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Endodontic Surgery

Endodontic Surgery

To understand Endodontic surgery, it helps first to know something about the nonsurgical endodontic procedure, or root canal. Root canal treatment is necessary when the soft inner tissue, or pulp, of the tooth becomes inflamed or infected. This may happen as a result of deep decay, repeated dental procedures on the tooth, or an injury to the tooth. Root canal (endodontic) treatment removes the damaged pulp. Then the tooths canals are cleaned and filled to help preserve the tooth.

In a few cases, however, root canal (nonsurgical endodontic) treatment alone cannot save the tooth. In such a case, your dentist or endodontist may recommend surgery. Endodontic surgery can help save your tooth in a variety of situations. Endodontic surgery usually takes less than 30 minutes and is is successful most of the time.

Treatment depends on the cause of failure and still another chance on maintaining the tooth. The most common Endodontic surgery is root end resection with root end filing also known as 'apico' or apicoectomy and retrofill.

Endodontic surgery Procedure Endodontic surgery Procedure Endodontic surgery Procedure

Gum Tissue opened
Tissue removed

Root End Resected
Root End Filled

Bone Healed

Indications for Endodontic Surgery

 

There are nine indications for resorting to endodontic surgery, and they are as follows:

1. Aberrant Anatomy : Maxillary molars, mandibular incisors, and first premolars are often problematic simply by virtue of their anatomy. At least 50% of all maxillary molars have a second canal in the mesiobuccal root. The ones that start in the pulp chamber are easy to clean and fill, but if the canal divides part of the way down the canal, diagnosis and obturation are difficult or impossible.

Thank goodness lower anteriors are the least treated of all teeth in the mouth, because two thirds of them have two canals, and half of those have a second apical foramen. Normal X-ray angulation does not reveal these potential problems.

Lower premolars (bicuspids)have a mesial invagination (groove) of the root sheath, formed during embryogenesis. One of the diagnostic signs of a lower first premolar is the mesial groove. The invagination of the root often creates a second canal, but fortunately, those second canals usually calcify shut. If they do not, endodontic failure may result..

2. Conventionally Blocked Apices : If you have a case with a post and core that would have to be removed prior to conventional retreatment, and such removal would jeopardize the ultimate prognosis of the case, surgery is the most conservative treatment.

Endodontic surgery usually takes less than 30 minutes and is is successful most of the time.

3. Iatrogenic Repair : Sometimes the only way to remove a broken file is with endodontic surgery. If a portion of the broken file protrudes through the apex, surgery is indicated.

4. Acute Pain : When a patient remains in so much pain that there seems to be no other relief. Often the tooth has been opened for drainage, but there is no relief. The tooth remains exquisitely painful to the touch.

The tooth and tissue are numbed. As soon as the pushed back the tissue, pus may be expelled, relieving the pressure, and the patient will experience immediate comfort.

When you achieve this type of drainage, it's important that you do the root canal right then. There's no reason not to.

You can see the apex, so quickly clean and shape the canal. File long, flush and dry with the three-way syringe. Push a master point through the apex, grab it with a pair of cotton pliers, pull it tight, and cut off the point.

If treatment is delayed, it may leave the periapical area open to further infection. It only takes 10 or 12 minutes to complete the case at the time of surgery, and the patient will go home and start getting better right away.

If a patient has cellulitis, however, that is not the time to do endodontic surgery.

The local anesthetic will not work because the pH is so low the anesthetic is neutralized. When you make an incision, nothing but blood comes out. You try to manipulate the tissue, and it feels like the hardest rubber you can imagine. Tese patients should be placed on a strong antibiotic regime until the swelling subsides.

5. Persistent Cyst : The most misunderstood area in all of endodontic surgery is the notion that all cysts must be completely removed to promote healing. If root canal problem is completed, then the cystic area will reverse. Therefore, 100% enucleation of the cyst is not necessary. If the cyst starts to encroach on sensitive anatomy, only a portion of it should be carefully removed. A cystic area will not recur following complete sealing of the apex.

If a cyst is removed, it should be sent it for a biopsy. If it's worth taking out, it's worth sending out for biopsy. This is standard of care in the endodontic community.

6. Cracked root : Cracked roots are very difficult to diagnose. When you find one, you can often do a root resection at the bottom of the crack. When the cracked portion is removed, the typical narrow, deep pocket will disappear.

7. Perforated Apex : The real problem with root perforation is that a portion of the canal is left unfilled. Apicoectomy removes the unfilled section of the canal, and retrofilling seals the new apex.

8. Diagnosis : Raising a flap is a tremendous diagnostic tool. You usually will see the cause of the problem and be able to treat it immediately.

9. Treatment alternatives: You often can save the patient a lot of time and money with apical surgery. It is often quicker and more cost effective to do an apicoectomy and retrofill than to remove and replace a post, core, and crown.

Silver point too long? Raise a flap and tap it back up and out of the canal.


Often, the only alternative to surgery is extraction of the tooth. The extracted tooth must then be replaced with an implant, bridge, or removable partial denture to restore chewing function and to prevent adjacent teeth from shifting. Because these alternatives require surgery or dental procedures on adjacent healthy teeth, endodontic surgery is usually the most biologic and cost-effective option for maintaining your oral health. No matter how effective modern artificial tooth replacements areand they can be very effectivenothing is as good as a natural tooth. Youve already made an investment in saving your tooth. The pay-off for choosing endodontic surgery could be a healthy, functioning natural tooth for the rest of your life

 

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