-apicoectomy in teeth with periapical lesions

endodontic surgery

1. •Apicoectomy
•By:
•Buhay
•De Guzman
•Engalan

2. •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.

3. •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.

4. •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 by-
products of non vital pulp, which
remained in the root canal.

5. •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

6. •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

7. •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

8. •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.

9. •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

10. •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.
• 

11. •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.

12. •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 45° angle.

13. •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

23. •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.

25. •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.

26. •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. 

27. •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.

28. •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.

29. •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 post-
operatively.

30. •Temperature
•It is
 
normal to run a low grade temperature (99-
100F) 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.

31. •Diet
•Drink plenty of fluids. 
Try to drink 5-6 eight ounce
glasses the first day. Drink from a glass or cup and
 
don’t
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
don’t burn yourself.
•Soft food and liquids can be eaten on the day of
surgery. 
The act of chewing doesn’t 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.

32. •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