This lecture by Dr. Thomas Wiser provides an overview of Apical Root Resection (ERR, referred to as Epical Root Resection in the transcript) and its surgical counterpart, Apical Implant Rejection. The discussion is framed around the new German guideline issued at the end of 2022, which addresses uncertainties in ERR indication, procedure, and success rates.
The key definition of ERR mandates the inclusion of a retrograde closure to ensure a bacterial-tight seal. For smaller lesions (up to 4-5 mm), non-surgical endodontic treatment remains the first choice. Indications for ERR include untreatable root canals, instrument fractures, and over-pressed filling material impinging on vital structures. The preferred surgical technique involves an intercurricular incision, a rectangular 3-4 mm resection of the root apex, and the use of MTA cement for retrograde filling. Prognosis is generally better in the maxilla and anterior teeth compared to molars, especially in younger, compliant patients. The lecture also highlights emerging technologies like Guided Modern Endodontic Surgery for minimally invasive procedures and concludes with a brief analysis of Apical Implant Osteolysis, noting that these are elective procedures requiring careful diagnosis and patient consent.
Summarizing Epical Root Resection: A Surgical and Guideline Review
0:30 Discrepancy in Success Rates: While high success rates (around 90%) are published for ERR, new guidelines (late 2022) highlight a significant discrepancy between these published rates and actual epidemiological data, prompting a need for clearer indications.
2:27 Mandatory Retrograde Closure: The modern definition of ERR (Apical Root Resection) requires reduction of the root apex after osteotomy and mandatory retrograde closure to achieve a bacterial-tight seal necessary for healing. Resection exceeding 6 mm significantly increases tooth displacement risk.
4:51 Hierarchy of Treatment: For apical osteolysis lesions up to 4-5 mm, the consensus is that non-surgical endodontic treatment is the first choice, and ERR is the second choice, unless patient preferences or technical reasons dictate otherwise.
7:05 Alternatives to ERR: Alternatives include non-surgical retreatment of root canals, hemisection (though implants are often found to have fewer complications than hemisected teeth), and, in exceptional cases, intentional tooth reimplantation. The practice of trepanation alone for pain relief is no longer recommended.
10:19 Key Indications for ERR: Indications include obliterated or untreatable root canals, persisting chronic apical periodontitis, endodontic instrument fractures, and over-pressed root filling material causing clinical symptoms (especially nerve canal participation).
13:59 Key Contraindications: Relative contraindications include extensive periodontal bone resorption, previous radiotherapy, use of anti-resorptive medications, and tight contact between the root and nerve canal or sinus maxillaris.
18:48 Prognostic Factors: Better prognosis is seen in younger patients (20-39 or <45), teeth located in the maxilla, and lesions smaller than 10 mm, provided there is no pre-operative pain or periodontal defect.
21:19 Pre-operative Planning: The patient must be informed that ERR is the "last attempt" to save the tooth. CBCT is generally not a standard radiological requirement but is useful if the root is projected close to important anatomical structures (e.g., nerve canal).
21:41 Preferred Incision: The preferred surgical approach is the intercurricular incision as it provides the best overview of the surgical area and allows simultaneous assessment of periodontal status.
26:57 Resection Technique and Dimensions: The root apex should be resected 3 to 4 mm, and the cut should be rectangular to the tooth axis, not slanted, to prevent remaining tooth fragments.
30:08 Retrograde Filling Material: The retrograde cavity should be prepared to a depth of about 3 mm. MTA (Mineral Trioxide Aggregate) or Super EBA cement are the materials of choice, with MTA being generally preferred for its ability to cover microfractures created during piezo surgery.
34:08 Role of Magnification: The use of magnification aids (microscope, glasses) is strongly recommended for microsurgical precision and identification of root fractures or defects, but ERR can still be successful without it.
39:01 Guided Surgery (GMES): Newer techniques like Guided Modern Endodontic Surgery (GMES) use navigation trays, based on CBCT and digitized models, to guide the drill, allowing for minimal invasive and highly precise apicoectomies.
43:56 Apical Implant Rejection (AIO): Apical osteolysis around implants (AIO) has a high variability in prevalence (1-13%). Active lesions usually require explantation, but for inactive lesions without symptoms, a conservative "watch and recall" approach is sometimes taken.
47:26 Conclusion: Both ERR and AIO are elective operations requiring individual assessment based on local and general patient status, as well as mandatory intensive informed consent.