|Year : 2012 | Volume
| Issue : 3 | Page : 147-151
Root amputation and bone grafting of failed apicoectomy of mesiobuccal root of maxillary first molar
Abdulaziz S Abu-Melha
Department of Endodontics, New York University, College of Dentistry, New York, USA
|Date of Web Publication||30-May-2013|
Abdulaziz S Abu-Melha
Department of Endodontics, New York University, College of Dentistry, 470, 2nd Avenue, Room #15E, New York, NY 10016
Source of Support: None, Conflict of Interest: None
Root amputation is an option available to extend the function of a molar tooth when there is a persistent endodontic failure. This case report of a 52-year-old male provides an overview of the feasibility of mesiobuccal root amputation and bone grafting with calcium sulfate of maxillary right first molar after failed non-surgical and surgical endodontics due to root fracture. A 2 year follow-up showed successful clinical and radiographic results. In specific situations, root amputation is a viable treatment to retain a functional portion of the tooth.
Keywords: Calcium sulfate, mesiobuccal root, root amputation, root fracture
|How to cite this article:|
Abu-Melha AS. Root amputation and bone grafting of failed apicoectomy of mesiobuccal root of maxillary first molar. Saudi Endod J 2012;2:147-51
| Introduction|| |
Root amputation (root resection) is "the surgical removal of all the root and adherent soft tissues leaving the crown of the tooth intact and supported by remaining root(s)".  It is one of several possible treatment modalities of teeth with periodontal, endodontic, restorative, or prosthetic problems, available to extend the function of the remaining tooth structure.  Proper case selection is essential for a good prognosis. According to Blomlof et al.,  the survival rates of root-resected molars were found to be 68% and 77% of root-filled single-rooted teeth over a 10-year period. This article describes a successful case of root amputation of a mesiobuccal root and bone grafting with a calcium sulfate barrier following failed periapical surgery due to a root fracture in a maxillary first molar.
| Case Report|| |
A 52-year-old male came to the endodontic post-graduate clinic with a chief complaint of a "bump" on the maxillary right posterior gingiva, which started 2 weeks earlier and discomfort when he bites. His medical history was non-contributory and his vital signs were within normal limits. His dental history was that he had surgery on his upper right first molar tooth (#16) 4 years earlier at a private clinic because he had swelling and infection related to that tooth. An endodontist advised him to do an apicoectomy and it was performed after he took a course of antibiotics to reduce the swelling. Tooth #16 was positive on palpation and percussion with no periodontal pocketing. There was a stoma present in the mucobuccal fold above tooth #16 and it was traced with gutta-percha cone to the middle of the mesiobuccal root of tooth #16 [Figure 1]. A radiograph had been taken [Figure 2] and showed an implant on the area of the right maxillary second molar (#17) with good osseointegration. Tooth #16 had a crown and cast-post with the post in the mesiobuccal canal. There was a well-defined periapical lesion, post and an apicoectomy on the mesiobuccal root.
|Figure 1: Periapical radiograph showing sinus track tracing with gutta-percha|
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|Figure 2: Periapical radiograph showing the previous apicoectomy, apical rarefaction and post of the mesiobuccal root|
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The pulpal diagnosis was previously treated and the periapical diagnosis was chronic apical abscess. The patient was given the option of extracting the tooth due to the poor prognosis of possibility root fracture. An implant was suggested, but the patient refused and wanted to save the tooth because he previously had a bad experience with an implant. The option of performing a second apicoectomy was not advisable because of poor prognosis of possible root fracture and it compromise the technique of root-end cavity preparation recommended distances associated with the post in the mesiobuccal canal. The decision was to do a root amputation of the mesiobuccal root. The patient was informed of the questionable prognosis and the patient agreed and signed a consent form for the procedure.
The amputation procedure was initiated with topical anesthetic gel (20% Benzocaine) applied on dried buccal mucosa for 5 min. Local anesthesia (34 mg Lidocaine with 0.017 mg Epinephrine) (Two carpules 1.7 ml) and (34 mg Lidocaine with 0.034 mg Epinephrine) (One carpule 1.7 ml) administrated in the buccal mucosa and palatally from tooth #17 to the first maxillary premolar (#14). A vertical incision was made mesial of tooth #14 (not crossing the canine eminence) with #15 scalpel blade then an intrasulcular incision from tooth #14 to tooth #17. The mucoperiosteal flap was elevated and a fracture located at the middle of the mesiobuccal root was noticed. Based on this finding, the diagnosis of root fracture was confirmed and the mesiobuccal root of tooth #16 was resected at the level of the crown margin with a straight diamond bur under saline irrigation coolant. A radiograph was taken to ensure that the entire root was resected [Figure 3]. The crown was reshaped at the area of the mesiobuccal root to prevent food impaction and securing the graft. Calcium sulfate (DentoGen®) (Biodenix Technologies Inc. Richmond, B.C, Canada) packed in the surgical area and then interrupted with 4-0 Vicryl double sutures (Johnson and Johnson Health Care Systems Inc. NJ, USA) were placed to close the flap tightly with the crown margins to avoid graft loss. Another radiograph was taken to view the calcium sulfate [Figure 4]. Post-surgical instructions given to the patient and analgesics were provided (400 mg Ibuprofen every 4-6 h). 0.12% Chlorhexidine Gluconate oral rinse was advised (1/2 oz. swishes for 30s × 2/day). Sutures were removed 6 days later.
|Figure 4: Post-surgical with calcium sulfate filling the area of the mesiobuccal root|
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Clinical and radiographic evaluation indicate good bone healing and a successful outcome [Figure 5] and [Figure 6].
| Discussion|| |
The present case represents a successful outcome of managing failed apicoectomy due to root fracture by root amputation. Apicoectomy is usually performed to treat periapical periodontitis of failed root canal therapy due to persistent infection and iatrogenic changes of the original canal anatomy during the root canal procedure. ,, The success of the apicoectomy was reported by several investigators.  In recent studies, microsurgery increased the prognosis of primary apicoectomy to 94% and to 92.9% in secondary apicoectomy. ,
Root fractures are encountered in intact teeth as well as endodontically treated. The prevalence is very high in endodontically treated teeth. , Over-preparation of the canal for a post and post placement can cause root fractures, especially in the apical region.  In addition, poor design, stresses of cementation and expansion of the post volume due to corrosion caused a root fracture too. , The palatal root of the maxillary molars is usually selected for post placement due to its great thickness. The mesiobuccal root should not be used due to its curvature and complex morphology. 
Root cracks or microfractures during root-end preparation with the use of (ultra) sonic tips have been addressed in several experimental studies and in one clinical study. , The fractured mesiobuccal root of the present case could be attributed to the previous apicoectomy procedure and post placement.
The prognosis of non-surgical and surgical endodontic treatment decreased in cases of root fracture. ,
Root amputation can be indicated in these cases of multirooted teeth when an implant is not feasible to extend the function of the remaining tooth structure.  Several studies have evaluated the long-term success of root-resected teeth. Failure rates of root amputations in molars have been reported to range from 25% to 38%. , The long-term prognosis depends on the quality of the performed surgery, the recontouring of the remaining tooth structure as well as the status of periodontal care. The quality of the root canal treatment in the remaining roots and the final restoration should be considered too. ,,,
Root amputated molars demonstrated the highest degree of failure when they were long standing terminal abutments.  It has been reported that molars with bone support of more than 50% of the remaining roots at the time of root resection had a significantly higher survival rate compared with that of molars with less than 50% bone support.  In the present case, there was an intact palatal bone and no mesial or distal furcation involvement, which provided a more favorable prognosis. Good post-operative oral hygiene is important, especially in the area of root resection. Occlusion should be evaluated, and the root resected tooth should receive full coverage if not already present to prevent a vertical root fractures, which is one of the most common complications following root amputation procedures. 
The patient of the present case came with a sinus tract which was confirmed by tracing it with gutta-percha. The presence of sinus tract was found in 13-42% of cases with vertical root fracture. , Tamse et al.  reported a deep osseous defect, mostly at the buccal tooth aspect, in 35% of their cases that had a sinus tract.
Calcium sulfate was used in this case to fill the bony crypt of the amputated root. There are some arguments about the benefits of calcium sulfate in bone healing but it was found that significantly more bone and cementum was found in the defects filled with calcium sulfate compared with unfilled controls. This usually occurred because it is biocompatible, bioresorbable, osteoconductive and an effective hemostatic.  It resorbs completely in 2-4 weeks, and does not cause an increase in inflammation as well as allowing fluid exchanges due its porosity. , The disadvantage of using it in root amputation cases, it can be easily loss due to the difficulty to completely close the flap in the area of the resected root but the type of the calcium sulfate had been used in this case can set in a few minutes and make the control of the material much easier.
In conclusion, root amputation remains a viable treatment to retain a tooth when an implant is not feasible.
| Acknowledgment|| |
The author would like to thank Dr. Paul Rosenberg for his great help and support.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]