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Endo tips    Better Endo    Endo abstracts    Endo discussions

The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. - www.rxroots.com

Weird lesion

From: Marga Ree
To: ROOTS
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 
root tip..........

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 crown margins. 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 disadvantage....:-) 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

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