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Photos: Courtesy of Noemi Pascual- www.rxroots.com
From: Noemí Pascual
To: ROOTS
Sent: Saturday, February 10, 2007 12:10 AM
Subject: [roots] Controversial treatment decision - Apical Surgery
I send this case because I think it could be discuss because the diagnosis and treatment decided.
It was very discused and controversial at my university.
It was decided to do an apical surgery of the 11 and 12 and the surgery was performed by a teacher.
The decision to do the surgery was also decided by a teacher. But after when it was discuss in a seminar
about clinical cases it was very critised and some teachers were not agree with the decision chose by the other
one. So I think it´s interesting to send this to roots.
1st thing....No retreatment was done in 11 and 12 before the surgery...what do you think about that?
2nd thing...You think it could have been possible to retreat 11 and 12 without the apical surgery?
More comments??
In my opinion..I believe the retreatment it should have done in 11 and 12 and wait for evolution...
But I think that at the end the 12 would have need the surgery but not the 11...what do you think??
Noemí Pascual , Barcelona - Spain
First of all Noemi, we very much appreciate you posting the case on ROOTS. Every once in a while (when we are not too
busy imagining a fictional middle mesial canal that isn't there or bragging about that MB5 we just found) we hear
ringing on the "reality phone" and are forced to pick it up. This is a good example of what goes on in the real
world. Its surprising (and shocking) that this is taught in a Dental school that is supposed to be teaching modern
endodontics in the 21st century.
As a student, it is never a good idea to pick a fight with a faculty member but in this case, I'll make an
exception. ( I finished school in 1986 – what can they do to me??) The violations in this case are just too great
to ignore.
1.Conventional retreatment is indicated in all teeth even before considering surgery. That is a given. Going to
surgery right away shows a complete lack of understanding of proper Endodontic treatment and a total lack of
appreciation for the role of coronal seal in treatment success. One other thing, if you are going to surgerize an
area, you should examine adjacent teeth for possible need for retrofill as well. ( The left central for example). If
you MUST cut a patient open, why do another surgery later when it would be easy to extend the flap and access the
area now?
2.Although the film image quality is not that good, it seems apparent that the central incisor crown margins are
either carious or have carious cleavage deeper than the late Anna Nicole Smith's boobs. Awful. There's NO WAY that
those teeth should have been surgerized without conventional retreat and new properly made crowns with good margins.
3.The flap design is terrible. Not only is that semilunar flap (in muscoa, no less) pretty well guaranteed to cause
scarring; the incision was made in multiple cuts (as evidenced by the ragged margins blue arrows) rather than a
smooth single incision. That does not help healing or scar prevention at all. This shows poor technique. (Your
teacher will love that critcism!! ;-) )
4. The retractor is frequently placed on the gingiva in many of the photos, rather than firmly placed on the bone.
This causes unnecessary damage to the flap edge. Part of the problem is that you are using a rounded edge retractor
when a FLAT edge is clearly needed to sit properly against that part of the maxilla. That design of retractor is a
poor choice in this situation .
5. Part of the reason the tissue keeps getting caught under the retractor is that the incision is also too small for
the surgery and the flap has not been retracted far enough apically. A flap like this can be much more easily
performed using a scalloped incision approximately 1 to 1&1/2 teeth mesial and distal to the teeth being surgerized.
(a Modified Lubke-Oschenbein or Boston U. design as it is known) Placing the incision in attached gingiva minimizes
scarring without risking exposure of the crown margins. (In this case maybe the teacher should have used a full flap
at least then he would now see how bad the crown margins are!! Scalloping the incision allows you to place the
flap back much more precisely giving better healing.
6. You did not say how the retro-preparations were prepared ( microbur or ultrasonics?). In any case if you resect
horizontally to the root axis AND make the crypt access as small as you did, the only way that you would be able to
assess the adequacy of the preparations is with a micro-mirror and a scope. There is no way that you can look at a
horizontally sectioned root from the buccal aspect and properly see down the retroprep without a micro-mirror. A
root bevel would be necessary without one, as in the surgery I showed above.
7. Amalgam is no longer being used as a retrofilling material in modern endodontics. The literature clearly shows
that MTA, bonded resins and even a cheap modified IRM like material such as Bosworth Super EBA are far superior in
sealing ability.
8. It is not necessary to use 4 "aircraft cable sized" silk sutures to suture the flap. We have much better materials
(Tevdek, Prolene etc.) that are smaller, less likely to gather food and that can be placed very, very accurately in
sizes 5/0 to 8/0 in order to minimize scarring and obtain optimal flap tension at the right locations.
9. I am not exactly sure why we are using such odd sized radiographs, when a size #2 x ray film, placed vertically
adjacent to #s 11 and 12 would have given you much better images and easier placement in the mouth.
Those are just a few of my suggestions. If you get in trouble for your criticism just blame it all on me. (That
loud mouthed Canadian guy!) It won't be the first time that being outspoken has made me unpopular with teachers!
Once in while we get caught up in the minutia on ROOTS: C factors in canal bonding, MB5s, irrigation formulations
that call for tincture of powdered Rhino foreskin, Implant machining devices that would barely fit in my garage
...etc. We need to remember that in some places in the world, THIS kind of Endo education is still taught
routinely. And that's scary.
Elevating the bar starts with first finding out how to make a bar in the first place never mind finding to what
level you want to raise it to. Looks like we still have a lot of work to do. Noemi, stay with us.it appears that
you need our help.- Rob Kaufmann DMD MS(Endo)
Hello Rob
I think your answer here was exellent.
These answers are what an endodontist should know and build their diagnosis and treatment on.
It is specially scary that a case like this come from a dental school and a teacher.
For me this would be a typically tratment choice for a dental surgeon who dos not want to know anything about
endodontics. He just cut the crap away
This is a good learning experience and a reminder that if endodontics is going to exist as a treatment modality we
have to build our treatment on a good fundament and try to do excellent treatment every time.
Thank you Rob. - Harald Prestegaard, Norway
Noemi, I would look at likely causes of the pathology and plan to solve these problems from the outside in, coronal
to apical.
Do we have a restorative problem? Yes, both restorations are likely to be leaking.
Is there sufficient coronal tooth structure remaining to predictably support new restorations? Maybe not.
Will proper restorations solve the problem? No.
Do we have a well sealed root filling? No, there is a lesion, the canals are contaminated.
Do we have a surgical problem? Only if retreatment and new restorations do not result in healing.
If there was sufficient coronal tooth structure to support proper restorations, I would therefore retreat the root
canals with proper technique, and place new restorations.
In defense of your teacher, there may have been many reasons why he chose this way, so I will not pass any judgement
on him without having been there. There may very well have been some patient factors that influenced the treatment
plan.
Did the patient want new restorations?
Did the patient want new root fillings?
Were the teeth not restorable and maybe your teacher was trying to buy some time for the patient? ???????
Dan Shalkey, General Dentist
Controversial treatment decision - Apical Surgery
