Periapical Microsurgery Technique: Principles, Steps, and Benefits

What Is the Periapical Microsurgical Technique?

There has been tremendous progress in terms of apical surgery over the last decade that has resulted in endodontic surgeons introducing potent microsurgical techniques for improving success rates in hopeless teeth indicated for re-root canal treatment or obstructed canals. The steps in microsurgical apical surgery are nearly the same as those of apical surgery, except that this is a more conservative way to perform the surgery and involves the use of microsurgical instruments.

What Are Its Indications?

Indications for apical surgery that have been updated by the ESE (European Society of Endodontology, 2006) are as follows :

1. Radiological findings that implicate apical periodontitis or clinical symptoms associated with an obstructed canal would indicate the need for apical surgery.
2. If the root canal obstruction proves not to be removable or eliminated easily, without any feasible displacement, or if the risk of damage is greater.
3. Extruded root canal material with clinical or radiological findings of apical periodontitis that can confirm why the clinical symptoms of the patient may be continuing over a prolonged time
4. Persisting or emerging periapical disease that follows root canal treatment when the root canal re-treatment is considered unsuccessful or inappropriate.
5. Perforation of the root or perforation to the floor of the pulp chamber.
6. Cases where it is not advisable or possible to treat from within the pulp cavity.

What Are the Contraindications of Apical Surgery?

Contraindications for apical surgery include the following:

• If the tooth has no functional efficiency or is like an antagonist without any strategic importance to chewing.
• When the tooth needs to serve as a pillar for a fixed prosthesis or fixed partial denture.
• If the tooth in question cannot be restored or there is a restorative challenge in the tooth.
• If the tooth in question has very little or inadequate periodontal tissue support.
• If the tooth indicated has any vertical root fracture in it.
• Additional general contraindications are in patients who are too aged or immunocompromised to receive apical surgery treatment in uncooperative patients or patients with a compromised medical history.

What Are the Steps of Apical Surgery?

Microsurgical principles in apical surgery mainly include the following implementations to be carried out by the endodontist:

• There would be firstly a production of a small osteotomy for gaining access to the root end.
• Then subsequently there would be the resection of the root end with the perpendicular axis to the long axis of the tooth root.
• The endodontist then inspects the resected root surface for any possible cracks or microstructures.
• Then, an endodontist will perform the preparation of a root-end microcavity.
• These surgical steps are important to note not only simply to minimize the surgical trauma that would be caused during the procedure, but also to create a beneficial and optimal condition for the subsequent root-end filling that needs to be done to avoid recurrence of apical periodontitis infection.

What Are the Principles of Apical Surgery?

Some of the important principles include:

• The main instruments that are utilized for the technical requirements for the apical microsurgery procedure include the use of mainly magnification or illumination as well as endodontic microsurgical instruments. in contrast to the conventional apical surgical procedures, the microsurgical procedure utilizes the microscope in apical surgery for a thorough inspection of the surgical field at a higher scale of magnification. The material that is best suited as a gold standard root-end filling material for smooth surfaces of the tooth post micro apical surgery intervention is mostly the MTA (mineral trioxide aggregate).
• The least amount of gutta-percha or the previous root canal filling disturbance that can be produced, that is removed by the dental operator or endodontist using a plain fissure bur is by using a low-speed handpiece and is then replaced by the use of MTA for the root end, according to current endodontic research. Mineral trioxide aggregate (MTA) hence seems to have become the current day gold standard for a root-end filling material in apical surgery procedures. Most research-based clinical comparative studies have established or reported much higher success rates for MTA than for other commercially available competitor materials in modern-day endodontic markets.
• A tight root seal is essential to prevent bacterial ingress and any potential toxins from creeping into the root-canal system or the periradicular tissues.
• Subsequently, after the surgical procedure, an adaptation of wound margins is accomplished by the dentist with interrupted sutures usually, utilizing fine suture material (5-0, 6-0, 7-0). Sutures are usually removed within three to five days after the apical microsurgery procedure.

What Are the Advantages of Apical Microsurgery?

The advantages of microscopy lie in detecting the smaller osteotomy preparations or in the identification of microstructures, cracks, additional canals, and isthmus. It helps in detecting any compromised situations of root integrity such as mild fractures or perforations, in detecting any distinctions between the bone and root. It also aids in the identification of adjacent important structures such as the roots of neighboring teeth, and in the visualization of the borders of the maxillary sinus, nasal cavity, mandibular canal, mental foramen, and other vital structures. The use of a surgical microscope requires that the dental operator or the endodontist also maintain an erect posture. This is of great occupational benefit to the general dentist or the endodontist because it can reduce backaches or physical stress to the operator. In addition to these benefits, video recordings of surgeries can be utilized for dental research, education, and valid case documentation.

What Are the Post Operative Steps of Apical Surgery?

The critical step after the apical microsurgery procedure is to first inspect the resected root end of the tooth in question. This is because even postoperatively, the endodontist needs to identify any possible areas of leakage if any accessory canals have not been filled or skipped, if there is an isthmus, if there are any dentinal cracks, or if there exists a possible gap between the existing root-canal filling and the walls of the pulp canal. Verifying this post-surgery hence ensures that the root canal of the tooth is not compromised. In case, any of these complications are still observed by the endodontist after the apical microsurgery procedure, then the tooth canal needs to be negotiated or in other words mainly to be filled by the orthograde approach.

Conclusion

It is to be noted that the main objective of apical surgery is to avoid re-infection of the tooth root canal. The tighter the root canal seal by preventing all the above-mentioned complications or microstructures in the tooth, the higher the success rate of the endodontic procedure. Periapical microsurgery is a sophisticated endodontic procedure that offers an effective solution for treating persistent root canal infections and preserving natural dentition. Its precision, high success rates, and minimally invasive approach make it a valuable option for patients seeking to retain their natural teeth and restore oral health.