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Endo Topics 2005. Surgical Endodontics. Quo Vadis?

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Endodontic Topics 2005, 11, 1–3 Copyright r Blackwell Munksgaard All rights reserved ENDODONTIC TOPICS 2005 1601-1538 Surgical endodontics: quo vadis? JAMES L. GUTMANN Surgical endodontic intervention has emerged over the in the surgical procedure and the judgment to be last 100 years as a significant treatment modality in the exercised in the assessment of what has been done (23). retention of sound teeth (1). While the evolution of this In essence treatment planning the choice of surgery treatment modality and the refinement of its principles may actually be more difficult and challenging than the have had a long and tumultuous history, biologically surgical procedure itself (24). This is especially true based directives are emerging and are integrated with with the massive and sometimes irrational movement significant advances in clinical modalities. No longer to replace every endodontically treated tooth with or does the endodontic literature support a litany of with symptoms with an intraosseous implant (25–30). indications for surgical applications, but rather, well- Retention of the natural tooth structure is still the goal thought, evidenced-based principles are guiding the of quality dental care and many previously root-treated selection of this treatment modality (2–7). Coupled teeth that appear to be done quite well, yet exhibit with the introduction of magnification through the use adverse signs or symptoms, are viable candidates for of the surgical operating microscope, refined principles non-surgical treatment revision or surgical revision of of soft and hard tissue management, use of tissue treatment (31–33). regenerative root-end fill materials, and enhanced With each patient that presents for treatment, the principles of wound closure and postoperative manage- clinician is challenged to make choices that result in the ment, surgical endodontics has emerged as a highly best treatment possible for the patient. These choices predictable and relatively painless procedure (8–13). are based on a number of factors that influence the Ironically, the impetus for the evolution of con- clinician in the decision-making, problem-solving temporary surgical endodontic principles came from a process (24, 34, 35). These factors include the better understanding of the challenges faced in the following: cleaning, shaping, disinfecting and obturating the Axioms that are commonly held in endodontics and complex and unpredictable anatomy of the root canal supportive disciplines. system. While technology in the non-surgical provision Formative knowledge to support the choices. of treatment has advanced significantly (14), there still Clinical skill. remains the challenge of eradicating microbial species Clinical experience. and their biofilms from the root canal system, primarily Problem solving skills. in the apical third of the root (15–18). Even with this Patient preference after being informed fully of dictate, it is still imperative to consider the choice of treatment options and their rationale. non-surgical root canal treatment (19) or the revision Economic factors. of previous less-than-ideal treatment (20) before Evidence-based concepts. surgical intervention, as outcomes of non-surgical Integrity. intervention would support this choice. Surgical intervention is not a substitute for failure to Failure to take all factors into account may lead to manage properly the root canal system non-surgically, treatment plans that are ill advised or not in the best to assess thoroughly the periodontal status, and to interest of the patient. While many teeth can be ignore the shortcomings of the coronal restoration(s) maintained with a surgical endodontic procedure, it (21, 22). Knowing when to choose surgical interven- may not be in the best interest of the patient to retain a tion is just as important as the expertise to be exercised tooth that has restorative or periodontal compromises 1 Gutmann (24). Furthermore, if a tooth cannot be returned to when used as root-end filling materials in endodontic symptom-free function following surgical intervention surgery. Int Endod J 2003: 36: 520–526. 7. Maddalone M, Gagliani M. Periapical endodontic removal may be indicated. Moreover, while tooth surgery: a 3-year follow-up study. Int Endod J 2003: retention is ideal for function and aesthetics, at times 36: 193–198. tooth resection or removal and replacement with a fixed 8. Arens DE, Torabinejad M, Chivian N, Rubenstein RA. partial prosthesis, a removable partial prosthesis, Practical Lessons in Endodontic Surgery. Chicago: implant, or no replacement may be in the best interest Quintessence, 1998: 79–87. 9. Pitt Ford TR. Surgical treatment of apical periodontitis. of the patient (24). In: Ørstavik D, Pitt Ford RT, eds. Essential Endodon- This volume of endodontic topics focuses on multiple tology: Prevention and Treatment of Apical Periodontitis. issues that deal with surgical endodontics, with a Oxford: Blackwell Science, 1998: 278–307. primary focus on apical surgery – a ‘first’ for this 10. Velvart P. Das operationsmikroskop in der wurzelspit- zenresektion. teil 1: die Resektion. Schw Monatsschr publication. Furthermore, other than textbook chap- Zahnmed 1997: 107: 507–521. ters, this is the first comprehensive literature-scientific, 11. Velvart P. Das operationsmikroskop in der wurzelspit- evidence-based publication on surgical endodontics in zenresektion. teil 2: die retrograde Versorgung. Schw 15 years. This publication and its focus on the Monatsschr Zahnmed 1997: 107: 969–983. principles of apical surgery are supported by a multi- 12. Velvart P, Peters CI. Soft tissue management in endodontic surgery. J Endod 2005: 31: 4. tude of general concepts that apply to treatment 13. Kim S, Pecora G, Rubinstein R. Color Atlas of planning choices both prior to and following surgery, Microsurgery in Endodontics. Philadelphia: WB Saun- pain prevention and management, postsurgical man- ders, 2001. agement and outcomes. As the availability of true 14. Peters OA, Dummer PMH Infection control through root canal preparation: a review of cleaning and shaping evidence-based information in surgical endodontics is procedures. Endod Topics 2005: 10: 1–190. sparse, there is in some topics presented by the author 15. Friedman S. Considerations and concepts of case more of a best evidence approach to this treatment selection in the management of post-treatment endo- modality. The fact that this topic is presented by a cross dontic disease (treatment failure). Endod Topics 2002: 1: 54–78. section of clinicians, academicians and researchers, 16. Friedman S Etiological factors in endodontic post- lends great credibility and reality to contemporary treatment disease: apical Periodontitis Associated with principles discussed. Hopefully this approach will Root-filled Teeth. Endod Topics 2003: 6: 170. encourage more evidence-based research and long- 17. Dahle´n G, Bergenholtz G Advances in the study of term outcomes studies to solidify or alter the concepts endodontic infections. Endod Topics 2004: 9: 1–96. 18. Nair PNR. Pathogenesis of apical periodontitis and the delineated herein. causes of endodontic failures. Crit Rev Oral Biol Med 2004: 15: 348–381. 19. Lazarski MP, Walker WA, Flores CM, Schindler WG, References Hargreaves KM. Epidemiological evaluation of the outcomes of nonsurgical root canal treatment in a large 1. Gutmann JL, Harrison JW. Surgical Endodontics. cohort of insured dental patients. J Endod 2001: 27: Boston: Blackwell Scientific Publications, 1991. 791–796. 2. Rubinstein RA, Kim S. Short-term observation of the 20. Aqrabawi J. Management of endodontic failures: case results of endodontic surgery with the use of a surgical selection and treatment modalities. Gen Dent 2005: 53: operation microscope and Super-EBA as root-end 63–65. filling material. J Endod 1999: 25: 43–48. 21. Saunders WP, Saunders EM. Coronal microleakage as a 3. Rubinstein RA, Kim S. Long-term follow-up of cases cause of failure in root canal therapy: a review. Endod considered healed on year after apical microsurgery. J Dent Traumatol 1994: 10: 105–108. Endod 1999: 28: 378–383. 22. Ray HA, Trope M. Periapical status of endodontically 4. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in treated teeth in relation to technical quality of the root periradicular surgery: a clinical prospective study. Int filling and the coronal restoration. Int Endod J 1995: 28: Endod J 2000: 33: 91–98. 12–18. 5. Testori T, Capelli M, Milani S, Weinstein RL. Success 23. Mead C, Javidan-Nejad S, Mego ME, Nash B, and failure in periradicular surgery: a longitudinal Torabinejad M. Levels of evidence for the outcome of retrospective analysis. Oral Surg Oral Med Oral Pathol endodontic surgery. J Endod 2005: 31: 19–24. Oral Radiol Endod 1999: 87: 493–498. 24. von Arx T. Failed root canals: the case for apicoectomy 6. Chong BS, Pitt Ford TR, Hudson MB. A prospective (periradicular surgery). J Oral Maxillofac Surg 2005: clinical study of mineral trioxide aggregate and IRM 63: 832–837. 2 Surgical endodontics 25. Rose LF, Weisgold AS. Teeth or implants: a 1990’s dilem- 31. Danin J, Stromberg T, Forzgren H, Linder LE, ma. Compend Contin Educ Dent 1996: 17: 1151–1159. Ramskold LO. Clinical management of nonhealing 26. Trope M. Implant or root canal therapy-an endodon- periradicular pathosis: surgery versus endodontic re- tist’s view. J Esthet Restor Dent 2005: 17: 139–140. treatment. Oral Surg Oral Med Oral Pathol Oral Radiol 27. Ruskin JD, Morton D, Karayazgan B, Amir J. Failed root Endod 1996: 8: 213–217. canals:thecaseforextractionandimmediateimplant 32. Kvist T, Reit C. Results of endodontic re-treatment:a placement. JOralMaxillofacSurg2005: 63: 829–831. randomized clinical study comparing surgical and non- 28. Moiseiwitsch J. Do dental implants tool the end of surgical procedures. J Endod 1999: 25: 814–817. endodontics? Oral Surg Oral Med Oral Pathol Oral 33. Siqueira JF Jr. Aetiology of root canal failure: why well- Radiol Endod 2002: 93: 633–634. treated can fail. Int Endod J 2001: 34: 1–10. 29. Heffernan M, Martin W, Morton D. Prognosis of 34. Bader HI. Treatment planning for implants versus root endodontically treated teeth? Quintessence Int 2003: 7: canal therapy: a contemporary dilemma.
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