Surgical endodontics (Proceedings)

Surgical endodontics is the treatment of choice where there is a history of recurrent facial swelling, the existence of anatomical or morphological problems, unresolved granulomatous tissue or sequelae remains after conventional endodontic therapy, or problems encountered during conventional endodontic therapy, such as fractured endodontic files or incomplete endodontic fill.

Surgical endodontics: when? what with? how? prognosis?

When? (Diagnosis)

Ninety-five percent of surgical endodontics is the result of conventional endodontic failures. Five percent of surgical endodontics should be the treatment of choice when unknown apical morphology may exist, or repeated inductions would be a surgical risk necessitating a onetime procedure for remission such as seen in exotic animals. Failed conventional endodontics is the result of incomplete apical fill or seal. Incomplete removal of pulpal contents. Failure due to fractured and retained endodontic files and other idiopathic and iatrogenic causes. Most frequently involved tooth is the upper fourth premolar (usually the lateral rostral root), followed in frequency by the lower canine and then upper canine.

What With? (Instrumentation)

Instrumentation of surgical endodontics is basically what is used in other dental procedures:

• high speed or slow speed dental hand piece and cutting burs

     o number ½ or 1 round bur

     o 699 or 700 tapered fissure bur

• I.R.M Super E.B.A or MTA cement

• Number 15 scalpel blade

• 4/O sutures

How? (Step by step procedure)

The procedure for surgical endodontics of the lateral rostral root of the 4th premolar will be described. Note: a preoperative radiograph is necessary to determine location, extent, and root involved.

1. Approximately a 2-3cm elliptical incision is made at midroot level and extended equi-distant rostrally and caudally.

2. The full thickness muco periosteal flap is elevated apically exposing the usually present fistula.

3. The fistula is debrided with a suitable curette exposing the apex. Note: extreme care must be exercised not to infringe upon the infra orbital foramen just rostral to the apex of the upper fourth premolar.

4. Approximately 2mm of the apex is amputated with a tapered fissure bur and dental handpiece at a 45-degree angle to the long axis of the tooth root. The amputation is tapered from apex to crown, medial to lateral, exposing pulpal canal, which will be quite evident by exposure of gutta percha inside the canal.

5. A number 1 or ½ round bur is carefully introduced into the exposed root canal removing exposed gutta percha and necrotic material debrided from around the walls of the canal to a depth of 2mm. The canal is prepared with a slight undercut to retain the filling material. Care must be exercised not to over prepare the canal.

6. The entire surgical site is packed with cotton balls (approximately 3mm in diameter), saturated with epinephrine to provide hemostasis and isolation of the apex.

7. Hand mixed cement of choice is condensed into the apical preparation. If MTA is used, it is carried to the apex with the use of a retrograde alloy carrier and condensed with hand pluggers into the apical preparation until filled.

8. Postoperative radiograph is taken to verify apical fill.

9. Tetra with 4/O absorbable suture.

Prognosis

With proper technique prognosis is very good. Failures can be usually attributed to iatrogenic causes.