Edema after resection of the apex of the tooth root

The operation is called resection of the apex of the rootbecause one of the moments of this intervention is the removal of the top of the root. In fact, the main purpose of such an operation is to eliminate the near-cerebral granulation focus, which occurs during chronic periodontitis. Therefore, this operation is more correctly called granulomectomy.
Indications for granulomectomy forchronic periodontitis and its consequences were severely narrowed due to the treatment of chronic inflammatory periapical processes with the help of root canal obturation with filling material and its administration for a medicinal purpose in the peri-vertex region. In rare cases, granulomectomy is also performed with acute periodontitis, when it is necessary to avoid tooth extraction at all costs, and the possibility of treatment through the root canal is excluded because of the presence of a hard filling material, an artificial tooth pin, or a foreign body, such as a broken pulp extractor. This also includes cases of obstruction of the root canals due to their curvature. The tops of the roots of the teeth in the cavity of the cyst also resect.
Granulomectomy is an operation that allowsTo keep the tooth in the absence of large damages by the pathological process of the near-apical region of the alveolus and its margin in the region of the tooth to be resected. The size of these disruptions is established using an X-ray. When the alveolus is destroyed by the apical process by more than one third of the root length, the resection of the apex of the root is contraindicated, since the resected tooth in these cases is not well strengthened in the alveolus. If the edges of the alveoli are destroyed as a result of periodontitis, resection of the apex of the root is indicated only at the I degree of atrophy of the alveolar margin.
When combined with the peri-suprarenal and marginalprocesses, it is necessary to carefully consider the indications for resection of the apex of the root. Significantly wider, in spite of the extensive destruction of the bone, it is possible to resect the apex of the root when preparing the tooth for permanent dentoprosthetics. In these cases, a fixed prosthesis, fixed on firmly seated adjacent teeth in the alveoli, plays the role of a fixing tire for the resected tooth.
Before the operation, the tooth is processed and sealed. In some cases, the tooth has to be sealed during surgery through the crown, or from the operating wound through the root stump.
As a filling material is bestapply phosphate cement. After the expansion and thorough disinfection of the canal, liquid cement is introduced into it, so that it can possibly penetrate the top of the root. To obtain the best sealing results in the root canal, before the hardening of the cement, a metal pin is sometimes inserted. In some cases, it is convenient to fill the canal between the injection of anesthetic fluid and the onset of anesthesia.
Sealing the canal during surgery throughThe crown of the tooth provides control over the pushing of the filling material beyond the tip of the root, but lengthens the operation. When the root stump is filled with amalgam after removal of the apex, the root canal is widened from the side of the wound by a small burr in the form of an inverted cone approximately 2-3 mm deep, after which the cavity is sealed with amalgam. The wound at this time is carefully drained with gauze napkins. Technically, this method of sealing is rather complicated, since the operating field is filled with blood. Results with this method are the worst: amalgam often falls out of the cavity prepared at the root, resulting in a gingiva after surgery.
On the roentgenogram such dropped out in operationalcavity metal seal resembles a pellet or a small fragment of a bullet. In some cases, sealing the root with amalgam through the wound is the only way to isolate the canal, for example, if there is a hard filling material in the mouth of the canal, an artificial tooth pin, etc.
The operation consists of a series of successive techniques: 1) the incision of the gum and the formation of the muco-periosteal flap; 2) trepanation of the wall of the alveolar process to expose the apex of the root; 3) root resection and scraping of the granulation focus; 4) suturing.
After the patient is appropriatelyprepared for surgery, with blunt hooks pulling off the lip or cheek and proceeding to anesthesia. When resecting the apex of the root on the upper jaw, conductive anesthesia is recommended in the infraorbital foramen or the upper jawbone in combination with infiltration anesthesia for bleeding the operating field. In some cases, an anesthetic of the dental plexus is sufficient. To perform a resection of the tip of the root on the lower jaw, you should use mandibular anesthesia in combination with infiltration. Several types of incisions have been proposed for the formation of the muco-periosteal flap. The most common and convenient is the arc-shaped section in the Parkchu (Figure 36).
When resecting the tips of the roots of the lower premolarsit is necessary to make a cut at the level of the middle part of the root in order to avoid injury of the vascular-neural bundle emerging from the chin aperture. When resecting the tops of the roots of the upper and lower canine teeth, an incision should be made, somewhat receding from the transitional fold to the edge of the gum, so as not to injure the rich arterial and venous network in the region of the transitional fold.
The formation of a trapezoidal flap is indicated in cases where, in addition to resection of the apex of the root, intervention is required in the region of the alveolar margin (Figure 37).


Fig. 36. Arc-shaped section in the Parkchu.
Fig. 37. Trapezoidal section of Novaku-Peter. In this incision, the gingival margin is damaged.

Formed mucosal-periosteal flap shouldbe wide enough and grab partially and the area of ​​adjacent teeth. After the incision, the mucous membrane with the periosteum is separated from the bone and the flap is pulled upwards.
The next stage of the operation is trepanation of the anteriorthe walls of the alveolar process of the jaw to expose the apex of the root - is greatly facilitated if in this wall in the region of the apex of the root there is already an usuric. In this case, it is enough to expand the bone defect with the help of a chipped chisel, a large round boron or a cutter in such a way that the top of the root is completely exposed. If the anterior wall of the alveolar process has not yet been usurped, then it is necessary to establish a place where the trepanation of the bone will be performed. This moment of surgery is perhaps the most difficult for beginning physicians: they do not immediately find the desired area to be trepanized, and cause an unnecessary trauma. Trepanation of the bone should be started 3-5 mm below the projection of the apex of the root along the boundaries of the lunar elevation of the underlying tooth. A flat chisel is removed from the bone layer by layer along the boundaries of the lunar elevation until a granulation tissue or root has a different color and density than the bone. After this, the grooved chisel increases the formed bone defect until the tip of the root is completely exposed and a wide opening of the inflammatory focus is made. Usually granulations surround the tip, so for a complete curettage it is more convenient to first resect the root. To do this, the root tip is sawed off with the help of a fissure boron. You can begin this removal of the top by sawing the root with fissure boron and finish with a light blow on the bit inserted into the formed saw. Resection of the apex of the root only with the help of a chisel and a hammer should not be done, as this may lead to fragmentation of the root or dislocation of the root from the alveolus (Figure 38). As a rule, the top of the root should be resected at the bottom of the granulation cavity, but still not more than a quarter of the root length. In some cases, experienced surgeons resect one third of the root length. After cutting off the tops, it is removed from the wound by tweezers or a spoon and proceed to remove the granulation. They are scraped with sharp spoons of different sizes, after which the bone edges of the wound and the amputation surface of the root are smoothed with a milling cutter. It is desirable that the amputation surface of the root has a slope to the threshold of the mouth: this allows more careful monitoring of the correctness of the canal filling (Figure 39). After this, the wound is again carefully scraped with a spoon, so that no bone or root fragments remain in it. To do this, you can also rinse the wound with hydrogen peroxide. The last act of the operation is suturing. Sutures are removed on the 6-7th day (Figure 40).


Fig. 38. Resection of the apex of the root with the help of a chisel.
Fig. 39. Resection of the apex of the root with the help of boron.

Fig. 40. Consecutive stages of granulomectomy.

Method of resection of the apex of the root of individual teethdiffers in some features. Upper first premolars in approximately 50% of cases have two roots. Therefore, when resection of the tip of the tooth, which has two roots, you need to check the number of channels. If during the operation a lumen of only one channel is detected, the existing inter-root septum between the buccal and palatal roots should be resected (about 2-3 mm thick). Only after this the palatine root is exposed.
When resecting the tip of the second upper premolarsshould be borne in mind the proximity of the tips of these teeth to the maxillary sinus. The latter can sometimes be installed previously with an X-ray. Sometimes the connection of the apex of the root with the maxillary sinus is established only during the operation. In these cases, the resection of the tip should be done with caution, so as not to push the resected root segment into the maxillary sinus. The healthy maxillary sinus revealed during resection of the apex of the root is not probed or washed. The wound in this case must be sewn tightly.
Resection of the apex of the roots of the first upper molarsrarely, at least when the periapical process is present only in the buccal roots or only in the palatine root. Resection of the buccal roots of the first upper molars does not present difficulties, since the roots of these teeth are located very close to the anterior wall of the alveolar process; resection of the palate of the palatal root, produced from the palatal side, is much more complicated. It has to be resorted to rarely, since the width of the canal of this root usually ensures the success of conservative methods of treatment. Resection of the apex of the roots of second molars is rare.
When resecting the apex of the roots of the lower premolars, one must remember the proximity of the neurovascular bundle emerging from the chin aperture.
Resection of the apex of the roots of the lower first molars is complicated due to the massive jaw and proximity of the mandibular canal.
In the lower second and third molars, resection of the apex of the root is not performed.
Complications that occur after root resection: Postoperative pain, bleeding, suppuration of the wound - treated in the usual ways. Some authors recommend that to reduce the postoperative edema and hemorrhage, apply a pressure bandage for 12 hours on the soft tissues of the face in the area of ​​operation. The best action is made by cold (ice) during the first day after the operation.
In general, with proper consideration of the testimony andcontraindications to resection of the apex of the root, with proper canal filling, with the correct technique of operation and normal healing of the operating wound, resection of the apex of the tooth root is an operation allowing for a long time to keep the tooth.