Two- and three-dimensional healing assessment after endodontic microsurgery in through-and-through periapical lesions: 5-year follow-up from a randomised controlled trial
Ritika Dhamija, Sanjay Tewari, Ambika Gupta
Now listen up. This could be life-changing. This paper came as a big surprise to me. Who would have thought that 40 years on I was going to learn something that has an immediate effect on my treatment planning?
Something I learned at the Eastman in my formative years has stayed with me and informed my decision-making and treatment planning for large periapical lesions that perforate the lingual plate.
Received wisdom says that if you carry out buccal apical surgery with a lesion that perforates the lingual plate, thus creating a through-and-through lesion, it will only heal through soft-tissue ingrowth leaving a radiolucent scar. If apical surgery is to be considered on these occasions then the lingual cortical plate defect needs to be closed through decompression: a technique that is relatively demanding and puts the patient through a regime of flushing through a drain over an extended period.
Since I started using CBCT, the ability to detect these lesions has meant a thriving market in decompressions, with me searching everywhere for the perfect drain size (a sterilised inner Bic tube).
So imagine my surprise when I found these endodontists happily carrying out surgical treatment on these through-and-through lesions without bothering to do decompressions. Not only that, the bone healing rates noted using CBCT were impressive. Healing assessment revealed improvement in overall success rate of 66.7% at one year to 83.3% at five years, with no deterioration in any healing category. PRP group exhibited significantly better 3D healing than control group; both at one year (84.6% vs. 45.5%) and five years (100% vs. 63.6%). A significantly higher number of completely healed teeth were observed in PRP group than the control group at five years. A lesion volume reduction of 88% (91.4% PRP, 84% control) was depicted at one year and 94% (97.1% PRP, 91.1% control) at five years.
The decompression is not quite dead. It is useful if a lesion strays over an adjacent vital tooth and you don’t want to devitalise it during surgery. But I am blown away by this information. Did I miss the update? Why has no one told me?
I do admit to sneakily carrying out surgery on very close through-and-through lesions where the lingual plate perforation was ever so small – and I did get away with it. I still held on to the mantra, though, and religiously taught it. The 25-year-old myth has been blown out of the water.
I clearly need to consider getting PRP from the local shops as the healing was always better with it. The trouble is, I am totally rubbish at venepuncture. I will have to stick with photobiomodulation (PBM) to enhance healing and reduce pain. Plenty of literature on this.
International Endodontic Journal. First published: 17 May 2024
https://doi.org/10.1111/iej.14084
