Recurrent endodontic infection occurred because the poor surgical technique employed was not able to provide an adequate apical seal of the mesial root of tooth #30. The use of the operating surgical microscope allows the complete visualization and preparation of the canals and the isthmus joining them and the accurate placement of the retrofilling material (MTA). Retreatment and obturation of the root canals allows a more complete elimination of the bacteria and should always be considered prior to apical surgery. The rapid healing seen in this case could be attributed to the thorough technique used and the use of MTA which is thought to have an inductive osseous effect.

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Case Report #2:  Apicoectomy with Silver Point Filling

History:
A 42 year old male presented with discomfort and swelling in his lower left muco-buccal fold. Radiographic examination (Fig. 1) revealed that tooth #20 had a periapical lesion. Previous root canal therapy had been performed using a sectional silver point filling technique. The tooth had been restored with a cast post and core and was the anterior abutment of a three unit bridge. Inta-oral examination revealed normal periodontal probing.

                                                       Fig. 1    

Fig. 2

Diagnosis and Treatment:
A diagnosis of chronic periapical periodontitis of tooth #20 was made. As the bridge was in good condition, the patient was scheduled for apicoectomy with retrofilling. With the aid of the surgical microscope and ultrasonic tips, the silver point was removed apically (Fig. 2) and the retrocavity preparation was sealed with MTA (Fig. 3). Care was taken to clean and shape the canal prior to placement of the MTA. Follow-up examination after 1 year (Fig. 4) and 2 years (Fig. 5) revealed complete healing.

Discussion:
Apicoectomy involving a root that has been filled with a silver point always presents with technical difficulties. Firstly, the breakdown poducts associated with a corroding silver point are highly toxic to the periapical tissues and secondly, the point itself impedes the preparation of an adequately deep (3-5mm) retrocavity preparation. Ideally, the point should be removed entirely from the canal prior to placement of the retrofilling.