Apical Surgery in Endodontics: An Overview

Introduction

Apical surgery is a dental procedure that a dentist may recommend, especially in cases involving redirected root canal-treated teeth. Apical surgery is a well-established practice in the field of endodontics, dedicated to improving the prognosis and success rate of problematic teeth. This article talks about the indications, rationale, and methodologies employed by oral surgeons and dentists when addressing endodontically infected teeth with uncertain outcomes.

What Is Apical Surgery?

Apical surgery, often viewed as the final option in dentistry, is a standard oral surgical procedure employed to save a tooth that cannot be effectively retreated from an endodontic perspective. The procedure is seen as the final option in dentistry. This procedure is typically considered when a tooth, which has previously undergone root canal treatment, faces recurrent issues that cannot be resolved through conventional endodontic retreatment.

The primary objective of apical surgery is to identify and address potential leakage points in the previously treated root canal system, commonly occurring at the cut root face or the root's tip. This meticulous approach ensures a secure root-end filling, subsequently benefiting the patient.

The primary goal of the dental professional, advising apical surgery, is to prevent persistent bacterial leakage or contamination from the root canal system into the surrounding tissues.

Apical surgery involves placing a secure root-end filling, often in conjunction with root-end resection performed by an endodontist or oral surgeon. To improve the precision, clinicians are recommended to use a surgical microscope during the procedure. The rationale behind apical surgery in dentistry is to establish a favorable long-term prognosis for teeth that have failed conventional endodontic treatments and ensure optimal post-operative healing. Apical surgery serves as a vital procedure for preserving teeth that would otherwise need extraction.

What Are the Protocols for Apical Surgery?

The successful execution of apical surgery depends on a carefully structured protocol, which has the following steps:

A. Delicate Incision and Flap Elevation: The procedure commences with a gentle incision and the elevation of a flap.

B. Precision Osteotomy: A small-sized osteotomy (a procedure that cuts and reshapes the bone) is created with utmost precision.

C. Sonic or Ultrasonic Microtips: Sonic or ultrasonic-driven microtips are utilized during surgery, for patient comfort, minimizing trauma, and promoting faster postoperative healing.

What Are the Steps in Apical Surgery?

• The initial step in apical surgery is the identification of all potential leakage areas or bacterial contamination at the cut root of the tooth. This step allows the dentist to assess whether the tooth's prognosis is poor or hopeless.

• If the prognosis is poor, even with apical surgery, extraction may be the most preferred option, if there is a possibility of achieving a secure root-end filling, the dentist may recommend this procedure.

• The next step is to achieve a tight and persistent apical obturation seal. Such an apical seal can promote periapical healing, ensuring the tooth's long-term stability and a favorable prognosis.

• In endodontic surgery, dentists often employ techniques such as incision and drainage, followed by the closure of bacterial leakages within the root canal system or tooth root perforations.

• The use of a surgical microscope is necessary, as it provides the magnification and illumination for a comprehensive analysis of the tooth's root canal system, particularly when dealing with cases of poor endodontic prognosis.

• The field of apical surgery is undergoing advancements, with the integration of various microsurgical techniques, further enhancing its effectiveness and precision in modern dentistry.

What Are the Indications for Apical Surgery?

As per the updated guidelines recommended by the ESE (European Society of Endodontology), the indications for apical surgery encompass the following conditions:

• When radiographic findings reveal an infection known as apical periodontitis.

• Cases where patients exhibit repeated clinical symptoms, and radiographic assessments indicate an obstructed root canal system. This obstruction should be confirmed as non-removable or impractical to displace.

• In situations where there is extruded material from the previous root canal treatment along with clinical or radiological signs indicating apical reinfection or reinfection of the tooth root.

• Situations where symptoms of periodontal infection persist over an extended or ongoing duration.

• When the dental surgeon or endodontist deems it inappropriate to retreat the root canal.

• Cases involving possible perforations in the tooth root or the floor of the pulp chamber (root canal), make it impossible to treat the root canal system from within the pulp cavity.

These defined indications serve as a guide for dental professionals to determine when apical surgery is the most appropriate and effective in treating specific dental issues, ensuring the well-being and oral health of their patients.

What Are the Objectives and Diagnosis for Periapical Surgery?

• The primary objective of the apical surgery procedure is to preserve a tooth that is affected by a severe endodontic lesion and has become highly infected. This surgery serves as one of the last options for patients who prefer to avoid tooth extraction.

• Dentists or oral surgeons recommend apical surgery only when the endodontic infection or the infection of the tooth root cannot be effectively resolved through a conventional root canal or endodontic retreatment.

• Before proceeding with apical surgery, the dentist will likely advise a comprehensive clinical and radiographic examination of the affected tooth. This step is important as it helps determine the suitability of the procedure for the specific tooth in question.

• Also, dental radiographic examinations, such as CBCT (Cone Beam Computed Tomography) and OPG (Orthopantomogram), offer the advantage of providing a comprehensive view of not only the affected tooth but also the adjacent and opposing dental structures.

• This comprehensive view helps the dental surgeon in making an informed decision regarding whether a surgical or non-surgical endodontic approach is most suitable for the patient and whether apical surgery should be carried out, or if extraction would be a more preferred one.

Conclusion

In dentistry, apical surgery serves as an important procedure, offering patients an alternative to tooth extraction while having complex endodontic issues. however the indications should be suited to performing this procedure, otherwise an inaccurate apical seal even if established by the dental surgeon cannot yield a good long-term prognosis. Current dental research and clinical studies document a success rate of 90 percent in this surgical procedure followed commonly in dentistry. The approach reaffirms its importance in preserving dental health and promoting patients' well-being.