Surgical endodontic retreatment
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Surgical retreatment is a predictable treatment option for teeth with post-treatment apical periodontitis. The main objective is to eliminate and prevent bacterial infection in the root canal system from causing an inflammatory reaction in the periradicular tissue.
KeywordsApical surgery Apicectomy Retrograde root canal treatment Surgical retreatment
Blocked root canals
Presence of posts, ledges, or broken instruments
Presence of foreign body in the periapical tissues
Surgical operating microscope
Aluminum chloride or ferric sulfate
Mineral trioxide aggregate (MTA)
To choose the treatment option a thorough clinical and radiographic examination, including adjacent and opposing teeth, should be performed. Along with the other basic assessments, following considerations should also be made during surgical retreatment planning :
In the lower jaw, proximity to the mandibular nerve and/or a thick cortical bone buccal to the tooth may limit the accessibility. In upper jaw, the accessibility to the palatal root is limited surgically especially for the second maxillary molars.
Surgical treatment on teeth with apex or a periapical lesion in close apposition to the maxillary sinus should be carefully performed.
There are no absolute medical contraindications to endodontic surgery. However, there are several medical conditions and medications that cause a depressed immune system, where surgical intervention is contraindicated until white blood cell count and antibody levels become normal. Patients with increased risk for bleeding need special attention. Patients with haemophilia or impaired liver function should only be treated after consultation and in agreement with the patient’s physician. Medication with antiplatelet and anticoagulant agents increase the bleeding time intra- and postoperatively. Surgical treatment is possible in most cases but need certain treatment protocols.
Endodontic surgery technique
To gain access to the root, a horizontal incision is given either including the papilla or cutting through the base of papilla. Submarginal incision is often recommended to minimize the risk of gingival recession in the esthetic zone. Subsequently, a full-thickness flap is raised.
The highly vascularized granulation tissue in the bone crypt is removed.
Hemostasis is achieved using local anesthesia containing epinephrine. Aluminium chloride or ferric sulfate can also be used for controlling bone crypt hemorrhage. If more severe bleeding occurs, electrocauterization may be considered.
Root resection is performed to eliminate infected ramifications, lateral canals and contaminated dentin.A root resection of 3 mm (mm) apically is sufficient to remove most of the infected ramifications and lateral canals. It is performed in a 90° angle to the long axis of the root. This minimizes any leakage that can occur through cut dentinal tubules. Retrograde root-end cavities are prepared by ultrasonic tips in exposed canal orifices. MTA is used for root-end filling (Fig. 4).
The wound surface is thoroughly irrigated with the saline and the wound is closed using surgical sutures for optimal healing. Surgical sutures should hold the edges of a flap in apposition until the wound has healed sufficiently to withstand the normal functional stresses and resist reopening.
Resorbable or non-resorbable threads in diameters 5–0 or 6–0 and three-eighths reverse-cutting or tapered needle are used. The sutures are removed after 7–14 days.
Pitfalls and complications
Pain and swelling after surgical treatment.
Secondary infection of the surgical site.
An insult to blood vessels.
Lack of control of possible coronal leakage and carious lesions under restorations.
Limited access to the root canal full length.
Limited possibility to use chemical disinfection.
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