6: Surgical endodontics

6 Surgical endodontics

INTRODUCTION

Success rates for contemporary endodontic therapy are in excess of 90%, depending on the skill of the clinician and the teeth involved. Surgical endodontic procedures are usually undertaken when conventional (orthograde) endodontics has failed. However, the chances of successful retreatment of a tooth with a failed root filling are higher when non-surgical endodontics is repeated (wherever possible) rather than by undertaking a surgical approach. Surgical endodontics may therefore not be the first option when conventional root canal treatment fails.

Non-surgical endodontics attempts to eliminate the bacteria by cleaning and shaping the root canal to remove infected dentine, disinfecting the canal and sealing with a root filling. If non-surgical endodontics fails, it is usually because of the persistence of noxious substances (toxins and other by-products of bacteria) within the root canal system. If a root canal therapy fails and the tooth cannot be retreated, surgical endodontics may be indicated to eliminate the noxious substances from the root canal system. Where surgical endodontics is indicated, it is desirable that a root filling has been inserted first to improve the chances of success.

Surgical endodontics may be indicated in the management of a lateral root perforation or a horizontal fracture of the apical third of the root, root resorption or persistent periapical pathosis (e.g. inflammatory cyst or granuloma, or a periapical neoplasm).

Surgical endodontics is usually undertaken under local analgesia, with or without sedation. A patient with a pre-existing extensive inflammatory cyst might be more appropriately managed under general anaesthesia. Prerequisites for surgical endodontics are an experienced dental surgeon and trained assistant, a compliant patient who is medically fit and a range of suitable surgical instruments and root-end filling materials.

PRINCIPLES OF SURGICAL ENDODONTICS

INDICATIONS FOR SURGICAL ENDODONTICS

CONTRAINDICATIONS FOR SURGICAL ENDODONTICS

Rarely, local anatomical or pathological conditions are a contraindication for surgical endodontics—for example, proximity of the periapical tissues to the maxillary antrum or mental foramen may necessitate removal of the tooth. Psychological conditions might compromise the success of surgical endodontics (e.g. a pronounced gag reflex). Some medical conditions may contraindicate any outpatient oral surgery procedure in general dental practice. Examples include haemorrhagic disorders, previous radiotherapy to the face and jaws, unstable angina, a compromised immunological state (e.g. due to steroids for rheumatoid arthritis, or disease of the immune system). An emerging concern is the patient taking bisphosphonates, in whom there is a risk of osteonecrosis. However, the relative risk of osteonecrosis is uncertain at present. Other medical conditions may be relative contraindications to surgical endodontics—e.g. myocardial or valvular disease. Each case should be judged on its merits. If there is any doubt about the suitability of a patient for surgical treatment, then the patient should be referred to a specialist.

TREATMENT PLANNING FOR SURGICAL ENDODONTICS

Careful preoperative planning is the key to success.

Radiographic examination

Radiographs demonstrate both anatomical and pathological features at the apex of the tooth (Fig. 6.4). A radiograph may demonstrate an incompletely sealed root canal, or bone loss around the apex of the tooth involved. If there is chronic apical disease, a lesion with the physical characteristics of a cyst may be identified at the apex of the tooth. Rarely, the cause of a failed root filling cannot be established through clinical or radiographic examination but it may become apparent when surgical endodontics is undertaken. For example, a root fracture not detectable clinically or radiographically may be identified on surgical exploration.

The operator should also consider the position of the apex of the tooth in a mesiodistal direction. If the apex of the tooth to be treated is inclined towards an adjacent tooth root, there is a risk of damaging the adjacent root structure.

Jan 14, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 6: Surgical endodontics
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