View from the Chairside: Root Resection Technique to Solve a Unique Clinical Dilemma
October 31, 2017
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Continuing the series of cases that Dr. Paul Belzycki shared with us on CDA Oasis, here he is today presenting a case, using the root resection technique. Dr. Paul Belzycki is a general dentist from Toronto, who has volunteered a number of clinical cases that will be presented on Oasis Discussions. Dr. Belzycki’s experience spans over 38 years of clinical practice in which he treated several complex cases that have required a combination of periodontal, endodontic, and prosthodontic treatments. Dr. Belzycki welcomes your feedback and suggestions which you can share with us at oasisdiscussions@cda-adc.ca We hope you find the case informative. Chiraz Guessaier, CDA Oasis Manager |
Highlights
- Root resection is a technique employed to maintain teeth that have less than an ideal long-term prognosis.
- A patient in his sixties presented asymptomatic, no pain, and with a sinus tract.
- Three crowns were previously placed over endoddontically treated teeth. The crowns were still viable; however, with the sinus tract present, they needed to be redone.
- The treatment plan was to attempt endodontic treatment with the crowns removed and restore the quadrant comprehensively.
Full Case Presentation (20.48″)
WELL SAID!! Before I saw the end I was going to say, ” Kind of old school, but it works” You speak philisophically from experience. Good job!
John Rogers 8T3
I wish to comment on this case.
Firstly, the use of the term “fistula” by Dr. Belzycki is incorrect. The definition of “fistula” as described in the American Association of Endodontists Glossary of Endodontic Terms as “an abnormal communication pathway between two internal organs or from one epithelial lined surface to another epithelial lined surface not a sinus tract.” Sinus tract is the correct term.
Secondly, use the term “clinically serviceable” is meaningless when it comes to an Endodontically treated/restored case in the presence of persistent of periapical symptoms/findings. Without removal of the restoration, it is impossible to tell whether long term coronal leakage may have contributed to the persistent Endodontic problem. The literature clearly has shown that coronal leakage plays an important part in endodontic treatment outcomes.
Thirdly, why was cbCT imaging not used to locate the canals in the MB root? cbCT imaging has become the standard, essential Diagnostic tool in Endodontic Specialty offices, ESPECIALLY in retreatment cases. Most MB root systems (and MB2) can be visualized using this technology and strategic microsurgical access with an SOM can made to deal with them when separate MB2 canals contribute to persistent periapical findings and associated symptoms.
Fourthly, I disagree with the previous Endodontist opinion that Endodontic microsurgical procedures would not be a good strategy for resolving the periapical area. Considering the fact that we have already accessed the coronal part of the canal, and that we will resect the apical portion of the root, the amount of unfilled canal space that will be left will be minimal.
Furthermore, skillfully performed, conservative Microsurgical apical procedures allow excellent access and visibility of the root tip. Judicious retro-preparation with the use of a SOM allows for good seal of the resected canal system with materials such as MTA and high success rates in selected cases. This is such a case.
In summation, I would like to congratulate Dr. Belzycki on some very fine restorative Dentistry. The work itself is exemplary but I believe that it was unnecessary to complicate the case by resecting the MB root and losing tooth structure when a conservative microsurgical endodontic procedure would have solved the apical periodontitis problem while at the same time retaining normal coronal tooth contours and structure.
On behalf of Dr. Paul Belzycki,
Dear Dr. Kaufman,
Thank you for taking the time to post your comment on this case. This is a new format for me and any feedback is welcome. There definitely is a learning curve in this arena.
Firstly, I apologize for the incorrect term “fistula”. This is what we used to call it “back-in-the-day”. Labels I have habitually used, such as Periodontosis, have been supplanted by others and regrettably, when rushed, I find myself going back to Periodontosis. I promise to be more careful on these public posts. But, by whatever label, diagnosis and treatment remain constant.
Secondly, I subjectively used the term “clinically serviceable” to describe the conditions of all the restorations in the area as quickly possible, as time is a precious commodity when composing these posts. Here and now, without the time constraint, I can elaborate on my thoughts.
I hope we can agree that all aging restorations are on a continuum ranging from ideal to “gotta-go”. The crowns in this case were somewhere in the middle on that continuum; and we all may judge this by our own criteria. They were placed decades ago by the patient’s previous dentist. Clearly, they appear less than ideal, but the patient was asymptomatic and these crowns were still giving “clinical service”. A second point I was trying to make, although implicitly, was that I do not suggest replacement of crowns merely because they do not look “pretty”. Thirdly, we do not suggest or provide treatment in a vacuum; and there are times when restorations are undeniably (a term we could also debate) in need of replacement, yet for patients’ financial or psycho-social reasons, it is not possible to do so. Yet, these very same failing restorations may continue to “serve clinically” for some time until a patient does consent to treatment or some clinical findings forcefully dictate treatment, i.e. pain.
For the record, and verified by one of the photos, teeth 24 and 25 looked worse than 26. Initially, I questioned involving these teeth, but surprisingly, the underlying preps had more staining than the 26, which in my mind indicated “leakage.” Yet, the 25, in which the endodontic fill does not go to length, has no radiographic lesion. Perhaps there too, a treating diligent dentist could get no further, and hence my reluctance to disassemble that tooth. The colour of the exposed tooth material of the pulpal floor in 26 indicated sound tooth structure. And yes, I am sure we could argue the ingress of bacteria in the absence of stained dentine. I am certain a paper exists somewhere.
With regards to your third and fourth points: the initial endodontic therapy was done many years ago by a specialist I know and trust. I called him pre-operatively and he informed me that he could not negotiate the mesial root, and he doubted he could do so a second time. I admit I have an ego, so I thought I could do better. Heck, in my 38-year career, I have only referred out a dozen or so endos. I am very tenacious and concluded “for sure I can find the canal!” Well, after 20 minutes or so, I gave up. Typically, I’d go for an hour before capitulating, but in this case, I did not want to make the work of a second endodontist more difficult, by destroying precious landmarks. The second endodontist, equally equipped to perform your stated “Microsurgical Techniques”, could not locate any canals in the mesial root without the danger of weakening the remaining structure and without a “misadventure” outside the root.
Here are that specialist’s remarks:
“Periapical healing in the presence of untreated canals following apicoectomy and retro filling is in the range of 65-80 percent, not 100%. Root amputation resolves the periapical inflammation 100% of the time. The 10-year survival for a tooth with a resected root is 71%. CBCT would not have changed the recommended treatment. It would have added cost and dosed the patient with the equivalent of 24 PA images. In my opinion, that’s the unnecessary procedure.”
For the sake of correctness, I am certain the dosage equivalents mentioned above might be higher or lower, depending on machine and technique, so do not take me to task on this issue. The point is, whatever the dose, it was not deemed necessary given the clinical findings.
A third endodontist I spoke to advised that the long-term prognosis of a root-end procedure in the presence of an untreated canal is near 0%. Whatever the number, it is not 100%
I am not adept at recalling accepted success rates for any given procedure that I provide. Here I rely on my own clinical experience. As this presentation has illustrated to you, I am reasonably adept at “some very fine restorative dentistry”. I am certain you too, perform at a “fine” level. What bothers me is the certitude with which one can propose treatment and prognosis at distance without seeing the case firsthand. Can any one of us boast to have successfully negotiated to length, every canal in every root we set out to treat, 100% of the time?
What I am certain of, is that these two “fine” endodontists tried their very best to complete the task at hand to the highest level. At some point, based on their years of clinical experience, they elected to abandon the attempt, each one of them, for shared or differing reasons. I certainly cannot stand in judgement of them. Which one of us can or should? Without question, I would have preferred to have salvaged the entire tooth. After a lengthy and considered deliberation, it did not play out that way. I am not in the least bit suggesting routine root resection, if there is a less invasive alternative. I am puzzled that my presentation led you to that inference. As stated, this case illustrates a “Unique Clinical Dilemma.”
An oral surgeon reading this debate might argue, “damn the both of you and place an implant if you want a better long-term outcome.” I have heard endodontists lecture to the contrary.
As for my colleague’s quote about 71% success rate after ten years for resected teeth, I laugh. If I thought it was that low, I would have extracted the entire tooth. Here too, I rely on my own clinical experience. The literature tells us that resected teeth fail more likely because of tooth fracture that is due to endodontic therapy rather than periodontal breakdown and I tend to agree with that statement. So, in this case, as with most endodontically treated teeth, if I can splint crowns together, I will. Strength in numbers argument to resist stresses. The fact that teeth 24, 25 and 27 would benefit from the placement of crowns played into my hand.
With four splinted crowns, you can anchor the Queen Mary.
What worries me is not the 26, but the short-filled 25.
In addition to “fine restorative Dentistry,” I do provide root-end procedures as well.
Will keep you posted.
Dr. Paul Belzycki