Periradicular surgery
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Peri-radicular surgery is concerned with the surgical management of recurrent pathology associated with the apex of a non-vital tooth. The symptoms a patient may experience are due to infection in the peri-radicular tissues around a root-treated tooth that can impede the healing process of the tooth after conventional root canal treatment.[1]
After removing the pulpal tissues, the aim of endodontic treatment is to seal the pulpal space to prevent further bacterial contamination and to allow healing of the peri-radicular tissues. However, the success rates for root canal treatment range from 47-97% which can be due to several reasons such as voids in the root canal filling, a root canal filling that it short for the tooth and the presence of a pre-operative periapical lesion.[2]
Treatment options to manage cases such as these can be non-surgical root canal retreatment or peri-radicular surgery. Access and cleaning of the pulp chamber and canals would be easier done with non-surgical root canal re-treatment however, this is contraindicated in some patients.[1]
There are numerous indications as well as contraindications for peri-radicular surgery which are explored thoroughly throughout this topic. The stages of peri-radicular surgery are:
1. Local anaesthesia
2. Flap design
3. Bone removal
4. Curettage
5. Apicectomy
6. Retrograde preparation and filling
7. Wound closure
These steps are all individually very important for the success of the overall surgery and should be carefully carried out at each stage in order to get the best outcome for the patient.
Indications
Periradicular surgery should always be very carefully considered and where possible re-root treatment is the preferable option.[5] 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.[6]
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.[5]
These include the formation of ledges, perforation of root or floor of pulp chamber,[3] extruded root filling material,[4] 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.[7][3][4]
Identification of possible root fractures[5][4] or perforations.[6]
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
There are two main flap designs that are used in endodontic surgery. These are known as full mucoperiosteal flaps and limited mucoperiosteal flaps. Within these categories there are sub-categories which are explained below:
Mucoperiosteal Flaps. Full mucoperiosteal flaps involve an intrasulcular horizontal incision with reflection of the marginal and interdental gingival tissues[10]. These can be 2-sided, 3-sided or envelope in shape.
- 2 sided (triangular) - formed by a horizontal, intrasulcular incision and one vertical relieving incision. The first horizontal incision follows the contours of the tooth cutting the gingival sulcus including the mesial/distal papilla. The relieving incision begins at the gingival margin and extends to the attached gingiva. For posterior teeth the horizontal incision is always placed mesially[10].
- 3 sided (rectangular) - formed by a horizontal, intrasulcular incision and two vertical relieving incisions. Although there is increased surgical access with this flap design it is, however, difficult to re-approximate the tissue[10].
- Envelope (horizontal) - a horizontal, intrasulcular incision is made with no vertical relieving incision. This design provides very little surgical access to the root surface[10].
Limited Mucoperiosteal Flaps. Limited mucoperiosteal flaps have a submarginal horizontal or horizontally oriented incision and do not include the marginal or interdental tissues.
- Submarginal curved (semilunar) - curved incision is made starting within the alveolar mucosa, dipping down into the attached gingiva and then extending back into the alveolar mucosa. Semilunar flaps have poor healing potential and often lead to scarring[10].
- Submarginal scalloped (Ochsenbein- Luebke) - similar to the rectangular flap however the horizontal incision is located in the attached gingiva. The incision is scalloped following the contour of the gingival margins below. This flap design also leads to delayed healing and potential tissue scarring[10].
Root end resection
Wound closure
Before closing the wound, there should be copious irrigation used in the wound to prevent infection and the flap should be compressed to reduce the risk ofhaematoma. Re-approximation of the flap is then carried out and the papillae should be the first suture placed.[1] After suturing the flap, a sterile damp gauze should be compressed on the wound for a few minutes and an ice pack can be used by the patient for the following 6 hours; 15 minutes on the wound, 30 minutes off. Depending on what type of sutures used, they should be removed 48-96 hours post-operatively.[1]
Complications and management
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Treatment outcomes
A range of benchmarks has been used to assess outcomes of periradicular surgery widely,[11] 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[12] 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.[6][13] However, re-surgical interventions are usually not as successful (35.7%)[6] and there is a consensus on refraining from re-surgery.[13]
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 d e "Guidelines for Surgical Endodontics" (PDF). www.rcseng.ac.uk. Retrieved 2018-12-12.
{{cite web}}: Cite has empty unknown parameter:|dead-url=(help) - ^ Ng, Y.-L.; Mann, V.; Rahbaran, S.; Lewsey, J.; Gulabivala, K. (2007-10-11). "Outcome of primary root canal treatment: systematic review of the literature – Part 2. Influence of clinical factors". International Endodontic Journal. 0 (0): 071011095702005–???. doi:10.1111/j.1365-2591.2007.01323.x. ISSN 0143-2885.
- ^ 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
- ^ 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.
- ^ a b c d e f www.ijrti.org http://www.ijrti.org/papers/IJRTI1709004.pdf. Retrieved 2018-12-15.
{{cite web}}: Missing or empty|title=(help) - ^ 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.