Controversies in Apical Surgery

 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.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.


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