[2] After removing the pulp, the aim of endodontic treatment is to seal the pulpal space to prevent further bacterial contamination and allow healing of the periradicular tissue.
[4] If re-root treatment is not possible, will not correct the problem or patient factors prevent it, periradicular surgery is indicated.
A biopsy may be used in suspicious or non-healing lesions, or when a patient has uncharacteristic signs and symptoms in periapical areas.
The lack of appropriate surgical access to the site contraindicates periradicular surgery; cutting the gum near important anatomical structures, such as neurovascular bundles, risks permanent jaw numbness.
Oral hygiene and overall dental condition indicates the patient's motivation for treatment and the tooth's restorative prognosis.
Cortical bone thickness, regional anatomy, and root fracture or resorption indicate possible difficulties.
[11] Special investigations include radiography, vitality testing of adjacent teeth and an occlusal loading assessment.
The relationship of the tooth to neighbouring structures (the inferior dental nerve, mental foramen and maxillary sinus) or to adjacent roots must be noted, to anticipate operative complications and inform the patient.
The main methods are: Bleeding in the bone is also affected by the local anaesthetic's vasoconstriction and topically-applied agents.
Full mucoperiosteal flaps involve an intrasulcular horizontal incision with reflection of the marginal and interdental gingival tissue.
The first horizontal incision follows the contours of the tooth, cutting the gingival sulcus (including the mesial or distal papilla.
[13] Limited mucoperiosteal flaps have a submarginal horizontal or horizontally-oriented incision, and do not include marginal or interdental tissues.
[13] Before closing the wound, it should be well-irrigated (to prevent infection) and the flap compressed to reduce the risk of haematoma.
Haemorrhaging may be prevented with adequate haemostasis, essential to improve visualisation of the site (minimising operating time and providing an optimal environment for placing filling materials.
[17] Prevention of infection is promoted by advising the patient to maintain oral hygiene and the use of an antiseptic mouthwash, such as chlorhexidine, immediately before and after surgery.
[2] Since a range of benchmarks has been used to assess the outcome of periradicular surgery,[18] comparisons are challenging; the classification most published papers adopt is by Rud et al,[19] which evaluates success radiographically.
[22] Careful evaluation of root canal filling material is required to optimise healing after the procedure.
[23] Calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) are considered more suitable, since they enhance periradicular tissue regeneration.
[23] Although it prevents leakage and is biocompatible, it has questionable antibacterial properties,[22] a long setting time (about three hours), manipulates poorly and is expensive.
[24] CEM cement is superior to MTA as a root-end filling material; it has greater antibacterial effects, a shorter setting time, less film thickness and a smaller particle size.