Surgical endodontics: quo vadis?JAMES L. GUTMANN

Surgical endodontic intervention has emerged over the

last 100 years as a significant treatment modality in the

retention of sound teeth (1). While the evolution of this

treatment modality and the refinement of its principles

have had a long and tumultuous history, biologically

based directives are emerging and are integrated with

significant advances in clinical modalities. No longer

does the endodontic literature support a litany of

indications for surgical applications, but rather, well-

thought, evidenced-based principles are guiding the

selection of this treatment modality (2–7). Coupled

with the introduction of magnification through the use

of the surgical operating microscope, refined principles

of soft and hard tissue management, use of tissue

regenerative root-end fill materials, and enhanced

principles of wound closure and postoperative manage-

ment, surgical endodontics has emerged as a highly

predictable and relatively painless procedure (8–13).

Ironically, the impetus for the evolution of con-

temporary surgical endodontic principles came from a

better understanding of the challenges faced in the

cleaning, shaping, disinfecting and obturating the

complex and unpredictable anatomy of the root canal

system. While technology in the non-surgical provision

of treatment has advanced significantly (14), there still

remains the challenge of eradicating microbial species

and their biofilms from the root canal system, primarily

in the apical third of the root (15–18). Even with this

dictate, it is still imperative to consider the choice of

non-surgical root canal treatment (19) or the revision

of previous less-than-ideal treatment (20) before

surgical intervention, as outcomes of non-surgical

intervention would support this choice.

Surgical intervention is not a substitute for failure to

manage properly the root canal system non-surgically,

to assess thoroughly the periodontal status, and to

ignore the shortcomings of the coronal restoration(s)

(21, 22). Knowing when to choose surgical interven-

tion is just as important as the expertise to be exercised

in the surgical procedure and the judgment to be

exercised in the assessment of what has been done (23).

In essence treatment planning the choice of surgery

may actually be more difficult and challenging than the

surgical procedure itself (24). This is especially true

with the massive and sometimes irrational movement

to replace every endodontically treated tooth with or

with symptoms with an intraosseous implant (25–30).

Retention of the natural tooth structure is still the goal

of quality dental care and many previously root-treated

teeth that appear to be done quite well, yet exhibit

adverse signs or symptoms, are viable candidates for

non-surgical treatment revision or surgical revision of

treatment (31–33).

With each patient that presents for treatment, the

clinician is challenged to make choices that result in the

best treatment possible for the patient. These choices

are based on a number of factors that influence the

clinician in the decision-making, problem-solving

process (24, 34, 35). These factors include the

following:

� Axioms that are commonly held in endodontics and

supportive disciplines.

� Formative knowledge to support the choices.

� Clinical skill.

� Clinical experience.

� Problem solving skills.

� Patient preference after being informed fully of

treatment options and their rationale.

� Economic factors.

� Evidence-based concepts.

� Integrity.

Failure to take all factors into account may lead to

treatment plans that are ill advised or not in the best

interest of the patient. While many teeth can be

maintained with a surgical endodontic procedure, it

may not be in the best interest of the patient to retain a

tooth that has restorative or periodontal compromises

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Endodontic Topics 2005, 11, 1–3All rights reserved

Copyright r Blackwell Munksgaard

ENDODONTIC TOPICS 20051601-1538

(24). Furthermore, if a tooth cannot be returned to

symptom-free function following surgical intervention

removal may be indicated. Moreover, while tooth

retention is ideal for function and aesthetics, at times

tooth resection or removal and replacement with a fixed

partial prosthesis, a removable partial prosthesis,

implant, or no replacement may be in the best interest

of the patient (24).

This volume of endodontic topics focuses on multiple

issues that deal with surgical endodontics, with a

primary focus on apical surgery – a ‘first’ for this

publication. Furthermore, other than textbook chap-

ters, this is the first comprehensive literature-scientific,

evidence-based publication on surgical endodontics in

15 years. This publication and its focus on the

principles of apical surgery are supported by a multi-

tude of general concepts that apply to treatment

planning choices both prior to and following surgery,

pain prevention and management, postsurgical man-

agement and outcomes. As the availability of true

evidence-based information in surgical endodontics is

sparse, there is in some topics presented by the author

more of a best evidence approach to this treatment

modality. The fact that this topic is presented by a cross

section of clinicians, academicians and researchers,

lends great credibility and reality to contemporary

principles discussed. Hopefully this approach will

encourage more evidence-based research and long-

term outcomes studies to solidify or alter the concepts

delineated herein.

References

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Surgical endodontics

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