Apicoectomy Tutorial – When, Why and How – PDP148

You're faced with a beautiful crown with what seems like a decent root filling - but there's an apical infection present. Is the answer always endodontic re-treatment? When should we instead consider apical surgery so we can clear the infection WITHOUT drilling through the crown or having to dismantle posts? In this episode, specialist endodontist Dr. Peter Raftery and his associate Dr. Manpreet Dhesi will be talking about the Apicoectomy procedure that can be used to treat root-filled teeth using a 'retrograde' approach. They will discuss about how it fits into general dentistry, its indications and contraindications, its cost analysis vs implants and and the entire protocol for performing Apicoectomy https://youtu.be/sZOsLuuf-Vo Watch PDP148 on Youtube Protrusive Dental Pearl: The periradicular surgery guidelines issued by BES and the Royal College of Surgeons. Download the guidelines about periradicular surgery or on the app under the Protrusive Vault (where all the different files and infographics and the different things that you get as a Protrusive premium member) BES-RCS-Peri-Radicular-Surgery-GuidelinesDownload Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:37 The Protrusive Dental Pearl 3:32 Dr. Peter Raftery’s introduction4:05 Dr. Manpreet Dhesi’s introduction5:16 What is Apicoectomy?6:29 Oral Surgeons vs Endodontists?8:48 Is a Microscope mandatory for Apicoectomy?10:08 Apicoectomy for posteriors11:00 Isolation Protocol for Anterior Apicoectomies11:35 Apicoectomy Protocol15:03 Disinfection Protocol18:41 Moisture control from the bleeding20:43 Risk of surgical emphysema - Is special handpiece needed?21:52 Indications and Contraindications for Apicoectomy 27:46 Endodontic Re-treatment29:05 Cost benefit analysis of Apicoectomy31:20 Success rate for Apicoectomy34:19 Case Scenario 1: 82-year old patient with a singular crown, root filling and a radicular pathology42:10 Retrograde fillings of choice  44:09 Grafting after Apicoectomy - is it needed?45:04 Equipments for Apicoectomy47:11 Learning more about Apicoectomy Apical Microsurgery Instrument Kit- the mirror, the pluggers, and the little curettes by Hu-Friedy UK Apical-Microsurgery-Instrument-KitDownload If you enjoyed this episode, check this another episode by Dr. Peter Raftery: How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique Click below for full episode transcript: Jaz's Introduction: Root canals are not 100% successful. Let's face it, nothing in dentistry is a hundred percent predictable, and sometimes we are confronted with a scenario such as a beautiful central incisor crown and it's a root filled tooth, or worse yet a tooth and incisor, usually with a long thick post inside of it. Jaz's Introduction:Now, just because it looks good on the radiograph doesn't mean it was a good quality x-ray. We all know that. But anyway, let's say it looks like a decent root filling. There are no voids in it, and now you're really questioning whether it's really feasible to go down a root canal re-treatment, or is there another option? And sometimes that other option, which really comes into play in these scenarios is an apicoectomy where a flap is raised, the infection is curetted, and a bit of the root, a bit of the apex is chopped away, and then boney healing takes place. Now this is known as microsurgical endodontics. It used to be done a lot by oral surgeons in the UK at least many years ago. And now endodontists have reclaimed this territory and suggest that actually this is the way we do it to get high predictability. And that's exactly what we're got to discuss in this episode. Hello, Protruserati. I'm Jaz Gulati. I'm joined in this episode by Dr. Peter Raftery, specialist endodontist and his colleague Manpreet Dhesi. We'll be talking about. All the things you'd want to know about apicoectomy, does it have a place in general dentistry? How does it compare to an implant in terms of cost benefit analysis? What are the indications and contraindications of this, as well as talking you through the entire procedure from start to end, including the little details such as what is the retrograde filling material of choice? Protrusive Dental Pearl:The Protrusive Dental Pearl for this episode, which really compliments this theme of apicoectomy really well, is the GUIDELINES. The peri-radicular surgery guidelines issued by BES and the Royal College of Surgeons. This is such a beautiful document, which covers so many themes of this episode, actually is a great revision for this episode itself, and talks about the indications, contraindications, and really just summarizes really nicely all the guidelines for carrying out peri-radicular surgery. Now, you can download this document on the Protrusive website. That's protrusive.co.uk/148 because this is episode PDP 148, so /148, or if you're on the app, it's on the Protrusive Vault section of all the different files and infographics and all the different things that you get as a Protrusive premium member. I've also recently added to the premium clinical video section of the app, a complete guide on how I did the walking bleach technique on a patient So discolored and non-vital lateral incisor, how I bleached it internally using the walking bleach technique, which we discussed in the previous episodes. If you haven't listened already, do checkouts episodes out with Dr. AJ Ray-Chaudhuri. And then I also show you how I did the bonding, including removal of the old composite. And mocking up and actually lengthening the teeth while respecting the occlusion and making sure that restorations are got to be unchippable. So that's all in the premium clinical video section. If you're not already a Protrusive premium member, it might be right up your street. If you're a dental geek like me, or for the cost of a tax deductible mandos per month. The website checkout is protrusive.app, or you can download it on the iOS or Android store to check out all the protrusive goodness. Now let's join the main interview with Peter and Manpreet. Now catch you in the outro. Main Episode:Dr. Peter Raftery and Manpreet Dhesi, welcome to the podcast. Peter, we had you a while ago on surgical extrusion technique, which is a really interesting way to save hopeless teeth. And today we'll be talking about apicoectomy. There's so many questions that come to mind about apicoectomy, and I know you two are got to be really great in helping us. But before we go into that, just remind us again, Peter about yourself, your practice, and you Manpreet, it's the first time on the show. So tell us about yourselves, guys. [Peter]Yeah. We are in Hampshire endodontics at the minute. We are coming from, speaking from Haven in Hampshire. Got a branch in Winchester also, but an endodontics only practice. My background was the sort of formal training route at the Eastman a long time ago now. But then as things got busier here, put the feelers out and delighted for about a couple of years now to have had Manpreet. He's been a great addition. [Manpreet]Yep. So I've been with an associate with Peter for past two years. I didn't do full on specialist training. I did a part-time MSC at Queen Mary, which I completed probably maybe six or seven years ago, and now spend three days a week doing purely endo and then two days a week, still doing a bit general practice as well. So, bit of a mix. [Jaz]So Manpreet, you did your master's and now you split your time between practice limited endodontics and also general dentistry. Is your plan potentially in the future to do more and more into endodontics, or do you like the balance and the split kind of like a GDP with enhanced skills? [Manpreet]Yeah, I mean, I do like still keeping a hand in with the general dentistry, kind of just so I don't forget doing all of it, but it does have a knock on effect on my endo as well. So it does help me in terms of being able to restore teeth nicely, sort of tying things in with GDPs who refer. So yeah, maybe eventually I'll start focusing purely, purely on endo, but for the time being, it's nice to do a little bit of a mix. [Jaz]Okay. Great. Well, thank you very much for the introductions. Now, let's get to the meat of the episode. So apicoectomy, right. Just for our young colleagues, just so we're on the same page. When I say, apicoectomy, some endodontics say, 'we don't call it that anymore. We call it microsurgical endodontics.' And that kind of stuff. So I, I've heard that one before. And also the spelling of apicoectomy, I've been told before by consultant for spelling it the way it kind of sounds like it should be spelled apparently is different. That always confused me, but that's just semantics. Tell me, what do you guys mean when you say apicoectomy? [Manpreet]So an a apicoectomy for me is a procedure where we purely come from the apical part of the, an apical approach, leave the coronal portion completely alone, and then we're essentially cleaning the lesion out directly from the bone and resecting a portion of the route as well. And I guess, yeah, there are lots of different terms for it. We call it surgery. When we're talking to patients here, we just purely call it apical surgery. But yeah, you're right. Some people call it microsurgery. When you look at courses, a lot of them, they focus and they call it endodontic microsurgery. So there are a few different names, but yeah, we generally tend to call it either apical surgery or apicoectomy. [Jaz]And do you think this is more the domain of the oral surgeon? Or the endodontist because when I was at dental school, the oral surgeons would actually be doing in the hospital department.