• Periradicular disease where iatrogenic or developmental anomalies prevent non-surgical
• Periradicular disease in a root-filled tooth where non-surgical has failed and it may be detrimental to the tooth if done non-surgically (e.g. presence of a post with high risk of root fracture)
• Biopsy of periradicular tissue
• Visualisation of periradicular is required due to suspected perforation or root fracture
• Patient considerations

• Patient factors (severe systemic disease, psychological considerations)
• Dental factors
  • unusual bony or root configuration
  • Lack of surgical access
  • Possible involvement of neurovascular structures
  • Unrestorable tooth
  • Poor supporting tissue
  • Poor oral status
• Skill, training, facilities available and experience of operator should be considered

• Long cone parallel periapical view
• May require additional views (parallax) for multi-rooted teeth, or when post perforation is suspected
• At least 3mm of tissues beyond apex is required
• If there is a large periapical radiolucency; may require DPT or Occlusal view
• If sinus tract present; need a view with GP in place

The flap design depends on:

• access to the periradicular lesion
• the periodontal status
• the restorative status of the coronal tooth structure
• aesthetics
• adjacent anatomical structures
• the tissue biotype

Key points:

• A papilla-base incision is recommended in the ‘aesthetic’ zone as post-surgical gingival recession and loss of interdental papillae is critical
• Semi lunar flaps have an increased incidence of scarring so are rarely used

Periradicular Curettage:

• Soft tissue in periradicular region should be removed with curettes to allow adequate visualisation of the root apex.
• Inflammatory tissues can be removed but peripheral tissues can be left especially if they are reparative in nature. Pathological material can be sent to histopathology.

Root-end Resection:

• Resection of the root should be 90 degrees to the long axis of the tooth as possible to reduce the number of exposed dentinal tubules and ensuring access to all of the apical anatomy
• 3mm of root end should be removed with a rotating bur (using saline and water coolant)

Root-end Preparation:

• Root end prep done best using ultrasonic tip.
• Should use EDTA at end to remove smear layer.

Root-end Filling:

• Isolate from moisture including blood (use haemostatic agent)
• Compact material into cavity – ensure no excess material on the resected root surface
• MTA is a osteo and cement-inductive material and is associated with a high success rate
• Amalgam not recommended
• Take radiograph prior to wound closure

Closure Of Surgical Site:

• Place sutures – remove after 2-4 days

There is a risk of pain, bleeding, bruising (ecchymosis), infection

Radiological exam is conducted at annual intervals until healing is observed

Guidelines for Periradicular Surgery
A.Qualtrough, A.Alani, S.Bandheri, D.Mehta. Y.Ng, A.Saksena, P.Tomson, created in colloboration with the British Endodontic Society