Apicoectomy teeth #s 23, 24, 25, 26 with bone graft

[Gental]

Hello, (see before and after images)

I had apicoectomys (apicoectomies?) done on my front 4 bottom teeth. I was under the impression that only the bottom 2 to 3mms of my teeth were going to be removed. I asked to see the after x-ray and I was surprised at how much tooth looks like was removed. Is it me or was a lot of tooth removed? Could someone explain if this just looks like a lot or hopefully there is some kind of reason this much had to be removed due to infection? I thought that the teeth were exposed, the very tips of the teeth were removed, and then as much infected bone and tissue needed to be removed would be removed, just a little surprised at how much actual tooth was removed.

I am a little concerned about if what is left of the teeth go down far enough to be sturdy long term? If my bone graft turns to real solid bone well, should they be strong? Hopefully my bone graft heals well, I did have a bit of a set back with wound dehiscence unfortunately, which is now healing through secondary intention. Right now the hole is just 2mm I think and is healing. The dentists/students? that have seen me on follow ups think that the bone graft should be fine and I am staying on the chlorhexidine until it fully closes.

I am reaching out on this forum because I have some questions but it is really hard to get questions answered at this residency clinic. They didn't really tell me all the info I should have known beforehand and I haven't seen the doctor who actually did my work after the surgery. Thanks for your time everyone, appreciate it.

 

[Dr M]

Good day

Firstly, it is important to note that this x-ray is 2 dimensional. Usually a tooth is also sectioned at the tip at an angle, so this x-ray might give you a misinterpretation of how much tooth was actually removed.
Secondly, as much tooth, bone and granulation tissue needs to be removed in order to facilitate healing. The ideal crown ( top part of tooth ) and root ratio is 1/3 to 2/3's. Or at the very least 50/50.
Judging from your x-ray and counting in the fact that you have a graft, the stability should be fine.
The tooth with the post and crown is a bit more of a worry, since the seal on the root end part might not be that good and could lead to failure.
It is also important to keep in mind that root canal treated teeth, with apicetomies, is no guarantee that the teeth will be fine in the long term.
There is always a chance that this could also fail, and then you will end up loosing the teeth, which would lead to either a partial denture, or implants as solutions.

Hope this helps.

 

[Gental]

Hi, yes that all makes sense, thanks for your reply. I agree about the crowned tooth, it was done by my hometown dentist and he did a great job so we have to just hope. And for the longevity of the apicoectomy as well, just hope I am a long term outcome, there must be some cases where they last impressively long.

About the wound dehiscence, it was not across the entire length of the opening and is now down to 2mm or less. Basically my question is can you have dehiscence in part of the wound and it not affect the bone graft? I am not showing any signs of infection. Just a little worried that maybe the wound closes but somehow the bone graft was compromised while the dehiscenced part was closing up.

Thanks again

 

[Dr M]

There is a risk, but it may be relatively small, depending on if the area was treated appropriately. My advice would be to watch and wait and to go for your scheduled follow up visits to confirm new bone formation in the graft area.
It is a good sign that everything is healing.

 

[Gental]

Great, will do. Thanks for your time.

 

[Gental]

Hi Again. I was wondering as well. Could you tell from the X-ray if the surgeon put a root end filling at the bottoms of the teeth? I am curious if this was done and I can not tell from the image and I asked the helpers to ask the surgeon and they said they’d get back to me but no one has told me.

 

[MattKW]

Sorry, but those are pretty rough apicos which I would expect to fail within 12-18 moths, either from reinfection or fractures. They appear to have been done by an oral surgeon and not an endodontist. There has not been much regard for the quality of the underlying RCTs which are of so-so quality. Normally an endodontist would try redoing the RCTs, and use apicos as a secondary intervention.

 

[Gental]

I would have rather had the roots retreated. When I went to the clinic I purposefully went on the one day a week that the endodontist is in. At first she said to try a root canal re-treatment of 2 of the teeth but then looked over it all for awhile and said that with the bone loss in the jaw that it is better to get in there and remove it all along with a bone graft. They made it seem that just root canal re-treatment would not completely solve the jaw bone infection, could re-treatments have cleared all the infection away?

Honestly I would have gotten a second opinion if I was aware of how significant apicoectomies are, they really made them seem like a very minor thing where the very very tip of the root is taken, and when I looked them up a bit on the web, everywhere seems to also make it look like this tiny bit of the apex is taken. But after having them and I watched an actual surgery video, it really is not that small of a thing.

As for the original root canals, I got them done in 2004/2005 when I was 17/18 after a basketball injury sent all 4 of them straight backwards from an elbow. I had no problems with them until around 2015 when I got a basketball shoulder that shattered the one that then got a crown. I never had any issues with those root canals until that second injury.

When you say fracture, do you say this because of how much tooth was taken and lack of stability will lead to them fracturing with normal use? I am a pretty healthy person, if the bone graft takes well is there a chance they can become pretty strong? Also what is your fear of reinfection, because of not all the infection being cleared when the apicos and bone graft were done, or the wound opening? The wound opening is nearly shut now.

 

[Dr M]

Good day

I agree with MattKw, that apicoectomies are usually done as second line treatment. A retreatment would have been first choice. It is possible that unfortunetly the infection was to severe, for only a retreatment to have cleared it up, and therefore apicoectomies might have been needed. Even with a retreatment, there is a chance that all the granulation tissue and infected bone, could result in the retreatment failing, or the teeth that are being retreated could end up fracturing during the retreatment process or the end result could have been similar with similar quality root canals. There are unfortunately a lot of possible outcomes, but at this stage it is too late to reminisce over what could have been done. The infection should have been picked up initially during check-up visits, before it got to such a severe stage.
Like I explained in my previous post, the root-crown ratio is a bit compromised now, and since these teeth are root canal treated, they might end up fracturing at a later stage.
In my personal experience it won't last you the rest of your life. You can consider crowning the remaining teeth, in order to prevent them from fracturing, but this should only be consider once the apicoectomies and bone graft have been deemed successful and there is no longer residual infection at the site. Crowns might increase the strength of the teeth.
If the roots fracture, because of weakened structural stability after the apicoectomies, then unfortunately they will have to be removed.

 

[Gental]

Thanks for both your time. Yes I wish I had at least once paid out of pocket to see my hometown dentist during this span of not having insurance/funds. I went to a few dentists that took my crappy insurance and asked them about the teeth and they were not concerned but my gut said that the darkness there was not normal. But you are right, you can't go back in time...

Just hope these last long enough for me to move up in my career and them not be so daunting to address financially, because everything is times 4. If/when... they fail, I hope that at least I can get an implant supported bridge, but would rather 4 implants. Though one dentist seemed like I could get 4 implants and another acted like there was not enough space. Would 4 implants be an option and if I got another bone graft and they were done by a good dentist could those last a real long time?

Thanks for the advice on maybe getting crowns for them, part of me feels like maybe just saving up for implants in the future. One dentist said that after the apicos I could get a special bridge made for support which confused me. I said I thought bridges are for missing teeth and that I was confused and he did not explain further. I am guessing like some kind of cap thing that would span the 4 hurt teeth and 2 neighboring teeth, which I don't really want to bother the neighboring teeth that are healthy.

Thanks again, appreciate the responses

 

[MattKW]

Once the integrity of the tips are removed like yours have been, then the root as a whole is weakened, and that leads to fractures. I would not advise crowns; it would be a waste of money. You would be better saving up for implants. You don't need an implant for each lost tooth; 2 implants would suffice to hold up a 4-unit bridge.

 

[Dr M]

Agree with MattKW. In terms of a long term solution, implants will be the best option.

 

[Gental]

I understand what you both are saying, though I still do not get why so much of the root tips were removed by the oral surgeon. If you have the window open why couldn't you scrape away the infected jaw bone and you should have visibility to take a smaller amount of the tips. Especially hearing that this is pretty important to long term outcome.

As for the implants, why is it not more advisable to get 4 implants? From everything I hear it seems like implants can last a really long time with proper care, they take up the socket space and keep the gums and bone from shrinking etc. The process of cleaning them is more straight forward and like regular teeth. Then you have the bridge, sure it is in implants so not affecting the natural teeth, but from what I have gathered, the bridge part needs to be replaced on average sooner than an individual implant would, there can be bone/gum loss going on underneath the bridge, and cleaning under them seems a bit less straightforward with possible issues arising. Not to mention maybe getting something stuck under by accident and pulling on the unit.

So why do dentists say a bridge. Is it that there is legit not enough space there? I don't care if it is a bit more expensive with more steps, is it just easier?

 

[Dr M]

Usually price is an issue. Most people can't afford 4 implants. There is also the issue of the amount of space needed between implants. Usually about 2.5-3mm of bone needs to be present between implants. In such as a case it is possible that 4 implants will not fit in the available space.
With good maintenance it is possible that the bridge components could also last a very long time before they need replacement.

With regards to the apicoectomies that were done...without seeing how much of infected bone was present or what the condition of the root apices were, it is difficult to say if he took too much off.

 

[Gental]

I see, thanks a lot for expounding. Thank you both for your time. Maybe I can hold out long enough for new advances in smaller but stable screws or something. Dental needs to be part of health insurance always and not this side thing, I guess too many people are lucky and don't get elbows to the face in high school and are just ignorant to the need.

 

[Dr M]

Good luck and all the best!

 

[Gental]

Thank you!