surgical endodontic

7/25/2019 Surgical Endodontic

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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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Surgicalendodontic

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

ARCHiiK, W. H. (1966) 'Oral Surgery . 4t l i edit ion. Saunders. Philadelphia.

BENDER, 1. U. (1972) A commentary on General l ihaskar 's hypothesis .

Oral

Surf;. 34. 469.

BUCHS, H. and REUt-, t , . (1962) Zur Frage der Knoclieii regeneration nach Wur/ckpit-^en rcsekiion m

retrogradcr Abfullung.

Disch. Zaharzil Z.

t7, 1635.

CUNNINGHAM. J. (1975) l inings at apiccclomy: a scanning clcciron microscope study.

IIIL-

seal of root can

Br. Dem. J. t39

430.

DlMASHKtEH, M. R. (1975)(a) A mclhod of using silver amalgam in routine cndodoniici and ils use in op

apiccb. Br. Dent. J. 138 298.

DIMASHKIEH, M. R. (1975)(b) The managcmeni of obsiructed root canals. The hollow i i ibc technique. Br. D

J.

1975 138. 459.

FINNE , K. , NO RD , P. G. , PERS SON , 0 . and L ENN AR TSSO N, H. Rei rograde root l il iing wi th amalgam a

Cavit. (1977)

Oral Surg.

43 . 621 .

FREEDt.ANt), J. B. (1970) Conservative reduction of large periapical lesions. Oral Surg. 29, 455.

G Rt JN G , B . (1973) Healing of gingival mu cope riosteal flaps after marginal incision in apiccctom y p roc edu r

Int. J. Oral

Surf .

2, 20.

HARTV. 1. J. (1976) ' lindodontics in Clinical Practice . Jolui Wright Sons, lirisiol.

H tL L . T. R. (1974) Surgical End odon tics. In: Harly , F. J . . and Roberts , D. H . (eds) Restoragivc Procedures

the Practising Dentist . John Wriglii

Sons, IJrisiol, p. 204.

HO DO SH , M., SH KL AR , G. and POV AR , M. (1974) Polymcr-coaied m etal endo dontic stabilizers.

OralSurg.

3

804.

ING L n, J . I . and BE VL RIDG E. E. E. ( t976) 'Endod onl ics ' 2nd edi t ion . L ea and Febiger . Phi ladelphia.

L EE , J. S. (1976) An am algam c arrier for use in retrog rade ntling of root canals.

J. Br. Endod. Soc.

9, 87.

MAINI, V. K. and REDPATH, T. H. (1975) An instrument for carrying out retrograde amalgam apical f i l l ing

J. Br. Endod. Soc. 8, 23.

M AT TIL A. K. and A L TO NL N. M . (1968) A clinical and rocntgenoligical s tudy of apicocctomised iccil i. Odon

T. 7(i, 389.

MAYR. W. D., (1967). Konirollen und Erfahrungen bei Wurzclspilzenreseklion unier Vc-rweriduiig v

Silberstiftcn.

Osterr. Z. Stomatol.

64 , 194.

MESSING, J.J. (1970) An investigation of the sealing properties of some root filling materials.

J. Br.Endod.

4, 18 .

MO OD NIK , R. M., L EVE Y. M. H .. BESEN, M . A ., and B OR DE N, B . G. (1975) Retrograde amalgam fil ling

scanning electron microscope study.

J.

Endod.

1, 28.

NI CH OL L S, E. , (1977) 'Bndod ontics , 2nd edit ion. W rigli t . Bristol.

PATTERSON. S. S. (1964) Endodontic therapy: use of a polyethylene tube and sl im for drainage.

J. Am. D

Assoc.

69 710.

PERSSON. G., (1966) Bedomning av resultatet efter rotampuiaiion.

Sven. Tandlak. Tidskr.

59. 219.

KENSON. C. E. . (1977) The use of diodontic implanls.

Dent. Update

4, 233.

RUD, J. and AN DR EA SE N, J . O. (1972) Operative procedures in periapical surgery with contem poran eous r

filling. //(/.

J. OralSurg.

1, 297.

RUD, J . AN DR EA SEN , J . O. , and M O L L E R - J E N S E N . J. E ., (1972) A mu hivar iate analysis of the influence

various factors upon healing after endodonlic surgery. //(/. J- Oral Surg. I , 258.

SEL TZE R, S. , MA GG tO, J . , WO L L AR D, R. and GR EE N, D . (1976) Ti tanium endodont ic implants : a scann

electron microscope, electron tnicroprobe, and histologic invesligatioti. J. Endod. 2, 267.

TA Y, W. M ., GA L E, K. M. and HA RT Y, F. J. (1978) The influence of periapical radioluceiicies on ihe suc ces s


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