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Apical abscess of #21 with palatal sinus tract - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: "Ilya Mer"
To: "ROOTS"
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.

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 Radicular Cyst before

Radicular Cyst after irootSP lateral view 11th Jan 2010

Radicular Cyst after irootSP 11th Jan 2010

Radicular Cyst after apicoectomy 28th Jan 2010

5th Dec predi

Sled irootSP enlarged

Sled irootSP 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

Protaper flaring

6 yr old Empress

Cvek pulpotomy

Middle mesial

Endo misdiagnosis

MTA retrofill

Resin core

BW importance

Bicuspid tooth

Necrotic #8 treatment

Finding MB2 / MB3

Deep in a canal

Broken file retrieval

Molar cases

Pushed over apex

MB2 and palatal canal

Long lower third

Veneer cases

CT Implant surgury

Weird Anatomy

Apical trifurcation

Canal and Ultrasonics

Cotton stuffed chamber

Pulp floor sandblasting

Silver point removal

Difficult acute curve

Marked swelling

5 canaled premolar

Sealer overextension

Complex anatomy

Secondary caries

Zygomatic arch

Confluent mesials

LL 1st molar (#19)

Shaping vs Cleaning

First bicuspid

In Vivo mesial view

Inaccesible canals

Premolar 45

Ortho and implant

Radioluscency

Lateral incisor

Obturation

Churning irrigant

Cold lateral

Tipped to lingual

Acute pulpitis images

Middle distal canal

Silver point

Crown preparation

Epiphany healing

Weird anatomy

Dual Xenon

Looking for MB2

Upper molar resorption

Acute apical abcess

Finding MB2

Gingival inflammation

Irreversible pulpitis

AG BU ortho band

TF Files

using TF files

Broken bur

Warm technique

Restorative prognosis

Tooth # 20 and #30

Apical third

3 canal premolar

Severe curvature

Interesting anatomy

Chamber floor

Zirconia crown

Dycal matrix

Cracked tooth

Tooth structure loss

Multiplanar curves