9. Periradicular Surgery

Surgery is an integral aspect of endodontic therapy for the treatment of cases when root canal therapy is not deemed sufficient to remove the infection. Over recent years the amount of endodontic surgeries has been decreasing as the reliability and success of root canal procedures have been increasing. Periradicular surgery is not always a necessary step towards endodontic success, it should never be used as a cure for a poor endodontic root canal technique. Surgery is often assumed to be the most radical procedure; however, sometimes the surgical procedure becomes a conservative effort to avoid further tissue injury, and extraction of the tooth. Resorption of the root canal apex was an indication for surgery to remove necrotic tissue, however some clinical cases have demonstrated that periapical healing can arrest the resorptive process by nonsurgical root-canal therapy. An incompletely developed apex was once assumed to require surgery, however there are now improved regeneration techniques for saving immature teeth. The accidental extrusion of sealer and obturation core material into the periapical tissues are only candidates for surgery of they cause a persistent periapical radiolucency, swelling and pain. A horizontal fracture of the root apex may not require surgery, if the apical canal fragment contains vital tissue. Only if the apical tissue becomes necrotic, then it may be necessary to remove the apical fragment. By trial and error, it has become clear that surgery is not always in the best interests of saving a tooth if a nonsurgical treatment can suffice. The types of surgery include: Anatomical Redesigning is needed as part of periodontal treatment, for root amputation, hemisection, and bicuspidization. Apical Resection is the removal of the root end of a tooth. Bicuspidization is the separation of a multirooted tooth by a vertical cut through the furcation. Hemisection is the removal of a root and its coronal portion from a multirooted tooth. Incision and drainage is needed to release exudates from swollen soft tissues. Intentional tooth replantation may be considered when no other course of root canal treatment is possible and extraction of the hopeless tooth is inevitable. Marsupialization is a decompression technique used to reduce a massive cyst without surgical curettage. A periapical curettage is performed by removing the pathologic tissues surrounding the apex of a tooth without disturbing the root. Root Amputation is the removal of a root from a multi-rooted tooth, leaving the coronal portion of the tooth intact. Trephination requires anesthetic and is the perforation of a cortical plate to release the pressure of an exudate with alveolar bone. Surgery has become a specialized field in endodontics and most surgical cases should be referred to specialists for treatment.