When it comes to compromised teeth, our goal may be to simply maintain a tooth for as long as possible. It also makes sense to plan for the future, so whenever I treat a tooth endodontically, I attempt to have all the possible outcomes in mind, including the eventual failure of the tooth.

This was such a case. The patient presented with a buccal sinus tract adjacent to the 11 (right central incisor). The 11 had been previously root treated. The tooth was mobile, but there were no periodontal pockets. To complicate matters an implant was present in the 12 position. The obvious treatment options were extraction, endodontic re-treatment and apical surgery.

A large area of bone loss adjacent to an Implant. Careful planning is required.

I suspected that endodontic re-treatment was not going to be successful in resolving the infection. Re-treatment would also have the downside of further weakening the root as well as added expense and treatment time. The initial root treatment was done to a high standard by a dentist I know performs high quality work. I judged the likelihood of this being an endodontic treatment failure as low.

Extracting the tooth with such a large area of apical periodontitis and perforated buccal plate of bone also carries risks. I was concerned that extraction would allow a significant amount of soft tissue in-growth, compromising the amount of bone available for future implant placement. There is also the added aesthetic risk of loss of supporting tissues for the mesial aspect of the 12 implant. An augmentation procedure could be performed at the time of extraction, but given the acute infection, I would be concerned about the possibility of infection of the grafting material.

The left image shows removal of the pathological tissue. On the right, an apical crack can be seen.

Ultimately, the patient elected to have apical surgery performed. A buccal flap was raised, sparing the papilla and the lesion curetted. The root was apicectomised. Upon inspection of the root under microscope, an apical fracture could be seen. This helps explain why no healing occured after initial endodontic treatment. I resected a few more millimetres to a level where no fracture was apparent. Staining with methylene blue showed a lateral canal. A retrofill with MTA was performed.

Further resection allowed removal of the crack. A lateral canal was seen and staining with methylene blue confirmed this. I knew there was a lateral canal at that level as during the initial removal of GP with ultrasonic, the GP could be seen expressing through the lateral canal. The image on the right is of the MTA retrofill.

I have no doubt that simply suturing the flap in place in this case would still result in significant soft tissue fill of the defect left by removal of the apical pathology. Ultimately, our goal now was to regenerate as much bone as possible. We are dealing with a five walled defect, and the placement of calcium sulfate in the defect will help prevent soft tissue invasion, as well as allow replacement with native bone. I also wanted to avoid having to place either a rigid membrane (with later removal required) or having to pin a collagen membrane in place.

On the left the extent of the lesion can be seen with implant threads exposed. These were debrided and scrubbed. Calcium Sulfate was then used to fill the defect. Note the complete deshiscence of bone over the central incisor.

The tooth was taken out of occlusion. It was lacking bony support prior to surgery and has even less post-surgery. Hopefully healing of the bone will facilitate further support of the tooth. It is possible that this tooth will fail, but it is also possible that the tooth could remain functional for a number of years. Ultimately, we have treated with an end-point in mind and given the complicated presenting situation, a compromise is the best that could be achieved at this stage.

The flap was closed with 6/0 sutures. A sling suture was used to keep the flap coronally positioned. The Xray shows the MTA fill, as well as the limited periodontal support.

The tooth was relieved from occlusion.

Would you have managed this differently? If so, please comment below.