According to our survey, a male patient, aged 38, showed up with a painful symptomatology involving tooth #26, exacerbated by mastication. The dental history and examination revealed that previous root canal treatment had been carried out but was unsuccessful as the symptomatology persisted.
The tooth had undergone an orthograde re-treatment and, as a consequence of that, the patient had noticed the spill of a liquid substance from his right nostril. The re-treatment had not solved the endodontic problem either.
Clinical tests did not show a fistulous tract, but it was possible to localize the tooth through percussion and biting tests.
The radiographic examination confirmed the presence of an incongruous root canal therapy, by also showing radiopaque material, probably cement and gutta percha, in contact with the maxillary sinus (Fig. 1).
The clinical examination radiograph confirmed the hypothesis according to which an iatrogenic communication may exist between the periapex of the tooth and maxillary sinus.
Our therapeutic treatment of choice had been to adopt an orthograde approach to try and resolve the patient’s problem.
After the removal of the provisional cement, the cone of the gutta percha had been isolated through an ultrasonic point RT2 (EMS), in association with copious irrigation using a physiological saline solution. The cone of gutta percha was then removed (Figs. 2 & 3).
The confirming radiograph showed that the remaining part of cone linked with the maxillary sinus had also been removed (Fig. 4). The endo-antral communication was then cleansed with lavages of physiological saline (Fig. 5).
Forty-eight hours later, a period of time which has been judged necessary to join the flaps of sinusal membrane, after the removal of the temporary filling, the perforation has been mended by lacing BIO-GEN (Bio-Tek, Torino, Italy) in order to create a matrix barrier against which a reparative material could be made more compact. This had been made by filling the perforation with mineral trioxide aggregate (MTA) (Figs. 6 & 7).
Forty-eight hours later, after checking the hardening of the material, the canal retreatment has been carried out.
The material of the previous filling has been removed, the endodontic system was cleaned and shaped with rotary instruments NI-TI (Pro tapers for the third coronal and medium, K3 for the third apical).
The seal of the endodontic system had been obtained through the technique of warm vertical condensation (Fig. 8).
Seven days later, the patient underwent another assessment and it was possible to notice a complete remission of the symptoms, an excellent indication of future recovery.
The radiograph at two months confirmed the complete remission of the symtomatology and it shows the tooth was on its way to recovery (Fig. 9).
This interesting case points out how some rather complex clinical situations that would be otherwise treated by a surgical approach can be resolved with an orthograde conservative retreatment.
The orthograde retreatment, whenever possible, is always to be preferred to the retrograde one; this often allows us to solve endodontic problems by avoiding the further weakening of the root structure and altering the crown root ration. It also saves the patient the stress of such an invasive surgical approach.
Dr. Marino Borrelli maintains a practice in Italy.
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