during endodontic surgery the irrigation solution used is:
a- Saline***
b- EDTA
c- Naocl
When a tooth has a lesion of endodontic origin, the usual therapeutic solution is orthodontic endodontic treatment or reprocessing.
However, when this tooth presents a unitary prosthetic reconstruction with root anchoring, or is part of a clinically well integrated plural reconstruction, access to the root canal can be extremely difficult if not impossible.
Conventional endodontic retreatment would involve removal of the coronadicular reconstitutions, which may be deleterious and may affect the prognosis of the tooth.
When the clinical situation allows, surgical endodontic retreatment can replace conventional endodontic retreatment.
This solution allows the preservation of the existing prosthesis. Indeed, thanks to current techniques, it is possible to prepare and seal the entire residual root canal system by guaranteeing success rates comparable to those of conventional endodontic reprocessing.
Prosthetic reconstruction and endodontic treatment are indissociable in terms of success.
If the endodontic treatment is correct but the prosthetic reconstruction does not guarantee coronal tightness, the success of the treatment can be compromised. The same is true if a prosthetic reconstruction is correctly performed on a tooth whose endodontic treatment is defective.
When a tooth treated endodontically and restored prosthetically presents a lesion of endodontic origin, it is therefore advisable to evaluate the endodontic-prosthesis couple before making a decision.
Evaluation of endodontic treatment:
It is usually done using a retro-alveolar radio. It's about evaluating the quality of the formatting, the density and the limits of the filling. It is also important to examine any problems encountered during the previous treatment: broken instruments, false roads or perforations, transport, stripping.
Evaluation of the restoration:
The evaluation of the corono-radicular reconstruction is done radiographically; the root part must be anatomical, without being too dilapidating, it must leave a closure of at least 3 to 5 mm of gutta-percha in the apical part.
The longer and wider the post, the greater the risk of fracture during removal. The more studs are important and the more divergent they are, the more difficult they are to remove.
The evaluation of the coronary restoration is done clinically and radiographically. The correct fit of the prosthesis should be verified using a 17-lead and a bite-wing radiograph to assess the adjustment of the proximal boundaries. We will also evaluate the absence of over or under-contours, the good occlusal and functional integration and finally the aesthetic rendering.
Decision making:
The choice between conventional or surgical reprocessing will depend on answers to a set of questions.
In the case of conventional reprocessing, it is necessary to assess the difficulties that may jeopardize its success. If there is a fractured instrument beyond a curvature, is it possible to eliminate it or to miss it? If the root is perforated or has a wrong route, is it possible to access it and conduct the treatment satisfactorily? If the prosthesis has root anchors, is it possible to safely deposit large, long or diverging posts [5]? If the root is the support of a large-scale plural reconstruction, is it reasonable to destroy the entire prosthetic construction for the sole purpose of treating the lesion? (clinical case 3) Finally, if the prosthesis is satisfactory and does not have a tenon, the realization of the access cavity through the crown will not it cause chips of ceramic?
In the case of surgical reprocessing, the aim is to evaluate the usual medical contraindications for surgery, as well as the anatomical difficulties. Does the patient's facial musculature allow access to the surgical site? Is the lesion close to an anatomical structure such as the maxillary sinus or the mental hole (clinical case 4)?
Will surgical access to the lesion not lead to excessive bone decay?
After answering all these questions, the choice between conventional and surgical reprocessing will be based on the benefit / risk ratio of each treatment option.
When a tooth has a lesion of endodontic origin, the usual therapeutic solution is orthodontic endodontic treatment or reprocessing.
However, when this tooth presents a unitary prosthetic reconstruction with root anchoring, or is part of a clinically well integrated plural reconstruction, access to the root canal can be extremely difficult if not impossible.
Conventional endodontic retreatment would involve removal of the coronadicular reconstitutions, which may be deleterious and may affect the prognosis of the tooth.
When the clinical situation allows, surgical endodontic retreatment can replace conventional endodontic retreatment.
This solution allows the preservation of the existing prosthesis. Indeed, thanks to current techniques, it is possible to prepare and seal the entire residual root canal system by guaranteeing success rates comparable to those of conventional endodontic reprocessing.
Prosthetic reconstruction and endodontic treatment are indissociable in terms of success.
If the endodontic treatment is correct but the prosthetic reconstruction does not guarantee coronal tightness, the success of the treatment can be compromised. The same is true if a prosthetic reconstruction is correctly performed on a tooth whose endodontic treatment is defective.
When a tooth treated endodontically and restored prosthetically presents a lesion of endodontic origin, it is therefore advisable to evaluate the endodontic-prosthesis couple before making a decision.
Evaluation of endodontic treatment:
It is usually done using a retro-alveolar radio. It's about evaluating the quality of the formatting, the density and the limits of the filling. It is also important to examine any problems encountered during the previous treatment: broken instruments, false roads or perforations, transport, stripping.
Evaluation of the restoration:
The evaluation of the corono-radicular reconstruction is done radiographically; the root part must be anatomical, without being too dilapidating, it must leave a closure of at least 3 to 5 mm of gutta-percha in the apical part.
The longer and wider the post, the greater the risk of fracture during removal. The more studs are important and the more divergent they are, the more difficult they are to remove.
The evaluation of the coronary restoration is done clinically and radiographically. The correct fit of the prosthesis should be verified using a 17-lead and a bite-wing radiograph to assess the adjustment of the proximal boundaries. We will also evaluate the absence of over or under-contours, the good occlusal and functional integration and finally the aesthetic rendering.
Decision making:
The choice between conventional or surgical reprocessing will depend on answers to a set of questions.
In the case of conventional reprocessing, it is necessary to assess the difficulties that may jeopardize its success. If there is a fractured instrument beyond a curvature, is it possible to eliminate it or to miss it? If the root is perforated or has a wrong route, is it possible to access it and conduct the treatment satisfactorily? If the prosthesis has root anchors, is it possible to safely deposit large, long or diverging posts [5]? If the root is the support of a large-scale plural reconstruction, is it reasonable to destroy the entire prosthetic construction for the sole purpose of treating the lesion? (clinical case 3) Finally, if the prosthesis is satisfactory and does not have a tenon, the realization of the access cavity through the crown will not it cause chips of ceramic?
In the case of surgical reprocessing, the aim is to evaluate the usual medical contraindications for surgery, as well as the anatomical difficulties. Does the patient's facial musculature allow access to the surgical site? Is the lesion close to an anatomical structure such as the maxillary sinus or the mental hole (clinical case 4)?
Will surgical access to the lesion not lead to excessive bone decay?
After answering all these questions, the choice between conventional and surgical reprocessing will be based on the benefit / risk ratio of each treatment option.
Surgery:
The appearance of recent techniques, using new instruments, has considerably improved the prognosis of endodontic surgery. Indeed, it is no longer limited to a simple apical resection but meets the objectives of conventional endodontic treatment: access to the root canal system, cleaning and sealing.
As in conventional endodontics, optical aids and more particularly the operating microscope are essential for the realization of each stage of this act of micro surgery.
Soft tissue management:
The purpose of the flap is to provide complete access to the lesion. It must be full thickness and its banks lie on a healthy bone. It must take into account the nature of the periodontal tissues, the amount of gingiva attached and focus on preserving the original aesthetics. To facilitate access to the apical third, it must have at least one vertical discharge incision.
There are several types of flap, triangular, trapezoidal, with sulcular incision or remotely, the choice of which will be made according to the clinical situation.
Hard tissue management:
Access to the apical third is through the cortical bone.
The osteotomy should be large enough to permit complete soft tissue removal from the peri-radicular lesion, visualization of the apical third, and access to ultrasound preparation instruments.
When there is already fenestration of the cortical bone due to the lesion, it is however necessary to rearrange the access in an ideal way.
Apical third party management:
Apical resection should cover the last 3 millimeters in order to eliminate the majority of the anatomical complexities of the canal network, to visualize all the channels and to facilitate the curettage of the lesion. This resection should be done with sufficient angulation to allow good visualization while being as perpendicular as possible to the major axis of the root.
The resected surface is examined at high magnification in order to demonstrate, using a micro-mirror and a probe 17, the isthmus and unprepared channels.
Apical preparation:
The preparation a retro is achieved through ultrasonic inserts whose tip is diamond. These inserts have many advantages: they are smaller and offer a clearance for better visibility under optical aids. They allow a finer work than rotary instruments and allow to prepare in the axis of the channel. They have different shapes to adapt to all clinical situations.
The removal of the old filling material and the cleaning of the canal system are achieved by the mechanical action of these inserts.
The first available inserts had a working part of 3 mm. A new kit for endodontic surgery is now available (Satelec Endo Success Apical Surgery®). It offers inserts of 3, 6 and 9 mm. These give the possibility to prepare the channels more deeply. Surgical preparation then resembles more and more that of conventional endodontics.
Retro shutter:
It is directly related to the length and quality of the preparation. The usual materials used are MRI, EBA and MTA. The material is supplied in small quantities and then condensed using micro-crushers of different lengths depending on the preparation. A new longer follower (Hu Friedy®) is now available. It is thus possible in some cases to perform fillings of the entire root canal system retrograde way obtaining success rates comparable to those of the orthograde endodontics.
Conclusion:
Surgical endodontics has made considerable progress in recent years. Thanks to the use of the operating microscope and new ultrasound inserts, it now gives results comparable to those of conventional endodontics. When properly controlled, it represents a reliable therapeutic solution. It preserves existing prosthetic constructions by intervening in a very conservative way.
Labels
Endodontics