Failures of conventional endodontic treatment can be multifactorial: presence of bacteria in the root canal system may cause persistent apical leakage, the anatomy of the tooth may inhibit adequate orthograde preparation, or debris forced out the apex may cause continual symptoms for the patient. Although alternative treatments exist such as extraction and implant reconstruction, many teeth and prostheses can be maintained with the use of apical surgery procedures.The provision of surgical treatment of endodontic failures should be recognized as an exploratory procedure. Decisions made during the surgery include the possibility of a limited apical resection with retrograde filling, removal of a root, or the extraction of the tooth if the situation is deemed to have a poor prognosis. Guidance preoperatively including a focused periodontal examination as well as radiographic evidence may provide indicators as to the potential success or failure of the planned apical surgical procedure.Recent developments in apical surgery include the continued development of an ideal retrograde filling material. Although materials such as amalgam have been shown to have excellent characteristics, the concerns with implanting this material as well as its potential for staining tissues has lead to the search for newer agents. Formulations of an intermediate restorative material (Super-EBA) and more recently the utilization of mineral trioxide aggregate (MTA) have been shown to adequately seal the root canal system and provide biocompatibility with the local tissues.Lastly, technical improvements in the preparation of the apex have contributed to the improved success of this surgical technique. The ultrasonic device permits a deep enough preparation to seal the apex without requiring a substantial amount of bone removal for visualization. Ultrasonic devices facilitate the preparation of isthmus regions and un(der)filled canals as well.ReferencesLieblich SE: Periapical surgery: Clinical decision making. Oral Maxillofac Surg Clin North Am 14:179, 2002Torabinejad M, Hong CU, Pitt Ford TR: Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: A preliminary report. J Endodont 21:569, 1995Von Arx T, Kurl B: Root-end cavity preparation after apicoectomy using a new type of sonic and diamond surfaced retrotip: A 1 year follow up study. J Oral Maxillofac Surg 57:656, 1999 Failures of conventional endodontic treatment can be multifactorial: presence of bacteria in the root canal system may cause persistent apical leakage, the anatomy of the tooth may inhibit adequate orthograde preparation, or debris forced out the apex may cause continual symptoms for the patient. Although alternative treatments exist such as extraction and implant reconstruction, many teeth and prostheses can be maintained with the use of apical surgery procedures. The provision of surgical treatment of endodontic failures should be recognized as an exploratory procedure. Decisions made during the surgery include the possibility of a limited apical resection with retrograde filling, removal of a root, or the extraction of the tooth if the situation is deemed to have a poor prognosis. Guidance preoperatively including a focused periodontal examination as well as radiographic evidence may provide indicators as to the potential success or failure of the planned apical surgical procedure. Recent developments in apical surgery include the continued development of an ideal retrograde filling material. Although materials such as amalgam have been shown to have excellent characteristics, the concerns with implanting this material as well as its potential for staining tissues has lead to the search for newer agents. Formulations of an intermediate restorative material (Super-EBA) and more recently the utilization of mineral trioxide aggregate (MTA) have been shown to adequately seal the root canal system and provide biocompatibility with the local tissues. Lastly, technical improvements in the preparation of the apex have contributed to the improved success of this surgical technique. The ultrasonic device permits a deep enough preparation to seal the apex without requiring a substantial amount of bone removal for visualization. Ultrasonic devices facilitate the preparation of isthmus regions and un(der)filled canals as well. References Lieblich SE: Periapical surgery: Clinical decision making. Oral Maxillofac Surg Clin North Am 14:179, 2002 Torabinejad M, Hong CU, Pitt Ford TR: Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: A preliminary report. J Endodont 21:569, 1995 Von Arx T, Kurl B: Root-end cavity preparation after apicoectomy using a new type of sonic and diamond surfaced retrotip: A 1 year follow up study. J Oral Maxillofac Surg 57:656, 1999
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