Endodontic Surgery (Apicoectomy)

Endodontic Surgery (Apicoectomy)In this modern eons patient increasingly wish to preserve their natural dentition and often disinclined to get there teeth extracted . Endodontic surgery (apicoectomy) is the treatment performed on the stock apices of an infected tooth, and its resection and removal of pathological tissues around the apices followed by placement of a filling (retrofilling) to seal the root end. Endodontic surgery offers patient a second chance or the final chance to save there tooth. victory of Root end surgery had a poor prognosis and success rate in the past but due to recent advances Endontics due to the working(a) operating microscope and new tecniques the rate is much higher than before successIts indications are as follows1 RCT treated tooth that has severe peri top(prenominal) excitation despite of a satisfactory RCT2 Tooth with persistant periapical inflammation and inadequate RCT and has the following problems a Severely curved root scum bagals where ac cess is an issue to reach the apexb exclusively calcified root canalsC Presence of post and cores in rootd Breakage of small instrument or filling material where it is not recoverable and an infection is still present in the apical region.Teeth with periapical inflammation where completion of endodontic therapy due to1 Foreign body present in the periapical tissues2 Perforation of the inferior wall of the pulp chamber3 Perforation of the root4 Fracture of the apical third of the root5 alveolar consonant anomalies (Dense in Dente )6 Access for periradicular curettageA non healing endodontic lesion is recognized by persistent pain and/or swelling, possibly with radiographic changes indicating increasing periapical grind away loss. Non healing endodontically treated teeth that do not appear to be healing are not automatic indications for extraction and replacement with an implant. Persistent nonhealing subjects can be saved by endodontic microsurgery with a predictably favorable p rognosisNonsurgical endodontic treatment has a high rate of clinical success despite the anatomic and pathologic challenges of the procedure. Success in case of tooth without periapical extension of pathosis is more than 90%. On the some other hand, studies show that infected root canals with an extension of pathosis into the periapical space have a reduced healing capacity . previously the conventional endosurgery has very low success rate . it was recorded as low as 37.4 % but now with recent advancement in endodontic surgery the success rate has improved significantly. According to a test conducted by shimon Friedman and Chaim Mor ( success of endodontic therapy -healing and employmentality) in patients were endodontic surgery is performed the chances of healing after retreatment is between 74 to 86 %and their chance of being functional extra time is 91 to 97 % .Another study ( modern endodontic surgery concept and practice by syngcuk Kim and Samuel Kratchman)said that the tra ditonal apical surgerybased on clinical symptoms and radiographic receiveings ranges from 44% to 90%.it has even higher success rate with the endodontic microsurgery. . According to another study (outcome of surgical endodontic treatment performed by a modern technique A meta anlysis conducted by Igor Tsesis , Surgical endodontic treatment have a success rate of 91 .4 % when followed up in a year time .According toa study named Outcome of endodontic micro re- surgery by Minju song and team . When an endodontic surgery fails we need to identify the problem and find the reason for failure. To solve the problem further treatment like retreatment with surgery and, extraction are the viable options. Some studies in the past have enter poor success rate if we have to redo a failed surgery again. But this study said that with the new microscope and microsurgical devices the success rate can be as high as 92.9 %. Most of the reason for failure is poor technique,poor seal at the apical r egion and not using biocompatible materials like MTA and tops(p) PBA in the past. In another recent study it was found that, at least in America, endodontic surgery was the least expensive intervention for failed RCT when compared to endodontic re-treatment and crown, extraction and fixed partial denture, or extraction and implant (Kim Solomon, 2011).When primary endodontic treatment fails retreatment should be done and when retreated and if there is severe inflammation in the periapical tissues then endo surgery can be an option using advance techniqies and good operationg skill can add to the success of endo surgery.1 MicroscopeThe microscope provide provide good visualization, identification and treatment of infected canals, isthmuses and variant anatomy not reachable with traditional instrumentation techniques. Microscope can reach to more antithetical locations and narrow spaces, by providing a clear field of vision. Good visualization also prevents damage to anatomical str uctures. Microscopic techniques significantly decrease complications and expand the case applicability for performing this procedure on teeth adjacent to these structures. With increased magnification and illumination, differentiating the root surface from the surrounding prink is also enhanced .A primary(prenominal) cause of nonsurgical endodontic failure results from the inability to clean and sterilize the apical canal space, which is a complex anatomical entity.2 unhearable tipsThat pull up stakes accurate preparation along the long axis vertebra of the root canal with clear visualization of the preparation . This technique will allow us to do root-end fillings in the proper position to seal the root canal to sufficient filling depth and thickness to effectively seal the canal, dentinal tubules and accessory canals. Ideal ultrasonic tip length is 3mm long. A minimum of 3mm preparation depth is needed to prevent leakage.3 Surgical advancesA smaller osteotomy will reduce bone removal (approximately 3-4mm) in diameter reducedbone and permits quicker uneventful postoperative healing postoperative healing. By removing less bone in the wreath direction, buccal bone can be preserved and subsequent periodontal sequelae that may lead to the loss of the tooth are prevented.Root-tip resection of 3mm is needed to eliminate lateral canals and apical ramification- A study shows that the resection of 3mm of apex eliminates 98 percent of apical ramifications and 93 percent of lateral canals.Root section bevel angle is reduced to 0 -10 degreesClear examination of the resected root surfaces for fracture and anoatomical variationsRoot-end fillings with MTA (Mineral Trioxide Aggregate- It has excellent biocompatibility, osteo- and cemento-inductive capabilities, effective antibacterial and sealing properties, and faster radiographic healing in comparison to SuperEBA and IRM. MTA will not cause soft tissue discoloration that can otherwise result from root-end filling mat erials like amalgamMagnification Eyes or Loupes (1-4x) Microscope (4-24x)Illumination Dental light Bright focused lightArmamentarium Macro-instruments Micro-instrumentsOsteotomy Size Large (7-10mm diameter) Small (3-3mm diameter)Bevel Angle Acute (45-60 degree) Shallow (0-10 degree)Root-end Preparation Non-axial Axial to long axis of toothDepth of Root-end prep 1mm non-axial 3mm axialInspection resected root surface None AlwaysRoot-end filling material Amalgam MTASuccess rate over 1 year Less than 50% Over 90%SummaryThere are many factors to consider when choosing to perform microsurgeryon a tooth versus performing other treatment options such asnonsurgical retreatment or tooth extraction. Fortunately for the patient,the ability to perform endodontic microsurgery is an effective and highlysuccessful procedure that produces minimal discomfort, alleviates periradicularpathosis, maintains restorations and provides for function andaesthetics as shown in Figure 6.33,34