Untoward Outcomes and Solutions Flashcards
Diseased Outcome:
■ Solution Options:
(4)
■ Extraction
■ Non-surgical Retreatment
■ Surgical Retreatment
■ Monitoring ?
Monitoring DISEASE is a NON OPTION:
“Supervised Neglect”
(2)
- Can be a basis for Legal Action
- Patient may decline TX recommendations*
Not all periapical lesions are active disease
(3)
-Is the lesion still healing, or growing larger?
-Symptomatic or asymptomatic?
-Is the lesion larger on CBCT than the PA shows?
When in doubt, refer!
Patient may select EXT over any Recc.
(3)
- Lost Faith or Fear of Additional Fees/Failures
- Weary of Unresolved Issues / Definitive Solution
- May be the High Prognosis Optio
Extraction:
Always preferable to retain healthy natural tooth for life:
(4)
■ Most Efficient Chewing
■ Normal biting force and sensation
■ Natural appearance
■ Protects other teeth from excessive wear or strain
Sometimes Extraction is the only solution - or
■ Patient may demand EXT following unsuccessful initial RCT
■ Educate* – Don’t argue
Concentrate on Replacement
(3)
■ Implant
■ FPD
■ RPD
No replacement has a— either!
100% success rate
Non-surgical Retreatment
■ A RCT tooth may not heal as expected
for a number of reasons:
(3)
■ Complicated, undetected, or untreated canal
anatomy
■ Delay in placement of definitive coronal
restoration
■ Inadequate previous RCT or Leaking coronal
restoration
New problems:
(3)
■ New decay
■ Loose, cracked, or broken restoration
■ Tooth or root fracture
If you are going to be successful in
solving the problem, you first must
determine exactly the — of
the problem *
etiology
AAE suggests that — should generally
be the first option considered
NSRT
NSRT Prognosis is generally poorer than
1st RCT
■ Failure rate of endodontic re-treatment was 16.6%
- R. B. Pekruhn, “Incidence of RETX Failure” JOE, ‘Feb ’86 P70
■ Overall Success Rate for ReTX was 65% with An
Additional Category of Uncertain (18.3%)
■ 90+% v. 60-75 %-?: You call it
■ Endodontist’s experienced best GUESS
REFER
MOST*
RETX
—% retention after 5 years
89%
Non-surgical Retreatment:
Technique
■ Problem must be identified:
(3)
■ Is it tooth or root FX? (? - hopeless)
■ Missed canal
■ Inadequate previous RCT
- Cleaning & Shaping
- Obturation
— must be done to provide access to previous
obturation material
Deconstruction
GP must be softened to facilitate removal of obturation material
■ GP – soften with (2)
■ (3)
■ (3) difficult or impossible to remove
■ All Problems discovered/confirmed
■ All Deficiencies must be corrected & Success documented by recall
solvents . . . or heat
Chloroform, Eucalyptol, Rectified spirits of Turpentine
Thermafil, insoluble pastes & Silver Points
Some NSRT cases may be done by skilled &
trained generalist
■ Obvious, correctable problem
■ Within your competence level
■ Most should be referred
Surgical Retreatment
■ Indications:
■ NSRT is completed & problem not resolved
■ Problem not accessible to NSRCT
■ Root Perforations or Resorptive Defects
■ DX Experimental Flap Procedure for VRF identification
■ Marked overextension of obturating material interfering with
healing.
■ Biopsy of suspect lesion
■ Separated Instrument not treatable by NSRT
■ Other blockages untreatable by NSRCT e.g. Ledges,
Transportations and Zips
■ Non-negotiable canals may be retrofilled (MTA)
Extraradicular
Biofilm
(2)
■ Sometimes biofilm has
matured so much that it
grows beyond the apex
or lateral canals and
onto the root surface
■ Disinfecting the canal
will not reach these
bacteria and disease
can persist
Endodontic Micro-surgery:
A clinical procedure intended to remove the root
tips, place a biocompatible material, and remove
the associated diseased soft tissue
A clinical procedure intended to remove the root
tips, place a biocompatible material, and remove
the associated diseased soft tissue
This procedure is referred to as
“Apical Curettage”
(Not often done by itself – followed by RETROFILL)
Most Endodontists today would think it prudent to follow-up
apical curettage @ time of surgery by removing and beveling
root tip and insuring an obturation seal by placing a “retrofill” to
seal the canal. — appears to be the current material of choice
for the retrofill
MTA
This procedure is termed “Apical Resection and
Retrofill”
Most Endodontists today would think it prudent to follow-up
apical curettage @ time of surgery by removing and beveling
root tip and insuring an obturation seal by placing a “retrofill” to
seal the canal. MTA appears to be the current material of choice
for the retrofill
“Apical Resection and Retrofill”
Desired result is a
regeneration of normal tissues
and architecture in the area of surgical intervention
AAE Illustration AAE Illustration
Stated another way: Endodontic Micro-
Surgery (Periapical Surgery) is
generally:
A procedure most commonly done to
remove …
— obturation appears to be
adequate but no healing following
reasonable time is an indication for
— obturation
If the tooth is asymptomatic and the
peri-radicular defect is not persistent
(i.e. healing proceeding within
reasonable parameters), surgery is
not indicated unless …
persistent peri-radicular
disease following apparently
adequate endodontic treatment.
Orthograde, Retrograde
reasonable follow-up is exceeded (>24 months)
Further:
OR: a procedure that is done when
conventional endodontics cannot
reasonably be performed or
conventional endodontics has failed
and conventional RETX would be
prohibitively difficult
OR: a procedure that is done when
conventional endodontics cannot
reasonably be performed or
conventional endodontics has failed
and conventional RETX would be
prohibitively difficult.
AAE states that Non-Surgical Retreatment
(NSRT) is the preferred first course of
action for a non-healing RCT if feasible.
BUT
RETX cases with easiest access to
apex via surgery may be chosen as most
reasonable course of action
Surgical Retreatment
CONTRAINDICATIONS
■ Dangerous Proximity to anatomical entities
(ie) neurovascular bundles, IA canal
■ Extreme thickness of cortical plate
■ Periodontally involved teeth
(2 disciplines involved: ? Prognosis of outcome)
■ Lack of Training, Skills, Equipment, Materials or Time
■ Inability to manage possible complications
■ Patient health considerations (ie) active leukemia, neutropenia, uncontrolled
diabetes, bleeding considerations, on meds such as anticoagulants, recent MI
■ Pregnant and in first trimester
■ Better prognosis from alternate TX option (Implant?)
— is
prohibitively
thickened in
some cases,
making
access,
visibility and
hemostasis for
retrofilling
difficult if not
impossible
22
Buccal shelf
skipped
Pre surgical case
assessment
■ Is there a better option for this patient?
■ Why propose Endodontic Micro Surgery?
■ What’s the Prognosis?
■ If RETX, what is the etiology of failure?
■ Has tooth been restored properly?
■ If not, Can it be? If not, why try to save it?
■ Is tooth periodontally sound?
■ Is tooth surgically accessible?
■ Is the tooth strategic and functional?
■ Will patient’s health allow surgery
■ Is patient on board with TX selection/limitations?
■ Are you competent & prepared
■ Would REFERRAL serve the patient’s BEST
INTERESTS***
Surgical Technique
■ Anesthesia
■ Elevation of Flap
■ Location of apical lesion
■ Osteotomy & Curettage
■ Root bevel & hemostasis
■ Retrofill preparation and filling
■ Suturing and PO instructions
Anesthesia & Hemostasis
■ (4)
■ (anesthetic) IF not CI’d,
infiltrated into papilla + regional block. (J
Bahcall, DT Aug ’04 p72>)
■ — also enhances profoundness of LA
“DM/MCP”, Little, 4th ed, p 172 (we produce .007-.014mg
epi/min in unstressed state-@what is in 1carp of LA,w 1/100K.)
If one is stressed, epi can go to @—mg/min!!!
■ Epi for — is a MUST! If epi is contra-
indicated by patient’s MD, do not do surgery
Articaine vs Lido vs Carbo vs Marcaine
PLUS Lido 2% w epi 1:50
Epi
.3
Hemostasis
Apical Root Resection
How much to resect-
This area contains greatest
# of (3)
- S Kim “Principles of Endo Surgery”
DCNA ’97;41:481-497
Create a – bevel so the
canal can be visualized &
accessed. – speed
(1000-1500 rpm)– NOT —. Use sterile saline
drip to ..
3mm.
deltas, isthmuses and iatrogenic blockages
45º
Low
air turbine
cool during osteotomy & resection
Hemostasis and
Identification
■ Control of — is paramount! You must
see what you are doing.
■ (5) for bleeders.
■ Crypt management
bleeding
CaSulfate,, Hemodent, Astringodent,
*Racemic Epinephrine, maybe Electrosurg
Unit
Telfa sponges w Hemodent
Root End preparation: How deep to retro fill?
■ Mattison, et al concluded that a minimum of — *of
amalgam significantly reduced apical leakage
3mm
For that matter, any retro filling material should be AT LEAST
—. into the canal space. This instrument design allows us to
create — of space to retain the material and provide an
adequate seal.
■ Amalgam, SEBA, Geristore have been used for retrofill. —
is now the material of choice*
3mm
3-5 mm
MTA
Apical Retroprep
Removal of Gutta
Percha with —
Establishment of
parallel walled root end
preparation at least —
mm deep.
Ultrasonic
3
These are apical micro-carriers
(similar to an amalgam carrier)
Used to
pick up and deliver the
mixed MTA to the apical
retroprep.
The MTA has been
delivered to the
apical retroprep and
now, an instrument is
used to —- the
MTA in the prep.
compact
Finishing up
■ Surgical area is Cleaned and Inspected and then —
■ Patient should be — evening of surgery to see “how well they
are doing”
■ Post-op patient & suture removal prn (– days)
Sutured
called
5
POST-OP Instructions:
■ Use
■ If XS bleeding occurs,
■ Pain is usually 3/10. 3
■ Soft diet for – days
■ Do not smoke for – days>surgery
■ Suture removal prn & POT check in – days!
ice pack 20” on, 5”off for 1st day to reduce P&S, warm
saline rinses qid 2nd day
place a wet tea bag over incision 15” to
stop bleeding
IBU Q4H + narcotic RX if necessary. If XS
pain occurs, call office
3-4
3
5
At UMKC-SOD
■ Opportunities poor for Endodontic Surgery in Undergraduate
■ Grad. Endo. does all EMS at UMKC
■ This presentation is designed to acquaint you with the
surgical opportunities available as well as little about the
technique.
■ Try to assist/observe in Grad. Endo. during Surgery
■ With additional training, general dentists may choose
to do less complicated apical surgery in their
practice.
