Surgical endodontics Cases

Case 1

•  34 year- old female patient, leukoderma,  presenting painful symptoms in

tooth #22
• In her medical history, she had reported heart murmur and hepatitis B, 
• Antibiotic prophylaxis was applied using 1 g amoxicillin, one hour before
surgery. After extra and intra oral antisepsis, the procedure began using
mepivacaine hydrochloride at 2% with epinephrine 1:100.000 local anesthesia
• root apex retrograde was performed. With the aid of an ultrasound and using
an angled ultrasonic tip, the cavity was prepared for retrofilling with
Endodontic Sealer 26. The sealer was applied to the cavity with the aid of a
spoon scavator, and press-condensed with a moistened cotton ball.
Case 2

• A 22-year-old female patient was referred to the Department of

Conservative Dentistry, FDM, Medical University-Varna by a general dentist
for retreatment of tooth #36.
• He found the presence of a periapical lesion between the roots of the tooth
#36 and a separated file in this lesion.
• An anamnesis was taken and clinical examination conducted, as well as a
radiographic examination which included a periapical
• radiograph of tooth #36 and a CBCT of the jaws
The triangular muco-periostal flap was opened under local anesthesia. All necrotic bone was curetted via
bone curette until the bone become clean, hard and healthy.
Apices of the molar were resected and no retrograde cavity was prepared and no root-end filling was used
Post operative
1 year follow up
Case 3

• 31-year-old male was indicated to treat the left upper lateral incisor #22. *e
patient stated a “bad experience” with the root canal treatment and a
“continuous discomfort”. *e patient’s clinical history did not present
relevant findings.
unsatisfactory endodontic treatment of the same tooth was found with
signs of root perforation due to a previous treatment
Treatment plan

• Retreatment with photodynamic therapy (PDT) and passive ultrasonic

irrigation (PUI) photodynamic therapy is a complementary technique, which
aids in additional disinfection using a light source like laser or light-emitting
diode (LED) acting over a photosensitizer and thus liberating reactive oxygen
specimens that disinfect some facultative microorganisms [23] and resulting
in more accelerated tissue repair
• PDT was then performed by filling the canal with methylene blue 0.005%
(Vetec Quimica Fina Ltda, Rio de Janeiro, RJ, Brazil) and maintained in the
canal for 5 min as a preirradiation time. *e irradiation procedure was
performed using a low-power diode laser (MMOptics Ltda, São Carlos,
Brazil) and an optical fiber (0.40 mm diameter and 16 ± 0.5 mm active
surface length) placed into the canal. *e irradiation was performed by a
visible red wavelength of 660 nm and an output power of 100 mW/cm2
activated for 2 min without interval, using a helical movement from apical
to cervical direction. An energy density of approximately 120.0 J/cm2 was
applied [27].
Apecectomy , retrograde filling and laser ablation

Metheylene blue filled cavity and irradiated with diode laser

Pre an post
1 year follow up
 Case 4
For treatment of teeth #13–23, a general dentist sent a 39-year-old male patient to the Hail Dental Centre.
The periapical region of #13, 12, 11, 21, 22, and 23 included a radiolucent lesion, which he discovered. Teeth
#12 and 22 both had internal root resorption and apical external root resorption.
The patient underwent a clinical examination, a medical history interview, a radiographic evaluation,
which comprised a panoramic radiograph of the jaws and periapical radiographs of the teeth numbers 13,
12, 11, 21, and 23. (Figure 1A, B)
• The diagnosis was follows: #13–23 necrotic pulp with asymptomatic chronic
apical periodontitis, apical external root resorption in #12, 22, open apex in
#12, 22, internal root resorption #12.
• Treatment Plan were considered as follows:
• OptionI: Extraction and implant.
• Option II: Long term calcium hydroxide then obturation after the apex gets
closed.
• Option III: One visit apexification with MTA.
• Option IV:Obturation using customized and thermo-plasticized guttapercha
(ObturaII). Periapical surgery if there is no healing
• Under Rubber dam isolation, teeth #13, 12, 11, 21, 22, 23 were excavated
from caries and accessed. During canal instrumentation using hand files,
some pale yellowish fluid was continuously draining from the canals.
• The canals were irrigated with 2.5% sodium hypochlorite solution and
medicated by non-setting calcium hydroxide paste for antimicrobial
consideration; then the teeth were temporarily closed with glass ionomer
cement.
• At the second visit, chemo-mechanical debridement was completed in this
visit. The master apical files (MAF) for teeth #12, 22 were #90 with no apical
seat, and #80 in teeth #11, 21. However, the MAF in teeth #13, 23 were #60
with good apical constrictions.
• Vertical compaction using heat carrying instrument (System B) was used for obturation #13 and 23. Customized
gutta-percha were used in #12, 11, 21, and 22, in addition thermo-plasticized gutta-percha (Obtura II) was used for
obturation of internal resorption in tooth #12 as shown in
• Figure 2.
• Post-fabrication were started in the third visit, cementation of cast post and core using zinc phosphate cement for
teeth #13–23 were done at fourth visit. After follow-up for 6weeks, sinus tracts in area #12,
• 22 were not subsided and slight pain on percussion had started. Because of the upper anterior teeth #13–23
needs surgical crown lengthening for restorative purposes, endodontic periapical surgery was planned at the same
time.
• Endodontic periapical surgery in conjunction with surgical crown lengthening were implemented for teeth #12, 11,
21, 22. Apicoectomy of 3mm from the root apex and retrograde filling using MTA were performed as shown in
• Figure 3.
• Patients were examined clinically and radiographically at intervals immediately after periapical surgery, 1month
later, 3months later, 1 year, and 2 years. A dentist who was treating the patients at the time of the visit performed
the clinical and radiographic evaluations.
 Case 5
• A 19 years old male patient reported with the chief complaint of pain, recurrent swelling, and pus discharge
from the upper right front tooth region of the jaw.
• a history of sports trauma 6 years ago and had then undergone root canal treatment. Also, he had an
incomplete re- treatment attempt with the same tooth, 1 week back.
• Clinical examination revealed, the tooth #12 was tender to percussion and palpation, also there was presence
of pus discharge from sinus tract near root tip, but no significant mobility (Figure 1).
• Radiographic examination revealed periapical radiolucency around root apex along with inadequate
endodontic therapy with gutta-percha extruding periapically
Treatment Plan

• Retreatment was recommended combining surgical approach with

retrograde restoration. Prior to surgery, hematological investigations were
carried outand the patient signed written consent. Antibiotics and
Chlorhexidine mouthwash was prescribed, a day beforesurgery.
• After mouth preparation with povidine iodine rinse and swab, local
anesthesia (2% lidocaine with 1: 100,000 epinephrine) was administered.
Using 15c blade and bard parker handle, a sharp incision was madedeep
into bone. A sulcular incision inaddition to two vertical releasing incisions
were given, and a full- thickness mucoperiosteal flap was raised.5Selection
of the incision technique and flap design depends on clinical and
radiographic parameters
Surgical procedural steps: (Figure 3)
1. Flap design markings
2. Incision given
3. Full thickness mucoperisteal flapraised &
curettagedone
4. Extruded Guttapercharemoved
5. Retrograde filling withMTA
6. PRFplacement
7. Bone Graftplaced
8. Single interrupted suturingdone
Hard Tissue Management Osteotomy
After elevating the flap and inspecting, a breach in the
cortical bone was located. A round carbide bur under
constant irrigation for cooling was used to enlarge bony
defect to the buccal window to gain access to the periapical
lesion and root end of the tooth with defect.
Hard Tissue Management Osteotomy
After elevating the flap and inspecting, a breach in the
cortical bone was located. A round carbide bur under
constant irrigation for cooling was used to enlarge bony
defect to the buccal window to gain access to the periapical
lesion and root end of the tooth with defect.
Careful evaluation and copious irrigation with normal
saline of the surgical field was done to ensure complete
debridement of a hemostatic agent, root-end filling material,
and debris, which may hinder the process of healing.
A damp gauze piece was slightly compressed to bring
back the flap in position. Single interrupted sutures were
given (Figure 4).
resection

• Apical end of 3mm was resected at an acute angle of 10 degree in

faciolingual direction to the long axis of tooth with a tapered fissure bur in
high-speed hand piece, under constant irrigation.
• The cavity was then filled with retrograde filling material once it was
isolated thoroughly.
• The material of choice for retrograde restoration was MTA because of its
high success rate. It was placed into the preparation up to 3- 4 mm apically
with dovgan’s carrier and plugger to assure dense filling and minimal voids.
A PRF and bone graft was placed in the bony defect to induce bone
 Case 6

A 36-year-old female was referred to the department of endodontics for management of her maxillary left central incisor
(#21).
The patient presented with a noncontributory medical history and a chief complaint of pain with biting for the last year.
The dental history indicated that she had undergone root canal treatment 3 years ago in a private dental clinic.
Clinical examination revealed that the tooth was sensitive to percussion. The tooth had no mobility, and the periodontal
probing was within normal limits (<3 mm). The tooth had a defective Class IV composite restoration [Figure 1]a.
• Radiographic examination revealed a radiopaque root canal filling material in the
coronal and middle thirds and an approximately 5 mm metallic fragment that indicated
a separated round bur in the apical third.
• Two radiolucent areas were detected in the periapical region and lateral to the root
[Figure 1]b.
• (CBCT) imaging was planned to provide a three-dimensional evaluation and to assess
the possible presence of apical perforation as a result of the broken bur.
• Examination of the CBCT images showed the presence of an area of low density
associated with the apex of #21 that does not cause any perforations in buccal or
palatal cortical plates. The broken instrument did not seem to perforate the root.
• Another low-density area is seen in the mesial surface of the root located more toward
the buccal surface [Figure 1]c and [Figure 1]d.
• During the first appointment, after local anesthesia and rubber dam isolation, the defective permanent
restoration was removed, and access was obtained under an operating microscope
• Gutta-percha was removed using ProFile #25/06) at 500 revolutions per minute (rpm). The fragment was
completely bypassed with a size 15 K-file, and the working length was confirmed with a radiograph [Figure
2]a.
• The glide path was established by hand filing with up to a size 25 K-file.
• An ultrasonic tip was placed inside the canal and activated without coolant for 1 min, and then the canal
was irrigated with 2.5% sodium hypochlorite (NaOCl) to cool the operating field and flush the debris out.
• However, several removal attempts with ultrasonic vibration were unsuccessful.
• Instrumentation was completed with ProTaper Gold rotary instruments with continuous irrigation with
2.5% NaOCl.
• The fragment could not be loosened from the root canal wall even with the repeated use of ultrasonic
vibration. Therefore, a decision was made to include a surgical approach to push the fragment from the
apex to the access cavity.
• an intrasulcular incision with a single vertical releasing incision was made with a #15 scalpel blade, and a
labial full-thickness flap was reflected.
• Osteotomy was performed with a round tungsten carbide bur under constant copious irrigation with sterile
saline followed by root-end resection with a carbide bur
• The periapical soft-tissue lesion was curetted, collected, and sent to the histopathology department for
analysis.
• For fragment removal, a high-volume suction tip was placed at the coronal access cavity, and a microsurgical
plugger was used to push the separated instrument from the root tip toward the access cavity.
• Then, methylene blue dye was applied to the resected root surface to identify the periodontal ligament,
root outline, and canal.
• Root-end preparation was performed using ultrasonic tips mounted on an ultrasonic
• To facilitate the placement and condensation of root-end filling material, a gutta-percha cone was placed
through the coronal access cavity 3 mm short of the root end. EndoSequence BC Root Repair Material Fast
Set Putty was inserted into the prepared root end.
1 year follow up
Case 7
• Weine2 has listed the following indications for toothresection
• Periodontal Indications:
• 1. Severe vertical bone loss involving only one root of
• multi-rooted teeth.
• 2. Through and through furcation destruction.
• 3. Unfavourable proximity of roots of adjacent teeth,
• preventing adequate hygiene maintenance in proximal
• areas.
• 4. Severe root exposure due to dehiscence.
• Endodontic and Restorative Indications
• 1. Prosthetic failure of abutments within a splint: If a single or multirooted
tooth is periodontally involved within a fixed bridge, instead of removing
the entire bridge, if the remaining abutment support is sufficient, the root
of the involved tooth is extracted.
• Endodontic failure: Hemisection is useful in cases in which there is
perforation through the floor of the pulp chamber, or pulp canal of one of
the roots of an endodontically involved tooth which cannot be
instrumented.
• 3. Vertical fracture of one root: The prognosis of vertical fracture is hopeless. If
vertical fracture traverses one root while the other roots are unaffected, the
offending root may be amputed.
• 4. Severe destructive process: This may occur as a result of furcation or sub. gingival
caries, traumatic injury, and large root perforation during endodontic therapy.
• Contraindications
• a. Strong adjacent teeth available for bridge abutments as alternatives to
hemisection.
• b. Inoperable canals in root to be retained.
• c. Root fusion-making separation impossible.
• d. When bony support for remaining root is insufficient for restoration
Case 6

• A 35 years old man reported with the complaint of pain and mobility of left
mandibular second molar.
• On examination, the tooth was sensitive to percussion.
• On probing the area, there was a 12 mm deep periodontal pocket around
the distal root of the tooth.
• On radiographic examination, severe vertical bone loss was evident
surrounding the distal root and involving the furcation area. The bony
support of mesial root was completely intact (Fig. 1).
• It was decided that the distal root should be hemisected after completion of
endodontic therapy of the tooth
• Under local anesthesia, full thickness flap was reflected.(fig2) Upon reflection of the
• flap, the bony defect along the distal root became quite
• evident. All chronic inflammatory tissue was removed with
• curettes to expose the bone. The vertical cut method was
• used to resect the crown. A long shank tapered fissure
• carbide bur was used to make vertical cut toward the
• bifurcation area. The distal root was extracted (fig3) and the
• socket was irrigated adequately with sterile saline to remove
• bony chips and amalgam debris (fig4). The furcation area
• was trimmed to ensure that no spicules were present to cause
• further periodontal irritation. Scaling and root planning of
• the root surfaces, which became accessible on removal of
• distal root was done.
Case 8

• Intentional replantation of an upper canine with invasive cervical

resorption. (a) Preoperative buccal view. (b) Preoperative, palatal view. (c)
Periapical radiograph showing severe cervical resorption. (d) Extracted
tooth with cervical defect. (e) Storage of the tooth in cell culture medium.
(f) Extraoral root canal treatment was performed. (g) Defect was restored
with composite. (h) Replantation. (i) Splinting. (j) Periapical radiograph after
3 years showing periodontal healing and no signs of ankylosis. (k) Follow-up
at 3 years, buccal view. (l) Follow-up at 3 years, occlusal view.
Case 9

Broken instrument in mesial root

Post obturation extending beyond apex
Replantation
After Apicoectomy
1 year follow up
Case 10