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Oral Surgery/Tooth #30- Extraction/Implant vs. Apicoectomy

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QUESTION: Hi! Hopefully this helps me make my decision. I am in pain a little bit more each day.
I had a root canal done on tooth 30 about 4 years ago. Due to finances, I didn't go back for the post-work until about 7-8 months ago. So to be clear, this tooth went 4 years without the crown. It was blue by the time the doctor got to the post/crown work. I had little to no symptoms until very recently. It was bothering when I would eat something cold. I went in to see the Dentist and he told me there was a file left in the root canal and has caused an infection. He gave me antibiotics for 10 days. I finished taking the antibiotics and am now deciding what I want to do. He told me I had two options, one was apicoectomy and the other was extraction. I want to make a decision ASAP because it is starting to hurt and since I am no longer taking antibiotics, I'm worried it will spread and make it worse.

My Questions are:

1) What is the success rate of an apicoectomy on tooth #30?  (I've read anything between 60-95% success rate AND also read that there is a 40% chance of having to get the tooth extracted after 5 years anyway, so I'm wondering...

2) Is it better to just get the tooth extracted and get an implant to avoid the apicoectomy (I'm terrified of surgery/recovery)?

3) If I do the apicoectomy- what is the filling used to cover up the root after the surgery? How long does it take for the bone to heal? And what are the chances of complications like the bone not healing and leaving a hole (as I've read this online)

4) What is the success rate of extraction/implant? What are the pros/cons?
Also, if the tooth went 4 years without the post/crown work, does that make it more vulnerable and does it increase the chances of the apicoectomy not working?

I am very very very very nervous about both processes. I don't want to be toothless for too long after the extraction. I need to consider recovery time because I don't want to miss work time which requires me to talk all day long. I also need to consider the pain during/after the procedures and of course, the cost of either procedure.

I felt a little rushed at the doctor so I did not get a chance to think of all my questions and get clear answers. Any information you can give me to make either option clear, I would really appreciate it. Thank you so much!

ANSWER: Ann - An apicoectomy, if performed by a skilled surgeon on tooth #30 can usually be successfull. One thing that might be a problem is the file.  Often such instruments are inundated with bacteria and that can cause a problem.  A nerve canal is not a single canal, but, in fact, there are microscopic branches off the canal and those branches may not be cleansed.  If so, an apicoectomy done at the end of the root may not incorporate a possible bacterial contaminated area.  Usually, straight forward apicoectomies in the hands of a skilled oral and maxillofacial surgeon can have a good success rate.  

I don't always recommend this, but with what you describe and the presence of the instrument in the canal, an apicoectomy might not be successful.  I would, therefore, recommend the extraction and placement of an implant by an oral and maxillofacial surgeon.  If done by a board certified oral and maxillofacial surgeon, the success rate should be quite high.

So with what you are faced with, I recommend an extraction and implant.  I will tell you that many endodontists will try to do it themselves and they are not surgeons.

If you have additional questions, feel free to contact me again.

---------- FOLLOW-UP ----------

Tooth #30
Tooth #30  
QUESTION: Thank you so much for your quick response. After reading your reply I realized I never said the location of the file, not that it might make a difference, but does it?
I'm attaching a picture to see if the location even matters, in your opinion. It is at the end of the right root. See picture attached.

ANSWER: Ann- The file is located almost at the tip of mesial root of tooth #30.  I see the area of infection or inflammation located at the tip. An apicoectomy might quell the problem, but I suggest that the surgeon do a high cutting of the root on the tooth, above the file to completely remove the portion of the root with the file in it.  The a sealing of the nerve canal can be performed and cleaning of the pathological tissue in the bone.  In h this situation, a knowledgeable and skilled surgeon can do the apico and probably save the tooth.

Thanks for sending the picture to better define what is there.

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your answers! I will definitely make sure to give you positive feedback on the reviews.
I have a few more questions. I want to be really sure before making a decision.

It seems doing the apico is the best option, given your responses as well as research I've tried to do.
I'm still wondering:

1) what is used to cover the tip of the root? I'm especially curious about this since it seems the surgeon will have to cut a significant part of the root. I also read somewhere that what is used to cover the root will determine how successful the surgery will be. Is this true? If so, what's the best (most effective/successful) material to use?

2) how long is the recovery period? I am a teacher so I spend a significant portion of the day talking and moving around.

3) I keep reading in my research that endodontists are the ones who usually perform apicoectomies but I keep reading in many of your responses to people, that a surgeon should do it. At first glance, my endodontist said a surgeon should do it, then after examining it and seeing it up close, he said he could do it. I want to make sure the most qualified person is doing it.

4) Is there anywhere on this site, or from your own knowledge, that I can look up good surgeons with high success rates in NYC? I'm limited by my insurance (UFT) as to where I can go, but I'd like to search for a good surgeon. I keep looking for reviews or group discussion on my endodontists but I cannot find very much info.

Thank you.

Answer
Ann - When the root is cut, the new end has the nerve canal in the middle and that needs to be sealed.  That sealing is done in a few ways, but in my surgical history, an amalgam filling creates the best seal and one which usually exists for the life of the tooth.

The recovery period is contingent on the difficulty of the surgery and the skill of the doctor.  Usually an apicoectomy on the lower first molar should produce some postoperative discomfort will exist.  That discomfort can last a few days, but it should not be excessive and medication should be able to control any discomfort.   I have done this type of surgery on teachers, doctors, nurses and others who function like you with a need for constant communication.  

Endodontists are not surgeons.  Yes they can do a simple apicoectomy on a front tooth, but the surgical knowledge of a board certified oral and maxillofacial surgeon will greatly decrease any chances of complications.

I would be more than happy to provide you a few names of surgeons near where you live.  If you could get back to me, tell me where you live and will send you the names of the doctors.

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicing for over 20 years. Assistant Clincal Professor at State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA- University of Connecticut DMD-University of Pennsylvania School of Dental Medicine Oral and Maxillofacial Surgical Residency - Roosevelt Hospital, NYC

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