INTERNAL APICOECTOMY: A NEW PROCEDURE FOR MOLARS WITH COMPLEX PROBLEMS

Daisuke Nagao, DDS, PhD1, Yasuhisa Tsujimoto, DDS, PhD2

Recently, microscopes are using for dental treatment and many materials and methods were developed. In endodontic therapy, success ratio were increased using microscope, however, invasion of endodontic surgery to patients is still problem. If patient tooth has morphological problem or huge cyst at upper molar palatal root, basically we have to select intentional replantation or extrac- tion. In these difficult cases, we developed new method named internal apicoec- tomy. We never give surgical damage to patient, root apical is cut off by long shank round bur via , and remove apical lesion, gutta-percha and any problem materials under microscope. Finally, root canal including apical part was filled by MTA. We have been procedure 20 cases internal apicoectomy, and good prognosis was obtained in all cases. Int J Microdent 2017;8:6–10

INTRODUCTION tal membrane at the time of the procedure.8-10 A microscope is a very useful tool in endodontic sur- Root canal retreatments are com- gery11-17 and, in general, apicoec- monly performed in routine endo- tomy or hemisection is carried out dontic therapy. All cases involve after making a small incision in the complex problems, such as ledg- gum tissue, which is then peeled es, perforations, fractured instru- back. The same procedure is used ments, and root canal morphology, in micro-endo surgery. While mi- and some require endodontic sur- cro-endo surgery is an effective gery or tooth extraction.1-5 When surgical technique, it still causes a performing endodontic surgery, certain amount of damage to the although apicoectomy is carried patient. In this paper, we will pre- out on the incisors, premolars, sent internal apicoectomy, which buccal root of maxillary molars, is a new method developed by us. 1Private practice in Ibaraki, Japan and mesial root of mandibular mo- In cases with large lesions in the 2Department of , Nihon lars, intentional replantation (IR) or palatal roots of maxillary molars, University School of at tooth extraction is suggested for the apical portion of the palatal Matsudo, Japan the palatal roots of maxillary mo- roots is removed via the root ca- lars and the distal roots of man- nal using long-shank round burs 6, 7 Correspondence to: dibular molars. In cases of IR, without surgical damage, and af- Daisuke Nagao root morphology and root dentine ter cleaning, the root canal is filled Nagao Dental Clinic thickness are risk factors as they with mineral trioxide aggregate 2598-1, Tsuda, Hitachinaka-shi, Ibaraki, can cause root fractures, and root (MTA). As a result, lesions in the Japan resorption may occur depend- apical portion disappear, resulting E-mail: [email protected] ing on the state of the periodon- in the recovery of dental function.

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a b c

d e f

g h

Figs 1a to h Procedure of internal apicoectomy. a : Black line showed 3mm from apex. b : Apex view of b. c : Stainless steel bar go through apical foramen a little. d : Apex view of c. e : A little by little, apex is shorten by stroke cut of stainless steel bar. f : Apex view of e. g : Before internal apicoectomy. h : After internal apicoectomy.

TREATMENT under microscopy. and 34-mm No. 2 MI stain- PROCEDURE less steel burs to slightly pass Points 5–9 are the outline of the through the apical foramen surgical methods using an extract- (Figs 1c and d). 1) Administer anesthesia. ed tooth. 8) With utmost care, cut the api- 2) Remove dental caries under 5) Intentionally destroy the apical cal foramen with No. 3, 4, or microscopic guidance. foramen using an ultrasonic tip 5 (28 mm) and No. 6 (28 and 3) Remove gutta-percha in the (Figs 1a and b; the black line 34 mm) MI stainless steel burs root canal using tools, such marks a point that is 3 mm using many small pull strokes as GPR (MANI Inc., Tochigi, from the apical portion18). (Figs 1e and f). Japan) or OK Micro-Exca 6) Remove the infected dentine 9) Finally, cut the apical foramen (SUNDENTAL Co., Ltd.) under present in the root canal using short up to the black line via microscopy. a 28- or 34-mm MI stainless the root canal using an MI 4) Visually check the apical por- steel bur or an ultrasonic tip. stainless steel bur (Figs1g and tion and collateral pulp canal 7) Use a 28-mm No. 1 and 28- h). This is the procedure of in-

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a b c

d e f

g h i

Figs 2a to i Intraoral photographs and X-ray photographs. a : Before treatment. Sinus tract is observed at palatal gingiva. b : X-ray photographs before treatment. c : Opening apical foramen. d : The bad granulation tissue is removed. e : X-ray photograph after internal apicectomy. f : MTA cement is filled in palatal root canal. g : X-ray photograph, 1.5 years after internal apicectomy. h : Intraoral photograph, 2.5 years after internal apicectomy. i : X-ray photograph, 2.5 years after internal apicectomy.

ternal apicoectomy. 12) Fill the root canal with MTA at for approximately 1 year. Although 10) Remove the periapical gutta- the following examination. there was no subjective pain, the percha and exuberant granu- patient had some discomfort. Pre- lation tissue using an OK vious root canal therapy had been Micro-Exca, remove blood CASE PRESENTATION carried out on the tooth a number of and discharged pus using a times at another dental clinic. The vacuum line, and wash the A 41-year-old woman was exam- patient had a history of hay fever. periapical area with saline so- ined at Nagao Dental Clinic (Hi- An intraoral examination revealed lution.19,20 tachinaka City, Ibaraki Prefecture). a sinus tract in the palatal gingiva 11) Apply calcium hydroxide to the Her chief complaint was a sinus of the left maxillary second molar root canal and temporarily seal tract in the left palatal maxillary (No. 15) (Fig 2a). X-ray revealed a the cavity. gingiva, which had been swollen piece of broken file in the mesial

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Fig 3 Proportion of postoperative painkillers used.

buccal root with a large periapical ramen, after which we used MTA is performed and the success area of radiolucency accompanied to fill the distobuccal and palatal rate increases with the use of a by non-radiolucency suggestive roots (Fig 2f). X-ray taken 1.5 years microscope.11-17 It is thought that of a large lump of gutta-percha. after the completion of the inter- new equipment and new drugs The bottom line of the maxillary nal apicoectomy following crown also help.24 On the other hand, sinus was unclear (Fig 2b). There restoration (Fig 2g) revealed that although endodontic surgery us- was no spontaneous pain in No. the large lesion had disappeared ing a true color microscope is very 15, and although there was no re- and the area of non-radiolucency precise, it is not exactly minimally sponse to cold stimulation, there around the root had increased in invasive. The case in this report was a response to tapping. Some size. An image of the oral cavity exhibited many anatomical and instability was also observed. We after crown restoration (Fig 2h) morphological problems, including further expanded the apical fora- showed that the sinus tract had large areas of infected dentine, men of the distobuccal root and disappeared and the condition of pus discharge, a piece of broken palatal root using an MI stainless the oral cavity was normal. Fur- file, perforation, a large lesion in steel bur and ultrasonic tip. Short- thermore, X-ray taken 2.5 years the apical foramen, and a root ca- ening the apical portion and ex- after the internal apicoectomy (Fig nal filling that protruded from the panding the apical foramen made 2i) revealed that the area of non- apical foramen. Thus, there was the exterior of the apical foramen radiolucency had further increased no hope of improving the tooth more visible (Fig 2c), allowing the in size, and although the remain- using normal root canal therapy. removal of the gutta-percha and ing dentine appeared thin, there Furthermore, because gutta-per- exuberant granulation tissue out- were no apparent symptoms and cha was protruding from the disto- side the apical foramen using a the patient’s condition was stable. buccal and palatal roots, it was not microscope (Fig 2d). X-ray after possible to perform apicoectomy. the internal apicoectomy showed Although IR was selected, it was that the distobuccal and palatal DISCUSSION considered difficult in this particu- roots had become shorter (Fig 2e). lar case because of the influence The lump of gutta-percha present As a rule, root canal therapy is of IR on the periodontal mem- inside the lesion was also shown non-surgically performed via the brane.8-10, 25 By selecting internal to have disappeared. We filled root canal.21-23 However, when it apicoectomy, which does not in- the mesial buccal root with gutta- is anatomically difficult to access volve tooth extraction and has no percha and used Terudermis® to the root canal or carry out root ca- time restrictions, the risk of tooth fill the area outside the apical fo- nal therapy, endodontic surgery fracture during IR is eliminated. In

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general, in cases where endodon- which produced favorable results Therefore, we believe that internal tic surgery is required for incisors as reported in this paper. It is clear apicoectomy can improve post- or premolars, IR is not selected as that this method is minimally in- operative patient QOL more than it is a treatment of last resort prior vasive as shown by the record of standard endodontic surgery. to tooth extraction. However, the postoperative analgesic drug ad- We conclude that the internal position of the molar makes it im- ministration (Fig 3), and patients apicoectomy procedure presented possible to perform apicoectomy experience very little unbearable in this report is clinically significant in some cases, leaving IR as the stress from surgery, such as inci- because it reduces the surgical only viable option other than tooth sion and peeling, allowing repeat- stress on patients. extraction. We performed internal ed treatment with this method apicoectomy on 20 cases, all of similar to root canal therapy.

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