Surgical Endodontics

What we mean by Surgical Endodontics

Surgical Endodontics is the procedure of choice for treating lesions of an endodontic origin (granulomas and cysts) that do not respond to a conventional endodontic therapy or that cannot be treated with a conventional endodontic therapy through the crown of the tooth. The goal in Surgical Endodontics is to obtain cleansing, shaping and three dimensional obturation of the apical portion of the root canal when it is not treatable through the access cavity created in the crown of the tooth, but is only accessible by raising a surgical flap. The operation is performed entirely with the help of an operatory microscope and it has a very high long term success rate (Fig. 10).

What causes the formation of a granuloma and a cyst

The formation of a granuloma or a cyst is caused by the toxic products of the bacteria that colonize the root canal that was previously occupied by pulp and that leak out through the communicating passages between the root canal and the surrounding tissues.
All one has to do, for the granuloma or the cyst to heal, is to correctly treat the root canal by removing the bacteria and any pulp residues that by now have become necrotic, and to obturate the canal with an inert material which is capable of sealing all the communicating passages, both apically and laterally, of the root. Healing will lead to the disappearance of the dark radio-transparent area which is visible on radiographs and this will usually happen over 6-12 months, irrespective of the lesion’s dimensions.

When surgery is indicated

The only real indication for Surgical Endodontics is the presence of an obstacle that won’t allow one to sound and therefore to prepare and then obturate the canals with a traditional approach. The obstacle in question may be represented by the presence of a post (although instruments that are capable of safely removing large metallic posts are available today), calcifications, old and irremovable obturation materials, etc. In other cases, during the failed previous endodontic therapy, the original endodontic anatomy may be so severely altered to render any sort of attempt to save the tooth with a traditional method, useless.
In all of these cases it’s preferable to raise a surgical flap and to treat the root apex by means of a retrograde approach, or in other words by placing a retrograde seal since the orthograde access was obstructed for one reason or another. The preservation of a tooth that may be treated with this method is an undeniable biological advantage for the patient. Furthermore, in just one appointment the patient will solve his/her dental problem without having to resort to lengthy and costly procedures, like a prosthetic treatment, such as a bridge to replace an extracted tooth, or an implant.

Treatment time

The treatment is carried out in the practice under local anaesthesia; it isn’t painful and can vary in length according to the difficulty of the case. It can also be performed on upper and lower molars   and not only on front teeth (incisors and canines) as is commonly believed. The only limitation is determined by how retractable the cheek is, since it can condition how easy the surgical access will be. The procedure in fact requires the operator to stretch the patient’s lips and cheeks while the patient clenches his/her teeth. A “wide” mouth will obviously make reaching the back teeth much easier.

The treatment stages

The treatment consists of an administration of local anaesthesia followed by a gingival incision to expose the underlying bone and access the tooth in need of treatment. At this point the most apical portion of the root is removed (generally about 3mm), using specific ultrasonic tips, 3 millimetres are prepared inside the apical part of the canal and the obturation material is then put in place: the retrograde seal. Today, biocompatible materials that guarantee higher success rates than what was possible in the past, are available. If the lesion was caused by bacteria in a lateral canal, the preparation and retrograde obturation of the lateral canal in question are obviously carried out (Fig. 11, 12).

Verifying treatment outcome

All endodontic therapies, both the ones that are performed traditionally, through the tooth’s crown, and the ones that are performed surgically, have to be regularly checked at 6 month intervals for at least two years. If the treatment is successful after about 6-12 months the radio-transparent area should have disappeared completely from any radiographs taken during the check up. The tooth that underwent an apicoectomy will have a long term prognosis that is effectively similar to that of other surrounding teeth, so long as it is correctly reconstructed from a conservative or prosthetic point of view.

Post-operative symptoms

The post-operatory symptoms that patients might experience are less pronounced than those related to tooth extraction. Any pain or swelling can be treated with analgesic and anti-inflammatory medication. After 2-3 days the symptoms resolve completely and often, during removal of sutures (which is done after 24-48 hours), patients will state that they didn’t use any analgesics at all.

When patients can go back to work

Patients will be able to go back to work, provided it isn’t physical labour, 4-5 hours after the operation. One day of home rest may be prescribed according to the type of operation performed.
However, care should be taken not to do excessive physical activity, any activity that causes an increase in blood supply to the head should be avoided, as should exposure to sun (in summer) and a diet that isn’t too hot or that requires excessive chewing .