Endodontic Clinical Case Reports
Case Report #1: Re-infected Apicoectomy
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.
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).
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.