Apicoectomy

By: Buhay De Guzman Engalan

Apicoectomy

Surgical resection of the root tip of a tooth and its removal together with the pathological periapical tissues. Accesory rot canals and additional apical foramina are also removed in this way, which may occur in the periapical area and which may be considered responsible for failure of an endodontic therapy.

Indications

Teeth with active periapical inflammation, despite presence of a satisfactory endodontic therapy. Teeth with periapical inflammation, and unsatisfactory endodontic therapy, which cannot be repeated because of:
Completely calcified root canal Severely curved root canals Presence of post or cores in the root canal Breakage of small instrument in root canal or the presence or irretrievable filling material.

Teeth with periapical inflammation, where completion of endodontic therapy is impossible due to:
Foreign bodies driven into periapical tissues Perforation of inferior wall of pulp chamber Perforation of root Fracture at apical third of tooth In the above cases, if after apicoectomy the apex has not been completely sealed, then retrograde filling is required. Purpose of a retrograde filling is to obstruct the exit of bacteria and the byproducts of non vital pulp, which remained in the root canal.

Contraindications

All conditions that could be considered contraindications for oral surgery conerning the age and general health problems, such as severe cardiovascular diseases, leukemia, tuberculosis, etc. Teeth with severe resorption of periodontal tissues
Deep periodontal pockets, great bone destruction

Teeth with short root length Teeth whose apices have a close relationship with anatomic structures such as: Maxillary sinus, mandibular canal, mental foramen, incisive and greater palatine foramen If causing injury to these during the surgical procedure is considered probable

Complication

Damage to the anatomic structures in case of penetration of the nasal cavity, maxillary sinus and mandibular canal with the bur. Bleeding from the greater palatine artery during apicoectomy of palatal root. Splattering of amalgam at the operation site, due to inadequate apical isolation and improper manipulations for removal of excess filling material

Incomplete root resection, due to insufficient access or visualization and misjudged length of root. As a result, the apical portion of the root remains in position and the retrograde filling is placed improperly, with all the resulting consequences.

Retrograde filling materials These materials should seal well and should be tissue tolerant, easily inserted, minimally affected by moisture, and visible radiograpically. It must be STABLE and NONRESORBABLE indefinitely. Amalgam(zinc free) Intermediate restorative material cement commonly used Super ethoxy benzoic acid(super-EBA) cement Cavit Gutta-percha Composites resin Glass ionomer cement recommended material to use Intermediate restorative material Cavit Different luting cements

Mineral trioxide aggregate(MTA) has shown favorable biologic and physical properties and ease of handling; it has become a widely used material. It has shown to be conducive to bone growth over the apical region. Its working time is about 10 mins, although it takes 2 to 3 hrs to reach final set, which is not an issue because the root apex is not a load-bearing region, at least not until bone fills in the defect. Surgeon must be careful not to irrigate MTA out after placement, so irrigation is done before placing the filling and any excess is wiped with just dampened cotton pellet. It may be placed in field in which some hemorrhage has occurred; the final set is not adversely affected by blood contamination. Amalgam should not be used if the field is bloody, if the root end preparation is less than 3mm, or if access is limited Composite resin with bonding agent must be placed in a perfectly dry field, which is complicated because of the nature of the surgery. This material may be used in a shallow, concave preparation and has been shown to be successful in molar root end surgeries. Each of these root end-filling has different, unique mixing and placement characteristics. Special carriers for MTA have been designed and work well to sleeve contains the material and keeps it from contacting additional moisture as it is carried to the surgical site. MTA can be condensed and added to so that the fill is complete.

Indication of Apicoectomy with Semilunar flap

The semilunar flap is indicated for surgical procedures of limited extent and is usually created at the anterior region of the maxilla, which is where most apicoectomies are performed. to ensure optimal wound healing, the incision must be made at a distance from the presumed borders of the bony defect, so that the flap is repositioned over healthy bone.

Apicoectomy with Semilunar Flap

Reflection of flap and retraction with broad end of periosteal elevator. Removal of bone covering apex of tooth Exposing periapical lesion and apex of tooth together after removal of respective buccal bone Removal of periapical lesion with hemostat and periapical curette. Resection of apex of tooth at a 45r angle.

Preparation of cavity at apex with microhead handpiece. Placement of filling at root tip with miniaturized amalgam applicator Condensing amalgam at periapical cavity with narrow amalgam condenser. Operation site after placement of sutures

Submarginal envelope flap or LeubkeOchsenbein flap design Generally, the incision is scalloped in the horizontal line, with obtuse angles at the corners. Used most successfully in the maxillary anterior region or occasionally, with maxillary premolars with crowns. The design, prerequisites are at least 4mm of attached gingival and good periodontal health.

Indication: when esthethics of the gingival margin cannot be compromised(Mx teeth with crowns) Majoradvantages Esthethics less risk of incising over bony defect provides better access and visibility.

Contraindication: periodontal breakdown, large periapical lesion and short root. Disadvantages: hemorrhage along the cut margins into the surgical site occasional healing by scarring.

Post-Operative Instructions

Immediately following surgery: Bite on the gauze pad placed over the surgical site for an hour. After this time, the gauze pad should be removed and discarded and replaced by another gauze pad. Avoid vigorous mouth rinsing or touching the wound area following surgery. This may initiate bleeding by causing the blood clot that has formed to become dislodged. To minimize any swelling, place ice packs to the sides of your face where surgery was performed.

Take the prescribed pain medications as soon as you can so it is digested before the local anesthetic has worn off. Having something of substance in the stomach to coat the stomach will help minimize nausea from the pain medications. Restrict your activities the day of surgery and resume normal activity when you feel comfortable. If you are active, your heart will be beating harder and you can expect excessive bleeding and throbbing from the wound. NO SMOKING UNDER ANY CIRCUMSTANCES.

Bleeding

Excessive bleeding may be controlled by first GENTLY rinsing or wiping any old clots from your mouth, then placing a gauze pad over the area and biting firmly for sixty minutes.Repeat as necessary. If bleeding continues, bite on a moistened tea bag for thirty minutes. The tannic acid in the tea bag helps to form a clot by contracting bleeding vessels. This can be repeated several times. To minimize further bleeding, sit upright, do not become excited, maintain constant pressure on the gauze (no talking or chewing) and avoid exercise.

Swelling

The swelling that is normally expected is usually proportional to the surgery involved. An apicoectomy generally does not produce much swelling so it may not be necessary to use ice at all. If there was a fair amount of cheek retraction involved with apicoectomy, then it would be appropriate to apply ice on the outside of the face on the affected side. The swelling will not become apparent until the day following surgery and will not reach its maximum until 2-3 days postoperatively.

Temperature

It is normal to run a low grade temperature (99100F) for 7-10 days following oral surgery. This reflects your immune response to the normal bacteria that are present in your mouth. A high temperature (>101F) might exist for a 6-8 hours after surgery but no more than that. 2 Tylenol or 2-4 Ibuprofen every 4-6 hours will help to moderate a temperature. A temperature >101F several days after surgery, especially if accompanied by rock hard swelling and increased pain, is usually indicative of infection.

Diet

Drink plenty of fluids. Try to drink 5-6 eight ounce glasses the first day. Drink from a glass or cup and dont use a straw. The sucking motion will suck out the healing blood clot and start the bleeding again. Avoid hot liquids or food while you are numb so you dont burn yourself. Soft food and liquids can be eaten on the day of surgery. The act of chewing doesnt damage anything, but you should avoid chewing sharp or hard objects at the surgical site for several days. Return to a normal diet as soon as possible unless otherwise directed. You will find eating multiple small meals is easier than three regular meals for the first few days.

References

An Atlas of Minor Oral Surgery

Principles and Practice Second edition David A McGowan Oral Surgery

Fragiskos D. Fragiskos Root end filling materials A review

http://medind.nic.in/eaa/t03/i2/eaat03i2p12.pdf