Controversial treatment decision - Apical Surgery
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Photos: Courtesy of Noemi Pascual- www.rxroots.com
From: Noemí Pascual
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?
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
Awful. There's NO WAY that those teeth should have been surgerized
without conventional retreat and new properly made crowns with good
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
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)
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
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
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
Your comments please