Int J Dent Case Reports 2012; 2(3):17-20 IJDCR 2012. All rights reserved www.ijdcr.

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CAS E REPORT SURGICAL MANAGEMENT OF A PERIAPICAL LES ION WITH MTA AND BONE GRAFT Kovvuru Suresh K.1 , Vineet Agrawal2 , Vaishali Parekh 3 , Ponachha KS4 , Rachappa5 , Purva Chaudhari6
1

Senior Lecturer, Depart ment of Conservative and Endodontics, K.M.Shah Dental College and Hospital, Piparia-

Vadodara
2

Senior Lecturer, Depart ment of Conservative and Endodontics, Manubhai Patel Dental College and Oral Research

Institute, Vadodara
3 4 5 6

Professor, Depart ment of Conservative and Endodontics, K.M.Shah Dental College and Hospital, Piparia-Vadodara Senior Lecturer, Depart ment of pedodontics, K.M.Shah Dental Co llege and Hospital, Piparia -Vadodara Senior Lecturer, Depart ment of pedodontics, K.M.Shah Dental Co llege and Hospital, Piparia -Vadodara PG student, department of pedodontics, K.M.Shah Dental College and Hospital, Piparia-Vadodara

Address for Correspondence Dr. Suresh Ku mar Kovvuru Senior lecturer, Conservative Dentistry & Endodontics K M Shah Dental Co llege & Hospital, Piparia 391760, Waghodia (T), Vadodara (D) Gu jarat State, INDIA Contact No. -+919375871947, 02668-245262 E-mail: dr_suresh44@yahoo.co.in, vineetdent@yahoo.co.in

ASTRACT One of the main p roblems in root canal retreat ment is the removal of the fractured instrument. The retrieval may be difficult, but is essential for successful retreat ment. Fractured instruments are tedious to remove and may reduce the chance of root canal success, as the position of fractured instrument has an influence on prognosis. The prognosis is poorer when the instrument is broken near the apex. Surgery may be undertaken after unsuccessful retreatment, or when retreat ment is impossible or has an unfavorable prognosis In this case report, a fractured instrument at the apex that could not be retrieved through orthograde approach was removed surgically by root resection fo llo wed by placement of MTA and bone graft for predicable outcome.

Key words: Fractured instrument; periapical lesion; MTA; Bone graft

Suresh, Agrawal, Parekh, Ponachha , Rachappa, Chaudhari

Surgical M anagement of Perapical Region

INTRODUCTION Instrument fractures within the root canal during root canal treatment are an unwanted and frustrating complication. Fracture often results from incorrect use or overuse of an endodontic instrument, and seems to occur most commonly in the apical third of a root canal. [1] Studies have reported prevalence ranging fro m 1% to 6%. [2] When an endodontic instrument fractures during use in a root canal, the best option is to remove it. [3] Only after removal of the fractured instrument can the root canal be negotiated, cleaned and shaped optimally. If the root canal cannot be cleaned and shaped successfully, remnants of pulp tissue and bacteria may remain and compro mise the outcome of root canal treat ment. [4] Success rates for both non-surgical and surgical retreatment range fro m 45% to 98%. Ho wever the success rate is even lower for teeth associated with periapical lesions (62% -78%). [5] A nu mber of studies have concluded that attempts at removing fractured instruments in the apical third are often unsuccessful and may lead to unwanted effects such as excessive dentine removal and weakening of the tooth, ledge formation, root perforation and ap ical extrusion of the frag ment into the periradicu lar tissues. Therefore, when an instrument fractures in the root canal, the clinician must evaluate carefu lly the options of attempting to remove the instrument, attempting to bypass the instrument, or preparing and filling to the fractured instru ment .[6]

opening was performed irt 41 in a private clinic. On Clin ical examination there was grade II mobility irt 41, absence of swelling or draining sinus tract and the tooth was tender on percussion and tilted. Radiograph showed a fractured instrument located in the ap ical third of the root and the root was curved. The case was diagnosed as non-vital tooth with apical periodontitis .The location of the fractured segment in the apical part beyond the curvature and a failed attempt to retrieve the file conventionally made nonsurgical approach non-feasible and periap ical surgery was planned to remove the fractured instrument.

Figure 1: Pre -operative IOPA showing bro ken instrument

Case report A female patient of age 15 years reported to the department of pedodontics with a chief co mplaint of pain and pus discharge in the lower front tooth. History revealed t rau ma [Road traffic accident] in the lower jaw 1 year back and also root canal acesses
Figure 2: File to check the patency

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Suresh, Agrawal, Parekh, Ponachha , Rachappa, Chaudhari

Surgical M anagement of Perapical Region

the flap reflected .The strands of granulation tissue attached with the flap was removed and the lesion curetted with a spoon excavator. After init ial excavation of the lesion a sterile surgical round bur was used to expand the lesion for visibility and to remove the remaining granulation tissue .The lesion was isolated and carefully examined for the fractured instrument. There was no evidence of instrument in the lesion, then a 20 no k-file was placed into the canal to check for canal patency. The file was seen passing through the foramen but still the fractured instrument was not found in the lesion, hence a radiograph was taken to confirm the presence or
Figure 3: Showing resected root with MTA bone graft

absence of the fractured instrument. Radiograph revealed the presence of instrument inside the canal. Since the root was curved in a disto- lingual direction and the fractured instru ment still inside the canal root resection was performed and confirmed

radiographically fo r the absence of instrument .Then the resected root surface was prepared to receive MTA [pro-root], and the periap ical lesion filled with bone graft. The sutures placed and periodontal
Figure 4: Lesions after complete curettage

dressing given. The patient was recalled after a week for suture removal and in the second visit the root canal was obturated with gutta-percha.

DISCUSS ION There have been significant advances in endodontic treatment in recent years but the fact remains that root canal treatment may fail if treat ment is not adequately executed. Clinical studies have shown that the presence of infection, the size o f periapical lesion,
Figure 5: M TA placement

and the level of root filling at the rad iographic apex influence the prognosis of root canal treatment.[7,8]

Periap ical surgery was planned after consultation with the child parents. After achieving proper anesthesia a trapezoidal flap design was placed and

Surgical approach may be necessary when the apical portion of the root canal system cannot be accessed coronally. This may be due to restorative reasons

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Suresh, Agrawal, Parekh, Ponachha , Rachappa, Chaudhari

Surgical M anagement of Perapical Region

(presence of a well fitting post and core restoration), iatrogenic reasons (presence of a fractured
1.

REFERENCES
Rahimi M, Parashos P. A novel technique for the removal of fractured instruments in the apical third of curved root canals. International Endodontic Journal, 42, 264270, 2009. 2. Madarati AA, Watts DC, Qualtrough AJE. Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intra-canal fracture of endodontic instruments. Part 2. International Endodontic Journal, 41, 1079 1087, 2008. 3. Machtou P, Reit C (2003) Non-surgical retreatment. In: Bergenholtz G, Hrsted-Bindslev P, Reit C, eds. T extbook of Endodontology, 1st edn. Oxford: Blackwell Munksgaard, pp. 300 10. 4. Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. International Endodontic Journal, 38, 112 123, 2005. 5. Baharin SA. Non-surgical Root Canal Retreatment of Multiple Teeth and the Removal of Fractured Instrument: A Case Report. Malaysian Dental Journal (2006) 27(2) 77-81 6. Souter NJ, Messer HH Complications associated with fractured file removal using an ultrasonic technique. Journal of Endodontics 31, 450 2. 2005 7. 8. Sjogren U, Hagglund B, Sundqvist G. Factors affecting the longterm results of endodontic treatment. J Endod 1990;16:498-504. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologicanalysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:86-93. 9. Caliskan MK. Nonsurgical retreatment of teeth with periapical lesions previously managed by either endodontic or surgical intervention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:242-8 10. T surumachi T, Honda K. A new cone beam computerized tomography system for use in endodontic surgery. International Endodontic Journal, 40, 224232, 2007. 11. Torabinejad M, Pitt Ford T R, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP Histologic assessment of Mineral Trioxide Aggregate as root end filling material in monkeys. Journal of Endodontics 23, 225 8. 12. PV Sreedevi, NO Varghese, Jolly Mary Varugheese Prognosis of periapical surgery using bonegrafts: A clinical studyJournal of Conservative Dentistry | Jan-Mar 2011 | Vol 14 | Issue 1

instrument/silver point, nonnegotiable ledge, and perforation in the middle or apical third of the root) or anatomical reasons (severely curved root apex, sclerosed canal). [9] Various radiographic imag ing techniques are available to visualize anatomical and pathological details, a cone beam CT could have been used to determine the accurate length and position of the fractured instrument.[10] In the present case the presence of a periapical lesion along with fractured instrument located in the apical third of the curved root and the possibility o f instrument being pushed beyond the apex necessitated for a surgical

approach.MTA was chosen as a retrograde filling material because in vivo studies have reported less periradicu lar inflammat ion as compared with

amalgam. In addition, the presence of cementum on the surface of MTA was a frequent finding. [11] The regeneration of bone following destruction by pathological processes has an important bearing on success following treat ment. The bone regeneration can be facilitated by placing bone graft into the periapical defect, which act as a filling materials as well as a scaffold, wh ich gradually gets resorbed while preosteoblasts and osteoblasts migrate fro m the adjacent bone (Osteoconduction).[12] Hence root resection followed by retgrograde MTA and bone graft placement ensures faster healing and clin ical success of roots with periapical lesion. CONCLUS ION This case reports the need for root resection in cases that are not amenable to non surgical management and emphasizes on placement of MTA and bone graft for proper periapical healing.

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