Apicoectomy: The Misunderstood Surgical Procedure

Transcription

CONTINUING EDUCATION
Volume 34 No. 2 Page 130
Apicoectomy: The
Misunderstood Surgical
Procedure
Authored by Ali Allen Nasseh, DDS, MMSc, and Dennis Brave, DDS
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Apicoectomy: The
Misunderstood Surgical
Procedure
were completed using antiquated armamentaria by surgeons
who applied apicoectomy, with a broad stroke, to all
conventional root canals that had failed. Not surprisingly, the
results of many outcome studies prior to the modern era of
endodontic surgery (ie, before the use of ultrasonics, operating
microscopes, cone beam [CB] CTs, and modern retrofilling
materials) were dismal.5-7
Today, the cause of persistent periapical disease is largely
attributed to either inadequate cleaning and disinfection of the
root canal space during the original root canal therapy, or
recontamination of the whole root canal space after initial
treatment due to a poor coronal seal (coronal leakage due to
faulty filling, core, crown, etc). Root cracks and fractures as well
as iatrogenic perforations, blockages, and missed canals can
also act as microbial sources to the periapex. Sealing these
sources from periapical egress has traditionally been the
function of endodontic therapy. As a result, the apicoectomy
procedure is more successful when correct diagnosis and case
selection5 is combined with a 3.0-mm deep retrofilling and
apical seal of the root end. Therefore, for the purposes of this
article, the term apicoectomy procedure is defined not only as the
cutting of the root end a minimum of 3.0 mm (apicoectomy
portion of the procedure), but also the retrofilling and sealing
of the remaining root with a minimum of a 3-mm deep
retrofilling material.
Effective Date: 02/01/2015 Expiration Date: 02/01/2018
About the Authors
Dr. Nasseh received his master’s in medical sciences
degree and certificate in endodontics from the Harvard
School of Dental Medicine in 1997. He received his DDS
in 1994 from Northwestern University Dental School. He
maintains a private endodontic practice in Boston
(msendo.com) and holds a staff position at Harvard’s
postdoctoral endodontic program. He has done research
in the areas of bone biochemistry and has lectured extensively internationally on
endodontic diagnosis, anesthesia and sedation, treatment planning, efficiency of
care, and microsurgery. He is the endodontic editor for several dental journals
and periodicals and serves as the alumni editor of the Harvard Dental Bulletin.
He is the CEO and president of RealWorldEndo. He can be reached at
[email protected] or visit the Web site located at realworldendo.com.
Disclosure: Dr. Nasseh is the president and CEO of RealWorldEndo.
Dr. Brave co-founded RealWorldEndo in 2000. He is a
Diplomate of the American Board of Endodontics and a
member of the College of Diplomates. He received his
DDS from the Baltimore College of Dental Surgery,
University of Maryland, and his certificate in
endodontics from the University of Pennsylvania. He is
an Omicron Kappa Upsilon Scholastic Award Winner and
a Gorgas Odontologic Honor Society member. He can be reached at
[email protected] or visit realworldendo.com.
Case Selection for Success
During the past 2 decades, a clearer diagnosis of the specific
cause of persistent periapical disease has resulted in better
treatment triage and case selection for teeth requiring
nonsurgical revision, surgical treatment (apicoectomy plus
retrofilling), or extraction.6 The source of persistent disease is
now understood to be the persistence of microbes or microbial
products in the root end and/or near a portal of exit.
Nonsurgical revision is always the ideal treatment option to
address the disease; as long as the procedure is feasible and restoration disassembly does not pose a significant risk of root
fracture or other complications during treatment. For cases in
which the periodontal condition of the tooth is poor, or when a
root fracture is present, extraction and implant placement will
be a more predictable option than apicoectomy. After thorough
evaluation through clinical and radiographic assessment as
well as verbal questioning of the relevant history, any
remaining questionable cases can be treatment planned for an
exploratory surgery instead of an apicoectomy, and the
apicoectomy performed only after exploration and the ruling
out of a fracture. If this does not seem feasible, the tooth should
be removed and the area grafted immediately. This limits the
Disclosure: Dr. Brave is the co-founder of RealWorldEndo and is a consultant to
Brasseler USA.
INTRODUCTION
Mention “apicoectomy” and you’re bound to get a funny look
from some dental colleagues. The fact is that this highly
successful and predictable endodontic procedure1-6 has
developed a bad reputation. The main reason is that most
apicoectomy literature quoted in the profession and taught in
dental schools is outdated and regurgitates old surgical
techniques and outcome studies conducted several decades ago.
These studies represent a time when the underlying causes of
persistent periapical disease following root canal therapy were
poorly understood and techniques to address the etiology of the
disease were inadequate.
Furthermore, procedures performed during earlier studies
1
patient’s investment only to cases
in which apicoectomy will have a
fair to good prognosis and extracts
teeth with fractures, cracks, and
significant periodontal limitations.
In conclusion, apicoectomy (and
retrograde filling) is indicated in
teeth where disassembly is not
possible, coronal leakage is not
present, and the disease process is
confined to the apex of a
periodontally
noncompromised
tooth. In such cases, surgical
apicoectomy has a very good
prognosis and will result in saving
the patient’s natural dentition.
This article briefly reviews some
of the advances in the apicoectomy
armamentarium and filling materials that have been introduced
during the past 2 decades, and
proposes a novel, more efficient
retrofilling technique called the
“Lid Technique.”8 This technique
has been inspired by material
science advancements in endodontic
cements during the past decade.
a
b
Figures 1a and 1b. The combination of light and magnification can greatly enhance visualization of the
surgical field and show the microanatomy of the apex. The above retrograde fillings were accomplished with
EndoSequence BC Root Repair Material (RRM) Fast Set (FS) Putty (Brasseler USA). (Photos courtesy of Dr.
Bradley Trattner, Baltimore, Md.)
a
b
Surgical Operating Microscope
and Cone Beam Radiography
The surgical operating microscope
had a significant impact on im- Figures 2a and 2b. (a) Cone beam (CB) CT imaging can show the 3-dimensional positioning of the tooth in a
bucco-lingual direction and can allow the clinician knowledge of hidden roots, bucco-lingual inclination, depth of
proving the success rate of endo- bone to access through to get to the roots, and any anatomical areas to pay attention to during the procedure.
dontic surgery from the historically (b) In this section, the severe lingual orientation of the mandibular second molar shows the clinical challenge
quoted outcome studies. This is due associated with apicoectomy. An intentional replantation was then chosen for treatment planning, instead of
conventional apicoectomy.
to the consequences of better visualization of the field at higher magnification, which in turn operating field and the determination of the exact location of
improves the clinician’s ability to find the source of pathology at the associated pathology prior to the actual surgical procedure
the root end (eg, discovery of additional canals, canal isthmuses, (Figure 2). This information improves case selection prior to the
fine cracks, and fractures)1,6 (Figure 1). As a result, all apicoectomy surgery, which in turn, helps improve case outcome.
outcome studies prior to the use of the operating microscope
should not be considered valid in the modern age.
Ultrasonic Apical Preparation
Furthermore, better case selection can be achieved through The advent of ultrasonic devices with surgical preparation tips
obtaining quality information presurgically using digital that allow conservative bony access cavities while still allowing
imaging, which helps establish a more accurate prognosis. for deep retropreparation depths (following root resection) have
Recent advancements in high-resolution, 3-D digital imaging further advanced the apicoectomy procedure.6,7,9,10 Piezousing limited CB radiography techniques have helped improve ultrasonic devices with their associated diamond coated and
surgical case selection through better visualization of the non-diamond coated surgical tips allow the surgeon to prepare
2
a
b
ERRM:
Figures 3a and 3b. (a) A 3.0-mm depth of retropreparation perpendicular to the apicoectomied
root allows debridement deep into the root canal, (b) achieving a long retrofill for a better seal.
a
The Lid-Retrofiling Technique
b
(Sealer)
(Paste)
(Putty)
Figure 4. From left to right: the BC Sealer,
RRM Paste, and RRM Putty FS formulations of
the EndoSequence (Brasseler USA).
Bioceramic material demonstrates different
flow and consistency in the same baseline
chemistry.
c
Putty FS
RRM Paste
or BC
Sealer
RRM Paste
Figures 5a to 5c. (a) After retropreparation, the RRM Paste was injected with a fitted syringe (b) and a layer of Putty FS was placed on top to seal
the RRM Paste. (c) Only a thin layer of the putty was required to seal the surface of the retrofilling, like a lid for a box.
a +3.0 mm deep retropreparation into the root canal after
sectioning off 3 mm of the apex (Figure 3). This combination
results in cleaning and the elimination of an effective +6.0 mm
of infected root canal space during the apicoectomy/retrofilling
surgical procedure. The use of a piezoelectric ultrasonic unit is
an absolute necessity for this kind of retropreparation (and for
improving the long-term prognosis of the treated tooth).
challenge. This makes the application of this material to the
surgical site more complicated, requiring additional time and
armamentarium.
Fortunately, advancements in material science have
addressed these concerns with the development of a new class
of nanoparticulate premixed bioceramic compounds: EndoSequence BC Sealer, Root Repair Material (RRM Syringeable), and
Root Repair Material Putty (RRM Putty) (Brasseler USA). These
compounds combine the biological advantages of these
bioceramic cements with excellent clinical handling properties
designed specifically for their intended purposes.15-27 The new
cements are pure bioceramics, built de novo, and composed of
zirconium oxide, calcium silicates, calcium phosphate
monobasic, calcium hydroxide, filler, and thickening agents.18
These bioceramics are available in 3 different consistencies: (1)
a low-contact angle, highly flowable syringeable sealer; (2) a
slightly more viscous syringeable RRM; and (3) an even higher
viscosity putty material (RRM Putty), which is also available in
fast set formulation (RRM Putty Fast Set [FS]) (Figure 4). These
materials are as biocompatible as MTA16-21 and promote
Bioceramic-Based Retrofilling Materials
There are several endodontic cements currently on the market,
but only a few that are categorized as bioceramics. While
several retrofilling materials have been used historically, it has
been understood that the ideal retrofilling material would not
only fill, but also promote the healing of the tissue it directly
contacts. The first material in this category was mineral trioxide
aggregate (MTA).11-14 Pro-Root MTA (DENTSPLY Tulsa Dental
Specialties) was originally released in the mid-1990s.
Unfortunately, the clinical handling properties of MTA are not
ideal, and predictable mixing and transferring of this material
from the bench top into the retropreparation can prove a
3
healing. They also demonstrate clinical
handling far surpassing MTA and other
bioceramics, making this class of cements the
preferred choice for endodontists.22-30 In this
article, we will use the superior clinical handling
advantages of this class of bioceramics to
describe a novel and more efficient retrofilling
technique. This technique, named the Lid
Technique,8 combines the advantages of
material science (bioceramics) with the
efficiency of technique made available by the
use of the syringeable paste and putty
formulations during the filling of the
retropreparation.
Figure 6. It is important to choose a delivery
tip that can fit all the way to the base of the
retropreparation; therefore, the delivery tip
should be fitted prior to injection of the
material.
Figure 7. If the delivery tip does not reach the
base of the preparation during injection, a void
may be trapped in the retrofilling. The delivery
needle should be chosen based on this rule in
order to avoid a void.
a
The Lid Technique
b
This technique’s underlying theory takes
advantage of the concept of using 2 chemically
similar materials with different viscosities in
order to get better adaptation of the overall
material to a biological surface.31 Examples of
this concept are seen in the often used and
current techniques of combining flowable and
bulk restorative composites during the filling of
a cavity preparation and similarly the simultaneous use of a light- and heavy-body im- Figures 8a and 8b. A Luer Lock-type delivery tip used for acid-etch delivery during bonding is
bent 90° and attached to an RRM Paste syringe. A similar configuration can be achieved with the
pression material during impression making for BC
Sealer syringe.
prosthodontics. Likewise, the Lid Technique8
utilizes the combined injection of the EndoSequence RRM diameter be thin enough so that the tip of the syringe can fit
Syringeable Paste into a retropreparation in order to fill the bulk deep into the standard retropreparation without excessive
of the cavity followed by the placement of the EndoSequence binding. This will allow for the escape of air and any excess
RRM Putty FS that acts as a lid over the injected material in order cement from its sides during the injection process (Figure 6). If
to seal the surface of the retrofilling and prevent any potential the syringe is not inserted deep into the retropreparation prior
washout. The paste material flows extremely well but can to injection, a void may be trapped under the flowable material
potentially wash out in the presence of blood or contact with deep in the preparation (Figure 7). This is similar to trapping a
irrigation. The goal of the Lid Technique8 is to seal and prevent void under a post during cementation in a root canal! This is
this washout by placing a layer of the washout-resistant Putty FS why the delivery tip should be fitted after the retropreparation
material on the cavosurface(s) of the retropreparation, thus cavity is made; and the appropriate delivery tip thickness used
allowing the material to set undisturbed. It’s important to (a tip that’s slightly loose in the canal) prior to prepping the site
understand that the RRM Paste does not wash out after setting for injection. The RRM Paste, Sealer, and Putty use a standard
(90-minute setting time). Therefore, the putty’s role is to allow Luer Lock attachment and are therefore compatible with a
this setting reaction to take place without blood contamination, number of tips. Experience has confirmed that a Blue Micro
and to that extent, the thickness of the Putty FS is incon- dispensing Tip (Ultradent Products) or equivalent can fit in the
sequential (Figure 5).
standard retropreparation and still allow RRM Syringeable
In order to achieve the goal of injecting the RRM material or BC Sealer to flow through it.
Syringeable Paste deep into the retropreparation, it’s important
By bending the first 3.0 mm of the syringe tip at 90° using either
that the delivery device’s inner lumen be wide enough to allow a hemostat or a pair of bird beak pliers, access can be achieved to
free flow of the flowable bioceramic material, yet the external the full depth of the retropreparation. After bending the delivery
4
Figure 9. Tooth No. 13
(with a previously retreated
root canal, post, and crown)
had a periapical
radiolucency and was
diagnosed with
symptomatic apical
periodontitis.
tip appropriately, the needle is screwed on to the EndoSequence
RRM Paste Syringe (Brasseler USA) through its conventional Luer
Lock attachment (Figure 8). This cannula’s diameter allows
injection of the premixed syringeable RRM or BC Sealer material
directly from the syringe deep into the retropreparation, thus
bypassing any necessity to mix or dispense the material at the time
of surgery. This time savings is significant, considering previously
described techniques for placement of MTA during this phase of
the retrofilling that have required sensitive mixing techniques and
special delivery devices.
Once the flowable material has been injected, a small ball
or cone of the RRM Putty FS is delivered to the site of the surgery
using a typical microspatula. The ball/cone is placed directly
over the flowable material, thus sealing the cavosurface area of
the retropreparation (acting as the lid and protecting the
flowable material until it sets). The RRM syringeable material’s
setting time is about 1.5 to 3 hours, and RRM Putty FS sets in 20
minutes. However, there is no need to wait for the putty to set to
complete the procedure. Immediately after placement, the
retropreparation can be cleaned and any flash from the putty
removed using a microbrush and a gentle spray of saline.
The Lid Technique8 can be summarized in the following
way: After resection of ideally 3.0 mm of the root end in a failing
a
b
root canal, a 3.0-mm retropreparation is made in the root canal
using ultrasonics. Once the retropreparation is complete, the
Micro Tip delivery syringe is fitted to the retropreparation,
ensuring that the tip reaches the deepest portion of the
retropreparation. Once this is confirmed, additional hemostasis
is obtained inside the bony crypt, and the retropreparation is
disinfected with a disinfectant of choice and dried thoroughly
using micro air blast or small paper points. The syringeable
EndoSequence RRM is injected using the fitted delivery tip,
starting from the depth of the retropreparation and slowly
moving the syringe out of the retropreparation while injecting.
This process will discourage or eliminate any voids. Once the
retroprep is filled to the cavosurface using the flowable
c
d
e
f
g
h
i
j
k
l
Figures 10a to 10l. (a) Following apicoectomy and root canal identification, retropreparation was made using a piezoelectric ultrasonic tip. (b and c) A
properly angled dispensing needle was fitted to make sure it reached the depth of the preparation. (d and e) The RRM Paste (or Sealer) was then injected
slowly while the syringe was withdrawn, filling the retroprepartion to the cavosurface margin. (f to h) Using a spatula, a small amount of the Putty FS was then
placed over the syringeable material covering the surface of the retropreparation, and flash was removed using a small brush. (i) The surface and the bony
crypt were cleaned with sterile saline and the tooth was sutured closed. (j and k) The immediate post-op and 2-year follow-up radiographs show the retrofilling
in place. (l) Exposure for apicoectomy on the MB root of the posterior tooth visually confirmed healing of the bony crypt over the previous apicoectomy site.
5
material, a small ball or cone of the RRM Putty FS
is used to seal the cavosurface area of the
retropreparation by directly placing the putty
over the flowable material and spreading it to the
margins of the preparation using a microspatula.
Any excess putty or paste material can be easily
cleaned out of the bony crypt using a spoon
excavator or microbrushes. Until experienced
with the technique, a digital radiograph can be
utilized to confirm an adequate fill without any
voids. If significant voids are noted, a 10-second
blast of ultrasonic and water inside the
retropreparation will remove all of the
bioceramic retrofil. Once done, the retrofilling
process can be started again, paying particular
attention to the fit of the syringe tip and the slow
movement outward during injection to prevent
voids. After confirmation, the crypt is cleaned of
any hemostatic agent, and bleeding is initiated
from the crypt prior to suturing the flap closed.
Five RealWorldEndo Tips for Success
1. If during the apicoectomy you see a crack on the root, abandon the
procedure, then extract and graft right away. It is important to have a high
success rate, and cracked teeth have a very poor outcome in the long run.
Wasting the patient’s resources with false hope is not good patient
management.
2. Be sure to pay attention to the coronal aspect of the tooth while
preparing the retropreparation. It is important to visualize the root anatomy
from the radiograph and transpose that mentally over the patient’s bone.
This way, you will be able to visualize and follow the path of the root canal
better inside the root canal and end up having a more effective seal. Do
not forget, you’re only preparing a seal if you are in the root canal space. If
you go off course, you will not only have a poor seal, you will also
predispose the tooth to fracture by weakening it unnecessarily.
3. Be sure that the tip of your syringe can reach the deepest part of your
retropreparation to help prevent void formation.
4. Use adequate hemostatic agents (eg, aluminum chloride, ferric
CASE REPORT
sulfate, or epinephrine pellets) and try to have a dry bony crypt at the time
A patient, who presented with a history of
of the fill. It is important not to get too much bleeding that can obscure
previous nonsurgical root canal therapy and
your view and contaminate your retropreparation during the retrofill.
coronal restoration in tooth No. 13 within the past
2 years, was referred for evaluation of a
5. Don’t forget that EndoSequence BC Sealer (Brasseler USA) can be a
symptomatic periapical radiolucency (Figure 9).
replacement for the EndoSequence RRM Paste.31 This is useful if you find
Following clinical evaluation and testing, a
the extrusion of the paste too hard through the syringe lumen necessary to
diagnosis of symptomatic apical periodontitis in
fit your retrofilling size. For thinner retropreparations, the sealer will be
a previously root canal-treated tooth was made.
easier to flow through the needle lumen and it will have the same
The tooth already had a nonsurgical revision and
chemistry as the paste material.
adequate coronal restoration (no coronal leakage
was observed). Given the healthy periodontal
therapy, and the presence of a well-sealed coronal
restoration, surgical treatment with apicoectomy
and retrofilling was recommended.
Syringe, and the paste was then injected, very slowly in the
Following the raising of a flap, surgical osteotomy to get access retropreparation while the tip was being withdrawn. This
to the root end, and surgical excision of 3.0 mm of the apex using technique allowed for the filling of the retropreparation (with the
a Lindeman Surgical Bur (Brasseler USA), the root end was exposed. RRM Paste) without trapping any voids.
Ultrasonic tips (BEST TIPS 1 and 2 [Brasseler USA]) were used in a
Once the entire retropreparation was filled with the RRM
Forza V3 piezoelectric ultrasonic unit (Brasseler USA) and a 3.0-mm Paste, a small ball-shaped piece of RRM Putty FS was placed
deep retropreparation was prepared (Figure 10). An acutely bent directly over the cavosurface area of the preparation using a
microdispensing tip (similar to the tip used for phosphoric acid microspatula. Next, a MicroBrush (Ultradent Products) was
etch [Ultradent Products]) was fitted in the retropreparation, used to clean the excess material/flash from the bone crypt and
making sure that the tip had reached the deepest portion of the a gentle stream of saline was used to wash away any loose debris
retropreparation. Hemostasis was obtained in the osseous crypt, (Figures 10a to 10h). A confirmation radiograph showed a lack
and then the retropreparation was disinfected and dried. Next, the of any voids in the retrograde filling. A small amount of flash
fitted dispensing tip was placed on an EndoSequence RRM Paste remaining was then removed prior to suturing (Figure 10i).
6
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12. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
comprehensive literature review—Part I: chemical, physical, and
antibacterial properties. J Endod. 2010;36:16-27.
13. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a
comprehensive literature review—Part II: leakage and
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14. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
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15. Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicatebased canal filling material. Int Endod J. 2010;43:769-774.
16. Ma J, Shen Y, Stojicic S, et al. Biocompatibility of two novel root
repair materials. J Endod. 2011;37:793-798.
17. AlAnezi AZ, Jiang J, Safavi KE, et al. Cytotoxicity evaluation of
EndoSequence Root Repair Material. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2010;109:e122-e125.
18. Ciasca M, Aminoshariae A, Jin G, et al. A comparison of the cytotoxicity
and proinflammatory cytokine production of EndoSequence Root
Repair Material and ProRoot mineral trioxide aggregate in human
osteoblast cell culture using reverse-transcriptase polymerase chain
reaction. J Endod. 2012;38:486-489.
19. Hirschman WR, Wheater MA, Bringas JS, et al. Cytotoxicity
comparison of three current direct pulp-capping agents with a new
bioceramic root repair putty. J Endod. 2012;38:385-388.
20. Zhang S, Yang X, Fan M. BioAggregate and iRoot BP Plus optimize
the proliferation and mineralization ability of human dental pulp
cells. Int Endod J. 2013;46:923-929.
21. Zhang W, Li Z, Peng B. Effects of iRoot SP on mineralization-related
genes expression in MG63 cells. J Endod. 2010;36:1978-1982.
22. Zhang H, Shen Y, Ruse ND, et al. Antibacterial activity of
endodontic sealers by modified direct contact test against
Enterococcus faecalis. J Endod. 2009;35:1051-1055.
23. Lovato KF, Sedgley CM. Antibacterial activity of EndoSequence
Root Repair Material and ProRoot MTA against clinical isolates of
Enterococcus faecalis. J Endod. 2011;37:1542-1546.
24. Candeiro GT, Correia FC, Duarte MA, et al. Evaluation of
radiopacity, pH, release of calcium ions, and flow of a bioceramic
root canal sealer. J Endod. 2012;38:842-845.
25. Zhang W, Li Z, Peng B. Assessment of a new root canal sealer’s
apical sealing ability. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2009;107:e79-e82.
26. Damas BA, Wheater MA, Bringas JS, et al. Cytotoxicity comparison
of mineral trioxide aggregates and EndoSequence bioceramic root
repair materials. J Endod. 2011;37:372-375.
27. Batur YB, Acar G, Yalcin Y, et al. The cytotoxic evaluation of mineral
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A 2-year follow-up radiograph of the area shows complete
healing of the bony crypt (Figures 10j and 10k). Unfortunately,
the patient had received another conventional root canal from
her other dentist, which had become symptomatic. The
subsequent surgical procedure for treatment of that tooth
exposed the surgical site for a second time, visually confirming
complete healing of the alveolar plate over the original bony
crypt of osseotomy (Figure 10l). The surgical procedure for that
molar was also documented and is available for review.8
CONCLUSION
Based on the contemporary understanding of endodontic concepts
for success and failure, assessment and subsequent treatment of
apicoectomy procedures have greatly improved. Advances in
apicoectomy armamentaria and materials (including bioceramic
retrofilling materials and clinical techniques for their efficient use)
have enabled endodontists to treat challenging cases with much
greater efficiency. While successful outcomes are still
predominantly a function of proper case section and triage, using
the novel retrofilling technique, as described in this article, can
make this previously challenging aspect of surgical endodontics
much easier for clinicians.F
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endo-restorative circle, Part II. Dent Today. 2010;29:98-105.
30. EndoSequence. Redefining endodontics: bioceramic technology
(brochure). brasselerusadental.com/brasselerusadental/assets/ File/B-3644-Bioceramic-Brochure.pdf. Accessed December 18, 2014.
31. Nasseh AA. Updated retrofilling technique using BC Sealer & Putty
[video]. realworldendo.com/videos/updated-retrofilling-techniqueusing-bc-sealer-putty. Accessed December 18, 2014.
8
POST EXAMINATION INFORMATION
To receive continuing education credit for participation in this educational activity you must complete the program post examination
and receive a score of 70% or better.
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3. The surgical operating microscope has really not had
a significant impact on improving the success rate of
endodontic surgery from the historically quoted
outcome studies.
This CE activity was not developed in accordance with AGD
PACE or ADA CERP standards. CEUs for this activity will not
be accepted by the AGD for MAGD/FAGD credit.
1. Today, the cause of persistent periapical disease is
largely attributed to either inadequate cleaning and
disinfection of the root canal space during the original
root canal therapy, or recontamination of the whole
root canal space after initial treatment due to a poor
coronal seal (coronal leakage due to faulty filling,
core, crown, etc).
a. True
b. False
a. True
b. False
a. True
b. False
5. Unfortunately, the clinical handling properties of mineral
trioxide aggregate are not ideal, and predictable mixing
and transferring of this material from the bench top into
the retropreparation can prove a challenge.
b. False
2. Nonsurgical revision is always the ideal treatment
option to address the disease; as long as the
procedure is feasible and restoration disassembly
does not pose a significant risk of root fracture or
other complications during treatment.
a. True
a. True
4. The advent of ultrasonic devices with surgical
preparation tips that allow conservative bony access
cavities while still allowing for deep retropreparation
depths (following root resection) have further
advanced the apicoectomy procedure.
POST EXAMINATION QUESTIONS
6. The technique named the “Lid Technique” combines
the advantages of material science (bioceramics) with
the efficiency of technique made available by the use
b. False
9
of the syringeable paste and putty formulations
during the filling of the retropreparation.
a. True
10. Once the flowable material has been injected, a small
ball or cone of the RRM Putty FS is delivered to the
site of the surgery using a typical microspatula.
b. False
7. The Lid Technique utilizes the combined injection
of the EndoSequence Root Repair Material (RRM)
Syringeable Paste (Brasseler USA) into a retropreparation in order to fill the bulk of the cavity
followed by the placement of the EndoSequence RRM
Putty Fast Set (FS).
a. True
b. False
a. True
b. False
a. True
b. False
a. True
b. False
a. True
b. False
a. True
b. False
11. The RRM syringeable material’s setting time is about
1.5 to 3 hours, and RRM Putty FS sets in 20 minutes.
However, the clinician must wait for the putty to set to
complete the procedure.
12. Once the retroprep is filled to the cavosurface using
the flowable material, a small ball or cone of the RRM
Putty FS is used to seal the cavosurface area of the
retropreparation by directly placing the putty over the
flowable material and spreading it to the margins of
the preparation using a microspatula.
8. In order to achieve the goal of injecting the RRM
Syringeable Paste deep into the retropreparation, it’s
important that the delivery device’s inner lumen be
wide enough to allow free flow of the flowable
bioceramic material.
9. Experience has confirmed that a Blue Micro
dispensing Tip (Ultradent Products) (or equivalent)
do not fit in the standard retropreparation.
10
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ANSWER FORM: VOLUME 34 NO. 2 PAGE 130
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1. o a. True
o b. False
7. o a. True
o b. False
4. o a. True
o b. False
10. o a. True
o b. False
2. o a. True
3. o a. True
o I have enclosed a check or money order.
o I am using a credit card.
5. o a. True
6. o a. True
My Credit Card information is provided below.
o American Express o Visa o MC o Discover
o b. False
o b. False
o b. False
o b. False
8. o a. True
9. o a. True
11. o a. True
12. o a. True
o b. False
o b. False
o b. False
o b. False
PROGRAM EVAUATION FORM
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Rating Scale: Excellent = 5 and Poor = 0
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How much time did you spend reading the activity and
completing the test?
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What aspect of this course was most helpful and why?
This CE activity was not developed in accordance with AGD
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What topics interest you for future Dentistry Today CE courses?
11

Apicoectomy: The Misunderstood Surgical Procedure

Transcription

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