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Surgical Endodontics
M R .
D. H.
EDMUNDS, Senior Leciurer, Department
of
Conservative D entistry, The Welsh
National Schoolof Medicine, Dental School, Heath, Cardiff.
l i
is
generally recognised thai endodontic surt;cry
is no
longer synonym ous with apicectomy
but covers
a
variety
of
surgical procedures ranging from incision
to
provide drainage
to
endodonlic endosseous stabilisation
or
diodonlic implant (Table
I). In
recent years
the
impor tance
of the
relationship between
the
pulpal
and
periodontal tissues
has
been
increasingly appreciated.
Table I Techniquesof fii lo liia ic sur >er.v
1)
E.xiraction
(2) Incision ;iiid drainage of soft tissue swellings
(3) Surgical liMulaiion
(4) I'eriapica surgery
(a) Curctuigc
(b) Apicccioniy
(c) Keirotilling
^d) MarsupialisiUion
(5) Perio/Etido Surgery
(a) Curciiagc
(b) Rooi amputahori
(6) Replanlation and iransplaniaiion
(7) Endodontic i-ndoiscous stabilisaiion
Books
on
endodonties published within the past two years contain
a
comprehensive revievk
o f surgical endodonlicsand it ismy intention not toattempt toreview the whole subject but
t o select certain topics
for
discussion.
T h e Indicutions
for
Kndodonlic
T h e indications tor surgery are summarised in Table 11.It is noticeable that in recently
published endodontic texts
by
Harty (1976), Ingle
and
Beveridge (1976)
and
Nicholls (1977)
considerable emphasis
is
placed
on the
role
of
surgery
as
being secondary
to
conservative
treatment. Although
the
concept
of the
conservative treatment
of
periapical lesions
is no
n e w ,
the
predictability
of
healing following carefully executed root canal filling
is
being
increasingly recognised. Therearealso anumberof reports describing lhe use of calcium
hydroxide pastes
to
treat lateral perforations, root resorption, root fractures, immature
pulp le ss Veeth and so on , so thatitappears likely vhat the position ofsurgery will increasingly
become secondary
to
conservative treatment.
Table II
Indicalions lur i-ndodonlic suRcry
( t ) Necessity lor drainage
(2) Failure ol' non-surgical treatment
(3) Predielabli; failure ol' non-surgieal trcatmciil
(4) Imptaciieality ol" non-surgical treatmetil
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iV/r.
D H dtntmds
There will remain, however, certain circumstances where surgery will slill be ihc ireaimciu
of choice, for example in cases where severe dilaceration of a rooi makes proper instru-
mentation impossible, cases where it Is more expcdiciu to use a .surgical approacli because of
the patient's inability to attend ior a prolonged course of treatmenl, in some cases of
eombined cndodontic/pcriodontal lesions and probably the eommonest of all , where i t is
undesirable to disturb a satisfactory coronal restoration in the tooth for example a post-
retained crown,
Periupical Surgery
Periapical surgery includes the operations of artificial fistulaiion, periapieal curettage,
apiceetomy and retrograde root filling.
Let us look morcclosely at certain aspects of periapical surgery: firstly flap design. Several
different incisions have been reco m m end ed for apicec loniy an d arc iilustratcd in Figu re 1. It
is usually recommended that the curved or trapezoidal incisions remain at least 5 mm from
the gingival margin. The trapezoidal flap may be modified so that it is scalloped to follow the
contours of the gingival margin.
Q Q
Fig. . Incisions for pcriapical surgery:
(;i) curved
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Surgical endodontic
The healing of flaps has been studied by Grung (1973) who found that visible scar
formation occurred in 91 per cent of cases when a curved incision was used. 65 per cent o
cases with a trapezoidal Incision and only 17 per cent ot cases with a gingival line incision.
H e also found that following the use of the gingival line incision, altho ugh there was no
increase in gingival crevice dcplh alter surgery, there was a signincaut migration of the
gingival margin apically of approximately I mm. He conciuded, theretore, that despite the
incidence of scarring, the trapezoidal incision placed 5 mm from the gingival margin was to
b e prc lon ed . How ever, this incision would appear to have the same disadvan tage as the
curved incision namely ihe dit'ticuUy ol ensuring livat llic incision line would lie over sound
b o n e sinee it is com mo nly o bserved that the bony defect seen at op eratio n is mo re extensive
t h a n the radiograph sugges ts .
This difficulty will not arise with the gingival line incision and any combination of gingival
o r perio don tal .surgery with endo do ntic surgery will dictate the use of a gingival margin (lap
s o that this design seems to be the most versatile. It should irivoKe tlie minim um nu m be r of
teeth compatible with good access and visibility and a firm base for the suture line. If it
involves only one tooth it should incorporate the modification described by Hill (1974)
which, by preserving the circular fibres of the periodontium and tlie gingival crevices of the
ad ja ce n t teeth, is claimed to reduce the apical migration of the gingival margin (f igure i(e)).
I f it is necessary to involve more than one loo th, the vertical incisions should b e placed
perpendicular to the gingival margin remote from the interdental papilla as illustrated
(F ig u re l(d)) . When com bined en dod ontic and gingival surgery is contemp lated or if the
lesion extends gingivally then it will be necessary to involve the whole of any intermediate
papillae as illustrated (Figure i(d)). Otiieiwisc an incision across the base of the papilla,
leaving the papilla in siiu is easier to suture and the risk of post operative distortion of the
papi l lae is reduced.
A number of reports of surveys of apiccciomy have been published with success rates
ra n g in g from 34 per cent (Uuchs and Reul, 1962) to 94.6 per cent (M ayr. 1967). Th e
co m p ar is o n of results is extremely ditlicuit because of tlie wide \ar iat io ns in techniqu es
employed, criteria used in determining the success of the proeedure, patient selection and
pe r iod of obse rva t ion .
Some of the factors which influence the success of surgery are illustrated in lhe following
case (Figure 2a) . They are :
(1) Size of lesion
(2) Histologieal nature of the lesion
(3) Adequacy of the apical seal
(4) Obliteration of the root canal space.
The influence of the size of the lesion has been reviewed recently by Tay and his co-
w o r k e r s (1978). It is suggested thai the best results are obtain ed when the lesion is I to 8 mm
i n dia m eter , ihai ihe re is a diminished success rate for lesions between 8 to 12 mm an d that
t h e success rate again increased for lesions over 12 m m .
Both Persson (1966) and Mattila and Altonen (1968) observed that the success rate was
higher for cysts than for granuloniata. Rud and his co-workers (1972) found that the success
r a t e was higher tor lesions vvith diam eters 16 to 19 mm an d 20 to 31 mm . Since the prob ability
is high that these larger lesions are cystic, this seems to agree with the earlier observations.
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Mr D H Edmunds
the likelihood of remnants of pathological tissue remaining to hinder repair is increas
However, il has commonly been observed that matiy apical lesions heal following no
surgical treatment and it has been argued by Bender (1972) that both cysts and granulonia
will do so. This raises the question of the validity of the assertion that it is necessary
remove all traces of the epithelial lining of a cyst or all granulation tissue from a granulom
Rud and his co-workers (1972) stiggcsl Ihai in the interests of preserving crcsial bone, cur
ting the soft tissue in this region should be avoided.
Fig. 2(a). pre-opcraiivc
appearance .
FIK. 2(b ). 10 mo nihs posi-
operaiivcly, showing retrograde
amalgam fillings and progress
of healing.
Fi({. 2(c) 22 month , po.st-
operalively showing breakdow
around I 2.
It would app ea r thai the most im por tant objeciive of treatm ent i.s to obliterate Uic to
canal space and seal the apex of the tooth, thus removing the aetiological factor whi
gave rise to the lesion. If this is done effectively at apiceetomy, why should the presence
epithelial remnants or granulation tissue prejudice the result?
The post-operative course of the ease shown (Figure 2) illustrates several possible reaso
for failure. Ten months postoperatively (Figure 2b) healing is apparently progressing. Thr
teeth have amalgam retro-fillings in place. One was non-vital at the time of operation, iw
were viiai. TJie roox canals of Ihe three leedi remain unfilled. Twenty-two months po
operaiively (Figure 2c) the region is breaking d ow n ag ain. Q uite clearly there is resorp tion
the roots of both incisor teeth. One possible stimulus for this resorption is leakage
material from the root canals, either through a lateral canal, as appears possible on t
lateral incisor wh ere the resorp tion is co ron al to the am alga m rctro-Cilling, or gen eral
around the entire periphery of the tilling as appears possible on the central incisor where t
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material would be a calcium hydroxide paste which could be removed easily with small risk
o f displacing the retro-filling during subsequent preparation of the canal to receive a post.
Rud and his co-workers (1972) found that the retrograde method was inferior to the
orthograde approach where a gutta percha cone was fitied through a coronal access cavity
a n d then sectioned with a scalpel at the time of apiceetom y. H owever, if the present tendency
continues whereby apiceetomy is restricted to those eases where conventional therapy is not
possible, it will still be necessary to employ a retrograde approach.
Amalgam continues to be the material most widely recommended. Finnc and his co-
workers (1977) cotnpared retro-filling with amalgam and 'Cavit' and conciuded that results
w e r e significantly better with am algam . The seal achieved by amalgam has been investigated
b y a number of auth ors . Cunningham (1975) compared the scanning electron microscopic
appearance of a sectional silver point, amalgam and gutta percha in an in-vitro apieectomy
sim ul at ion and concluded that the smoothest surface was that of the silver point after cutting
w it h a bur and that amalgam apparently produced a good seal but the surface was rough.
T h e number of teeth studied however, was very small. Moodnik and co-workers (1975)
carried out a similar examination oi three teeth treated in vivo which were extracted three
years later atter successfully effecting periapical repair. They observed defects between the
fillings and the dentine walls of the canals but were unable lo draw any eonelusions as to
their significance.
Leakage around amalgam used to seal a tooth via a coronal approach was studied by
M essin g (1970) who was unable to demonstrate diffusion of fluorescc in conjugated to
g a m m a globulins along the interface between the amalgam and the dentine wail ol the root
c a n a l . Again the number of teelh studied Is small.
Actual leakage of material around retro-filUiigs either into or out ot the root canal does
n o t seem to have been investigated and would seem to offer a profitable line of research.
A number of descriptions of amalgam carriers for retrograde fillings have been published
in recent years, Maini and Rcdpath (1975) described a modification of a pair of college
tweezers and Lee (1976) a modification of an Ash No. 5 amalgam carrier. The carriers
described by Dimashkich (1975) are very suitable for the purpose but are expensive. Thomas
(1978) has described a modification of a lumbar puncture needle which is considerably
cheaper and easily available and has been found lo be very convenient resuming in little
'splashing' of excess amalgam around the root apex such as is common if too large a earrier
is used.
Marsupialisaliun
T h e next topic would like to examine briefly is the use of marsupialisation as a techniqu
f o r managing large apical radioluccncies. Archer (1966) recomm ends the more widespread
use of marsupialisation techniques for the treatmenl of large cysts and lists a number of
advantages over enucleation including the preservation of the vitality of eoincidentally
involved teeth and the avoidance of surgical damage to normal anatomical structures, for
example, nerve bundles, tnaxillary antrum and nasal cavity. Patterson (1964) advocated the
u s e of an acrylic stint with a polyethylene tube to maintain the patency of the opening.
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Mr D H Edmunds
Fig 3. Large radiolucency
Ubsociaicd willi 2 j . lioili
are vital.
Fig 4 Same case as Fig 3 showing polyvinyl Fig 5 18 mo nths post -operat
Ml caiheicr inseried into the lesion and proinid ing appe aranc e showing progress
app roxim ately I mm into buccal siilcus. hea ling. Root L-anal thera py a
rcstoralion completed
Attempts to enucleate the cyst might well have produced oro-aniral and oro-nasal fistula
and w ould p robab ly have devitalised one or m ore leeth. Instead it length ol polyvitiyt arter ia
catheter of approximately 2 tnm internal diameter was itiserted through a stab incision in th
buccal mucosa after exploration of the buccal cortex and aspiration of Huid with a larg
bone needle {Figure 4). Care m ust be taken to ensure tha the tubing is inserted to the m os
distant part of the lesion betore it is cut otT, otherwise the tube may fall inside the lesion
Approximately I mm should be left protruding through the mueosa into the buccal sulcus
Th e tract epithelialises within 7 to 10 day s, after which the patient is tau gh l to rem ove an
reinsert the tube daily after cleaning it. As the lesion reduces in size the tube is shortened a
necessary. Figure 5 shows a radi ogra ph taken eighteen mo nth s later and dem on
strates considerable regeneration of bone. Final healing occurred after approximately tw
year s. As can be seen from Figure 5 it is possible to com plete root eana l the rap y a n
res tora tion of the too th b efore the lesion has finally hea led. It is essential that the pa tien
should appreciate the necessity for removing and cleaning the tube regularly and should b
capable ot doing so . It is, of course, possible to use a marsu pialisation technique to achieve
reduction in size of a lesion and then enucleate it when there is less risk of damage t
adjacent structures.
Endodontic Endosseous Implants
Finally I would like to consider very briefly, endodontic endosseous implants. Thei
indications and the basic technique for Iheir usage have been described recently by Renso
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Surgical endodontics
Hodosti and co-workers (1974) advocated the use of polymer coated Vital l ium wires which
were claimed to be superior to plain Vitallium because connective tissue fibres attached to
the polymer coating. Wayman and Mullaney (1975) carried out an experimental study on
extracted teetli using three differLMit types of stabilizer. All showed greater leakage apically
t h a n conv ention al roo t scaling lechn iques . Figure 6 shosvs a series ol ra diog raph s take n oV a
t o o t h originally treate d in 1974. The tilrn taken in 1978 show s early break do w n in the
periapical region. One weakness of the technique is that there must be a relatively large area
o f exp osu re of the luting cement at the ape.x of the too th . E ven if the stabilizer is fitted at an
open, apicectomy type operation it is impossible to eliminate this exposure of the cement to
tissue fluids and since all cements are soluble to some e.\tent, this will eventually result in a
defect which will prejudice the long-term survival of the implant.
FiR. 6(a). 29.4.1974. Post
o p e ra ti v e r u i
Fig. 6(b). 27.6.1974.
Fig. 6(c). 27.2.1975. FiR. 6(d). 14.3.1978. Note
evidence of rcsorpiion of
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Hill (1974) and Harty (1976) describe a combination of the Wiptam Wire technique i
simple and speedy technique for dealing with fractured roo ts. It has th
References
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