Retreatment vs. Surgical Intervention
the years, endodontic research has reported a wide range of success
rates, some as optimistic as 90% for all cases. In reality, while
well instrumented and obturated vital cases enjoy a high success
rate, the long term success for other cases is lower. Teeth with
pre-operative necrotic pulps and well developed apical lesions
have a lesser prognosis and may eventually require surgery.
In the late 1980's and
early 90's advances in the use of the surgical operating microscope
(SOM) by endodontists resulted in a proliferation of surgical
cases. We were now able to visualize resected root surface anatomy
and accurately place retrofilling materials into small preparations
made with new generation ultrasonic instruments and micro mirrors.
Even with advances in endodontic surgical techniques, surgery
cannot fully eliminate bacteria and their by-products from the
root canal system. If surgery is performed and the root canals
are not clean, the prognosis is compromised. The most advanced
microsurgical instruments are only capable of retroprepping into
the canal space to a depth of 3-4 millimeters. That combined with
various retrofilling materials may not provide the seal necessary
to withhold the future apical leakage of bacterial by-products.
development of surgical microinstruments led to the evolution
of microinstruments that could be used within canal spaces. Needless
to say, with regard to the microscope and microinstruments, the
cart came before the horse. The incidence of surgical intervention
is lower now than ten years ago. Retreatment aided by intracanal
microinstrumentation offers the opportunity to address anatomical
complexities or iatrogenic problems such as perforations and broken
instruments that were not managed initially.
The two factors generally
responsible for endodontic success are: (1) management of complex
root canal system anatomy and (2) prevention of post endodontic
orthograde microleakage. Endodontic surgery as a treatment option
will not be successful unless these two factors are addressed.
Consider non-surgical retreatment
first unless exploratory surgery for diagnostic reasons is the
goal or disassembly of the existing restoration (i.e. crown, core,
and post) would be impractical.
As always, evidence based
treatment planning with proper informed consent and prognosis
will be the foundation for the treatment of choice.
ENDODONTICS 488 EAST VALLEY PARKWAY SUITE 307 ESCONDIDO, CA 92025
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