Surgical Endodontics: Periradicular Surgery, Intentional Replantation, and Microsurgical Principles
Indications
Surgery is indicated when nonsurgical treatment has failed or cannot be performed: blocked or calcified canals, irretrievable posts or separated instruments, persistent periapical disease with adequate nonsurgical treatment, anatomical barriers, perforations that cannot be managed from within, and the need for biopsy. Modern endodontic microsurgery combines magnification, illumination, microinstruments, ultrasonic root-end preparation and biocompatible root-end filling, with success rates approaching 90%.
Technique essentials
Design a flap (submarginal for aesthetics, intrasulcular when access to the crest is needed) with a papilla-sparing incision; avoid the mental nerve and the long buccal nerve. Remove bone conservatively and identify the root end and the isthmus. Resect approximately 3 mm of the root end - this eliminates the majority of apical ramifications and lateral canals - with a bevel of 0° to a maximum of 10° in order to preserve canal walls. Prepare the retrograde cavity with an ultrasonic tip aligned with the canal, then fill with a calcium-silicate cement. Reposition the flap and suture without tension.
Intentional replantation
Reserved for teeth that cannot be treated surgically in situ. Atraumatic extraction, minimal extraoral time (ideally under 15 minutes), handling of the root only by the crown, extraoral root-end management, replantation and flexible splinting. Prolonged extraoral time risks replacement resorption.
Traps
- A 45° bevel (the old technique) leaks, exposes tubules and makes retrograde preparation blind - it is the classic wrong answer.
- Biopsy of every lesion is not required, but tissue should be submitted when the diagnosis is uncertain.
- Surgery does not compensate for a poorly treated canal; nonsurgical retreatment should be considered first.
Rule of thumb: resect 3 mm, bevel near 0°, prepare with ultrasound, fill with a calcium-silicate cement.