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As practitioners have increased their knowledge and skills in the art of saving teeth, periradicular surgery has increased in importance. This article, the second in a short series, considers how the practitioner should incorporate the many advances in endodontic surgical techniques and materials into their practice in order to ensure more predictable results.
It is generally accepted that non-surgical endodontic therapy eliminates periapical inflammation or infection and allows teeth to be restored that previously might have been extracted. However, failure does occur in a small percentage of cases. When confronted with such cases the clinician should be prepared to initiate alternative procedures, including surgery, to enhance the rate of success. This, the first of two articles, describes refinements in endodontic surgical techniques and introduces the research that has been used to develop new materials and devices.
The most common materials in endodontics are gutta-percha and sealer. For certain tasks, however, such as repairing perforations or filling apical preparations, a special-purpose material is needed. The "ideal" special-purpose material in endodontics is still elusive. Most of the materials available today have found their way into endodontics from the restorative field without much consideration of the special conditions and requirements of the periradicular tissues. To address some of the these shortcomings, a material called Mineral Trioxide Aggregate cement (MTA) has been developed at Loma Linda University to seal off the pathways of communication between the root canal system and the external surface of the tooth. At LLU, a series of experiments have been conducted to assess the suitability of this new cement. The experiments began with physical properties of the material and biocompatability studies, followed by clinical studies. The results have been promising, offering for the first time the possibility of regeneration rather than just repair.
The principal modalities available to manage endodontic treatment failures are orthograde retreatment and apical surgery. Both modalities have specific advantages, clinical implications, and risks, and their selection involves a complex decision-making process. A review of the literature pertaining to the treatment outcome of each modality was undertaken to establish an objective reference for practitioners involved in the management of endodontic treatment failures. Based on a weighted average calculation of the results reported in the reviewed studies, the orthograde retreatment of teeth associated with apical periodontitis results in a success rate of 66 per cent, an uncertain healing rate of 11 per cent, and a failure rate of 23 per cent. Apical surgery results in a success rate of 59 per cent, an uncertain healing rate of 22 per cent, and a failure rate of 19 per cent. These figures are discussed with reference to the characteristics of the reviewed studies. It appears that many of the reviewed studies have lesser relevance today, due to the current technical improvements in both treatment and modalities.
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An unusual case of a second maxillary molar with a dilacerated root visible clinically is described. Apicectomy followed by retrograde amalgam filling was performed whereby gingival coverage and gingival seal was achieved.
With bright illumination and magnification under the operating microscope, and addition of many microinstruments, endodontic surgery has become microsurgery. The microsurgical approaches allow the clinicians to perform endodontic surgery with smaller osteotomies, shallow bevels, preparation of isthmuses, examination of resected root surfaces, retropreparation in line with root canal, and precise placement of new filling materials. This article illustrates the advantages of microsurgery in endodontics.
There are numerous ways to achieve hemostasis. With the abundance of hemostatic agents available and with the introduction of new products, one has to make an objective decision. A good agent achieves hemostasis within a short period of time, is easy to manipulate, is biocompatible, does not impair or retard healing, must be relatively inexpensive, is reliable, and works best for the particular surgical procedure. With these purposes in mind, the following sequence is recommended to achieve hemostasis during endodontic microsurgery. I. Presurgical: Give 2 to 3 Carpules of 1:50,000 epinephrine local anesthetic with multiple infiltration sites throughout the entire surgical field. II. Surgical: A. Remove all granulation tissue. B. Place an epinephrine pellet into the bony crypt followed by dry sterile cotton pellets. Apply pressure for 2 minutes. Remove all the cotton pellets except the first epinephrine pellet. Continue with the surgical procedure and remove the epinephrine pellet before final irrigation and closure. C. Alternatively, calcium sulfate can be mixed into a thick putty and packed against the bone cavity. Because it is a biodegradable material, calcium sulfate can be left in situ. In fact, in large bone defects and through-and-through lesions, additional calcium sulfate can be placed to fill the entire bone cavity as a barrier material. Healing is more predictable with little chance of scar tissue formation. Calcium sulfate resorbs in 2 to 4 weeks. D. Small bleeding sites in the bone can be brushed with ferric sulfate solution. III. Postsurgical: Tissue compression before and after suturing cuts down on postsurgical bleeding and swelling. Hemostasis is imperative in endodontic microsurgery for better visualization, a good environment for placement of retrograde filling material, and a more efficient surgical procedure with less blood loss.
Root end preparation techniques have historically been approached from the perspective of the restorative dentist. This article discusses how Black's principles for cavity design and preparation have been modified to reflect the advances in bonding chemistry.
Operating microscopes and ultrasonic instruments have been used in root end filling procedures. The concepts, techniques, and materials for root end filling have been evolving. After eradicating or minimizing the irritants in the root canal system, the root end cavity has to be filled in a practical and convenient way. Super EBA seems to have more advantages. Some other potential root end filling materials and techniques are also discussed.
Periradicular surgery combined with final laser sterilisation was performed on 62 teeth of 50 patients by 3 trained oral surgeons, according to a well defined treatment protocol. It concerned a 5 Watt continuous wave CO2-laser. After a follow-up period ranging from 6 to 17 months all patients were recalled. 28 patients (56%) or 33 teeth (53%) could be evaluated. The success rate was determined by a questionnaire, a standard clinical examination and an X-ray evaluation. Complete surgical healing was found in 59% of the teeth and incomplete healing in 23%. Uncertain healing and unsatisfactory healing were observed in respectively 11% and 7% of the teeth. Better healing results were found in elements with one endodontic canal (67% complete healing) and when endodontic treatment was combined with the intervention (71% complete healing). Comparison of the results of the present study with comparable studies without laser sterilisation, showed however no statistical significant improvement.
In addition to the successful replantation of avulsed permanent teeth, the replantation of primary anterior teeth may also be indicated. The decision is based on age and stage of tooth development, development of dentition, storage of the avulsed tooth and the way it is transported to the treatment site, the appropriate in vitro treatment of the tooth before reinsertion, and the willingness of the child to cooperate. A method involving retrograde filling of the primary tooth root with calcium hydroxide after resecting the root apex has proved successful. Other commercially available root filling materials and pins are not indicated. Calcium hydroxide allows the tooth to heal in place without reaction and prevents the development of apical periodontitis. As regards any surgical intervention, the attending dentist in this case has to weigh the benefits against the risks.
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Many clinicians have benefited from using surgical telescopes and headlamps to enhance the visual access of clinical procedures. Historically, the surgical operating microscope has provided opportunities for the medical community in the development of new treatment strategies. Recently, the operating microscope has been introduced into the endodontic community, and its benefits in surgical endodontics have become widely known. Cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. This article describes the advantages of the surgical operating microscope.
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