Endodontic Surgery in the Esthetic Zone

One of the big challenges with dental implants is working in the esthetic zone (anterior maxilla). Crestal bone loss, which often occurs with dental implants, can lead to loss of gingival papilla. Loss of the papilla will lead to dark triangles and long clinical crowns. In an areas as esthetically sensitive as the maxillary anterior, loss of crestal bone can become a big challenge.

Endodontic microsurgery may allow you to save a natural tooth and preserve the crestal bone. Since endodontic surgery is an advanced technique taught in specialty residencies, many dentists are not as familiar with the possibilities of endodontic surgery. In addition, the advancement of surgical techniques and instruments have completely changed the endodontic surgical technique and it's outcomes.

The following case is an example of endodontic microsurgery.

Pt presents with a draining sinus tract on #10. A periapical radiolucency is noted. While pt reports the RCT was completed "eons ago", the post and crown are only a year old. The silver cone obturation, while past the apex, has served this patient well for many years. Options were discussed and the patient elected to have endodontic surgery.

An Ochsenbein-Luebke flap was used to help preserve the marginal gingiva. The silver point was removed and the canal was retrofilled with MTA (Mineral Trioxide Aggregate).

Post-op radiograph


3 month recall finds complete function, significant radiographic healing & preservation of the crestal bone.

Getting the Stain Out!

Following trauma, tooth discoloration is very common. The discoloration comes from the bleeding inside the pulpal chamber. The dentin becomes stained as the blood gets into the dentinal tubules and trapped in the pulp horns. The first step in restoring the natural color to the tooth is good endodontic therapy with adequate removal of the stained facial dentin and complete removal of the pulp horns. If the natural tooth color is not restored with this procedure, then the additional treatment of non-vital internal bleaching is indicated.

A common error is incomplete removal of the pulpal horns due to a small apically placed access. Care must be taken to remove stained dentin and pulpal horns while trying to preserve maximum tooth structure.

The following case shows how to "get the stain out".

Tooth #9 & #10 sustained traumatic injury.

Note the discoloration on #9.

After opening the access, staining can be seen in #9. #10 looks normal.


A round bur is used to remove the stain from the facial surface of the pulp chamber. Careful examination with magnification reveals remaining stain in pulp horns. The access is carefully refined to remove stain from pulp horns while keeping access as conservative as possible.


Following removal of rubber dam, the change in coloration is noted. Patient is informed that the tooth is dehydrated and will continue to change color until rehydration is complete. At that time, evaluation can be made if additional internal bleaching procedures will be needed.

Obturation completed.

Adequate endodontic therapy alone will often resolve the patient's esthetic concerns. Non-vital bleaching is a good adjunct for teeth requiring additional whitening.