Apicectomy

Lecture7
Apicectomy
The term periradicular surgery has superseded the olderterm of apicectomy and reflects the fact that the surgerymight not always be related to an apical problem but can affect the side of the root, as when a post has perforatedinto the periodontal space. Virtually any tooth can betreated in this way although anterior teeth, beingstrategically and aesthetically more important, are morecommon. The indications for periradicular surgery willbe discussed, followed by a consideration of surgical techniques and post perforations.
Indications for surgery:
Endodontic failure:
canal obstruction, problems with root filling, other, e.g. canal number and shape ,Pathology and Post-crowned teeth.

Surgical technique
1-Anaesthesia:
Infiltration with an adrenaline (epinephrine)-containingsolution is preferable and significantly improves visibilityby its haemostatic effect. Even where a block anaestheticis given, additional infiltration is wise. Palatal or lingualinfiltration is needed for full gingival margin flaps toallow suturing but may be necessary for larger lesions inany case, e.g. upper lateral incisor where the infectionhas eroded palatal bone.
2-Flap design:
An L or inverted L -shaped flap from the gingival marginis the flap of choice (see Ch. 23). Only one verticalincision is normally required and the access afforded isexcellent (Fig. 29.4). The only perceived disadvantagemay be gingival recession postoperatively, but this can beminimised by careful suturing.
The older semilunar flap avoids the risk of recessionbut has several disadvantages (Fig. 29.4). It gives lesssurgical access, is more difficult to suture accurately and, by cutting across the gingivae, can lead to dysaesthesia(painful altered touch sensation) of the gingivae, whichmay be long lasting.
3-Bone removal :
It may be necessary to remove bone over the apex of thetooth to gain surgical access. This is relatively easy whenthe pathology has destroyed bone, but accurate assessmentof the location of the apex is required when the areaof infection is smaller, and good radiographs may be veryhelpful. The apical third of the root should be found byusing a fast-rotating round bur with good suction andlight, and bone then removed over the apex and sufficientlyabove it to allow access.
4-Removal of apex:
Normally, 3 mm of apex is removed using a narrowtaperedfissure bur. Ideally, the cut across the root shouldbe at right angles to the long axis of the root and thisstage should be carried out early in the procedure to clearthe field for curettage of the existing infection.
5-Curettage:
Large to medium-sized caries excavators are ideal forcurettage. The cavity should be clean but it is probablyunnecessary to spend too much time removing everyfragment of soft tissue. Ideally, curettings should be sentfor histopathology.
6-Retrograde root filling:
The vast majority of teeth treated require retrogradesealing of the root canal. This need may be obvious fromthe outset with good radiographs but visual inspectionand probing will almost inevitably indicate therequirement.
The root canal needs to be prepared and cleansed to adepth of 3 mm (Fig. 29.5). In practice, this can be accomplishedwith a small rose head bur (a small contra-angle
hand-piece may be helpful) or by ultrasonic preparationusing specially designed tips.
After drying the canal, various sealants can be used,including zinc oxide and Eugenol® preparations, ethoxybenzoic acid cement (EBA) and, more recently, mineraltrioxide aggregate (MTA). No material will produce ahermetic seal, although this must be regarded as theultimate objective of the procedure. Excess filler shouldbe removed carefully to reduce foreign body reactions.
7-Wound closure :
After thorough irrigation with sterile saline the woundshould be closed. In the anterior region, especially, afiner gauge of suture and smaller needle may facilitate aneater result. Great care should be exercised to ensurethat the interdental papillae are repositioned accurately.
8-Follow-up: Sutures are usually removed 5-7 days postoperativelyand patients are normally seen 3-6 months after this toassess the longer-term results. Absence of pain, tendernessof the sulcus sinus formation and undue mobility areindicative of success. Radiographs should show theretrograde seal in good position and a reduction in theradiolucency compared with the preoperative film.

Reasons for failure
a-Inadequate apical seal

b-Inadequate tooth support

c-Vertical tooth fracture




Written by:
Mushtag t. mohammed