Endodontic surgery for periapical lesion in upper second premolar. Patient referred by a specialist colleague after non-remission of the fistula after successive changes of intracanal medication in the second upper right premolar. It was then decided to perform endodontic surgery with apicectomy, after the final obturation performed by the colleague. The apical resection was then performed with an ultrasound tip.
In: Ricardo Machado: Endodontics. Technical and Biological Fundamentals. Ed. Gen, 2022:
Introduction
The endodontic therapy presents several challenges during its realization, the main one being the anatomical complexity. The total elimination of microorganisms responsible for the development or maintenance of a periapical lesion is impracticable, precisely because they are present within a tangled system of root canals. Endodontic treatment therefore aims to reduce as much as possible this microbial contingent to levels favorable to repair.
Bacteria organize themselves in biofilms to enhance their antimicrobial resistance and pathogenicity. The elimination of these communities occurs mainly through the mechanical action of endodontic instruments. However, these instruments are not able to touch all canal walls, and therefore the use of auxiliary chemical substances capable of dissolving organic matter, among which sodium hypochlorite stands out, is essential for the elimination of intraradicular biofilm. Other alternatives to intensify control of endodontic infection are the use of different substances as intracanal medication, activation of irrigating solutions, and photodynamic therapy. Even so, complete eradication of endodontic infection has not yet been achieved.
Faced with a primary endodontic failure, three treatment possibilities are usually considered (in order of preference): endodontic retreatment, para-endodontic surgery and exodontics, followed by the installation of a dental implant. The paraendodontic surgery represents an alternative for cases of failure after retreatment or for the resolution of errors and accidents that occurred previously.
In many situations, patients and professionals have doubts about the best alternative to be instituted when comparing endodontic surgery with extraction followed by implant placement. In these cases, the cost-benefit of both procedures must be well evaluated. Certain factors may contribute to this decision, among which are the patient's age, systemic and financial conditions, the location and proximity of the tooth to important anatomical structures, the amount of remaining bone, the root length and the extent of periapical lesion (if present).
Systematic reviews and meta-analysis point to an increase in the success rates of para-endodontic surgeries when performed under the "light of operating microscopy" and using retro-obturator materials, mainly mineral trioxide aggregate (MTA). Thus, the procedure is able to prolong the maintenance of teeth in the oral cavity, postponing the installation of implants. Iqbal and Kim, in 2008, observed that, whenever possible, patients preferred to keep their natural teeth by using different alternatives (treatment, retreatment and para-endodontic surgery) rather than replacing them with implants.
The following will present and discuss philosophical concepts and techniques currently used for the maintenance of natural teeth in the oral cavity, from different modalities of endodontic surgery.
Indications for paraendodontic surgery
As previously stated, paraendodontic surgery should only be indicated when endodontic retreatment fails or when it cannot be performed. However, one should always evaluate the cost/benefit of this surgical procedure due to the irreversibility of its operative acts. For example, in teeth with a well adapted prosthetic crown and previous satisfactory endodontic treatment, it is necessary to evaluate if the best treatment would be the removal of the crown and intraradicular retainers, followed by endodontic retreatment and making a new prosthetic crown, or if it would be a para-endodontic surgery.
Thus, the main indications for performing paraendodontic surgery are:
-Failures in previous treatments
-Anatomical complications
-Iatrogenies
-Trauma
-Persistence of infection
-Failures after apparently well-performed endodontic retreatments
-Difficulty in accessing the root canal system
-Well adapted crowns with previous endodontic treatments apparently well done
-Patient choice.
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