The importance of apex removal on PET.

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Posted on By armando ponzi In Other

Patient received a PET on tooth #12: the tooth root was hemisected and prepared in order to include the apex.
The x-ray shows the maintenance of IBH, promoted by the root presence. Bone around implant is well represented (PET was performed before implants).30 days X-ray control was made on march 21 and PET performed on September 29.
On the removal of palatal fragment an apical cyst was detected, attached on the apex. (in 6 months time a cyst start developping)
The epithelial rest of Malassez, are frequent on lateral incisor being a possible cause for apical cyst.
So, IMO, careful root hemisection should be carried out, possibly involving the entire root apex. What do you think about it?
2.5 mm of root was removed from gingival margin on vestibular area: this is a data on which we should work, trying to establish a depth consensus.
Armando

initial
X-ray 6 months earlier

PET starting
cyst and root fragment


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14 Comments

detail of PET
Marginal tissue rapid oedema and bending over the socket


Reply

Armando, thank you for sharing and bringing this important point to discussion.
I`m always about 6 months behind PET experts (called envelopes) on Forum, wisely waiting to see results. I remember PET molar cases from you and Chuck with apex left. Since this can be considered as a risk factor it didn`t become a part of PET procedure in our clinic.
I don`t succeed each time to take out a palatal root part inclusive apex. Sometimes I am even forced to do apicoectomy.
For each PET case (SS or RST) CBCT is prerequisite, don`t you think so?
Your case is going to be predictable beautiful, looking forward to see final result and long term stability.
#14: RST, PS or SS?
Best regards
Snjezana


Reply

Armando. Important point of discussion. In addition to apical
Infection, what is your opinion on SECONDARY DENTIN in regard PET diagnostics? I notice impaired tissue attachment and root submergence when secondary dentin remains. IMO
we need to focus more on PET DIAGNOSIS rather than techniques and kits. "There is only one diagnosis......." Best wishes. Chuck


Reply

Chuck,
The diagnosys will be many up until we achieve complete data.
On that sense it is never easy to give a value to secondary dentin.
One concept it seems to me interesting: biology hates volume and likes bidimensional: is this a key for PET biological success on healing?
I guess there is a lot to learn; if you could choose: better a PET on mandibular premolar or on maxillary molar?
Warm regards, my friend.
Armando


Reply

Sniezana, yes CBCT is, IMO, a mandatory advice too. Infact present case as you see from project is based on CBCT data. About apex, I believe that frontal maxillary teeth are not easy to manage either endodontically or for PET/RST. I agree, molars are more difficult to manage for PET expecially if you want to remove apex: but as you say initial diagnosys is always essential. Also do consider that you can work on inner part of remaining PET root and that might be a success key, maybe integrated with densah drill use. Warm regards. Armando

Planning project
virtual extraction and lateral incisor


Reply

Armando,

You continue to show us the way!

Cheers,

Richard


Reply

Martin,
As Scott Ganz used to say:
'It"s not the scan it is the plan'.
Digital is a new mind state and not a simple technology shift.
Best.
Armando


Reply

Hi Armando, I do agree with you: the diagnosis is important!
The root must be healthy, before treatment.
Excellent documentation and questions, as usuall!
Regards
Jorge


Reply

Jorge, thanks for comments, you are a master here! You are right the diagnosys is important. And I'd say establishing a risk profile, IMO, more issues on a lateral than a molar. Best. Armando


Reply

You always need to remove the apex It is not negotiable. as well as all endo material.


Reply

Howie, totally agree with you. I believe we should apply the endodontic crown-down concept to the PET, that's what I try and do on my PET approach. Best regards. Armando


Reply

Howie. What you say is logical, but IMO EVERYTHING we do in implant dentistry is negotiated by the host response. As our diagnostics improve we will better predict what the body will tolerate (or not)Cheers. Chuck.


Reply

Howie, Chuck and Armando: I do not think we need to remove apex allways: we don´t do it at the RST!
If the Diagnosis is correct and a healthy nerve or pulp is there, I´m not worried about the apex.
Regards my friends.
Jorge


Reply

Jorge, You are right, it is always a matter of right diagnosys. But if goal is to try and remove Apex, it will be done most of the time, and we should try & think about removal technique. Otherwise, it might be a simple task with some unpredictable issue on long term result. Best regards my friend. Armando


Reply


Hu-Friedy
Salvin