Periradicular surgery
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Indications
Periradicular surgery should always be very carefully considered and where possible re-root treatment is the preferable option.[3] However, in cases where re-root treatment is not possible/will not correct the problem or if patient factors are preventing re-root treatment, periradicular surgery is indicated.[4]
These may prevent complete cleaning and obturation of the canals. For example; root canal calcification, pulp stones, severely curved roots, bifurcations, secondary roots, lateral canals, delta apexes, internal and external resorption resistant to conventional treatment, incomplete apex.[3]
These include the formation of ledges, perforation of root or floor of pulp chamber,[1] extruded root filling material,[2] file breakages or underfilling the canals. However, these are only indications for periradicular surgery if they’re causing a persistent periapical radiolucency, swelling and pain.[5][1][2]
Identification of possible root fractures[3][2] or perforations.[4]
This may be used in suspicious and/or non-healing lesions or when a patient presents with uncharacteristic signs and symptoms of periapical areas.
There are a few factors to consider before carrying out periradicular surgery.
Patient factors
Systemic factors
Presence of severe systemic disease poses risk of poor healing response following surgery. Patient’s psychology towards surgery should also be taken into consideration.
Dental factors
A tooth is not suitable for periradicular surgery if it does not have good periodontal support or coronal seal as these factors will reduce the prognosis of the tooth following surgery. More importantly, the tooth needs to be restorable following surgery, for instance having enough tooth structure to support restoration.
Filling the root canals of the tooth from the crown (orthograde root canal therapy) should have been done as the first treatment option to resolve inflammation caused by the tooth. Periradicular surgery is only considered if the inflammation persists following conventional root canal treatment.
Patient’s oral hygiene level must also be taken into account for poor oral status will increase risk of infection and impair healing of surgical site.
Anatomical factors
Lacking appropriate surgical access to the site contraindicates periradicular surgery. For instance, cutting the gum near important anatomical structures such as neurovascular bundles will risk permanent numbness of the jaw. Other than that, bone structure and root arrangement of tooth that are deemed unusual should also be considered.
Operator factors
Operator’s skills and experience as well as facilities available should be considered.
Procedure
Assessment
Anaesthesia and haemostasis
Flap design
Root end resection
Wound closure
Complications and management
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Treatment outcomes
A range of benchmarks has been used to assess outcomes of periradicular surgery widely,[9] this therefore makes comparisons for outcomes of surgery between various studies more challenging. The classification that most published papers adopt is by Rud et al[10] which evaluates the success based on radiographs. However, clinical criteria have also been considered which has been outlined by the Royal College of Surgeons (England) in determining outcomes of periradicular surgery.
| Clinical | Radiological | |
|---|---|---|
| Successful Outcome | Previous signs & symptoms are resolved | Regular PDL space or slightly wider.
Previous periapical radiolucency reduced or resolved with normal replacement of bone and lamina dura. Sound roots without resorption. |
| Incomplete Outcome | Previous signs & symptoms are resolved | Some bone seen surrounding root of tooth with gradual replacement but still incomplete healing.
Periapical radiolucency still present. |
| Uncertain Outcome | Indefinite symptoms - slight ache or discomfort associated with tooth in question | Some bone seen surrounding root of tooth with gradual replacement but still incomplete healing.
Periapical radiolucency still present. |
| Unsuccessful Outcome | Unresolved signs & symptoms associated with tooth in question | No bony replacement seen surrounding root of tooth. |
If the periapical surgery is unsuccessful, investigations must be carried out to determine the causes of failure before further treatment can be done.[4][11] However, re-surgical interventions are usually not as successful (35.7%)[4] and there is a consensus on refraining from re-surgery.[11]
Other options to consider if periapical surgery has failed, besides re-surgery would be:
- Leave it & monitor
This can be advised if the patient is symptom-free but has persisting radiographic indications of disease
- Extract the tooth
- Re-perform root canal treatment
References
- ^ a b c von Arx, Thomas (January 2011). "Apical surgery: A review of current techniques and outcome". The Saudi Dental Journal. 23 (1): 9–15. doi:10.1016/j.sdentj.2010.10.004. ISSN 1013-9052. PMC 3770245. PMID 24151412.
- ^ a b c d Serrano-Giménez, Mireia; Sánchez-Torres, Alba; Gay-Escoda, Cosme (November 2015). "Prognostic factors on periapical surgery: A systematic review". Medicina Oral, Patología Oral y Cirugía Bucal. 20 (6): e715–e722. doi:10.4317/medoral.20613. ISSN 1698-4447. PMC 4670252. PMID 26449431.
- ^ a b c d e f g Pop, I. (28 September 2013). "Oral surgery: part 2. Endodontic surgery". British Dental Journal. 215 (6): 279–286. doi:10.1038/sj.bdj.2013.876. ISSN 1476-5373. PMID 24072296.
- ^ a b c d e f g h i Evans, Glynis E; Bishop, Karl; Renton, Tara (2012). "Guidelines for Surgical Endodontics". RCS Faculty of Dental Surgery. Version 2.
- ^ Murray, Peter (2015), "Periradicular Surgery", A Concise Guide to Endodontic Procedures, Springer, Berlin, Heidelberg, pp. 177–184, doi:10.1007/978-3-662-43730-8_9, ISBN 9783662437292
- ^ "Guidelines for Surgical Endodontics" (PDF). www.rcseng.ac.uk. Retrieved 2018-12-12.
{{cite web}}: Cite has empty unknown parameter:|dead-url=(help) - ^ Pop, I. (September 2013). "Oral surgery: part 2. Endodontic surgery". British Dental Journal. 215 (6): 279–286. doi:10.1038/sj.bdj.2013.876. ISSN 1476-5373.
- ^ Dawood, A. (May 2017). "The Dental Practicality Index – assessing the restorability of teeth" (PDF). British Dental Journal. 222: 755–758.
- ^ Torabinejad, Mahmoud; Nash, Brandon; Mego, Miguel E.; Javidan-Nejad, Salvia; Mead, Cary (2005-01-01). "Levels of Evidence for the Outcome of Endodontic Surgery". Journal of Endodontics. 31 (1): 19–24. doi:10.1097/01.DON.0000133158.35394.8A. ISSN 1878-3554. PMID 15614000.
- ^ Serrano-Giménez, Mireia; Sánchez-Torres, Alba; Gay-Escoda, Cosme (2015-11-01). "Prognostic factors on periapical surgery: A systematic review". Medicina Oral, Patologia Oral y Cirugia Bucal. 20 (6): e715–722. doi:10.4317/medoral.20613. ISSN 1698-6946. PMC 4670252. PMID 26449431.
- ^ a b Saunders, William P. (2005-07-01). "Considerations in the revision of previous surgical procedures". Endodontic Topics. 11 (1): 206–218. doi:10.1111/j.1601-1546.2005.00155.x. ISSN 1601-1546.