Microsurgical Management of a Three-Rooted Maxillary Premolar: A Case Report

Root canal treatment aims to treat and prevent apical periodontitis within the complex canal anatomy by disinfecting and sealing the canal system and removing causative factors [1,2]. Successful treatment is indicated by the absence of both apical periodontitis and symptoms over the observation period [3]. The outcome of endodontic therapy can be affected by multiple factors, including the status of the root canal, the extent of periradicular infection, the presence of iatrogenic mishaps, the quality of obturation and the complexity of the root canal system [3-6]. Surgical intervention can be an appropriate approach in managing a variety of cases involving canal complexity and mishaps [7]. A significant extrusion of root canal filling is one of the complications after root canal treatment resulting in an inflammatory response and symptoms [8]. In a clinical situation when it was impossible to solve the problem by orthograde treatment, then the surgical option is better [9,10]. Variation is a common finding in endodontics and three-rooted maxillary premolars have a low prevalence of approximately 1.4-0.3% [11,12]. Three-rooted maxillary premolars represent a rare anatomical variant with a documented prevalence of 1.0-1.7% in the Saudi population [13], posing significant diagnostic and therapeutic challenges. Given the presence of a fiber post in the palatal root and well-obturated canals, orthograde retreatment was deemed impractical. This case report describes an endodontic surgical approach to manage an extruded root-filling material of a premolar with anatomical variation.

An 18-year-old male patient, unaware of any medical problems, was referred from the prosthodontic department regarding an upper left first premolar, with a chief complaint of pain upon palpation after root canal treatment done six months ago. Clinical examination revealed a crowned tooth with mild, dull, localized pain that required a stimulus (Figure 1). Radiographic examination showed a three-canal system with an extruded material, a full coverage crown with a fiber post in the palatal root (Figure 2, 3).

Apicoectomy and surgical debridement were selected, with preoperative preparation including ibuprofen 600 mg

Figure 1: Preoperative clinical photo

Figure 2: Pre-operative periapical radiograph showing extruded gutta-percha in the buccal and palatal canals

Figure 3: Axial and coronal CBCT images confirming three distinct roots and extrusion of material into periapical tissues

Figure 4: Clinical view after flap reflection showing the extruded material

Figure 5: Root-end preparation of 3 mm in depth using surgical ultrasonic tips

Figure 6: Preapical radiograph confirmed the proper root-end filling with no voids

and a 0.2% chlorhexidine gluconate mouth rinse for one minute. A lidocaine L.A. with 18 ml 1:100,000 epinephrine was administered with buccal and palatal infiltration.

A triangular intrasulcular incision was made from mesial to the canine with a vertical incision to mid-buccal of the first molar and a full-thickness mucoperiosteal flap was raised. Care was taken to preserve the interdental papilla and minimize trauma to ensure optimal soft tissue healing. The extruded material was easily detected after the flap reflection (Figure 4). Osteotomy was performed using a round carbide bur, a 3 mm root end resection for three roots one palatal and two buccal using a multipurpose bur by high speed handpiece. Curettage removed all granulation tissue and extruded filling material. Root end cavity preparation for the roots was done using ultrasonic tips (AS3D, Satelec Acteon Group, Merignac, France) under water cooling to a 3 mm depth (Figure 5). Retro-filling was performed using bioceramic putty filling material TotaFill (FKG Dentaire SA, Switzerland) (Figure 6, 7). TotaFill bioceramic putty was selected for its high sealing ability, biocompatibility and osteoconductive properties, making it a suitable choice for retrograde filling.

Figure 7: Placement of bioceramic putty as root-end filling material

Figure 8: Bone graft material mixed with saline and placed into the bony defect

Figure 9: A collagen membrane was placed on top of the bone graft

A xenogeneic bone graft (InterOss Anorganic Canoncellous granules, Austria) mixed with saline was gently packed into the apical area (Figure 8) and then covered with a wet, absorbable collagen membrane (Cytoplast, RTM Collagen, Germany) (Figure 9). The wound edges were carefully re-approximated to allow for primary intention

Figure 10: Suturing using 5-0 Vicryl

Figure 11: Three-month follow-up radiograph showing periapical healing

healing. The repositioned flap was compressed with saline-moistened gauze to reduce the coagulum between the flap and the cortical bone. Single interrupted sutures were placed using 5-0 vicryl (Figure 10). Postoperative instructions were given, which included a one-week course of amoxicillin 500 mg three times a day, ibuprofen 600 mg every 8 hours for three days and CHX mouthwash. After one week, the sutures were removed. The patient was educated on oral hygiene measures, advised to avoid trauma to the surgical site and scheduled for periodic follow-ups. BCT imaging at 10 months revealed substantial bone fill and disappearance of the periapical radiolucency, indicating complete resolution of the lesion.

At follow-up visit performed at 3 and 10 months, the patient was found to be asymptomatic, soft tissue healing and resulotion of periapical radiolucency (Figure 11-13).

A three-rooted maxillary premolar is a normal variation where radiographic interpretation plays an essential role in evaluating root canal morphology [14]. Cone beam computed tomography can provide a more detailed evaluation of canal morphology and detect lesion extension and proximity to vital structures, which can play a crucial role in the success of endodontic treatment [15-17]. In our case, CBCT showed a rare finding of a present three-root system in all premolars, with the first left premolar showing gross extrusion of a material. In cases where symptoms persist despite orthograde treatment and extruded materials are involved, surgical intervention becomes essential for definitive management [7,8].

Many studies demonstrate that endodontically treated teeth with an extruded material beyond the apex that remain symptomatic may require apical surgery [18,19]. The presence of a foreign body, such as extruded root filling materials, in the periapical region may make it more difficult for the periapical tissue to repair after treatment, according to clinical and histologic evidence [19]. A foreign body reaction can be a causative factor of non-microbial reaction of apical periodontitis. Despite new advancements in sealers and biocompatibility, extruded thermoplastized gutta-percha and sealer can have adverse effects depending on the previous

Figure 12: Clinical view showing soft tissue healing

Figure 12: Ten-month follow-up radiograph showing periapical healing

status of radicular tissue [20,21]. These extruded materials probably became a significant factor in treatment failure only if the microorganisms are present [18].

In well-obturated teeth, an orthograde retreatment is unlikely to resolve the problem, as it does not remove the extruded materials beyond the root canals [19]; surgical management is preferable when persistent pain cannot improve by other means [22-23]. Orthograde retreatment, though effective in many cases, is often inadequate in removing extruded material, particularly when access is obstructed by posts or restorations [18,19] As new technologies such as microscopes and biocompatible materials have been introduced, the concept of microsurgery in endodontics has increased, with an increasing success rate. Modern endodontic microsurgery, aided by magnification and ultrasonic root-end preparation, has demonstrated superior outcomes, with success rates reaching up to 94% compared to 59% with traditional methods [24]. Apical surgery performed with the aim of guided tissue regeneration has the potential to increase bone regeneration and can increase the success rate of periapical surgery [25-27]. Guided tissue regeneration helps reestablish the periodontal architecture by preventing soft tissue invasion and promoting osseous regeneration at the surgical site [25,26] In addition to offering the chance to eliminate the extruded materials that cause apical radiolucency, a surgical procedure enables a retrograde method to clear the apical part of the root canal system from any possible infection [19].

The main purpose of this case report is to highlight the successful surgical management of a three-rooted maxillary premolar with an extruded material when orthograde retreatment is not feasible. With advanced imaging (CBCT) combined with precise microsurgical techniques and bioactive materials the treatment provides predictable outcomes for teeth with complex anatomy which cannot be treated orthograde. The correct identification of anatomical divergences becomes essential for creating effective endodontic treatment strategies.

Conflicts of Interest

The authors report no conflicts of interest related to this case report.

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