Endodontic Surgery (Apicoectomy)

In this modern times patient increasingly wish to preserve their natural dentition and often reluctant to get there teeth  extracted . Endodontic surgery (apicoectomy) is the treatment performed on the root apices of an infected tooth, and its  resection and removal of pathological tissues around the apices followed by placement of a filling (retrofilling) to seal the root end. Endodontic surgery offers patient a second chance or the final chance to save there tooth. Success of Root end surgery had a poor prognosis and success rate in the past but due to recent advances Endontics due to the surgical operating microscope and new tecniques the rate is  much higher than before success

Its indications are as follows

1 RCT treated tooth that has severe periapical inflammation  despite of a satisfactory RCT

2 Tooth with persistant  periapical inflammation and inadequate RCT  and has the following problems

a Severely curved root canals where access is  an issue  to reach the apex

b Completely calcified  root canals

C  Presence of post and cores in root

d Breakage of small  instrument  or filling  material where it is not retrievable and an infection is still present  in the apical region.

Teeth with periapical inflammation where completion of endodontic therapy  due to

1 Foreign body present in the periapical tissues

2 Perforation of the inferior wall of the pulp chamber

3 Perforation of the root

4 Fracture of the apical third of the root

5 Dental anomalies (Dense in Dente )

6 Access for periradicular curettage

A non healing endodontic lesion is recognized by persistent pain and/or swelling, possibly with radiographic changes indicating increasing periapical bone loss. Non healing endodontically treated teeth that do not appear to be healing are not automatic indications for extraction and replacement with an implant. Persistent nonhealing cases can be saved by endodontic microsurgery with a predictably favorable prognosis

Nonsurgical endodontic treatment has a high rate of clinical success despite the anatomic and pathologic challenges of the procedure. Success in case of tooth without periapical extension of pathosis is more than 90%. On the other hand, studies show that infected root canals with an extension of pathosis into the periapical space have a reduced healing capacity . previously the conventional endosurgery has very low success rate . it was recorded as low as 37.4 %  but now with recent advancement in endodontic surgery  the success rate has improved significantly. According to a study conducted by shimon Friedman and Chaim Mor ( success of endodontic therapy -healing and functionality) in patients were endodontic surgery is performed the chances of healing after retreatment is between 74 to 86 %and their chance of being functional overtime is 91 to 97 % .Another study ( modern endodontic surgery concept and practice by syngcuk Kim  and Samuel Kratchman)said that the traditonal apical surgerybased on clinical symptoms and radiographic findings ranges from 44% to 90%.it has even higher success rate with the endodontic microsurgery. .   According to another study  (outcome of surgical endodontic treatment performed by a modern technique – A meta anlysis conducted by Igor Tsesis , Surgical endodontic treatment have a success rate of 91 .4 % when followed up in a year time .

According toa study named Outcome of endodontic micro re- surgery by Minju song and team …. When an endodontic surgery fails we need to identify the problem and  find the reason for failure. To solve the problem further treatment like retreatment with surgery  and, extraction are the viable options. Some  studies in the past have documented poor success rate if we have to redo a failed surgery again. But this study said that  with the new microscope and microsurgical devices the success rate can be as high as 92.9 %. Most of the reason for failure is poor technique,poor seal at the apical region and not using biocompatible materials  like MTA and super PBA in the past. In another recent study it was found that, at least in America, endodontic surgery was the least expensive intervention for failed RCT when compared to endodontic re-treatment and crown, extraction and fixed partial denture, or extraction and implant (Kim & Solomon, 2011).

When primary `endodontic treatment fails retreatment should be done and when retreated and if there is severe inflammation  in the periapical tissues  then  endo surgery can be an option using advance techniqies and good operationg  skill can add to the success of endo surgery.

1 Microscope

The microscope will provide good  visualization, identification and treatment of infected canals, isthmuses and variant  anatomy not reachable with  traditional instrumentation techniques. Microscope can reach to more different  locations and  narrow spaces, by providing a clear field of vision. Good visualization also prevents damage to  anatomical structures. Microscopic techniques significantly decrease complications and expand the case applicability for performing this procedure on teeth adjacent to these structures. With increased magnification and illumination, differentiating the root surface from the surrounding bone is also enhanced .A main cause of nonsurgical endodontic failure results from the inability to clean and sterilize the apical canal space, which is a complex anatomical entity

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2 ultrasonic tips

That allow accurate preparation along the long axis of the root canal with clear visualization of the preparation . This technique will allow us to do root-end fillings in the proper position to seal the root canal to sufficient filling depth and  thickness to effectively seal the canal, dentinal tubules and accessory canals. Ideal ultrasonic tip length is 3mm long. A minimum of 3mm preparation depth is needed to prevent leakage.

3  Surgical advances

A smaller osteotomy will reduce bone removal (approximately 3-4mm) in diameter reduced

bone and permits quicker uneventful postoperative  healing postoperative healing.  By removing less bone in the coronal direction, buccal bone can be preserved and subsequent periodontal sequelae that may lead to the loss of the tooth are prevented.

2. Root-tip resection of 3mm is needed to eliminate lateral canals and apical ramification- A study shows that the resection of 3mm of apex eliminates 98 percent of apical ramifications and 93 percent of lateral canals.

3. Root section bevel angle is reduced to 0 -10 degrees

4. Clear examination of the resected root surfaces  for fracture and anoatomical variations

6. Root-end fillings with MTA (Mineral Trioxide Aggregate- It  has excellent biocompatibility, osteo- and cemento-inductive capabilities, effective antibacterial and sealing properties, and faster radiographic healing in comparison to SuperEBA and IRM. MTA will not cause soft tissue discoloration  that can otherwise  result from root-end filling materials like amalgam

Inspection                         resected root surface                    None Always

Summary

There are many factors to consider when choosing to perform microsurgery on a tooth versus performing other treatment options such as nonsurgical retreatment or tooth extraction. Fortunately for the patient, the ability to perform endodontic microsurgery is an effective and highly successful procedure that produces minimal discomfort, alleviates periradicular pathosis, maintains restorations and provides for function and aesthetics as shown in Figure 6.33,34