Testing the Limits of Endodontic Surgery

This patient came to our office in 2012.  She reported trauma in the early 1970's - when one of her kids accidentally head butted those teeth.  They became infected and a RCT was done in the early 70's.  Original crowns still in place.  Her dentists ever since have pointed out the radiolucency, but for the most part is has been mostly asymptomatic.  Our exam finds #24 and #25 with mild percussion sensitivity, normal probings and class II+ mobility.  We discussed the resorption that appears to have affected the apex of #25.  We discussed options and she wanted to try to retain the tooth, so we decided to attempt an apicoectomy with guarded prognosis.

PreOp #24 and #25 - RCT done about 40 years earlier.

PostOp Apicoectomy

 Because of the resorption at the apex of #25, a traditional root end preparation and filling was not possible with removing too much tooth structure.  In this case, we bonded Geristore on the root apex and tried to "cap" the apex.  Retrofill #24 is MTA.

At one week, the patient reported some pain and throbbing following the treatment with increased mobility. We stabilized the teeth with some bonded resin and recommended Augmentin.

At two weeks, patient reported improvement, but gingival inflammation was present and #25 had a class III mobility.  Teeth were removed from occlusion to remove any occlusal trauma.  We recommended a second antibiotic at that time, Clindamycin.

At three weeks post op, area is feeling better, inflammation/infection has resolved, tissue looks improved and both teeth are class II mobile.

From this point, the patient has remained asymptomatic and we have seen full resolution of PARL.
This is a tooth that would be extracted by most dentist, and by many endodontists, however, apical surgery is too often overlooked as a treatment option.

6 month Re-evaluation.

1 Year Recall

1 Year Recall

2 Year Recall - complete bony healing.

We should not forget how lucky we are to work in a biologic enviroment that is so forgiving and with such ability to regenerate bone.

CBCT Reveals Root Resorption Unseen in Regular Radiography

The following case shows the advantage of CBCT in endodontic diagnosis.


The following patient returned to our office today for re-evaluation of #14. We previously looked at #14 which had some gingival swelling, yet we could not definitively diagnose the tooth as necrotic. We assumed the swelling was a periodontal abscess and had given him an antibiotic. He returned reporting no relief with the antibiotic and short, spontaneous episodes of severe pain. Once again our diagnostics were inconclusive. Normal to palpation, normal to percussion, normal to probing, responsive to cold on the lingual and unresponsive on the buccal, normal response to EPT. The canals were obviously calcified and the pdl looked normal around the roots. We decided we would take a CBCT to see if we could see any additional radiographic changes.

The CBCT clearly shows a resorptive defect on the palatal. The CBCT also tells us the location (mesio-palatal), the size of the defect which allows us to make a restorative call.

Look again at the initial film. There is no sign of this resorption with traditional 2D imaging. CBCT continues to surprise me.

Saving Teeth: Repairing a Resorptive Defect with MTA

In 2006, #19 was diagnosed as necrotic pulp w/ acute apical periodontitis. An irregular radiolucency was noted on the mesial aspect of distal root. This was diagnosed a resorptive defect. While some may have elected to remove the tooth and place an implant or bridge, this patient wanted to preserve her tooth, so a root canal and root repair was performed.


During our RCT procedure, the resorptive defect was cleaned out without perforation of the root. The appearance of the post-op radiograph appears to show some kind of communication.


At 20 months, the patient returned for recall and a large furcal lesion was present. Once again, more may have elected to extract the tooth and replace it with an implant or bridge. We discussed options/prognosis and decided to retreat and try to repair the resorptive area with MTA.


#19 was retreated and resorptive defect repaired with MTA. You can see the resorptive defect was opened more aggressively and there was extrusion of MTA into the periodontal ligament.


3 year recall (since the retx and repair with MTA) shows complete healing of the furcal lesion. The tooth is fully functional and asymptomatic. This is a tooth was was saved by endodontic therapy using the right material. This tooth was saved by endodontic therapy and the use of MTA to repair and seal the resorptive defect.