Indications and Contraindications for Periradicular Surgery
- Failed previous endodontic treatment
- Anatomical deviations preventing access or preparation of canal
- Procedural errors causing persistent periapical radiolucency, swelling, and pain
- Exploratory surgery identifying possible root fractures or perforations
- Suspicious or non-healing lesions requiring biopsy
- Severe systemic disease affecting healing (contraindication)
- Poor periodontal support or coronal seal (contraindication)
- Inflammation persists after conventional root canal treatment (contraindication)
- Poor oral hygiene increasing infection risk (contraindication)
- Lack of appropriate surgical access or unusual bone structure (contraindication)
Procedure and Assessment for Periradicular Surgery
- Assessment involves history, clinical exam, and special investigations
- Anaesthesia and haemostasis achieved with local anaesthetic and topical agents
- Flap design options include full and limited mucoperiosteal flaps
- Bone removal and curettage for optimal visualisation and cleaning
- Apicectomy and retrograde preparation and filling for sealing the root surface
- Thorough history and clinical exam for assessment before surgery
- Radiography to identify disease presence and evaluate root treatment
- Examination of tooth's relationship to neighboring structures
- Vitality testing of adjacent teeth and occlusal loading assessment
- Assessment of cortical bone thickness, regional anatomy, and root condition
Complications and Management of Periradicular Surgery
- Periradicular surgery has a risk of complications, which can be minimised by the surgeon.
- Pain and swelling are common post-surgery and can be managed with prescription analgesics.
- Swelling can be minimised by applying pressure with an ice pack for four to six hours after surgery.
- Damage to blood vessels during surgery can lead to hemorrhage; severe hemorrhage is rare but serious.
- Infection of the surgical site can result from poor surgical technique, poor oral hygiene, or smoking.
Outcomes of Periradicular Surgery
- Various benchmarks are used to assess the outcome of periradicular surgery.
- Success is evaluated radiographically and clinically.
- Successful outcomes include resolution of previous signs and symptoms and reduction of periapical radiolucency.
- Incomplete outcomes show partial healing and persistent periapical radiolucency.
- Unsuccessful outcomes are characterised by unresolved signs and symptoms and lack of bony replacement.
Root Canal Filling and Other Considerations
- The outcome of periradicular surgery depends on factors including the root canal filling.
- The filling promotes cementum and bone formation and acts as a barrier for the root canal.
- Amalgam filling was commonly used until the 1990s when safety concerns arose.
- Calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) are considered more suitable for root-end fillings.
- CEM cement is superior to MTA as a root-end filling material.
- Considerations in the revision of previous surgical procedures, including persistent symptoms and incomplete healing.
In the dental specialty of endodontics, periradicular surgery is surgery to the external root surface. Examples of periradicular surgery include apicoectomy, root resection, repair of root perforation or resorption defects, removal of broken fragments of the tooth or a filling material, and exploratory surgery to look for root fractures.
Symptoms may be due to infection in the periradicular tissue around a root-treated tooth, which can impede healing of the tooth after conventional root canal treatment. After removing the pulp, the aim of endodontic treatment is to seal the pulpal space to prevent further bacterial contamination and allow healing of the periradicular tissue. Success rates for root-canal treatment range from 47 to 97 percent; failures may be due to spaces in the root-canal filling, a root filling which is too short or a preexisting periapical lesion.
Treatment options are nonsurgical root-canal re-treatment or periradicular surgery. Although accessing and cleaning the pulp chamber and canals would be easier with the former, it is contraindicated in some patients.
The stages of periradicular surgery are:
