Endodontic Surgery

Dr. Azmeel Mazlee Bin Anuar BDS (Malaya), MDS (OMFS Hong Kong)

Definition
Surgical resection of the root tip of a tooth and its removal together with the pathological periapical lesion

Retrograde filling

To obstruct the exit of bacteria and the byproduct of non-vital pulps

Indications
When conventional tx or retreatment has failed Teeth with active periapical inflammation, despite the presence of a satisfactory endodontic therapy

Indications
Teeth with periapical inflammation and unsatisfactory endodontic therapy, which cannot be repeated because of: Completely calcified root canal. Severely curved root canals. Presence of posts or cores in root canal. Breakage of small instrument in root canal or the presence of irretrievable filling material

Indications
Teeth with periapical inflammation, where completion of endodontic therapy is impossible due to: Foreign bodies driven into periapical tissues. Perforation of inferior wall of pulp chamber. Perforation of root. Fracture at apical third of tooth. Dental anomalies (dens in dente)

Indications
When biopsy or investigation is required. Sometimes a biopsy of periradicular tissue is required or direct visualization of the periradicular tissues and tooth root is needed in order to assess a perforation or to confirm the presence of root fracture or cracking. Foreign material that has been extruded from the root canal and appears to be associated with an inflammatory reaction or infection should be removed

Indications
Anterior teeth with periapical lesion for aesthetic reason Very sound condition of the crown despite having active periapical lesion and having good occlusion with opposing teeth Patients preference (must discuss thoroughly about pros & contras)

Contra-indications
All conditions that could be considered contraindications for oral surgery concerning the age of the patient and general health problems, such as severe cardiovascular diseases, leukemia, tuberculosis etc. Teeth with severe resorption of periodontal tissues (deep periodontal pockets, great bone destruction)

Contra-indications
Teeth with short root length Teeth which apices have a close relationship with anatomic structures (such as maxillary sinus, mandibular canal, mental foramen, incisive and greater palatine foramen) and if causing injury to these during the surgical procedure is considered probable.

General surgical technique

Perform RCT on the tooth either few days earlier/at the same time Designing of flap. Localization of apex, exposure of the periapical area and removal of pathological tissue. Resection of apex of tooth. Retrograde filling, if deemed necessary. Wound cleansing and suturing

Procedures step by step

Incision

Reflection of mucoperiosteum and exposure of labial alveolar plate after elevation of flap

Removal of labial bone covering apical third of root

Removal of periapical lesion

Resection of apex with fissure bur

Preparation of cavity at root tip of tooth using microhead handpiece

Cavity created (inverted cone-shaped) where filling material is to be placed

Placement of filling material in cavity of apex

Operation site and placement of sutures

Radicular cyst on 22

Pre-op stage

Post-RCT

Radicular cyst on 22

Post-apicectomy 1/7

Post-apicectomy 6/12