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Apicoectomy and retrograde amalgam in mandibular molar teeth
Apicoectomy and retrograde amalgam in mandibular molar teeth Melvyn
H. Harris,
D.M.D.,*
Boston, Mass
BOSTON UNIVERSITY The apicoectomy with retrograde amalgam is an excellent and accepted surgical technique for salvaging teeth. Anatomic considerations in molar teeth are not a contraindication to this technique.
T
he apicoectomy with retrograde amalgam is a well-established and accepted surgical technique. It is most often indicated for salvaging teeth which have previously, but unsuccessfully, been treated by conventional, nonsurgical, root canal therapy. In addition, the technique is often indicated as the primary method of treatment when nonsurgical endodontics is either not possible nor expedient. Some examples are a broken instrument in the canal; calcified canals; tortuous, malformed, or inaccessible canals; perforations; and posttype crown restorations. There are many references in the literature regarding periapical surgery in molar teeth. Unfortunately, most are of a negative nature when referring to mandibular molars. Most often cited as a contraindication is the potential damage to the inferior alveolar neurovascular bundle. The technique of extraction, retrograde filling, and replantation has been advocated as a substitute for periapical surgery. However, the difficulty in extracting molar teeth intact and atraumatically, along with the total disruption of the attachment apparatus, decreases the percentage of success considerably. Successfully replanted teeth have a rather short life-span, since resorption of the root frequently takes place and the tooth is eventually resorbed and rejected. In addition, these teeth often become ankylosed as a result of the loss of the periodontal ligament. The purpose of this article is to dispel the misconception that the potential for nerve damage or excessive hemorrhage precludes the performing of mandibular molar retrograde surgery. I have had the opportunity to perform retrograde amalgam fillings on 327 mandibular first molars, 66 mandibular second molars, and 4 mandibular third molars. Of these teeth, there has been only one instance of nerve damage, which was of very short duration. In *Associate Clinical Professorof Oral Surgery.
CKI30-4220/79/110405+03$00.30/0
0
1979 The C. V. Mosby Co.
Fig. 1. Case I. Preoperativeradiograph demonstrating periapical radiolucency. Post precludes re-treating canal conserva-
tively. Patient had acute symptoms.
that particular case, a large cystic sac had formed at the apices of a mandibular first molar and had displaced and partially incorporated the neurovascular bundle. It was thought that removal of the cyst, rather than surgical exposure of the root apices, was the cause of the temporary nerve damage. There has not been one instance of excessive hemorrhage due to injury or rupture of the inferior alveolar vein or artery. The inability to retract the buccal tissues completely places limitations on the surgical approach to mandibular molars. These limitations require that the surgical exposure of the apices be from a somewhat superior approach rather than from a direct lateral approach. In addition, it is necessary to section roots at a bevel in order to expose the canals. The inferior alveolar nerve passes through the mandible below the root apices of the mandibular first and second molars. Therefore, it is not necessary to expose the neurovascular bundle; nor
406 Harris
Oral Surg. November, 1979
Fig. 2. Case I. Immediate postoperative radiograph.
Fig. 5. Case 2. Immediate postoperative radiograph.
Fig. 3. Case I. Radiograph taken 6 months postoperatively demonstrating bone regenerating.
Fig. 6. Case 2. Radiograph taken 6 months postoperatively. Note distal bone loss around mesial root of the first molar.
Fig. 4. Case 2. Preoperative radiograph demonstrating periapical radiolucencies of asymptomatic teeth treated several years ago by conservative endodontic means. The teeth involved were to be restored with new crowns.
Fig. 7. Case 2. Radiograph taken I year postoperatively. Mesial root of tirst molar removed because of vertical fracture.
Volume 48 Number 5
Apicoectomy
is it necessary to compromise root length sufficiently (as illustrated). Unfortunately, this is not true for mandibular third molars. However, the need to perform the procedure on a mandibular third molar is very uncommon, and in those rare instances has involved a tooth which was the key distal abutment of a bridge where the tooth had migrated anteriorly. Accordingly, the apices were not in proximity to the inferior alveolar nerve. Case selection is very important in the case of mandibular third molars, for two reasons. First, root length may have to be compromised in order to avoid the neurovascular bundle. Second, after the apicoectomy has been performed, the sealing of the canals can be difficult because of the complex nature of the root canal system. Third molars are frequently more variable; therefore, the beveling of the root may expose very fine anastomoses existing between the main canals. Further, these are very difficult to observe and/or seat. Unfortunately, in one of the four cases referred to here the situation was recognized only after failure and subsequent extraction.
and retrograde
amalgam
in mandibular
molars
407
The main purpose of this report is to encourage the surgical approach of apicoectomy with retrograde amalgam in mandibular molars. The indications should be the same as for anterior and premolar teeth. Anatomic considerations are not a contraindication to surgery in mandibular first and second molars. REFERENCES I. Edwards, T. S.: Treatment of Pulpal and Periapical Disease by Reimplantation, Br. Dent. J. 121: 159-166, 1970. 2. Goldsmith, L. P.: The Scope of Surgery in Endodontics, Dent. Dig. 76: 512-517, 1970. 3. Kingsbury, B. C., and Weisenbaugh, J. M.: Intentional Reimplantation of Mandibular Molars and Premolars, J. Am. Dent. Assoc. 83: 1053-1057, 1971. 4. Reed, J.: A Follow-up Study of One Thousand Cases Treated by Endodontic Surgery, Int. J. Oral Surg. 1: 215, 1972. 5. Ross, J. W.: Retrograde Root Filling in Oral Surgery, Trans. Congr. Int. Assoc. &al Surg. 4: 9%iO1, 1973. 6. Weine, F. S.: Endodontic Therapy, ed. 2, St. Louis, 1976, The C. V. Mosby Company. Reprint requests to: Dr. Melvyn H. Harris 665 Beacon St. Boston, Mass. 022 15
H. Harris,
D.M.D.,*
Boston, Mass
BOSTON UNIVERSITY The apicoectomy with retrograde amalgam is an excellent and accepted surgical technique for salvaging teeth. Anatomic considerations in molar teeth are not a contraindication to this technique.
T
he apicoectomy with retrograde amalgam is a well-established and accepted surgical technique. It is most often indicated for salvaging teeth which have previously, but unsuccessfully, been treated by conventional, nonsurgical, root canal therapy. In addition, the technique is often indicated as the primary method of treatment when nonsurgical endodontics is either not possible nor expedient. Some examples are a broken instrument in the canal; calcified canals; tortuous, malformed, or inaccessible canals; perforations; and posttype crown restorations. There are many references in the literature regarding periapical surgery in molar teeth. Unfortunately, most are of a negative nature when referring to mandibular molars. Most often cited as a contraindication is the potential damage to the inferior alveolar neurovascular bundle. The technique of extraction, retrograde filling, and replantation has been advocated as a substitute for periapical surgery. However, the difficulty in extracting molar teeth intact and atraumatically, along with the total disruption of the attachment apparatus, decreases the percentage of success considerably. Successfully replanted teeth have a rather short life-span, since resorption of the root frequently takes place and the tooth is eventually resorbed and rejected. In addition, these teeth often become ankylosed as a result of the loss of the periodontal ligament. The purpose of this article is to dispel the misconception that the potential for nerve damage or excessive hemorrhage precludes the performing of mandibular molar retrograde surgery. I have had the opportunity to perform retrograde amalgam fillings on 327 mandibular first molars, 66 mandibular second molars, and 4 mandibular third molars. Of these teeth, there has been only one instance of nerve damage, which was of very short duration. In *Associate Clinical Professorof Oral Surgery.
CKI30-4220/79/110405+03$00.30/0
0
1979 The C. V. Mosby Co.
Fig. 1. Case I. Preoperativeradiograph demonstrating periapical radiolucency. Post precludes re-treating canal conserva-
tively. Patient had acute symptoms.
that particular case, a large cystic sac had formed at the apices of a mandibular first molar and had displaced and partially incorporated the neurovascular bundle. It was thought that removal of the cyst, rather than surgical exposure of the root apices, was the cause of the temporary nerve damage. There has not been one instance of excessive hemorrhage due to injury or rupture of the inferior alveolar vein or artery. The inability to retract the buccal tissues completely places limitations on the surgical approach to mandibular molars. These limitations require that the surgical exposure of the apices be from a somewhat superior approach rather than from a direct lateral approach. In addition, it is necessary to section roots at a bevel in order to expose the canals. The inferior alveolar nerve passes through the mandible below the root apices of the mandibular first and second molars. Therefore, it is not necessary to expose the neurovascular bundle; nor
406 Harris
Oral Surg. November, 1979
Fig. 2. Case I. Immediate postoperative radiograph.
Fig. 5. Case 2. Immediate postoperative radiograph.
Fig. 3. Case I. Radiograph taken 6 months postoperatively demonstrating bone regenerating.
Fig. 6. Case 2. Radiograph taken 6 months postoperatively. Note distal bone loss around mesial root of the first molar.
Fig. 4. Case 2. Preoperative radiograph demonstrating periapical radiolucencies of asymptomatic teeth treated several years ago by conservative endodontic means. The teeth involved were to be restored with new crowns.
Fig. 7. Case 2. Radiograph taken I year postoperatively. Mesial root of tirst molar removed because of vertical fracture.
Volume 48 Number 5
Apicoectomy
is it necessary to compromise root length sufficiently (as illustrated). Unfortunately, this is not true for mandibular third molars. However, the need to perform the procedure on a mandibular third molar is very uncommon, and in those rare instances has involved a tooth which was the key distal abutment of a bridge where the tooth had migrated anteriorly. Accordingly, the apices were not in proximity to the inferior alveolar nerve. Case selection is very important in the case of mandibular third molars, for two reasons. First, root length may have to be compromised in order to avoid the neurovascular bundle. Second, after the apicoectomy has been performed, the sealing of the canals can be difficult because of the complex nature of the root canal system. Third molars are frequently more variable; therefore, the beveling of the root may expose very fine anastomoses existing between the main canals. Further, these are very difficult to observe and/or seat. Unfortunately, in one of the four cases referred to here the situation was recognized only after failure and subsequent extraction.
and retrograde
amalgam
in mandibular
molars
407
The main purpose of this report is to encourage the surgical approach of apicoectomy with retrograde amalgam in mandibular molars. The indications should be the same as for anterior and premolar teeth. Anatomic considerations are not a contraindication to surgery in mandibular first and second molars. REFERENCES I. Edwards, T. S.: Treatment of Pulpal and Periapical Disease by Reimplantation, Br. Dent. J. 121: 159-166, 1970. 2. Goldsmith, L. P.: The Scope of Surgery in Endodontics, Dent. Dig. 76: 512-517, 1970. 3. Kingsbury, B. C., and Weisenbaugh, J. M.: Intentional Reimplantation of Mandibular Molars and Premolars, J. Am. Dent. Assoc. 83: 1053-1057, 1971. 4. Reed, J.: A Follow-up Study of One Thousand Cases Treated by Endodontic Surgery, Int. J. Oral Surg. 1: 215, 1972. 5. Ross, J. W.: Retrograde Root Filling in Oral Surgery, Trans. Congr. Int. Assoc. &al Surg. 4: 9%iO1, 1973. 6. Weine, F. S.: Endodontic Therapy, ed. 2, St. Louis, 1976, The C. V. Mosby Company. Reprint requests to: Dr. Melvyn H. Harris 665 Beacon St. Boston, Mass. 022 15