t'.iidodUnil fmiimiilol t')')(,: t2: tS^-t

t'nilleil III ttnimaik • .Ml righls lesenmtMuiik.sgaard t 996

Endodontics &Dental Traumatology

tS.SN 01(19-2502

Reasons for apicectomies. A retrospectivestudyEl-Swiali ]M, Walker RT. Reasotis for apicectomies. A retrospec-tive study. Endod Dent Tranmatol 1996; 12: leS.5-191. © Mnnks-gaard, 1996

Abstract - A retros]3ective study was carried ciut to evaltiate theclitiical factors invohed in deciding to perform apicectomies.Fi\'e hundred and sexenteen teeth from .H92 patients (211women and leS] men) that had tmdergone apicectoni)' dnringthe period from September, 1990 to December, 1992 were as-sessed using ibe jDatients' clinical records. The information re-corded inc hided the sotirce ol referral, the qtialitv of preopera-tive root canal Ulliiig, the si/e of periradicnlar lesion, the type ofthe lesicMi (for biopsed lesions), the type of coronal and radicti-lar restorations, and the different factors that influenced the de-cision to perfbrtn an apicectomy for each tooth. These factorswere classified into technical and biological, and when thev oc-curied togedier they were classified as combined. The decisionsto perform apicectomies most commonly involved combinedtechnical and biological factors. Biological factors alone onlyamotmted to ?>^-)"/o ofthe total. Technical factors alone amotintedto only ,H% ofthe total. When all factors were considered, biolog-ical factors cc:)nstituted 60%, whilst technical factors constituted40%, ofthe total. The most cotiimou biological factors were per-sistent symptoms (54%), and contintiing presence c:)f a periradic-ular lesion (44%). The mc:)st common technical factors were postcrown (60%)) and crowned teeth withotit posts (."̂ 1 %). This studyemphasised the need for a high standard of conventional rootcanal treatment in OITUM' \O a\'oid surgical treatment.

J. iVI. El-Swiaii,

R. T. Walker

Leeds Dental Institute/Division of RestorativeDentistry, Leeds, UK

Key words: apicectomy: endodontic therapy

Jamal Mustafa El-Swiah. Leeds Dental Institute,

Division of Restorative Dentistry. Level 6. Wotsley

Building, Clarendon Way,

Leeds-LS2 9LU, England

Accepted October 30. 1995

The general objective of endodontic treattnetit isto retain both the \'ital tooth with irreversible pul-pal disease and the non-vital tooth in lunctioti inthe dental arch. Endodontic tberapy is oftenthought to be syncMiymotts with root canal treat-metu, which involves the removal ol ptilp tisstte orpttlp tisstie renmants from tlie root canal system,followed by thorough cleaning, shaping and tbreedimensional baclcriological sealing and obtttra-g gtiou of tbe prepared space. Tbe objective of rootcanal tieatmenl is lo lemove ihe cati.se or poten-tial catise of the disease from the pulp space tolitnit die effect on the pet iradicular lissttes. Where

these effects are ahead)' established the objecdxeis to remove the causes and encouiage tbe resolu-tion of an established periradictilar lesion (1,2).

Non-stirgical eiulodontic treatment can be car-ried out sticce.ssftilly for most ofthe teeth which re-quire root catial treattnent, provided that the pulpspace is adeqtiateh' shaped, cleaned and obtti-rated. In the past, when periradicnlar patholog)'did not respond to non snrgical treatment, stirgi-cal iutei veution has been ad\'ocated in order io re-moxe di.seased periradicnlar ti.ssue and seal anyconnection between tbe root canal and periodc:)n-tium. hi reviewing the literature the success rate of

185

El-Swiah & Walker

conventional endodc:)iitic treatment ranges be-tween 6(S-93%) (.H-6). One of tbe common surgicalscopes of endodontic therapy which in\'olves thesurgical lemoval of the tooth root apex, is knownas apicectomy, or root end resection, which may beperformed alone or in conjunction witb placing aretrograde lilling to seal the apical jxirt ofthe root.Apical ctuettage is the sttrgical removal of periapi-cal pathological material by means of sttrgical cti-rettage (7), both procedtires are normally adoptedwhen convenlional endodontic treatment hasfailed and the sttccess ol cotiventional re-treatmentis not predictable. It is now thotiglit that the treat-ment ofthe |3itlpand periradictilar diseased tisstiesshotild be rotitinely undertaken by non-stirgicalmeans, and the stirgical intervention should onlybe adopted as an alternative when conventionaltherapy is clearly not possible, and as an additionto conventional treatment when a bio|:).sy or correc-tive or reparative surgery are reqtiired (8),or as analternative way of placing a root canal filling whenconventional endodontic therapy is not possible.

The classical indications for apicectomy (withor without retrograde filling) are:

1. Inability to undertake conservative endodon-tic treatment. This may be dtie to:

a. Anatomical, pathological and/or iatrogenicdefects in die root canal (9-1!^).

b. Blockage of the root canal which makes con-ventional root canal therapy physically impractica-ble, like adec]tiate coronal and/or radictilar resto-ration (9, 11, 12, 14-16).

c. Medical and/or lime (expediency) reasons.For example, when the |)atient cannot tolerateroutine endodontic therapy atid is likely to betreated tinder general anaesthesia, cjr when thepatient or the operator cannot offer more thancjne visit i'ov routine endodontic treatment. (9, 10,13, 17).

2. Failure to achieve complete conservative en-dodontic treatment, which may be dtie to persist-ence of extraradicular infection, symptoms andtmcoiurolled suppuration or exudate throtigh theroot canal (9, 1.5, 16).

3. Failure of previotis ccMiventional root canaltreatment, and when tbe success of conventicTualre-treatment is not predictable (10, 1.3-15, 18),and is tmlikely to achieve a good restilt witb con-ventional retreatment or if the teeth fail to re-spond to conventional endodontic therapy after along period of follow ii|3 (11, 12).

4. The need for biopsy ol apical patholog)' (18,19), and the persistence of extraradictilar endo-dontic inlection by certain types of bacteria (20)indicate the need for stirgical therapy which in-volves curettage of die infected apical area with re-

.section ofthe involved rool(s) and the administra-tion of antibiotics e.g. actinomycosis periradicularinfection (21).

5. Apicectomy may be indicated in the case olposterior teeth to avoid the need for posteriorfixed c3r removable appliances and becattse rootsmay be severely cttrved (22). In general terms theindications for apical surgery in posterior teethare similar to the indications for anterior teeth(2.3).

6. Apicectomy may also be indicated to evaltiatetbe resected root face for any additional canals orfractures, and examitie the quality ol apical seal aspart of re-platitation procedtires (19).

The criteria for successftil apicectomy are: - Thetooth should be symptom free and ftmctional fortwo or more years; there shotild be no obviotisclinical evidence of infection (absence ol tender-ness and flsttila); the radiographic follow-upshould sbow satisfactory evidence of bone healingand the periodontal ligament remains normal orreturns to uormal (24). fn reviewing the litera-ture, the sticcess rate of apicectomy ranges be-tween 50-90%, which is not higher than the con-ventional root canal treatment (8, 16, 2.5-27). It isclear that there are different reasons for |3erlorm-itig an a|Dicectomy. Some of these reasons areinvalid in the light of new concepts in endodonticpractice. It is crticial that the right decision betaken belbre j^erforming an a|3icectomy to pre-serve an affected tooth where the i^ractical difli-ctilties of performing conventional root canaltieatment, or conventional re-treatmenl are recog-nised.

Generally speaking it mttst be recogtiised thatfew trtie indications exist for surgical euclodontictreatment and these indications shottld be in thebest interests ofthe patient and satisfy the basic bi-ological principles ol inodern conventional endo-dontic therapy. Surgical interventioti shotild be at-tempted only after it is not possible io achieve con-ventional re-treatment or when patients cannot beconvinced to accejDt endodontic retreatment.

Tbe aim ol this sUidy was to identify the clinicalfactors involved in fleciding to ]:)erform a|)icecto-mies at the Leeds Dental Instiuite, and investigateihe extent to wliich the decision making jjroce.ss isbeing inlluenced l)y modern thinking.

iViaterial and methods

The study plan involved samjile selection and datacollection, data prc:)cessing and analysis.

This retrospective stttdy was based on a sam]3leol 517 leeth that had undergone apicectomy for392 patients from September, 1990 to December,

186

Decision to perform apicectomiesTable 1. Distribution of tiie treated patients and teeth according to tbe sourceot reterral.

Source of referral

G.D.P'

Interdepartmental

SelfreferralOthers

No.

233

152

5

CSJ

Patient

(%)

(59.4)

(38.8)

(1.3)

(0.5)

No.

299

210

6

Teeth

(%)

(57.8)

(40.6)

(1.2)

(0.4)

517 (100)Total 392 (100)

' General dental practitioner (G. D. P)

1992, at tbe Leeds Dental institiUc, in the Depan-uicnl of Oral and Maxillo-Facial Surgery. Patient.swere idenlified (patient name, hospital number,date (if operation, looth ntimber) from the day aj)-pointment book surgical .sheets in the Departmenlol Oral and Maxillo-Facial Surgery. Their clinicalrecord cards were located in the main offtce. Nosearch was undertaken for anv missing records(Hve clinical records), and it was not possible toidentify those referrals wliich were eilher rejectedfor or allocated to ahernati\e treatments.

A piloi stttdy of 2.5 cases was cai i ied otit to de-termine the ptacticalities of the stn'vey, and to as-sist in the design ofthe (inal data collection foim.

The facts derived from tlie treatment recordsheet were ;

1) Patient's demograpliic data. (Name, date ofbii th, sex, hosjiital nttmber)

2) Clinical details. (Referral details, cliiel com-])laint, tooth nnmber, date oldj^eration. suspectednatitre of the periraflicttlar lesion, biopsy result,wheti taken and recorded in the patient trc-atnientrecord).

3) Rafliogra|)hic details.The follo\vitig information was collected at the

time ol examinitig the jMeoperatixe radiogtapli:Size (maxitiitim diameter) in millimetres o( tlie

apical lesion related to alfected tooth if anv; (jtial-ity of root canal treatment; The material used lorroot canal lilling as recorded in jjatient tteatmentrecotfl; The c]tialit)' of preoperatix'e root (anal fill-itig as judged hv close examination ofthe j^eopet-ati\e iadiogra])li (or each tooth; root lillings wereclassilied itito satisfactory, or ttnsatislactorv whetithe qualitx' of loot eanal lilling <k-m<)nstra(ed lackol detisitv, voids, tttulet ftlled catials, loss of (on-tour, tmlilled canals (in nmlti(analecl teetli). over-extensioti, atid tnidetextetision ol' the tcxM catialfilling; citiality and material ofst'al; t\pe of coronaltestoration; tvpe oT tadicular testoratiou (l.etigtho( post in millimc-tres, diameter of post in millime-ires at the apical end of the post).

4) Rationale for performitig apicectomy. Thereasotis for perfortiiing apicectotiiies were classi-fied in to two main headings for the ptnpose ofanalysis (technical and biological).

The teehnical factors that make conventionalroot eanal treatment impossible or impractical re-corded in this stncK- were; post crown restoredteeth; crowned teeth; fractured instrittnents; pres-ence ol old root canal lillings which eould not betemoved; perfotated root c;mals; opeti apices;sclet (ised root catials; others.

The biological factors, which teflected contitui-itig infection recorded in this study were; pei.sist-ent sytiiptoms; ditnensioual change iti radio-gra]5hic appearatue (R.A) of ])eriradicular le-sions; catial tiot dtv (uticotitroUed root catial exu-date).

\A'here technical and biological factors were oc-(itrtitig together atid were both invohed in the de-cision tiiaking process they weie cotisidered to becombined.

Sample selection;'fhe samples were selected as follow:

Itiitial .sample selectioti.i. Patients who had undergone apicectomv dur-

ing tbe period from January, 1988 to February,199S wete idetitified.

ii. The cases selected for the study weie thosecases selectc-d for surgical endodontic treatmentonh, from September, 1990 to Decembet, 1992.The total number of teeth which had undergonean apicectomv dtning this period wete 538 teethfor -110 i^atietits.

Final samjjle selections.i. All the selected cases clitiical record cards

wete collected chronologically itito grotips. start-ing from September, 1990 to December. 1992

ii. The details of each tooth were tecorded sei)a-tateh- tising the data collection form. If a toothhad more than one ajiicectomv details of eachwerc^ reeorded separately.

iii. Fighteen patietits' records (21 leeth) weteexcluded from the study because there were nopreojietative radiographs, atid two ofthetu h;ul notreatment record sheets. The final nnmber ofteeth investigated was .517 lor 392 patietits (Table1).

Data collectioti. .\ fortii was designed as a meatisol d a t a coUec tion.

The inlotiuatioti tecotded lor the ftti;tl satiipleo( (ases were tiansreirecl to a coinptiter .system. Acomptttitig lotiii Avas designed to facilitate the col-lection, transcription, and transference oC the in-lortiiation lrotii each patient's tecord card to thecomputer ='• (tising a Micrcxsoft work spread sheetpiogtamtiie lor an;tl\sis).

187

El-Swiah & Walker

Table 2. Distribution of the study sample according to the number of patientsand teeth by gender

Women

No. (%)

Men Total

Number of patients 211Number of teeth 291

(53.8)(56.3)

No.

181

226

(46.2)(43.7)

No.

392

517

(100)

(100)

Note: Percentages given in parenthesis are included in the table to assist com-parison.

Table 3. Distribution of treated patients according to age and gender

Age ranges Women Men Total

Under 20

20-29

30-39

40-49

50-5960 and over

Total

No.

8

61

62

41

2217

211

(%)

(3.8)

(28.9)

(29.4)

(19.4)

(10.4)(8.1)

(100)

No.

5

42

63

31

2911

181

(%)

(2.8)

(23.2)

(34.8)

(17.1)

(16)(6.1)

(100)

No.

13

103

125

72

5128

392

(%)

(3.3)

(26.3)

(31.9)

(18.4)

(13.0)(7.1)

(100)

Table 4 Distribution of the number of the treated teeth in tiie two arches bytooth type

Tooth type

Central incisors

Lateral incisors

Canines

1st. Premolars

2nd. Premolars1st. Molars

Total

No.

159

173

36

34

252

429

Maxilla

(%)

(37.1)

(40.3)

(8.4)

(7.9)

(5.8)

(0.5)

(100)

Mandible

No.

52

28

4

1

3-

88

(%)

(59.1)

(31.8)

(4.6)

(1.1)

(3.4)

(100)

No.

211

201

40

35

282

517

Total

(%)

(40.B)

(38.9)

(7.7)

(6.8)

(5.4)(0.4)

(100)

Table 5. Distribution ot treated teeth according to the preoperative quality ofroot canal filling

Quality of root canal tilling

SatisfactoryUnsatisfactory

Total

Root canal treated

No.

138370

508

teeth

(%)

(27.2)(72.8)

(100)

*l\line teeth out of 517 teeth had calcified root canals.

Results

The processed data and restilts for the retrospec-tive sttidy are presented using tables and/or-graphs.

Table 6. Distribution of the number of treated teeth according to the size of theradiographic periradicular lesion in the two arches

Size ot lesion

in millimetres."

Maxilla Mandible Total

1-4

5-8

9-1213 and over

No.

119

143

62

40

No.

(32.7)

(39.3)

(17)

(11)

28

34

17

3

(34.1)

(41.5)

(20.7)

(3.7)

No.

147

177

79

43

Total 364 (100) 82 (100) 446

'Out of 517 cases, 71 cases had no periradicular lesions.

(33)

(39.7)

(17.7)

(9.6)

(100)

The distribution of the sttidy sample accordingk) numbci- of paticnt.s and teeth are presented inTable 2. The majoiity of cases were referred bygeneral dental practilionens a.s presented in Table1. The age grotips were classified in to six gioti]3langes as pie.sented in Table 3, and each range iscompletely inchisive. Apicectomy procedtn es weretindertaken moie often in maxillary teeth as pre-sented in Table 4 (8.^% of total ntnnber of caseswere in the maxilla). Tbe difierciice between theteeili involved in the two arches was statisticallysignificant (%'= 1(3.89, df?>; p< 0.0008 ).

There was no statistically significant differencebetween maxilla and mandible according to thesize ol periradictilar lesions as presented in Table6 ()(•= 4.37, df"?>\ n.s). The total number of biop-sied teeth was 180 from total of 446 cases with per-iradiciihu' lesions as found in the patient treal-ment lecords. These were classified according to(he results of the biops)' as presented in Table 7.

Analysis of factors involved in the decision toperform apicectomies:

The clinical factors involved in deciding to per-form apicectomy procedures in this sttidy (Table8) were classified into technical, biological, andcombined (where the decision was inlluenced byboth biological and technical factors).

The relative proportion of all the technical fac-tors, i.e. inchiding those combined with other fac-tors, and all the biological factors, i.e. inchidingthose combined with other factors is shown in Fig.1 The relative proportion of the different ]:)iologi-cal factors for performing apicectomy in this ret-rospective sttidy is shown in Fig. 2, and the relativeproportion of the different technical factors isshown in Fig. ?>. The peicentages have beenrcjtinded by the computer.

Discussion

In order to .satisfy the endodontic needs of teethwith periradictilar lesions the surgical removal of

188

Table 7. Distribution of fhe histopathological results by tooth type •

Tooth fype Abscess Granuloma

Cenfral incisorsLateral incisorsCanines1st.Premolars2nd.Premolars

Total No. of lesion

No.

2

2

No.

(50)

(50)

(100)

51

41

8

11

5

116

(44)

(35.3)

(6.9)

(9.5)

(4.3)

(100)

Cyst

No.

15

28

3

1

47

(31.9)

(59.6)

(6.4)

(2.1)

(100)

Decision to perform apicectomies

others*

No.

8

4

1

(61.5)

(30.8)

(7.7)

13 (100)

Total No. ot teeth

No (%)

1

76

75

12

11

6

(42.2)

(41.7)

(6.7)

(6.1)(3.3)

180 (100)

1st molars excluded trom the sample in this table as there were no biopsies recorded.Twelve cases were diagnosed as scar tissue. Two were scar tissue with a foreign body. One case was diagnosed as chronically inflamed antral mucosa.

Table 8. Distribution of the study sample number according fo fechnical andbiological factors

The factors

Technical onlyBiological onlyCombined

Total

Number of feefh

17182318

517

Relafive proportion (%)

(3.3)(35.2)(61.5)

(100)

diseased periradiettlar ti.ssne and the placetnent ofan ajiical seal does not etadicate the sonrce olinfection. This can only be successfully achievedby a non surgical approach, performed in a thor-ough tiiatinet. Petiapieal sttrgety performed aloneis not a total ctne Ibr periradicnlar indannnation.The i)rimary t)bjectives of sutgical endodontics ateto teniove the inllamed periradiettlar tissne. andplace an apical seal. Snrgical intervention shonldlje considered as ati altetnative ainpioach whennon snrgical tteattitetit is tiot feasible. It tnay alsositpplement non smgical tieatment when it hasfailed. This opitiioti is based oti atiahsis of tteat-metit results in tioti sittgical ;nid sntgical etido-dontic cases atid emjjhasises the importance (if

ij stndies (8). With the mattnation of

etidodontics as a speciality, re-treattnent of rootcatials after treatment failtne has become a clini-cal teality. Non sttrgical re-treattnent, in eases ofpreviousl)' failed t oot canal treatment provides thebest prognosis. Man\- appat etit indications for sur-gei7 ate no longer relevant (15). The resvtlts ofthe present stttdy at e discussed and where possiblerefetence is made to previous stitdies which havedealt largely with the prognosis, success and lail-me of apicectotiiy procedures, atid the tnatetialsand techniques used. There has been litde investi-gatioti itito the relative itnportance of the differ-ent lactot s considered wheti decisions are tnade inthe pt escription of endodcnitic surgeiy.

The quality ofthe recorded information in a pa-tient's clitiical tecotd ate of utmost importance ina retrospective study. In the presetit study most ofthe clinical lecords did not give complete detailsregarding the factors which influeneed treatmentseleetioti or the reasotis for performing apicecto-mies.

The tnajotity of cases (59.4%) were referred bygenetal dental practitioners, i.e. 233 patients (299teeth) of the whole satiiple. Most of the patientsrecei\ed tteatmetit in the 30-39 years, followed by20-29 years age groups. Stockdale &: Chatidler(28) also lound that the tiiost common age group

60%

D Total biological factors• Total technical lactots

I. RrUuiw proponion of Ici hnical and liiologit al tanor.sspc"! tive ol each oilier.

44%

54%2%

O Pesistant symptomsB Catial tiot dryH R.A. of periradicular lesion

/•)>. 2. Relative piojiortion.s olbilotiical laclors.

189

El-Swiah & Walker

MW/,

2.6%/ " ' - ( 1 . 3 %

2.6% 2..1% 1.2%

Post crown reslored teethFractured itistrutncntCrowned leetliPertoratci! root c;inal

Sclerosed root eattalPresence of old K.C. lillingO])en apexOthers

F i g . >. R c h t l i v c p i o p o r l i c i t i . s o f U ' ( l t n i ( ; i l l a t l o i . s .

ill whicli cudodoutic surgery was |jcrformcd Icll into tlie range 31-40 years, in both sexes. Few pa-tieuts fell into the age group of less than 20 years,and from 50 years and over the number of pa-tieuts wa.s low. f hi.s may lx' due to the liigb sticcessrate of eonventional root canal treatment experi-enced in this age group (29).

Eighty-three percent of the treated teeth weremaxillary teeth, and this is in agreement withStockdale & Chandler (28). It appears tbat maxil-lary teeth receive convfiitional root canal tieat-metit more often than mandibular teeth (3t), 31).Despite the difficulties commonly encountered intreating maxillary lateral incisors endodontieallyonly 3% more lateral incisors were found to re-quire stirgical treatment. The percentage ol per-maiu'iit incisors involved in the maxillary arch was77.4% in relation to other maxillary tecdi. In themandible the most common teeth were the cen-tral incisors. This highligbtt'd the difficulties en-coimterc'd in trcaling these teeth endodontieally.Tbe manchbiilar central incisor frec[uciuly bas tworoot canals, 41.4% (32). Ninc-ty-one percent ol thetreated mandibular teeth were |5crmancnt inci-sors. This highliglitc'd the need (or tlic clinician tosearch for the second canal. Failure of conven-tional root canal tieatment of the mandibular inci-sors may arise from the uncleancd second < anal.

Four bunched and forty six teedi had pcriiadie-iilar lesions (3tH iu maxilla and 82 in mandible).The lesions were mosl commonly from 5-8 mm insize, in f)oili arcbes, which may exj^lain tbat theperiradicular lesion is lirst discovered radiographi-cally or becomes sym|)loniatic and noticeable bythe patient when it reaches this size. Bio|:)sy le-]3orts were availabk- for 180 teetb. The predomi-nant lesion was the pcriapical granuloma ((54.4%)).True cysts occurred in only 2(i.l% ol cases. Tbissupported the previous researcli lindings (33).

fbrec hundred and seventy teeth were found tohave jDrc'-opcrative root lilling which were consid-ered to be unsatisfactory (72%) (Table 5). The ajj-parent causes lor faihirt- ciii|3hasiscs the need toimprove the slandards of regular conventional

teclinicjtu's in orrlcr lo prevent or reduce the needfor rc'-treatmcnt or surgcr). It is |jai tic iilarly signif-icant in those teeth rc-cjuii ing coronal and post-re-tained restorations.

Technical factors alone- only accounted (or3.3%; of the apicectomy cases. These included 1perforation repair, 2 separated instrimicnts. 3 re-treatment cases, and 1 1 c ascs where teeth were ap-icected in conjunclion with other apicectomy pro-cedures (because those teeth were endodontieallytreated and crownc-d) presumably to exclude- tberisk of die need (or future- apiece toinics if thc-irconvcnticMial endodontic tie-atmcnt (aile-el.

Te-chnical factors we-re- taken into account e-ithe-ralone or in combination with biological (actors in40%) of the cases. Within this group the most com-mon factor was the ]3iese-nce of a |De)st crenvn.which constitnte-d (iO.4 )f the total. Crownedteeth (including bridge- retaine-rs) without postsmade- up a (tirther 30.7%) e)( the cases. The need tocare-fully c-vahiate die endodontic status of vitaland root filled teeth prior to rc-storation is of para-mount im]3oi tancc- if suigc-ry is to be- avoided.

Biological factors alone constitttte-d 35.2% oftlu- total factors, and in combination with otherfactors were (it)% of the lotal sample. Within thisgroup the most common factor fotmd was the pcr-sisle-nce- of symptoms after conventional root canaltherapy (.54.'l%).

The most likely catisc of du-se persistent symp-toms probably was inadec]uate disin(e-ction and bi-ological se-aling of the ptilj:) sj^ace. The- se-condcommon biological factor was the presence ol apel Iradicular lesion (44.1%). Of the teeth biop-.sied (i4% were apical granulomas. When the rootcanals were accessible, ce)nventional treatmentwould have bec^n expected to bring about resohi-tion in the great majority of cases. Two percent o(the cases were carried out bccatise the icjot canalcould not be dried. The proper use of cleaning, ir-rigation and intracanal medication ]Drocc-dtire-swould elo mtich lo eliminate the nee-el for surgeryin these cases.

Tbe combined factors were involved in the deci-sion making process in 62% of the total sample.Technical and biologieal factors most commonlyc-xisted together. The pre.sence- of continuing in-fection, evidenced by the biological factors, associ-ated with a situation in which the pnlp s|3ace is dil-(icult to access would appear to be a dominant fea-ture in the decision making process.

Conclusions

The following conclusions can be- drawn from diedata |3rcsc-nted in tins study.

190

1) Most of the J3atieiits referred for surgicaltreatment were frotn tbeit general dental jDiacti-tioner.

2) Maxillary teetb were apicected more oftetitban mandibtilar teetb.

3) Petniatient iticisors were tbe most cotinnoiilytteated teetb. Maxillaty lateral incisors, and nian-clibitlar cetittal iticisois were tbe most commonteetb to be treated in tbe respective arches. Tbedifliculties encotititered wben treating tbese teethsbotild be borne in niitid wben performing con-ventional endodontics.

4) Utisatisfactory root canal ftlliiigs (72.8%) ap-peared tbe most common candidates for surgicalenclodontic treatment. Mote cate in treatment isrequired to acbieve tbe objectives and biologicalptincijales of cotiventional toot catial tbetapy, atidavoid itnuecessary sut gery.

5) Periradicular gtautilomatotts lesiotis were tbemost commonly biopsied lesion in tbis study. Tbissup]3orted pie\'ioiis rmcliiigs recorded in tbe litera-ture.

6) Combined biological and tecbnical factorsare most commouly involved in tbe decisioti mak-ing process. Tbe post retained crowned andcrowned teetb proxidecl tbe most common tecbtii-cal factors, and tbe |3ersistence of symptoms andthe jDiesence of petiradicular lesiotis were tbemost (ommon biological factors involved in fliedecision making process to pet form ai^icectotiiies.

References

1. S a u n d e r s KM. .Sauiul r i s \ \ P. Coin iMi l iona l iciol e ana i l l ier-

a|)y, I: Pix-parat idn of rool l a n a l .s\.sk-in. In; Marly F | , :'nd

c d . E n d o d o n t i c s in (.liiiieal P i a i l i ( i ' . L o n d o n : Wrinl i t

1990; 12S-1.W.2. l'.iiiopen Society ot tMulDdonlolos^y. (.onscnsus rr])orl of

the Enro]5eaii Society o t EiidodontologA- on qtiality gnidc-liin'.s lor cndodoiuii- iri-alinenl. Int Endod | 1994; 27: 1 15-121.

'5. llaily F|, Parkins lij, Wcni^ral .\Nt. Siu'c<'ss laie in rooi ca-nal tbfiapy. A ri'ti'ospceli\c siiuh ol coin'cniional eases. HiDcntJ 1970; 128: (W-7().

4. Keivkes R, Trtjiistad L. Long-icini icsnlls ol cndodoniii-ti'calmciu pcrfornu-d willi a siandaidiscd UH lini(|iu-. | En-dod 1979; 5: 83-90.

C). Swxuiz DB, Skidmore AK. ClriHin )A. Twcntv yoais ol endo-dontic success and faiUirc- ] Endod 1983: 9: 198-202.

(). Molvcn C). llatsc /\. Siicc-e.s.s rak-s lor gnlla-pi-i-clui andkloropei-ka.N.0 root Tillini^s nuulc hv niulcrgiadnaU' sin-dent.s: Radiographic lindings aflci 10-17 \cars. Inl KiulodJ 1988: 21: 2 1.̂ -2.50.

7. Mowe CL. Minor oral sni\>(M\.:')i-d cd. Krislol :\\'i-it;lu. ]and sons, \98~r, :M."i.

8. Citing tV Molvcn (). liaise A. Periapical snigriv in a Nor-wegian country bos|)ilal: Folli)\v-np liiiding ol 177 icclli. |Endod 1990; 111: 11 1-117.

9. Hill TR. Rool canal iliciapx l)\ means ol apic-ccloinv Br |Oral Snrg 1'.170: 7: 1118-177.

Decision to perform apicectomies

10. Maisliall I'J. Endodoniic snigcrv: criU'iia. indicalion. andprocedures. | Can t^cnl .Vssoe 19(14; :iO: 703-71:5.

1 1. Sniiinicrs L. Oral surgery in general dc-iual praclice. Part\' .Vpicectoniv. .\tist Dent J 197.5; 20: 205-207

12. 1 kill is MIL AiMcoectom)' and retrograde anialgam inmandibtilar niohir leetli. Oral Siiig Oral Med Oral Patliol1979: 48: 40.5-407.

i;V Nehammer CF.Snrgical endodonlics. Br Dem I 1985; 158:400-409.

14. Litebke RG. Click DH. Ingle ]I. Indications and (-oiitiain-dicalions for endodoiuic stiigerv. Oral Snrg Oral MedOral Patliol 1964; 18:97-113. '

15. Bloek RM. Lewis t^R. Snrgieal liealnieiil of iatrogenic ca-nal blockage. Oral Surg Oral Med Oral Patliol 1987; (1.3:722-7:52.

1(1. Mohen O. I lalse A. Crtnig B. Stirgieal nianagemeiit olCn-docloiuic failures: indications and treatiiient resnlts. InlDentJ 1991; 41: :x5—42.

17. Barnes IE. Surgical luidodoniii s. Cotonr Mitnuat. 2nd ed.Wrigbi: 1991: page 15-18.

18. Gulniann Jt,, Harrison, J\V. Posterior endodoniic siirger\:anatoiiiieal consideration and elinical leehniqties. Int En-dodJ 1985: 18: 8-:Vl.

19. Gntnianii jL, Harrison |\V. Pei iriidicnlai- i uretlage, rooi-end lesection, rool-end lilling. In: Cntmann ]L and Harri-son JW. Stirgical Endodonlics, 1 st ed Blackwell seienliriepublications. 1991: 2():i-2tl:i.

20. IVonslad L, Barnett F. Riso K, SlotsJ. b^xmuadicttlar endo-donlii infections Endod Dent Tiatimatol 1987; .''.: 8(i-90.

21. Happonen R-P. Periapical aclinomycosis: A follow-upsludy of 16 stugically treated cases. Endod Dem Trannia-lol 1986; 2: 20.5-209.

22. La.s:iridis N. Zotilouinisi L. .Vntoniadis R. Bonv lid a]>proaeh lor apicectoni\ of inandihulai molars. .Vnsi Dent |1991; 36: .3(l(i-.368.

2:V Filz|)atiick B. Endodonlie snvgerv on posievioi leeili. .\nsiDem I 1974: 19: 2.36-24 1.

24. ]ohns RB. Stirgical EiKlodomics.tiem t'pdale 1977; 4:223-229.

25. Ericson S. Finne K. Persson C;. Resulls of apieec lonn ofmaxillary canines, premolars, and molars wilh speeial lef-erenee to oioantial coninitinication as a j-iiognostic factor.Int I Oral Surg 1974: 3: :^8(i-:W:V

2(1. PerssonG. Periapieal snrgeiA a\^ molars. Int | Oral Snrg1982: 1 I: 96-100.

27. Friednuin S. LnsiiiKinn |. Sbaliai:ibanv \'. Irealineni re-snlis ol apical snigei v in |)HMiu>lai- and inol.u let ih. | En-dod 1991: 17: :M)-:l:V

28. Stockdale CR. Chandler NP. Ihe nalnre ol ilu- peiiaiiic.illesion a review of 1108 cases. | Dent 1988; 16: 12.V129.

29. Many F|, Parkins BJ, Wengial .AM. The sneee.ss rate of api-eeeloniy. A letrospei ii\e siud\ of 1016 eases. Br Dem |1970:129:407-413.

:ll). Ingle JL Beveridge FE. (ilick DH. Weic bman jA. Aboti-Ra.ss M. Modern endodomii tlierap). In: Ingle ] IDE andTaimor JF .3rd ed. Endodomii s. PIiiladelpbia:Lea .̂ - Fi--biger. 1985: 34-:V5.

.31. Manogue M. Manin DM. Changes in paliem age andt o o l l i d i s l i i b m i o n t i n r o o l c a n a l I r e a l n i e n t i n a l e a c l i i n g

hospital over a 1.5-\eais period.hit Endod ] 1994; 27: 148-153.

32. Benjamiii K.\. D(nvson |. huidence ol two rool canals inhiiin.in nKiiulibiilar ineisor leelb. Oral snrg 1974: :?8: 122-126.

y^. BliaskarSX. Periiipical lesi()ns-'r\p(-s, imidence. and clini-eal leatnies. Oral Snrg 1966; 21: (157-671.

191