Controversies in Apical Surgery

by Roberto Sacco

 For many years, apical surgery preparation was carried using micro-handpiece with small round or inverted cone burs. However, it's been shown that this technique has many limitations: axis of preparation not parallel to root canal, risk of perforation of lingual dentin wall, insufficient depth of root-end preparation, difficulties due to a limited working space with the need for more invasive preparation.1

In attempts to solve these problems, the application of sonic and ultrasonic devices has been widely encouraged.2-3 They produce cleaner, well centered and more conservative root-end cavities than the rotary instrumentation, which has significantly raised the success rate of endodontic surgery.4 Despite the improvements promoted by ultrasound in endodontic surgery field, the appearance of cracks on the apical surface has been reported.5-6 

Therefore, more efforts have been put in place to find new methods in this regard. Some authors have promoted the use of laser in apical surgery. Many studies have shown that Er: YAG laser is more useful than ultrasound tip demonstrating successful improvement in dentin-cement cracks and root-end fillings leakage.7 Unfortunately, we can't say that the use of laser in apical surgery is gold standard as there's not enough evidence.

Another controversial topic in the field of apical surgery is related to the need for bone regeneration after surgical removal of apical lesions. The use of guided bone regeneration (GBR) techniques has been suggested in adjunct to endodontic surgery in order to stimulate bone healing and help regenerate bone defect caused by surgery. Many studies have been published with regards to the use GBR as a viable procedure with many different outcomes, treatment protocols, follow-up periods and inclusion criteria, thus generating unreliable and confusing results. The inconsistency in the results of studies assessing GBR as predictable outcome of surgical endodontic treatment might be related to the lack of standardisation in the assessment criteria 8-9. As an example, several biomaterials were used as scaffold in endodontic surgery, and none achieved worldwide consensus 10-11-12-13.

Based on the currently available data, GBR techniques may improve bone regeneration after surgical endodontic treatments performed in specific cases, with certain peri-apical lesions, such as large lesions and through-and-through lesions. A positive outcome is expected if a resorbable membrane over a non-resorbable membrane or a graft alone is used. Unfortunately, further robust studies are needed in order to evaluate the benefits of GBR techniques in endodontic surgery 14.

References

  1. von Arx T, Walker WA 3rd. Microsurgical instruments for root-end cavity preparation following apicoectomy: a literature review. Endod Dent Traumatol 2000;16:47-62.
  2. Khabbaz MG, Kerezoudis NP, Aroni E, Tsatsas V. Evaluation of different methods for the root-end cavity preparation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:237-42.
  3. Bernardes RA, de Moraes IG, Garcia RB, Bernardineli N, Baldi JV, Victorino FR, et al. Evaluation of apical cavity preparation with a new type of ultrasonic diamond tip. J Endod 2007;33: 484-7.
  4. Rubinstein RA and Kim S (2002): Long-term follow- up of cases considered healed, one year after api- cal microsurgery. Journal of Endodontics, 28:378- 383.
  5. Gondim-Junior E, Gomes BPFA, Ferraz CC, Teixeira FB, Souza-Filho FJ. Effect of sonic and ultrasonic retrograde cavity preparation on the integrity of root apices of freshly extracted human teeth: scanning electron microscopy analysis. J Endod 2002;28:646-50.
  6. Taschieri S, Testori T, Francetti L, Del Fabbro M. Effects of ultrasonic root end preparation on resected root surfaces: SEM evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:611-8.
  7. Karlovic Z, Pezelj-Ribaric S, Miletic I, Jukic S, Grgurevic J and Anic I (2005): Erbium: YAG laser versus ultrasonic in preparation of root-end cavi- ties. Journal of Endodontics, 31:821-823.
  8. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature. J Endod 2009;35: 1505–11.
  9. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod 2006;32: 412–6.
  10. Tobon SI, Arismendi JA, Marin ML, Mesa AL, Valencia JA. Comparison between a conventional technique and two bone regeneration techniques in periradicular surgery. Int Endod J 2002;35:635–41.
  11. Dietrich T , Zunker P, Dietrich D, Bernimoulin JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apico-marginal defects in periradicular surgery: results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:474–82.
  12. Murashima Y, Yoshikawa G, Wadachi R, Sawada N, Suda H. Calcium sulphate as a bone substitute for various osseous defects in conjunction with apicectomy. Int Endod J 2002;35:768–74.
  13. Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: a comparative histomorphometrical study. Int Endod J 2002;35:255–63.
  14. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of Guided Tissue Regeneration on the Outcome of Surgical Endodontic Treatment: A Systematic Review and Meta-analysis. J Endod. 2011 Aug;37(8):1039-45.

 

 

 

 

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