Apical abscess of #21 with palatal sinus tract - Courtesy ROOTS
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From: "Ilya Mer"
Sent: Sunday, February 07, 2010 4:24 PM
Subject: [roots] Need you advice!
This patient was referred to me due to apical abscess of #21 with
palatal sinus tract. The tooth was treated 8-10 years ago and filled
with cement like Harvard cement, all joking aside. Referral tried to
remove the filling and no wonder did perforation on the buccal wall.
It wasnít problem to me to break out the cement. Magnification and
ultrasonic helped a lot. I got fantastic stream of pus from #21.
Lateral incisor had not got any response to cold but bled being
opened. I change calcium hydroxide twice and flare up came down.
The problem is how to close the apex of central incisor. It looks
like black hole in microscope. I didnít measure the apex but I
believe the apical size is more than 140 ISO. If I have small lesion
I would close it with any matrix (Iím used to use Gelatamp for this
purpose), but at this case I wouldnít. So should I wait with
obturation till complete healing? Somebody has any idea?
Ilya, When the flare is down I would fill this root with MTA. And
during the filling process make a lot of photo's to be sure that
the filling is correct and on the write spot. I did this several
times and worked good - Rob Kroese
Dear Ilya, In cases like this I use surgical calcium sulfate as a
barrier and MTA on top of it. If you get any MTA out of the apex it
doesn't matter much anyway, just looks awkward on the x-ray. But as
Marga always tells we are treating people, not the x-rays... - Thomas
Hi Ilya, I would say in case like yours patient defintely needs a
combined treatment - endo + apical surgery to ensure best possible
outcome. As first stage you can fill and seal the # 140 ISO canal by
use of "capillary condensation" technique filling the canal with
bioceramic sealer iRootSP ( or Brasseler equivalent). See how I have
done it in case of # 120 canal of similar tooth. Apical third is
filled by bioceramic only. ( see enlarged part ) A few days later
you can do the apicoectomy taking care not to reach the part of the
canal where you have both gutta cone and bioceramic. Thus, the part
of canal which will be in contact with bone will still be filled with
bioceramic only. See attached case - right after apicoectomy
- Valeri Stefanov
I don't use calcium sulphate barriers anymore. Quite difficult
procedure and I just can't find a reason to do it.
So in my chair, it would be an MTA plug without barrier - Bart