Surgical Intervention
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Figure 15. Arrow indicates fracture on mesial root. |
Figure 16. Retrieved fragments of the fractured root showing infection. |
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Figure 17. Resected root surface revealing mesiobuccal canal with MTA filling and mesiolingual canal with gutta-percha filling. |
Figure 18. KiS D1 ultrasonic tips (Obtura Spartan). |
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Figure 19. Radiograph showing the mesial root end was resected, and calcium sulfate was placed in the osteotomy. |
Figure 20. Radiograph taken 6 months after surgical intervention, showing complete healings of periapical lesion and widened periodontal ligaments. |
The surgical intervention under a dental operating microscope (Opmi 111 [Carl Zeiss]) revealed that the tooth had a vertical fracture line on the mesiobuccal root coronally extending approximately 5 mm from the apex (Figure 15). The patient was informed of the partially fractured root during the surgical procedure, but insisted on retaining the tooth. Thereafter, the mesial root end was entirely resected with a Lindemann bur (Hu-Friedy) up to the end of the fracture line (Figure 16). The resected root surface was then stained with methylene blue to identify more anatomical details. Both mesiobuccal and -lingual canals were identified and there was no sign of further fracture line or an isthmus left on the resected root surface (Figure 17). Gutta-percha filling material was removed from the mesiolingual canal, and the root end was prepared with the KiS D1 ultrasonic tip (Obtura Spartan) (Figure 18) on a piezoelectronics (Obtura Spartan). The root end cavity was carefully inspected at high magnification under the microscope to confirm the integrity. A 17% EDTA solution was used to remove the smear layer from the root end. ProRoot MTA was then mixed with water. The mesiolingual canal was retrofilled with it and the osteotomy was filled with calcium sulfate to induce bone growth (Figure 19). The patient was placed on 3-month recall. The 3-month postoperative radiograph showed that the periapical lesions associated with the mesial root had largely disappeared, but the widening of the periodontal ligament still remained the same as before, which indicated the presence of abnormal forces from occlusion. Adjustment of occlusion on the tooth as well as treatment for her bruxism was suggested to the referring dentist, and the patient was again placed on another 3-month recall. She returned 3 months later, and the 6-month postoperative radiograph after the apical surgery finally showed the periodontal ligament was back to normal and periapical lesions was completely healed (Figure 20).