IP Indian Journal of Conservative and Endodontics 2021;6(1):59–63

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IP Indian Journal of Conservative and Endodontics

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Case Report
Salvage through endodontic surgical management: A case report

Deepak Kumar Sharma1 , Savina Gupta2 , Manu Bansal1 , Krishna Popat1 ,

Sidhartha S P Behra3, *
1 Dept. of Conservative Dentistry & Endodontics, Jaipur Dental College, Jaipur, Rajasthan, India
2 Dept. of Oral and Maxillofacial Surgery, Jaipur Dental College, Jaipur, Rajasthan, India
3 Dept. of Prothodontics & Implantology, Smile Dental Pvt. Ltd, Hyderabad, Telangana, India

ARTICLE INFO ABSTRACT

Article history: The aim of this report is to discuss a case about a failed root canal treated upper right lateral incisor
Received 24-11-2020 presented with chronic periapical pathology with extruded guttapercha. Apicoectomy involves surgical
Accepted 25-01-2021 management of a tooth with a periapical lesion, which cannot be resolved by routine endodontic treatment.
Available online 16-03-2021 The goal of apical surgery is to prevent leakage of bacteria and their byproducts from the root canal system
into peri-radicular tissue. With the advancements in magnification, armamentaria and materials, the success
rate of treatment outgrows. Hence, present study describes a case of retreatment successfully treated by
Keywords: endodontic periapical surgery.
Periapical lesion
Apicoectomy © This is an open access article distributed under the terms of the Creative Commons Attribution
MTA License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.

1. Introduction radicular infection, foreign body material, or cystic tissue. 2

According to the updated guidelines by the European
Surgical endodontics is a time tested method for correcting
Society of Endodontology, indications for apical surgery
those teeth with periapical lesions that donot respond well
comprise. 3
to conventional root canal treatment or when orthograde
treatment is not viable. 1 It aids to maintain the form,
1. Radiological findings of apical periodontitis and/or
function and esthetics of the relevant teeth and their roots
symptoms associated with an obstructed canal (the
when conservative instrumental, pharmacotherapeutic and
obstruction proved not to be removable, displacement
physiotherapeutic treatmentsfailed.
did not seem feasible or the risk of damage was
The primary objectives of surgical approach are to make
toogreat).
the root canals free of diseased necrotic tissue, debride
2. Extruded material with clinical or
them thoroughly and to seal the cavity or defect to bring
radiological findings of apical Periodontitis and/or
down the microorganism spread in the periradicular tissues,
symptoms continuing over a prolonged period.
thus rendering an environment conducive of a normal
3. Persisting or emerging disease following root-canal
periodontal apparatus regeneration. This goal should be
treatment when root canal retreatment is inappropriate.
attained by root-end resection, root- end cavity preparation,
4. Perforation of the root or the floor of the pulp chamber
and a bacteria-tight closure at the apical end of the root-
and where it is impossible to treat from within the pulp
canal system with a retrograde filling. Besides, curettage
cavity.
plays an important role for debridement of the periapical
5. In addition, traumatic injury, cases with severe
pathological tissue in favour of removing any extra-
destructive processes due to furcation or sub- gingival
* Corresponding author.
caries, and large root perforations also require
E-mail address: sidharth_sp@yahoo.co.in (S. S. P. Behra). apicoectomy.

https://doi.org/10.18231/j.ijce.2021.013
2581-9534/© 2021 Innovative Publication, All rights reserved. 59
60 Sharma et al. / IP Indian Journal of Conservative and Endodontics 2021;6(1):59–63

1.1. Contraindications of apicoectomy include:

1. Strong adjacent teeth available for bridge abutments as
alternatives to hemisection
2. Inoperable canals in root to beretained
3. Fused roots making separation impossible
4. The tooth has no function (no antagonist, no strategic
importance serving as a pillar for a fixedprothesis)
5. Unrestorable tooth
6. Periodontally compromised tooth and
7. An uncooperative patient or a medically compromised
patient for an oral surgical intervention. 4 Fig. 2: Pre-operative Radiographic picture with
extrudedGuttapercha in periapical radiolucency
The treatment success is qualified by major factors
including the correct indication, the correct technique, the
follow up and patient’s observance of the post-surgery
1.4. Treatment Plan
recommendations. The treatment outcome of apical surgery
needs periodic clinical and radiographic assessment. Retreatment was recommended combining surgical
This paper presents a case report of surgical removal approach with retrograde restoration. Prior to surgery,
of a periapical pathology due to failure of conventional hematological investigations were carried outand the patient
endodontic treatment, persistence of pathology and sinus signed written consent. Antibiotics and Chlorhexidine
formation. mouthwash was prescribed, a day beforesurgery.

1.2. Case Report 1.5. Surgical Intervention

A 19 years old male patient reported to the Department After mouth preparation with povidine iodine rinse and
of Conservative Dentistry & Endodontics, Jaipur Dental swab, local anesthesia (2% lidocaine with 1: 100,000
College and Hospital, Jaipur, with the chief complaint epinephrine) was administered. Using 15c blade and bard
of pain, recurrent swelling, and pus discharge from the parker handle, a sharp incision was madedeep into bone.
upper right front tooth region of the jaw. Patient notified A sulcular incisioninaddition to two vertical releasing
a history of sports trauma 6 years ago and had then incisions were given, and a full- thickness mucoperiosteal
undergone root canal treatment. Also, he had an incomplete flap was raised.5 Selection of the incision technique and
re- treatment attempt with the same tooth, 1 week back. flap design depends on clinical and radiographic parameters
Clinical examination revealed, the tooth #12 was tender (Von ArxandSalvi,2008). 4
to percussion and palpation, also there was presence of
pus discharge from sinus tract near root tip, but no
1.5.1. Surgical procedural steps: (Figure 3)
significant mobility (Figure 1). Radiographic examination
1. Flap designmarkings
revealed periapical radiolucency around root apex along
2. Incisiongiven
with inadequate endodontic therapy with gutta-percha
3. Full thickness mucoperisteal flapraised &
extruding periapically (Figure 2).
curettagedone
4. Extruded Guttapercharemoved
5. Retrograde filling withMTA
6. PRFplacement
7. Bone Graftplaced
8. Single interrupted suturingdone

(a. Root resection, b. MTA Retrograde filling with

bonegraft, c. Obturation d. Follow up at 6months)

Fig. 1: Pre-operative Clinical picture 1.6. Hard Tissue Management Osteotomy

After elevating the flap and inspecting, a breach in the
cortical bone was located. A round carbide bur under
1.3. Diagnosis
constant irrigation for cooling was used to enlarge bony
Based on clinical and radiographic examination, the case defect to the buccal window to gain access to the periapical
was diagnosed as the chronic periapical abscess. lesion and root end of the tooth with defect.
 Sharma et al. / IP Indian Journal of Conservative and Endodontics 2021;6(1):59–63 61

Fig. 4: Radiographic Pictures

regeneration. Adaptation of filling material was confirmed

by using radiograph.

1.8. Closure of Surgical Site

Fig. 3: Surgical procedural steps Careful evaluation and copious irrigation with normal
saline of the surgical field was done to ensure complete
debridement of a hemostatic agent, root-end filling material,
Curettes were then used to remove the soft granulation and debris, which may hinder the process of healing.
tissue, which further aided in adequate visualization of A damp gauze piece was slightly compressedto bring
root apex. Hemostasis was achieved with the use of sterile back the flap in position. Single interrupted sutures were
gauzes. The extruded gutta-percha, then clearly seen was given (Figure 4).
removed out with a tweezer.
1.9. Histopathology
1.7. Root Resection The histopathological report of the removed tissue showed
a lesion covered by histiocytes with some neutrophils,
Apical end of 3mmwas resected at an acute angle of macrophages, lymphocytes and plasma cells, showing
10 degree in faciolingual direction to the long axis of compatibility with periapical granuloma wall.
tooth with a tapered fissure bur in high-speed handpiece,
under constant irrigation. The cavity was then filled with
1.10. Post-surgical considerations
retrograde filling material once it was isolated thoroughly.
The material of choice for retrograde restoration was MTA The patient was then advised to follow post-operative
because of its high success rate. It was placedinto the instructions such as to apply cold compresses with an ice
preparation up to 3- 4 mm apically with dovgan’s carrier and pack for the first 4–6 hours after surgery, followed by mouth
plugger to assure dense filling and minimal voids. A PRF rinses to maintain a good oral hygiene. The patient was
and bone graft was placed in the bony defect to induce bone also prescribed antibiotics and analgesics for 5 days. The
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patient was recalled after three days to access the surgical nowadays. The advantages of microsurgery include easier
site for healing and the absence of signs and symptoms identification of root apices, smaller osteotomies and
such as pain and sinus tract. After 7 days, post-operative, shallower resection angles that conserve cortical bone and
the suture was removed and root canal prepared coronal root length. In addition, a respected root surface under high
to the MTA placement was filled with gutta percha by magnification and illumination readily reveals anatomical
lateral compaction technique followed by composite resin details of apical delta. 9 Combined with the microscope, the
restoration on the same day. After complete procedure, the ultrasonic instrument helps in conservative, coaxial root-
patient was then recalled at 3 months-6months-1 year to end preparations and precise root-end fillings to satisfy the
assess the clinical and radiographic signs of healing. required mechanical and biological principles of endodontic
surgery.
2. Results Anatomical study of the root apex showed that at least 3
mm of the root-end must be removed to reduce 98% of the
After 6 months follow up, there was absence of significant apical ramifications and 93% of the lateral canals. 10
sign and symptoms clinically. Radiograph showed reduced Bogdan et al compared the outcomes of apicoectomy
lesion size with new bone formation at periapical area. After with traditional and modern concepts and suggested the
12 months follow up, the offending tooth was accepted both clinical success rate after 1 year increased to 85-96.8%
functionally and aesthetically (Figure 4). with microsurgery compared to 40-90% with traditional
way. 9 The success rate also depends on multiple factors
3. Discussion including prognosis, size of periapical lesion, apical seal
Apical lesions can occur or recur in dental organs with and techniques and materials used to treat the tooth.
endodontic treatment when the root canal system has Moreover, use of CBCT enhances the pre and post-
not been properly cleaned, shaped and disinfected by operative examination three dimensionally, providing better
instrumentation and copious irrigation, or the absence of comparison with the site and size of actuallesion. 11
disinfection, or due to apical or coronal leakage. 5
Apicoectomy is the standard surgical procedure for 4. Conclusion
such failed endodontic cases to sill preserve the tooth. Based on the contemporary understanding of endodontic
The advantage of surgical endodontics over non-surgical concepts for success and failure, assessment, and
endodontics is the ability to address the entire root canal subsequent treatment of apicoectomy procedures have
system and complete elimination of bacteria. greatly improved. Advancements in apicoectomy
In this case, MTA was chosen as a retrograde filling armamentaria and materials have enabled endodontists
material because of its ideal properties. It has easy to treat challenging cases with much greater efficacy. The
and moisture independent application, biocompatibility, surgical technique, which has been, applied in this case
superior seal and ability to strengthen the root. 6 With time, i.e. apicoectomy, was appropriate and the results were
a new cementum deposition was found on the surface of the satisfactory. Hence, apical surgery is a predictable option to
material. Literature reviews higher success rate in follow-up save the tooth that is unmanageable by conventional, non-
studies with MTA as root-end filling material. surgical endodontics.
In recent times, GTR techniques i.e. use of bone graft
and barrier membranes in addition to endodontic surgeries
5. Source of Funding
has been used to promote bone healing. 2 Freshly prepared
PRF from patient’s whole blood was utilized as PRF being No financial support was received for the work within this
autologous biomaterial is a safe graft with absence of risks manuscript.
such as rejection or allergy. 7,8
PRF supports and encourages healing of wounds as well 6. Conflict of Interests
as reduces post-operative pain. Since the main objective
of apical surgery is to avoid re-infection, the tight seal of The author declares that they do not have any conflict of
the microstructures at apical end is a necessity to prevent interests.
egress of bacteria and toxins from the root-canal system
into the periradicular tissues. 4 Thus MTA was allowed to References
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