PERIAPICAL SURGERY Medical Assignment Help

PERIAPICAL SURGERY

Periapical (i.e., periradicular) surgery includes resection of a portion of the root that contains undebrided or unobturated (or both) canal space. It can also involve reverse filling and sealing of the canal when conventional root
canal treatment is not feasible. It is often performed in conjunction with apical curettage for reasons explained later in this chapter.

Indications

The success of apical surgery varies considerably, depending on the reason for and nature of the procedure. With failed root canal treatment, often retreatment is not possible or a better result cannot be achieved by a coronal approach.’ If the cause of the failure cannot be identified, surgical exploration may be necessary (Fig. 17-1). On occasion an unusual entity in the periapical .region requires surgical removal and biopsy for identification (Fig. 17-2). Those indications for periapical surgery are discussed in the following sections (B9X 17-2).

FIG. 17-1 Surgical exploration. A, Periradicular'lesion on mesial root may be caused by perforation, incomplete debridement (lateral and apical), or vertical root fracture. B, Visualization after flap reflection shows vertical root fracture (arrow); root must be removed or tooth extracted. (Courtesy of Dr. L. Batdossori-Cruz, Universitv of Iowa.)

FIG. 17-1 Surgical exploration. A, Periradicular’lesion on mesial root may be caused by perforation,
incomplete debridement (lateral and apical), or vertical root fracture. B, Visualization after flap reflection
shows vertical root fracture (arrow); root must be removed or tooth extracted. (Courtesy of Dr. L.
Batdossori-Cruz, Universitv of Iowa.)

Restorative Concideration. Root canal treatment may be risky because of problems that may occur from attempting access through a restoration, such as through a crown . on a mandibular incisor. An opening could compromise retention of the restoration or perforate the root. Rather than attempt the root canal treatment, root resection and root-end filling may he preferred to seal in irritants.

Horizontal   Root Fracturel. Occasionaijy,.after a traumatte root fracture, the rical segment undergoes pulp necrosis. Because this cannot be predictably treated from a coro al approach, the apical segment is removed surgtcally after root canal ‘treatment of the coronal portion (Fig. 17-5).

BOX 17-3

Contraindications (or Cautions) for Periapical Surgery
Unidentified cause of root canal treatment failure When conventional root canal treatment is possible Combined coronal treatmentiapical surgery When retreatment of a treatment failure is possible II Anatomic structures (e.q., adjacent nerves and vesj .sels) are in jeopardy I Structures interfere with access and visibility a Compromise of crown/root ratio
D Systemic complications (e.q., bleeding disorders)

Procedural error.’ Separated instruments, ledging, gross overfills, and perforations (Figs: 17-8 and 17-9 on pages 388 and 389, respectively) may result in failure. Although overfilling is not in itself an indication for removal.of the material, surgical correction is frequently necessary in these situations.

fiG. 17·2 Surgical removal-of pathosis. A, Pulp is responsive; this indicates that radiolucent lesion is not endodontic (i.e., pulpal) in origin. B, Because roots must be resected while removing the lesion; root canal treatment is performed. C, Distal root is resected and lesion is excised. D, Biopsy shows this to be an ossifying fibroma.

fiG. 17·2 Surgical removal-of pathosis. A, Pulp is responsive; this indicates that radiolucent lesion is
not endodontic (i.e., pulpal) in origin. B, Because roots must be resected while removing the lesion;
root canal treatment is performed. C, Distal root is resected and lesion is excised. D, Biopsy shows this
to be an ossifying fibroma.

Decompression and. not curettage, which may damage adjacent structures (rig. ] 7-]0 on page 390). Often, decompression alone is” sufficient to manage these lesions; su.r.g’ical correction (i.e., removal) is unnccessary.

Contraindications (or Cautions)

Contraindications (or Cautions)

If other options are available, periapical surgery may no referred choice (Box] 7-3).

Relying on surgery to try to correct all root canal treatment failurescould be .la eled indiscriminate. An important considerationis to first, identify the cause of fallure.vthcn S(,COllcCdesign an appropriate corrective treatment plan. Usually.retreatrnent is indicated and will  the best chance 01success. Surgery to correct a treat men! failure’ forwhichthecause can-rot be identified is often. Surgicalmanagenient at all large .

FIG. 17-3 A, Very small canal· (i.e., calcific metamorphosis) with pulp necrosis and apical pathosis. Canal could not be located with occlusal access. B, Apical resection and root end retrograde amalgam ~~~i~~ . FIG. 17-4 A, Irretrievable fractured post and apical pathosis. B, Root end resection and filling with amalgam to seal in irritants, Hkelyfrom coronal leakage. C, Regeneration of bone is evident after several months; prognosis  to eal.

FIG. 17-3 A, Very small canal· (i.e., calcific metamorphosis) with pulp necrosis and apical pathosis. Canal could not be located with occlusal access. B, Apical resection and root end retrograde amalgam ~~~i~~ . FIG. 17-4 A, Irretrievable fractured post and apical pathosis. B, Root end resection and filling with amalgam to seal in irritants, Hkelyfrom coronal leakage. C, Regeneration of bone is evident after several months; prognosis to eal.

FIG. 17-4 A, Irretrievable fractured post and apical pathosis. B, Root end resection and filling with amalgam to seal in irritants, Hkelyfrom coronal leakage. C, Regeneration of bone is evident after several months; prognosis is good.

FIG. 17-4 A, Irretrievable fractured post and apical pathosis. B, Root end resection and filling with
amalgam to seal in irritants, Hkelyfrom coronal leakage. C, Regeneration of bone is evident after several
months; prognosis is good.

FIG. 17-5 A, Horizontal root fracture, with failed attempt to treat both segments. 8, Apical segment is removed surgically and retrograde amalgam placed. C, Healing is complete after 1 year.

FIG. 17-5 A, Horizontal root fracture, with failed attempt to treat both segments. 8, Apical segment
is removed surgically and retrograde amalgam placed. C, Healing is complete after 1 year.

When conventional root canal treatment is possible. In most situations orthograde conventional root canal treatment is preferred (Fig. 17-11′ on page 391).4 Surgery is not indicated just because debridement and obturation are in the same visit, although there has been a long-held, incorrect notion that single-visit should be accompanied by surgery, particularly if a periradicular lesion is present.

Anatomic considerations. Most oral structures do not interfere with a surgical approach but must be considered, An example is the maxillary sinus, whic may become exposed. Creating a sinus opening is neither unusual nor dangerous. However, caution is necessary to not introduce foreign objects into the opening and to remind the patient not to exert pressure by blowing the nose until the surgical wound has healed (in 1 to 2.weeks).

Poor crOW1Iand root ratio. Teeth with very short roots have compromised bony support and are’ poor candidates for surgery; root end resection in such cases may compromise stability. However, shorter roots may support a relatively long crown if the surrounding cervical periodontium is healthy (see Fig. ’17-5)

Surgical Procedure

The following eleven steps, with modifications as appropriate, make up the typical approach: (1) flap design, (2) incision and reflection, (3) access to the apex, (~) curettage, (5) root end resection, (6) root end preparation and filling, 17) radiographic verification, (8) flap replacement and suturing, (9) postoperative instructions, (10) suture removal, and (11) long-term evaluation. This sequence IS shown in Hg. 17-13 on page 393.

Flcu) design. A properly designed and carefully reflected flap will result in good access and uncqrnplicated healing. The basic principles of flap design should be followed these are detailed in Chapter 8. Although several

FIG. 17-6 A, Irretrievable separated instruments in mesial canals, B, After complete obturation, root is resected to level or obturation and to include files, C, Bone regeneration is occurring apically, but additional monitoring is necessary.

FIG. 17-6 A, Irretrievable separated instruments in mesial canals, B, After complete obturation, root
is resected to level or obturation and to include files, C, Bone regeneration is occurring apically, but
additional monitoring is necessary.

possibilities exist, the three most common incisions are (l) submarginal curved (i.e., semilunar), (2) submarginal, and (3) full mucoperiosteal (i.e. sulcular). The submarginal and full mucoperiosteal incision will have either a three-corner (i.e., triangular) or four-corner. (i.e., rectangular) design.

Submarginal incision. The horizontal component is in attached ~ingiva with one or two ‘accompanying vertical incisions (Fig. 17.-15 on Rage 394). Generally the incision is scalloped in the horizontal line, with obtuse angles at the corners. It is’ used most succe-ssfully in the maxillary anterior region or, occasionally, with maxillary premolars with crowns. ‘Because of the design, prerequisites are at least 4 rom of attached gingiva and good periodontal health.

The major advantage is esthetics. Leaving the gingiva intact around the margins of crowns is less likely to result in bone resorption with tissue recession and crown margin exposure. Compared with the semilunar inci

FIG. 17-7 A, Irretrievable material in mesial and lingual canals anu <If.'lca'pathos.s. B, CH1~ls are retreated but there is Iailu-e C, Treatment is root end resection to level 01 gutta-percha In the Iresl<l' and lingual aspects, D, After 2 years, healing is complete.

FIG. 17-7 A, Irretrievable material in mesial and lingual canals anu <If.’lca’pathos.s. B, CH1~ls are
retreated but there is Iailu-e C, Treatment is root end resection to level 01 gutta-percha In the Iresl<l’
and lingual aspects, D, After 2 years, healing is complete.

ion, the submarginal provides less risk of incising over a bony defect and provides better access and visibillty. dvantages include hemorrhage along the cut mar- !l 0 the surgical site and occasional healing by scarornpared.

11I1I1II1I(ol’erio’>t(‘{// lncision. This is an incision into the gingival sulcus, extending to the gingival crest (rig. ] 7-16 on page 39-+), This procedure includes elevation of interdental papilla, free ningi,’al margin, attached gingl\’a, and alveolar mucosa. One or two vertical iPlaxlI1g incisions may >e used, creating a three- or /lJ’.l-corner design,

FIG. 17-8 A, Overfill of injected obturating material has resulted in pain and paresthesia as a result of damage to inferior alveolar nerve. B, Corrected by retreatment, then .apicectomy, curettage, and a root end amalgam fill

FIG. 17-8 A, Overfill of injected obturating material has resulted in pain and paresthesia as a result
of damage to inferior alveolar nerve. B, Corrected by retreatment, then .apicectomy, curettage, and a
root end amalgam fill

When feasible the full mucoperiosteal design is preferred over the other two techniques. The advantages include maximum access and visibility, not incising over the lesion or bony defect, less tendency for hemorrhage, complete visibility of the root, allowance of root planing and bone contouring, and reduced likelihood of healing with scar formation. The disadvantages ate somewhat more difficult to replace .and to suture; also, gingival recession frequently develops, exposing crown margins or cervical root surfaces (or both) .

To avoid air emphysema, the use of handpieces ,that direct pressurized air.. water, and abrasive particles (or combinations) into the surgical site should not be used.’? Vented high-speed hand pieces or electrical surgical handpieces are preferred during osseous entry, root end resection, or both. Sealed-end air-pressurized handpieces also direct air away from the surgical site. Regardless of the handpiece used, there should be copious irrigation with a syringe or through the handpiece with sterile saline solution. II Enough overlying bone should be removed to expose the area around the apex and at least half the length of the root. Good access and visibility are important; the bony window must be adequate.

FIG. 17-9 Repair of perforation. A, Furcation penoration results in extrusion of material (arrow) and pathosis. 8, After flap reflection and ex'posure, the defect is repaired with mineral trioxide aggregate (MTA). C, Evaluation at 2 years shows successful healing. (Courtesy Dr. l. Baldassari·Cruz, University of Iowa.)

FIG. 17-9 Repair of perforation. A, Furcation penoration results in extrusion of material (arrow) and
pathosis. 8, After flap reflection and ex’posure, the defect is repaired with mineral trioxide aggregate
(MTA). C, Evaluation at 2 years shows successful healing. (Courtesy Dr. l. Baldassari·Cruz, University of
Iowa.)

with a suitably sized sharp curette. although total lesion removal usually does not occur. A cleaner bony cavity wil.l.pave the least hemorrhage and the best visibility. Tissu~ emoval should not jeoPilrdize the blood supply to an adjacent tooth. In addition, some areas of the lesion may be inaccessible to the curettes, such as on the lingual aspect of the root. Portioris of inflamed is um may be left, without compromisin removal is not necessarv.

FIG. 17-10 Decompression of large lesion. 'A, Extensive periradicular lesion failed to resolve. Coronal leakage in either treated tooth is possible. a, Surgical opening is created to defect; polyethylene tube extends into lesion to promote drainage, C, After partial resolution, root end res:ction and filling ~ith amalgam are performed.

FIG. 17-10 Decompression of large lesion. ‘A, Extensive periradicular
lesion failed to resolve. Coronal leakage in either treated tooth is
possible. a, Surgical opening is created to defect; polyethylene tube
extends into lesion to promote drainage, C, After partial resolution,
root end res:ction and fillingith amalgam are performed.

Root end resection. Root end resection is often, but not always, indicated. It is useful in two situations: (1) to gain access to the canal for examination and placement of a root end preparation and restoration and (2) to remove an un debrided or ‘unobturated (or both) portion of a root. This may be necessary in cases with dilacerated roots, ledged or blocked canals, or apical canal space that is inaccessible because of restorations, as well as in accessing of lingual structures.

Ultrasonic instruments offer some advantages of control and ease of use; they also permit less apical root removal in certain situations (Fig. 17-23 on page 397), Another advantage of the ultrasonic tips, particularly when
diamond coated.!” is the formation of cleaner, better shaped preparation. Evidence suggests that success rates are s’lgnificantly improved with ultrasonic preparation.

Amalgam (preferably zinc free), intermediate restorative material (IRM), and Super ethoxy benzoic acid (Super EBA) cement have been commonly used materials. IS Gutta-percha, composite resin, glass ionomer cement, IRM, Cavit,  and different luting cements have also been recommended these materi ls have less.clinical documentation of success. Mineral trioxide aggregate (MTA)has shown favorable biologtc’? and physical properties and ease of handling20 it has become a widely used material.

No single, all-purpose, superior root end-filling material exists. Those that demonstrate the best combination of physical and biologic properties, as well as documentation of clinical success, are amcMgam, MTA, composite resin and reinforced zinc ~xitle cements ‘(e.g., IRM and

FIG. 17-11 This case is poorly done and done for the wrong reasons. A, inadequate root end resection and root end filling does not seal apex. B, Root canal treatment is readily accornplished, with good chance of succ <

FIG. 17-11 This case is poorly done and done for the wrong reasons. A, inadequate root end
resection and root end filling does not seal apex. B, Root canal treatment is readily accornplished,
with good chance of succ <

Super EBA)i one of thesernaren, Is should be selected, according to the conditior should not be used if thefleld is bloody vi if the root end preparation is less than 3 millimeters, or if access is limited. Composite resin with a bonding agent must be placed in a dry field. This material may be used in a shallow, concave preparation .and has shown to besuccessful in molar root end surgertes.F MTA, with its good properties, may be placed. in a field in which some hemorrhage has occurred the final set is not adversely affected by blood contamination. The long-term stability of MTAis unknown, because’ the material is relatively new. It likely has good longevity. Irrigation. The surgical site is flushed with copious amounts of sterile saline to remove soft and hard tissue debris, hemorrhage, blood clots and excess root end-filling  material.

Postoperative instructions. Both oral and written ,’information should be supplied in simple, straightforward descriptions. The wording should ‘minimize anxiety arising from normal postoperative sequelae by describing the ways in which the patient can promote healing and comfort. Instructions inform the patient of what to expect (i.e., swelling, discomfort, possible discoloration, arid some oozing of blood) and the ways in which these sequelae can be prevented, managed, or both. The surgical
site should not be disturbed, and pressure should be maintained (cold packs over the surgical area until bedtime might help). Oral hygiene procedures are indicated everywhere except the surgical site;’ careful brushing and flossing may begin after 24 hours, Proper nutrition and fluids are important but should not traumatize the area.

FiG. 17-12

FiG. 17-12

FIG. 17-13 Periapical surgical procedure. A, Submarginal inciSion, four-corner (i.e., rectangular), reflected flap. Large bony window is created to show apex. B, Root end is resected and prepared (arrow) for fill. C, Amalgam (arrow) has been condensed. 0, Flap is replaced, compressed, and sutured (i.e., interrupted). (Courtesy Dr. T.Eric~son, University of Iowa.)

FIG. 17-13 Periapical surgical procedure. A, Submarginal inciSion, four-corner (i.e., rectangular),
reflected flap. Large bony window is created to show apex. B, Root end is resected and prepared
(arrow) for fill. C, Amalgam (arrow) has been condensed. 0, Flap is replaced, compressed, and sutured
(i.e., interrupted). (Courtesy Dr. T.Eric~son, University of Iowa.)

Suture reinoval and evaluation. Sutures ordinarily are removed in 3 to 6 days, with shorter periods being preferred to enhance healing. After 3 days swelling and discomfort should be decreasing. In addition, there should be evidence of primary wound closure; tissues that were reflected should be in “apposition. Occasionally: a loose or torn suture may result in nonadapted tissue. In these cases the margins are readapted and resutured.

Posted by: brianna

Share This