The advent of predictable implant technology has challenged endodontists to adopt more techniques into their armamentarium. Endodontists need to be able to provide high quality predictable treatments. Gone are the days of the clumsy apicectomy and amalgam retrograde fillings. Like all other aspects of endodontics, endodontic surgery has now evolved to become a technically accurate, highly predictable procedure. It has changed so radically that we no longer call the procedure an apicectomy, rather endodontic microsurgery.
We use high power microscopes, small volume CBCT scans for planning, micromirrors, ultrasonics retrograde tips and MTA. It is a shame that it is considered so infrequently as a treatment option as the success rates are remarkable. It is well established the excellent success rates that implant therapy enjoys. What may surprise some readers is that endodontics enjoys equally successful outcomes as implants.
A study by Iqbal & Kim in 2007 analysed 23,000 root canal treated teeth over a median time span of 8 years and 12,000 implants over a median time span of five years. They concluded that the decision to place an implant or save a tooth endodontically should be based on criteria other than outcome as both enjoy similar outcomes. With the advent of implant technology, many teeth of questionable prognosis are now extracted in the name of future predictability. Implants are a wonderful adjunct in the dental armature, and rightly so, however our primary role as dentists is to try and conserve the existing dentition that has a good long-term prognosis. Dentists rely on a limited number of heuristic principles which reduce the complex task of assessing probabilities and predicting outcome to simplify judgemental operations. These heuristics can be useful but sometimes can lead to poor decision making. A lack of understanding of endodontics can result in lazy ideals such as if a post is present the tooth will fail ultimately, so therefore the tooth should be extracted now. Case selection, however as always is key.
The decision to restore a diseased tooth with endodontic treatment or to extract the tooth and replace it with implant restoration might be influenced by the clinician’s proficiency and clinical background. Bader & Shugars reported on this phenomenon in the restorative literature. We also know if the options are explained to the patient in a biased manner then the patient is likely to chose that option. We have a responsibility as clinicians to present all the options to our patients in a non-biased way and work closely with other members of the dental team who can help cover areas where ours skills, experience and interests may not be at the cutting edge.
Classically an apicectomy was a treatment of last resort, using large bulky instruments, rough approximations and sometimes excess amounts of amalgam. The biological ramifications of additional canals, cracks, apical deltas and poor initial root canal treatments may have been overlooked resulting in poor success rates. This has understandably resulted in a negative perception associated with apical surgery amongst the dental profession, with many clinicians not even considering this as a treatment option. When we do lectures or treatment planning sessions the perception of success rates of an apicectomy is around 50 per cent.
The actual success rate for endodontic microsurgery (or so called new age apicectomies) is over 91 per cent after five-seven years. Modern techniques using state of the art equipment has transformed the procedure. Using CBCT scans from the outset we can plan exactly how the surgery will be executed. The three dimensional picture of the bone loss is clear. The position of anatomically sensitive structures is obvious. Lengths can be accurately measured. A better assessment of existing treatment can also be made. Posts can be assessed to ensure they are centered in the canal, and MB2’s can be assessed to ensure they have been identified and treated at the outset.
So in summary endodontic surgery is more predictable now than it ever was and provides an avenue for patients to retain their teeth as opposed to extracting and placing a dental implant.
Daniel is a specialist in Endodontics and will be speaking about Endodontic Microsurgery on behalf of the British Endodontic Society at the BDA conference in Manchester on the 26th of May 2017.