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From: Marga Ree
Sent: Monday, May 17, 2010 7:25 AM
Subject: [roots] Extra-radicular biofilm, for Maarten
This lesion looked weird from the start. I packed Ca(OH)2 for
some time, and the sinus tract decreased in size, but never went
away completely. I don't know why, but my gut feeling said that
this lesion would never resolve with conventional treatment alone.
I decided to fill the apical part with MTA and then do the surgery
in the same session, the pack and wack method of John K. When I
raised the flap, I saw a very thick layer of calculus on the
It's funny, but this shape of lesion seems to be indicative of
an extra-radicular infection......this is just my clinical
impression, no scientific back-up for this observation.
Anyhow, I submitted the soft tissue and the root tip for
histological evaluation, but there were no specific
findings.....too bad, I should have submitted it to someone
who knows how to deal with root tips.
6 month follow-up shows healing. - Marga
Dear Marga, Very interesting perspective on this kind of
pathology. Thanks for sharing and taking the
time and effort to educate us!
Why don't even publish your findings??
Lots of interesting responses on your thread. One question
though: In this case you cut the apical let's say 3 mm of
this tooth. The lesion obviously extended beyond the resected
surface. Did you treat (eg perio scaling) the reminder of the
root to remove any calculus/biofilm in that area?
Superb case documentation as we expected! - Maarten
Good question Maarten! I was in doubt what to do. I removed
the calculus of the remaining root surface as good as possible,
didn't want to resect more than 3 mm. - Marga
Dear Marga, How did you deal with the double papilla? Or did
it spontaneously dissapear? In this case, when a fracture was
possible, i would have chosen for a papilla base incision.
Indeed, it can also show some recession, but the papilla stay
kinda stable... not? - Bart
Bart, A double papilla usually disappears spontaneously, as
happened in this case. If not, then take out a a high speed
handpiece with a coarse diamond, and remove the epithelium of
the papilla. You make a graze that will solve the problem.
As I said to Javier, I usually know the perfect incision after
raising the flap, and maybe even more important,
after evaluating healing of the soft tissues....:-) - Marga
LOL Totally right, Marga! And let's be honest. First, there was
already a recession. Second, the recession is MAYBE a half a
millimeter more outspoken. This doesn't outweighs the beautiful
healing result and the resultant saving of the element. In a lot
of cases, an implant would have been more unesthetic. Let all
those who question your pink tissue present their own apico's
:-D - Bart
Hello Bart, Papilla base incision is indeed good to avoid
interdental papilla shrinkage, but IMO buccal recession
still can happen. See attached case - Maarten
Indeed Maarten. Your case indeed illustrates this. Although
there is some recession, the gums are still quite symmetrical.
With a new crown, this is a good result! - Bart
Nice case Maarten, beautiful healing of the peri-apical lesion.
This has happened to me as well with the PBI. - Marga
Absolutely beautiful pictures of untouched biofilm, before the
root tip was cut off. I never get a chance to take these kind
of pictures because I usually cut the root tip off in the
beginning of the surgery, so I can get an easier access to
curette the lesion. I guess I should be more patient if I want
pictures like that of my own Congratulations. - Leo Mazzoleni.
Hi Marga, The case you have shown nicely demonstrates my personal
"endo phylosophy" for PA lesions bigger than 3mm in diameter.
A.Bioceramic in the canal - apico - healing
B.Bioceramic in the canal - apico - no healing - implant.
Thanks for sharing. - Valeri Stefanov
Beautiful case. What made you suspect extra-radicular infection ?
More coronal position of the lesion ? Why you choose this type of
flap ? - Vitali
Thanks Vitali. It was the long standing sinus tract that made me
suspicious, in conjunction with the size and shape of the lesion.
See my post to Sergiu re flap design. - Marga
Very nice result Marga. One question though. If you fill the apical
part with MTA and then remove the apex in the same session, isn't
there danger of "washing out" the MTA? Just wondering, because I
did a similar case but waited in between the MTA placement and the
surgery. - RafaŽl
Thanks RafaŽl, No worries about washing out of MTA.
1. If you apply MTA in such a way that there is a dense plug,
I challenge you to remove the superficial layer
with just a water spray. Let's bet a good bottle of wine...:-)
2. I always make sure that I have at least a 5 mm plug, so suppose
half a mm MTA gets washed away, there is
still enough MTA to provide a seal. - Marga
I quit betting ever since I still owe 7 bottles of champagne to
2 colleagues ;-) Thanks for the explanation. - RafaŽl
Marga do you really think a submarginal incision is better here
with such a bony recesion in the lateral incisor and canine and
the apical and lateral deffect? donīt you think it would have been
too risky? What about papila base incisions? Thanks for share Marga
and nice discussion. - Javier Pascual
Risky? Do you mean regarding wound healing and the development of
scar tissue? If you don't want gingival recession, the best choice
is a submarginal incision. Thomas von Arx published
a nice paper in which he evaluated 70 surgery cases with different
flap design after 1 year.
He is a very skillful surgeon, and did all surgeries himself.
He found that with the submarginal incision there is considerably
less gingival recession compared with the intrasulcular incision
AND also the papilla-base incision. That has been my experience as
well, I have had some cases with a papilla-base incision that still
showed gingival recession. In addition, the biotype of the patient
(thin-scalloped vs thick-flat) and the pre-treatment probing depths
were other significant factors affecting attachment levels.
I usually do a submarginal incision when there is a risk of exposing
Here is an example, the last 2 pics show 1 year follow-up - Marga
Thanks for your reply Marga. I thought submarginal incision could be
risky here because the small space between the cervical bone level in
lateral and canine and the lateral defect, maybe associated with the
fistula, maybe the horizontal incision could have be done within the
lateral defect in a submarginal incision. Would this have been a problem?
Thanks for your time and your post. itīs truly apreciated - Javier.
Javier, After raising the flap, I ususally know exactly what would have
been the best incision....:-)) - Marga
I don't like the gums after the surgery, we can easily see 1-3mm retraction.
Maybe it shoud have been chosen a different type of incision. - Sergiu
Thanks for reminding us to not only look at the root, but also at the
soft tissues. Sometimes (I speak for myself now) we forget that. Good
thing that once in a while we get a reminder. :-) - RafaŽl
Nice observation Sergiu! Which alternative incision would you have chosen?
There is preoperative bony recession to begin with. How could have one
possibly avoided the recession withe the bone level being
what it is pre op? - Sanjay Jamdade
Good point Sergiu! My dilemma was to choose between 2 evils. A submarginal
incision, e.g. Luebke-Ochsenbein, means less visibility. I couldn't exclude
a root fracture, that was the reason why I decided to do a tri-angular
flap design with an intrasulcular incision.
With hindsight, knowing what I know now, I would go for a submarginal
incision. At that time, I choose for a design with full access to the root.
We have a saying in Dutch, and that is: every advantage has its
Patient was scheduled for a crown, so I think the esthetic component
will be taken care of. - Marga
Well this is for sure a big dilema . probably i would have chosen the
triangular flap design too, in order for me to exclude a VRF. - Sergiu