Periapical Surgery of Mandibular Posterior Teeth: Anatomical & Surgical Considerations

By Lin L, Skribner J, Shovlin F,  Langeland K.

Date: 09/1983
Journal: JOE

Purpose:  to consider some important anatomical  and surgical  factors related to peri-apical surgery especially in mandibular posterior teeth. 

Anatomical consideration:

•Mandibular canal often contacts the roots of the third molar and sometimes comes in proximity of the roots of all mandibular molars . Situated lingually to the roots of the posterior teeth .

•The inferior alveolar nerve (IAN) travels closely with the inferior alveolar artery, a branch of the maxillary artery.

•Mental foramen (MF) may be situated directly over the roots of either premolar or between them.

  •Premolars and first molars are generally close to the buccal alveolar plate, whereas the second and third molars are closer to the lingual plate .

Surgical consideration:

•Diagnostic radiographs are essential to show the accurate length of the involved teeth & its relation to the mandibular canal. Best obtained by paralleling technique.

•Entry of the surgical bur should be kept at least 4 mm above the estimated apex, in case of absence of radiolucency or intact cortical bone, and the last is carefully removed until the apical third of the involved root is located. •Deep vertical releasing incision into the periapical area between the two premolars is avoided because MF is usually located here.

•The depth of the Muccobuccal fold may forecast the degree of difficulty. •Flap design depends on the periodontal condition, the restoration present, and the location of the MF.

•Triangular and  Modified triangular full thickness are the most commonly flaps used.

•The apex should be resected 45 degree angle to the occlusal surface when periapical surgery is performed on the mesial root of mandibular molar. •Amalgam is best to use as retrograde filling material. 

Clinical Significance :

•Many studies have shown that conventional root canal treatment has a better prognosis than endodontic surgery. Thus, before considering the periapical surgery, all possible avenues of conventional endodontic solution to the problem should be completely ruled out.

•Case selection is an important factor to the periapical surgery of mandibular posterior teeth & cooperation with an oral surgeon should be considered in certain cases.