Tratamiento del tejido blanco en cirugía endodóncica / Soft tissue management in endodontic surgery

La cirugía endodóncica moderna incluye tanto la preparación del ápice como el correcto sellado de todas las foraminas apicales. Ambos componentes son requerimientos para el éxito mecánico y biológico, pero el tratamiento de los tejidos blandos se ha hecho cada vez más importante para conseguir un tratamiento estéticamente satisfactorio. Unos tejidos blandos sanos juegan un papel importante en el resultado estético de la cirugía periradicular. Esto es cierto en cuanto al mantenimiento de los niveles de inserción y la cantidad de posible recesión después de los procedimientos quirúrgicos. La completa curación, predecible y sin recesiones, del tejido blando es un objetivo importante del tratamiento quirúrgico endodóncico. Una revisión crítica de las técnicas empleadas en la actualidad, basado en datos clínicos y científicos revela un gran potencial de mejora. Se subrayan las posibles razones de la formación de cicatrices y recesión específicamente en patologías de origen periodontal que requieren el tratamiento con cirugía periapical. Se evalúan varios tipos de incisión y se hacen recomendaciones, basándose en consideraciones anatómicas. Una comprensión clara de como se produce el cierre de la herida y los patrones de cicatrización llaman al uso de procedimientos atraumáticos, tejidos de sutura no irritantes y técnicas de sutura adecuadas. Este artículo da una visión global y guías para integrar los diseños de colgajos y métodos de cierre de heridas actuales y algunos también nuevos, que se han mostrado exitosos. Los métodos descritos tienen la intención de mantener el nivel de inserción y evitar la recesión postoperatoria tras el tratamiento quirúrgico endodóncico

Modem endodontic surgery involves both root-end preparation and proper sealing of all apical portals of exit. Both components are requeriments for mechanical and biological success, but the management of soft tissues becomes increasingly important for an esthetically successful treatment. A healthy appearance of soft tissues plays an important role in the esthetic outcome of periradicular surgery. This is true considering maintenance of attachment levels and regarding the amount of possible recession after surgical procedures. Complete, recession-free and predictable healing of gingival tissue is one important goal of endodontic surgical treatment. A critical review of currently used techniques based on clinical and scientific data reveals great potential for improvements. Possible reasons for scar formation and recession specifically in healthy periodontal conditions requiring surgical endodontic intervention are highlighted. Based on anatomical considerations various incisions types are evaluated and recomendations made. Clear understanding of wound closure and tissue-healing patterns call for the use of atraumatic procedures, nonirritating suture materials and adequate suturing techniques. This article gives and overview and guidance for integrating current and new successful flap designs and wound closure methods. The methods described have the intention of maintaining the attachment level and avoiding postoperative recession after surgical endodontic therapy

Comparison of long-term papilla healing following sulcular full thickness flap and papilla base flap in endodontic surgery.

AIM: To compare long-term loss of papilla height when using either the papilla base incision (PBI) or the standard papilla mobilization incision in marginal full thickness flap procedures in cases with no evidence of marginal periodontitis. METHODOLOGY: Twelve healthy patients, free of periodontal disease, who had intact interdental papillae were referred for surgical treatment of persisting apical periodontitis and included in the study. The flap design consisted of two releasing incisions connected by a horizontal incision. The marginal incision involved the complete mobilization of the entire papilla in one interproximal space but in the other interproximal space the PBI was performed. Further apically a full thickness flap was raised. Following flap retraction, standard apical root-end resection and root-end filling was performed. Flap closure was achieved with microsurgical sutures. The PBI was sutured with two to three interrupted sutures (size 7/0), the elevated papilla was reapproximated with vertical mattress sutures (size 7/0), which were removed 3-5 days after the surgery. The height of the interdental papilla was evaluated preoperatively and postoperatively after 1-, 3- and 12-month recall using plaster replicas. The loss of papilla height was measured using a laser scanner. Papilla paired sites were evaluated and statistically analysed. RESULTS: Most papilla recession took place within the first month after the surgery in the complete elevation of the papilla. Further small increase in loss of papilla height resulted at 3 months. After 1 year the loss of height diminished to 0.98 +/- 0.75 mm, but there was no statistical difference between the various recall intervals. In contrast, after PBI only minor changes could be detected at all times. There was a highly significant difference between the two incision techniques for all recall appointments (P < 0.001). CONCLUSIONS: In the short as well as long-term the PBI allows predictable recession-free healing of the interdental papilla. In contrast, complete mobilization of the papilla displayed a marked loss of the papilla height in the initial healing phase although this was less evident 1 year postoperatively. In aesthetically relevant areas the use of the PBI is recommended, to avoid opening of the interproximal space, when periradicular surgical treatment is necessary.

Comparison of papilla healing following sulcular full-thickness flap and papilla base flap in endodontic surgery.

AIM: To compare the loss of papilla height when using the papilla base incision (PBI) or the standard papilla mobilization incision in marginal full-thickness flap in cases with no evidence of marginal periodontitis. METHODOLOGY: Twelve healthy patients referred for surgical treatment of persisting apical periodontitis, who were free from periodontal disease and had intact interdental papillae, were included in the study. The preoperative papilla height was recorded by measuring the distance between a reproducible coronal point on the tooth and the most coronal point of the papilla. The flap design consisted of two releasing incisions connected by a horizontal incision. The marginal incision involved the complete mobilization of the entire papilla in one interproximal space, and the PBI in the other interproximal space. The PBI consisted of a shallow first incision at the base of the papilla and a second incision directed to the crestal bone creating a split thickness flap in the area of the papilla base. Further, apically, a full-thickness flap was raised. In the other interproximal space, the buccal papilla was carefully incised and elevated completely. Following flap retraction, standard root-end resection and root-end filling were performed. Flap closure was achieved with microsurgical sutures. The PBI was sutured with two to three interrupted sutures (size 7/0) and the elevated papilla was reapproximated with vertical mattress sutures, which were removed 3-5 days after the surgery. The height of the interdental papilla was evaluated preoperatively and postoperatively after 1 month and at the 3-month recall, using plaster replicas. The loss of papilla height was measured using a laser scanner. Twelve papilla-paired sites were evaluated. The results were statistically analysed using the t-test. RESULTS: Complete closure of the wound was achieved in all treated sites followed by uneventful healing in all patients. The total mobilization of the papilla resulted in loss of papilla height of 1.10 +/- 0.71 mm at 1 month and 1.25 +/- 0.81 mm at the 3-month recall. At the 3-month recall, the retraction had increased in nine sites, whereas in three sites, the loss of height had slightly diminished compared to 1 month. In contrast, after the PBI, only minor changes could be detected: 0.07 +/- 0.09 mm at 1 month and 0.10 +/- 0.15 mm at 3 months. There was a significant difference between the two incision techniques studied (P < 0.007). CONCLUSIONS: In patients with healthy marginal periodontal conditions, the PBI allows rapid and predictable recession-free healing, whereas complete mobilization of the papilla led to a marked loss of the papilla height. In aesthetically relevant areas, the use of the PBI is recommended, to avoid opening of the interproximal space, when periradicular surgical treatment is necessary.

Papilla base incision: a new approach to recession-free healing of the interdental papilla after endodontic surgery.

AIM: The purpose of the present study was to describe and evaluate a new incision technique: the papilla base incision. METHODOLOGY: Twenty healthy patients referred for surgical treatment of persisting apical periodontitis, who were free of periodontal disease and had intact interdental papillae were included in the study. The preoperative papilla height was recorded by measuring the distance between the contact point and the most coronal point of the papilla. The papilla base flap, consisting of the papilla base incision and two releasing incisions, was used to expose the bone. The papilla base incision consisted of a shallow first incision at the base of the papilla and a second incision directed to the crestal bone, creating a split thickness flap in the area of the papilla base. Further apically a full thickness flap was raised. Following standard root-end resection and filling, flap closure was achieved with microsurgical sutures. The papilla base incision was sutured with 2-3 interrupted sutures, which were removed 3-5 days after the surgery. The experimental sites were evaluated at the conclusion of the surgery, at suture removal and after 1 month, and compared to the preoperative findings. The healing pattern, complications and postoperative recession were recorded. The experimental sites were observed with a x 3 magnification and graded as to whether a visible scar resulting from the incision could be detected. Twenty experimental sites were analysed. RESULTS: Complete closure of the wound was achieved in all cases after surgery. Except for four patients with delayed healing at suture removal, all other patients displayed rapid healing. No noticeable space was created beneath the contact point area. The change in distance between the reference point and the most coronal point of the papilla comparing the preoperative and the one-month postoperative situation was 0.05 +/- 0.39 mm. The probing depth remained within normal limits. One month postoperatively, observation of the incision demonstrated: four sites with a visible incision line (grade 1), in seven sites the incision defect could be partially detected (grade 2) and nine incisions could not be detected (grade 3). CONCLUSIONS: In patients with healthy marginal periodontal conditions the papilla base incision allows rapid and predictable recession-free healing following marginal surgical exposure of the soft tissues. One month postoperatively the majority of the incisions were completely or partially invisible. Long-term healing will be studied.

Detection of the apical lesion and the mandibular canal in conventional radiography and computed tomography.

OBJECTIVE: The purpose of this study was to compare the information gathered from dental radiography and high resolution computed tomography (CT) scans with regard to the detection of the endodontic lesion and its relation to the important neighboring anatomic structures such as the mandibular canal. STUDY DESIGN: Fifty patients with a persistent apical lesion referred for endodontic surgery were selected. The teeth involved were 6 mandibular premolars and 44 mandibular molars. Eighty roots were evaluated. For each case 1 CT scan and 1 periapical radiograph were taken. The apical lesion and the mandibular canal were evaluated for possible identification in CT scan or radiograph. The presence of the lesion was correlated to the findings during the surgical procedure. The CT scans of the involved roots were further evaluated with regard to the bone thickness and differentiation between cancellous and cortical bone. The position of the lesion/root within the mandible was studied in all dimensions. RESULTS: All 78 lesions diagnosed during surgery were also visible with the CT scan. In contrast, only 61 of the lesions were noted by conventional radiographs. The mandibular canal could be identified in 31 cases in dental radiographs, whereas in the oblique cuts of the corresponding CT scans the mandibular canal was detected in all patients. The amount of cortical and cancellous bone and the bone thickness as well as the three-dimensional extent of the lesion could only be adequately interpreted in CT scans. CONCLUSIONS: The use of CT provides additional, beneficial information not available from dental radiographs for treatment planning in apical surgery of mandibular premolars and molars. When the mandibular canal cannot be detected in dental radiographs or is in close proximity to the lesion or root apex, CT should be considered before endodontic surgery. The presence, extent, and location of the lesion and its relation to the mandibular canal can be predictably evaluated in a CT scan of the area.

[The cleaning effect of different root canal instruments. A semiquantitative comparative study]. / Die Reinigungswirkung verschiedener Wurzelkanal-Instrumente. Eine semiquantitative Vergleichsstudie.

The efficacy of various root canal cleaning instruments was evaluated in this in vitro study. 60 freshly extracted teeth were divided into 6 groups of 10 teeth each. The root canals of the teeth were cleaned with hand-instruments, sonic instruments (Sonic Air 3000 and Endostar 5), mechanical instruments (Canalfinder System), and ultrasonic instruments (Cavi-Endo with or without integrated rinsing) according to the manufacturer's instructions. The canals were then examined in a SEM at 60 selected points to assess the presence or absence of smear layer, dentin chips, and cellular remnants. The smoothness of the canal walls was also evaluated. Similar amounts of tissue remnants were scored by the SEM method. None of the instruments tested were able to produce debris-free specimens. The Cavi-Endo, Endostar 5, Sonic Air 3000, and the hand-instruments yielded similar scores. However, the Endostar 5 cleaned the canals quicker and with fewer problems than the other instruments. The efficacy of the integrated rinsing in the Cavi-Endo must be questioned. The smear layer was somewhat reduced by the Cavi-Endo, using a syringe and needle, but without the integrated spray. The Canalfinder System produced poorer cleaning scores but they were not significantly different from the other instruments' scores.