| Exodontia.Info |
| Apicectomy & Retrograde Root Filling (RRF) Warnings |
An apicectomy (also known as surgical endodontics,
apical surgery or peri-radicular surgery) should be
considered only when conventional endodontic root
filling or re-treatment (root canal treatment) techniques
have failed.
This list of warnings might seem excessive to some
however the legal ruling in the case of Chester vs Afshar
(2004) would suggest that it is quite prudent / necessary to
list them. Others might say that there isn't enough
information but where do you stop?
The following list of warnings regarding apicectomies is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
You can expect the following.
Apicectomy & RRF / Endodontic Surgery-Specific
Warnings
No / Incomplete Root Canal Treatment Reduces Operation
Success. If the tooth that is being operated on has no /
incomplete root-canal filling than the operation success is
much reduced. Ideally, the tooth should be root-canal
treated (well) before it has an apicectomy.
Anatomical Considerations. Certain teeth (such as
premolars / bicuspids, molars & lower incisors) can be
more tricky to treat and consequently, the success rate is
not as high as one would hope. This is due to the anatomy
of the tooth (e.g upper premolars have multiple canals
within roots that may not have all been filled) and the
anatomy of the mouth (e.g proximity to nerves & sinuses;
thickened bone overlying the operation site; cheek bone
buttresses hampering access and overactive muscles of
facial expression again hampering access).
Operation Failure. The operation can sometimes fail (80 -
96% chance of success). If so, it can be repeated
however the chances of success become progressively
smaller each time the operation is done anew (2nd time
around, success rates drop to 30 - 35%).
Root Fracture. Sometimes, it is not until the gum is peeled
back & the root is in front of the surgeon that it will be
noticed there is a root fracture. If this is the case, the
tooth can not be salvaged. If this should happen, you will
be given an option to have the tooth removed then & there.
Increased Tooth Mobility. If the root tip is removed, as in
an apicectomy, there is a consequent reduction in the root
area of the tooth in contact with the bony socket. This has
the effect of making the tooth very slight mobile. The more
a tooth tip is cut back, the more mobile the tooth will be
after the operation.
Gum Recession. Often the tooth being operated is
crowned/capped. After the operation, the gums will recede
from the margins of the cap / crown. The recession is
likely to worse if the tooth is in proximity to a frænum, a
fibrous band linking the gum to the lips or cheek. The
recession can be such that you may even consider having a
new crown made with the crown margins hidden below
gum-level.
Involvement Of Nerves & Subsequent Nerve Trauma. The
nerves that supply feeling to the tongue, lower lip and the
chin run close to the root-ends of the molar teeth and exit
onto the gum close to the roots of the premolars /
bicuspids.
There is a risk that when lower teeth (especially the molars
& bicuspids / premolars) have endodontic surgery, these
nerves can be affected, resulting in numbness (at the
worse end of the scale) to altered sensation (at the other
end of the scale) in the region of the lower lip ± chin ±
tongue. The nerves that supply feeling to the upper lip &
gum run within the upper gums.
On operating on upper front teeth, these nerves can be
affected resulting in numbness of the gum surrounding the
tooth (though not the upper lips). This improves with time,
should it occur. Alterations in nerve function tends to be
temporary (rarely are they permanent) but ‘temporary’
often means several months.
Adjacent Teeth. The surrounding teeth may be sore after
the operation; they may even be slightly wobbly but the
teeth should settle down with time. It is possible that the
fillings or crowns of the surrounding teeth may come out,
fracture or become loose. If this is the case you will need
to go back to your dentist to have these sorted out.
Sometimes, in trying to apicect the tooth in question, the
blood supply to the surrounding teeth may be
compromised. This can lead to the death of adjacent
teeth; if this is the case, they may need endodontic
treatment.
Mouth-Sinus / Mouth-Floor of Nose Communications.
Upper back teeth often have their roots in close proximity
to the floor of the nose or the sinus. In operating on the
ends of these teeth, there is a chance that the sinus will be
perforated (10 – 50% of cases). After the apicectomy, the
perforation into the sinus will be closed however you are
likely to have a acute +/- chronic sinusitis (a chronic
sinusitis is more likely if root debris has gone into the
sinus). There is a chance, on blowing your nose post-op,
that you will get bleeding from the nose or sinus. This is
treated with antibiotics, painkillers & decongestants.
Surgical Emphysema. Very rarely, air can enter the skin
around the apicectomy operation site and become
trapped. This can lead to swelling, especially around the
eyes or over the cheeks. This can be quite disconcerting
however it slowly subsides and there is nothing really to
worry about.
General Surgical Warnings
Pain. As it is a surgical procedure, there will be soreness
after the tooth removal. This can last for several days.
Painkillers such as ibuprofen, paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history & the ease
with which the tooth was removed.
Swelling. There will be swelling afterwards. This can last
up to a week. Use of an icepack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed
will help to decrease the swelling. Avoidance in the first
few hours post-op, of alcohol, exercise or hot foods/drinks
will decrease the degree of swelling that will develop.
Bruising. Some people are prone to bruise. Older people,
people on aspirin or steroids will also bruise that much
more easily. The bruising can look quite severe; this will
eventually disappear but can take several weeks (in the
worst cases).
Bleeding into Cheeks. Swelling that does not resolve
within a few days may be due to bleeding into the cheek.
The cheek swelling will feel quite firm. Coupled with this,
there may be limitation to mouth opening and bruising.
Both the swelling, bruising and mouth opening will resolve
with time.
Stitches. The operation site will often be closed with
stitches. These dissolve and ‘fall out’ within 10 – 14 days.
Limited Mouth Opening. Often the chewing muscles and
the jaw joints are sore after the procedure so that mouth
opening can be limited for the next few days. If you are
unlucky enough to develop an infection in operation site
afterwards, this can make the limited mouth opening worse
and last for longer.
Post-op Infection. You may develop an infection in the
operation site after the procedure. This tends to occur 2 –
4 days later and is characterised by a deep-seated
throbbing pain, bad breath and an unpleasant taste in the
mouth. This infection is more likely to occur if you are a
smoker or are on the contraceptive pill or on drugs such as
steroids.
If antibiotics are given, they are likely to react with alcohol
± the Contraceptive Pill (that is, the ‘Pill’ will not be
providing protection).
Failure of Anæsthesia. In rare cases, the tooth can be
difficult to ‘numb up’. This can be due to a number of
reasons. The more common ones include inflammation and
/ or infection associated with the tooth, anatomical
differences & apprehension.
apical surgery or peri-radicular surgery) should be
considered only when conventional endodontic root
filling or re-treatment (root canal treatment) techniques
have failed.
This list of warnings might seem excessive to some
however the legal ruling in the case of Chester vs Afshar
(2004) would suggest that it is quite prudent / necessary to
list them. Others might say that there isn't enough
information but where do you stop?
The following list of warnings regarding apicectomies is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
You can expect the following.
Apicectomy & RRF / Endodontic Surgery-Specific
Warnings
No / Incomplete Root Canal Treatment Reduces Operation
Success. If the tooth that is being operated on has no /
incomplete root-canal filling than the operation success is
much reduced. Ideally, the tooth should be root-canal
treated (well) before it has an apicectomy.
Anatomical Considerations. Certain teeth (such as
premolars / bicuspids, molars & lower incisors) can be
more tricky to treat and consequently, the success rate is
not as high as one would hope. This is due to the anatomy
of the tooth (e.g upper premolars have multiple canals
within roots that may not have all been filled) and the
anatomy of the mouth (e.g proximity to nerves & sinuses;
thickened bone overlying the operation site; cheek bone
buttresses hampering access and overactive muscles of
facial expression again hampering access).
Operation Failure. The operation can sometimes fail (80 -
96% chance of success). If so, it can be repeated
however the chances of success become progressively
smaller each time the operation is done anew (2nd time
around, success rates drop to 30 - 35%).
Root Fracture. Sometimes, it is not until the gum is peeled
back & the root is in front of the surgeon that it will be
noticed there is a root fracture. If this is the case, the
tooth can not be salvaged. If this should happen, you will
be given an option to have the tooth removed then & there.
Increased Tooth Mobility. If the root tip is removed, as in
an apicectomy, there is a consequent reduction in the root
area of the tooth in contact with the bony socket. This has
the effect of making the tooth very slight mobile. The more
a tooth tip is cut back, the more mobile the tooth will be
after the operation.
Gum Recession. Often the tooth being operated is
crowned/capped. After the operation, the gums will recede
from the margins of the cap / crown. The recession is
likely to worse if the tooth is in proximity to a frænum, a
fibrous band linking the gum to the lips or cheek. The
recession can be such that you may even consider having a
new crown made with the crown margins hidden below
gum-level.
Involvement Of Nerves & Subsequent Nerve Trauma. The
nerves that supply feeling to the tongue, lower lip and the
chin run close to the root-ends of the molar teeth and exit
onto the gum close to the roots of the premolars /
bicuspids.
There is a risk that when lower teeth (especially the molars
& bicuspids / premolars) have endodontic surgery, these
nerves can be affected, resulting in numbness (at the
worse end of the scale) to altered sensation (at the other
end of the scale) in the region of the lower lip ± chin ±
tongue. The nerves that supply feeling to the upper lip &
gum run within the upper gums.
On operating on upper front teeth, these nerves can be
affected resulting in numbness of the gum surrounding the
tooth (though not the upper lips). This improves with time,
should it occur. Alterations in nerve function tends to be
temporary (rarely are they permanent) but ‘temporary’
often means several months.
Adjacent Teeth. The surrounding teeth may be sore after
the operation; they may even be slightly wobbly but the
teeth should settle down with time. It is possible that the
fillings or crowns of the surrounding teeth may come out,
fracture or become loose. If this is the case you will need
to go back to your dentist to have these sorted out.
Sometimes, in trying to apicect the tooth in question, the
blood supply to the surrounding teeth may be
compromised. This can lead to the death of adjacent
teeth; if this is the case, they may need endodontic
treatment.
Mouth-Sinus / Mouth-Floor of Nose Communications.
Upper back teeth often have their roots in close proximity
to the floor of the nose or the sinus. In operating on the
ends of these teeth, there is a chance that the sinus will be
perforated (10 – 50% of cases). After the apicectomy, the
perforation into the sinus will be closed however you are
likely to have a acute +/- chronic sinusitis (a chronic
sinusitis is more likely if root debris has gone into the
sinus). There is a chance, on blowing your nose post-op,
that you will get bleeding from the nose or sinus. This is
treated with antibiotics, painkillers & decongestants.
Surgical Emphysema. Very rarely, air can enter the skin
around the apicectomy operation site and become
trapped. This can lead to swelling, especially around the
eyes or over the cheeks. This can be quite disconcerting
however it slowly subsides and there is nothing really to
worry about.
General Surgical Warnings
Pain. As it is a surgical procedure, there will be soreness
after the tooth removal. This can last for several days.
Painkillers such as ibuprofen, paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history & the ease
with which the tooth was removed.
Swelling. There will be swelling afterwards. This can last
up to a week. Use of an icepack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed
will help to decrease the swelling. Avoidance in the first
few hours post-op, of alcohol, exercise or hot foods/drinks
will decrease the degree of swelling that will develop.
Bruising. Some people are prone to bruise. Older people,
people on aspirin or steroids will also bruise that much
more easily. The bruising can look quite severe; this will
eventually disappear but can take several weeks (in the
worst cases).
Bleeding into Cheeks. Swelling that does not resolve
within a few days may be due to bleeding into the cheek.
The cheek swelling will feel quite firm. Coupled with this,
there may be limitation to mouth opening and bruising.
Both the swelling, bruising and mouth opening will resolve
with time.
Stitches. The operation site will often be closed with
stitches. These dissolve and ‘fall out’ within 10 – 14 days.
Limited Mouth Opening. Often the chewing muscles and
the jaw joints are sore after the procedure so that mouth
opening can be limited for the next few days. If you are
unlucky enough to develop an infection in operation site
afterwards, this can make the limited mouth opening worse
and last for longer.
Post-op Infection. You may develop an infection in the
operation site after the procedure. This tends to occur 2 –
4 days later and is characterised by a deep-seated
throbbing pain, bad breath and an unpleasant taste in the
mouth. This infection is more likely to occur if you are a
smoker or are on the contraceptive pill or on drugs such as
steroids.
If antibiotics are given, they are likely to react with alcohol
± the Contraceptive Pill (that is, the ‘Pill’ will not be
providing protection).
Failure of Anæsthesia. In rare cases, the tooth can be
difficult to ‘numb up’. This can be due to a number of
reasons. The more common ones include inflammation and
/ or infection associated with the tooth, anatomical
differences & apprehension.
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| Last Updated 13th July 2011 |