J.O. Ajayi1, I.M.F. Abiodun-Solanke3, O.A. Olusile2, A.O. Oginni2 and T.A. Esan2
- Department of Dental and Maxillofacial Surgery, University of Abuja Teaching Hospital, Abuja, Nigeria
- Department of Restorative Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
- Department of Restorative Dentistry, Faculty of Dentistry, University of Ibadan, Oyo state, Nigeria
Background: High success rate has been reported widely with conventional endodontic. When failure occurs, re-treatment alone or with surgical endodontics is the recommended treatment.
Objective: To compare the treatment outcome following apicectomy techniques, apicectomy with and without retrograde root – end filling.
Methods: Fifty three patients presenting with clinical and radiological evidence of pulpal and periapical pathology >5mm that will require apicectomy were randomly recruited into the study groups A or B over a period of 12 month. In group A apicectomy was performed without root – end filling and in group B apicectomy was performed with root – end filling. Patients were recalled 12 months and assessed clinically and radiologically.
Results: 35 out of 53 recruited patients reported for 12 month re-call visit. Two were excluded because of missing baseline radiographs. 33 patients that reported at 12months recall visit with complete radiographs were used for analysis. Patients age ranged from 16 – 66 years, with those in age group 21 – 30 years predominant, Majority (57.6%) were males. Forty teeth were treated, 14 had root – end filling and 26 without root – end filling. Maxillary incisors were the most frequently apicectomized teeth. 32 (80%) out of 40 apicectomized teeth were successful, 14 (88.5%) out of 26 teeth treated without root end filling were successful, while 9 (64.3%) out of 14 teeth treated with apicectomy with retrofil were successful.
Conclusion: Though apicectomized teeth without root-end filling had a higher percentage of success it was not statistically significant (p=0.15).
Dr. I.M.F. Abiodun-Solanke
Department of Restorative Dentistry,
Faculty of Dentistry,
University of Ibadan,
Oyo state, Nigeria
Apicectomy is the excision of the apical portion of the tooth and the attached soft tissues during periapical surgery.1 It is the most common surgical endodontic therapy procedure, it often involves periapical curettage, root-end resection, root-end preparation and root-end filling2. Endodontic therapy is performed to maintain pulp vitality or treat necrotic pulp to maintain the tooth in the arch, thereby maintaining arch integrity.
Despite high success rates of conventional endodontic approach, failures still occur due to inadequacies in cleaning, shaping, obturation, iatrogenic events and loss of coronal seal. When failure occurs, re-treatment rather than extraction of teeth has been advocated. Re-treatment usually involves conventional (nonsurgical) or surgical endodontic approach.3
When appropriate, conventional, nonsurgical retreatment efforts are directed to target deficiencies or repair of pathogenic and iatrogenic defects. Nonsurgical management of endodontic failures have recorded high success rates and is favored due to less discomfort and morbidity in comparison with periradicular surgery.4 However, when periradicular lesions with diameter>5mm4 are present, lower success rates have been recorded with non-surgical approach. Surgical endodontic management of periradicular lesions is resorted to when conventional endodontic therapy is not indicated, impossible or unsuccessful5. Traditionally, apicectomy procedure involves placing a root-end filling following apical resection which is favored by some authors, 6,7,8 while others9,10 support adequate cleaning and obturation of the canal, followed by apical resection without root-end filling as the treatment of choice. However, evidence in support of both schools of thought remains equivocal. The aim of this prospective study therefore was to compare the treatment outcome following the two apicectomy techniques: apicectomy with and without retrograde root-end filling, with a view to evaluate the technique with better prognosis.
PATIENTS AND METHODS
This was a prospective study of consecutive patients presenting at the Dental Hospital of the Obafemi Awolowo University Teaching Hospitals Complex,(OAUTHC) over a period of 12 months. Teeth with pulpal and periapical pathologies (with periradicular lesions >5mm), either as primary endodontic treatment or following failure of conventional endodontic treatment or retreatment were recruited into the study. However teeth with obliterated or blocked canals that would not allow conventional cleaning and obturation were excluded; so also were patients with any systemic conditions that would contraindicate surgery or would need special precautions. The study was approved by the Ethical and Research Committee of the OAUTHC and informed consent obtained from participants. All the fifty three patients that met the inclusion criteria and who presented within the 12 month study period were randomly assigned to either treatment group A (Apicectomy without root-end filling) and group B (Apicectomy with root-end filling) using simple random sampling technique. The patients were treated under local anesthesia using 2% lignocaine hydrochloride with 1: 80,000 adrenaline. Canals were accessed through a coronal access cavity in all cases and conventional canal debridement performed using K-type reamers and files. In cases of failed conventional root canal treatment, inadequately obturated canals, old canal obturations were removed and canal cleaning repeated. During instrumentation, canals were irrigated with 5.25% sodium hypochlorite solution.
After canal instrumentation and irrigation, surgical procedures were performed with apical access via full mucoperiosteal tissue flap. The undermining elevation flap reflection technique was used. Care was taken during tissue retraction to position and maintain the periosteal retractors on cortical bone. Generally, the cortical bone overlying the apical lesion was removed with burs at high speed using brush stroke approach under continuous normal saline irrigation until the apex of the tooth was exposed. However, in four cases, bone cutting using burs was not required because bone overlying the root apices were completely destroyed with root exposure. Curettage was accomplished with curved surgical bone curettes. Root-end resection was performed with high speed burs, with about 2 mm of resection at an angle of about 45degrees to the buccal surface for good canal visibility and access5.
For those in group B, (apicectomy with root-end filling), a small oval root-end cavity preparation was created using diamond burs, irrigated copiously with normal dried and root-end filling of Super- (ethoxybenzoic acid) EBA was placed within the cavity. Any excess or spilled over material was removed. After setting, a fine diamond bur was used to polish the filling and the apical surface. Reflected tissues were reapproximated to their original positions after irrigation and hemostasis was achieved. Tissues were compressed, stabilized and sutured with non-absorbable 3/0 black silk suture. Coronal access cavities were lined with glass ionomer cement and restored with composite.