Symptomatic apical lesion

The opinions within this web page are not ours. Authors have been credited for the individual posts and images where they are. Photos courtesy Maarten Meire

From: Maarten Meire
To: ROOTS 
Sent: Tue, 17 Feb 2009 4:00 pm
Subject: [roots] Surgical case - without RD! ;-(

Surgical endodontic procedure on 11 due to symptomatic apical lesion.
1 week postop aspect of soft tissues - Maarten





Very nicely done, I will have to search for some cases to do surgery on, then you can guide
and help me on these ones. -  Rafaël

Really nice!! Do you ever use methylene blue to stain the resected apex? - Fred

I always use methylene blue to stain the resected surface before inspection under high mag.
Remnants of it can be seen on the second slide, upper left pic - Maarten

Really nice nice Marteen. I´m preparing my surgical kit and can´t find racellets in Spain.
What have you placed in the bone crypt in order to achive hemostasia??
What do you recomend me to use for this porpouse?? What have you use in this case?? - Javier

Thanks, Javier. I used ferric sulfate in this case (Adstringedent, Ultradent Products). - Maarten

For hemostatsis...try calcium sulfate or Viscostat--but scrape it out before closing the flap - Fred

Thanks for the hemostatic agents information Dr. Barnett and Dr. Serota. I have just printed the article,
I think I can get Expasyl from Kerr and ferric sulphate easily in Spain. Great!! - Javier

Stropko recommended Monsel's Solution, not sure why, but ......... he did invent the Stropko clot kit.
He also used to recommend Limoncello as a sedative. - Ken

I’ve used Expasyl (a hemostatic agent used for crown and bridge procedures, it’s made by Pierre Roland/Acteon,
the same company that brought you Satelec) for nearly two years now, with great results.

Attached is an article I wrote for a Dutch dental journal. A picture tells a thousand words and the original study
by Von Arx (from Berne, Switzerland) is worth checking out - Michiel de Cleen

Hi Maarten,
Please explain what exactly the methylene blue staining does at the
resected apex? does it help you to find accessory canal branching? if
so, then do you put MTA in each of those tiny little little spots? how
do you sterilise the methylene blue? are there any articles/papers on this topic? - viji

Hi Viji, Mb staining of the resected surface is interesting in a few aspects:
- it nicely stains the PDL, so you can follow the PDL to verify if the resection extends over the entire root.
- Moreover, the shape of the PDL can help you in determining the angle of your resection. Eg, in a central upper
  incisor, the root is more or less round in cross section. If the stained PDL appears as an oval, then you know
  the resection plane is not perpendicular to the long axis of the root.
- MB will also stain cracks, uncleaned isthmuses,  and all kinds of other untreated canal anatomy, which makes this
  more easy to diagnose and to treat, of course using the microscope.

"does it help you to find accessory canal branching?"
Yes. Although the resection of the apical 3mm should take care of most accessory canals. If there appears a lateral
canal in the resected surface, I will cut back a little more.

This article mentions the use of MB for this purpose:
Kim S. & Kratchman S. Modern Endodontic Surgery Concepts and Practice: A Review, JOE 2006, 32: 601-23. - Maarten



Beautiful Maarten.....exactly - Fred

Nice case! Why did you leave the sutures in place for 1 week? - Bart

Thank you, Bart. Sutures were removed After 1 week because patient wasn't able to come in earlier.
Usually they are removed after 4-5 days - Maarten