Resection of the apex of the tooth root as it happens. Indications, conduct and consequences of gum resection

Tooth resection is a procedure during which a part of the root is removed simultaneously with the elimination of the inflammatory process in the root canal. Such an intervention is carried out only when there is no possibility to achieve positive dynamics with the help of endodontic treatment. The operation of resection of the apex of the tooth root is a rather complicated manipulation, but it allows you to extend the life of the tooth and eliminate the source of chronic infection.

What is a root apex resection?

The meaning of the operation is to remove the affected root tip, while removing only the part that is not subject to therapeutic treatment. Together with part of the root, they are carried out, while healthy tissues are not touched. Resection of the apex of the tooth root is a minimally invasive and less traumatic procedure that does not take much time. Most often it is performed on the frontal teeth (incisors and canines) upper jaw.

Indications and contraindications

Gingival resection is performed only if there are certain indications:

Chronic periodontitis, not amenable to conservative treatment.
Removal of a significant amount of filling material beyond the top of the teeth in the periodontium during endodontic treatment.
pathological process in bone tissue around the causative tooth, previously treated, with the formation of a tooth cyst or granuloma.
Perforation of the root wall in the apical third.
Fracture of the upper third of the root of the tooth.
Impossibility of endodontic treatment according to the standard protocol. For example, when covering a tooth.
As a treatment for osteomyelitis.
Impossibility of standard treatment for obstruction root canal.
Breakage of the instrument in the apical third of the root canal.

There are also contraindications for resection of the apex of the tooth root:

Significant destruction of the coronal part in combination with root damage.
The impossibility of prosthetics of this tooth in the future.
Severe tooth mobility.
The last stages of periodontitis and.
Acute periodontitis or periodontitis in the acute stage.
Acute infectious processes of ENT organs, SARS, diseases of the mucous membrane.

Preparing for the operation

The operation is performed only after the preparation of the tooth for the procedure. Initially, dental plaque is removed and the root canal is prepared - it must be sealed for at least 2/3 of its length. If it is impossible to carry out this procedure, the question of the possibility of retrograde filling, that is, the introduction of filling material through the root apex, should be resolved.

Stages of tooth resection

All manipulations are carried out under. The operation includes several successive stages:

An incision is made along the transitional fold (at the point where the gums pass into the immovable mucous membrane of the lips) in the projection of the top of the causative tooth. The incision is given an oval shape for ease of folding the flap and facilitating wound suturing. Its length is on average 5-10 mm.
Raspatory exfoliate the flap of the mucous membrane and periosteum. The base of the flap is turned towards the entrance to the oral cavity to improve its nutrition.
With a spherical or cylindrical bur, the outer wall of the bone of the alveolar process of the jaw is removed and the top of the root is exposed.
The root of the tooth is opened to the level of filling with filling material.
The resulting bone defect is cleaned from granulations, tooth cysts, filling material and other undesirable elements.
Sharp bone protrusions are processed with a cutter.
The level of resection of the root apex coincides with the level of the bottom of the cavity - this is necessary to prevent root protrusion.
If necessary, the root canal is retrogradely sealed, the resulting cavity is filled with synthetic material. To do this, moisten the granules or powder with a special solution and bring it into the cavity, filling it by 80%. The wetted material swells, evenly filling the space, and does not fall out of the area.
The cavity filled with synthetic material is covered with a special membrane. The mucoperiosteal flap is put in place and the wound is sutured.
A pressure bandage is applied to the operation site and cold is applied, which should be kept for 30 minutes to prevent severe swelling and hematoma.

Postoperative care

The pressure bandage applied immediately after the operation is removed only after 12 hours. The patient is prescribed antibacterial drugs to prevent the development of an infectious process. The oral cavity should be rinsed several times a day with antiseptic solutions, for example, chlorhexidine, miramistin, furacillin and others. To accelerate healing, you can use drugs such as Rotokan, Solcoseryl and Stomatofit in the form of rinses and ointment applications.

To reduce pain, you can take painkillers from the group of non-steroidal anti-inflammatory drugs - Nise, Ketorol, Ketonal and others. In addition to withdrawing pain syndrome, these funds will help suppress the inflammatory response.

Oral hygiene in the first days after the procedure should be carried out with caution - while brushing your teeth, you need to make sure that you do not touch postoperative suture. Food should be warm, not hot, while it is desirable to exclude spicy and salty dishes.

Complications

Resection of the roots of the teeth is a surgical intervention, after which complications may develop, such as:

Bleeding as a result of vascular damage is quite rare. As a result, acute post-hemorrhagic anemia may develop if measures for hemostasis are not taken in time. In order to minimize the likelihood of bleeding, it is recommended to take tests to assess the function of the blood coagulation system before surgery.
Perforation of the maxillary sinus or nasal cavity.
Branch injury trigeminal nerve- as a result of such damage, the patient will feel pain, impaired facial sensation and oral cavity, crawling sensation and chills.
Attachment of infection with the development of purulent pathologies - abscess, phlegmon, periostitis. This happens when the rules of asepsis and antisepsis are violated, as well as the patient ignoring antibiotic therapy in the postoperative period.
Re-formation of cysts - this is possible with poor-quality cleaning or drainage of the cavity. The complication requires repeated resection and revision of the wound.

Price

On average, prices for such surgery range from 4,000 to 7,000 rubles, depending on the clinic. The prices are current as of October 2017.

Not all dental surgeons perform resection of the apices of the roots of the teeth, since this procedure is quite laborious and requires certain skills. Do not be afraid of the operation, you just need to choose an experienced specialist who has experience in this area.

Useful video about resection of the apex of the tooth root

To date, to get rid of the cyst on the root of the tooth and eliminate the inflammatory process in the gums, dentists opt for tooth-preserving surgical procedures. One of them is the resection of the apex of the tooth root: it has practically no contraindications, the postoperative period is minimal, and complications are quite rare.

Indications for resection of the apex of the tooth root - who needs the operation and when?

The considered type of surgical intervention is indicated in the following cases:

Loose fit of the filling material to the root canal . This phenomenon favors the development of infection, which, in turn, leads to the formation of a cyst. If the canal is not filled in the root area, and / or the size of the cyst exceeds 10 mm, it is more expedient to eliminate the top of the tooth root with a drill and remove the cyst. With a significant destruction of the crown, this operation does not make sense to carry out.
Poor filling of the tooth at the root apex in the presence of a pin / stump inlay in the dental canal . If the seal does not fit snugly along the entire length of the root canal, it is necessary to carry out the sealing through the crown, which does not always reflect well on the safety of the tooth, especially with curved canals.
Inflammatory phenomena under the crown, when the root of the tooth is not available for therapeutic measures. Removing the prosthesis and completely unsealing the canals will cost more: after the end of the treatment, a new crown will be required.
The presence, the dimensions of which exceed 10 mm. Ignoring this pathology can provoke frequent suppuration, inflammation in the future, which requires a gum incision. In addition, this negatively affects the protective reactions of the body: doctors recommend resection of the top of the tooth root. If the cyst is inflamed and there are signs of acute periodontitis, the manipulation in question is not carried out.

Preparation for resection of the apex of the tooth root - is anesthesia necessary?

The primary measure in preoperative preparation is root canals. This procedure is done in a maximum of two days: otherwise there is a risk of an inflammatory reaction.

The ideal material for filling a cavity in the body of a tooth is phosphate cement . Before its introduction, the doctor expands the root canal, performs disinfection, and the substance itself is injected in such a way that it goes beyond the root apex.

For better filling use a pin : before the cement begins to harden, it is injected into the root canal.

Before carrying out the manipulation in question, the operator performs one of the following types of anesthesia:

Infiltration anesthesia . Relevant during the surgical procedure on the upper jaw, which is associated with the porous structure of its bone tissue. The doctor, through a needle, injects an anesthetic (often ultracaine) under the mucous membrane. In this case, the gum begins to turn white, which indicates that blood does not enter the periodontium.
Conduction anesthesia . An anesthetic drug is injected into the area near the trigeminal nerve. The desired effect is achieved by impregnating the nerve fiber and the area around it with the specified drug. This type of anesthesia is indicated for the treatment mandible.
. It is used very rarely, in the absence of contraindications. In this case, the patient should refrain from eating food and liquids 8 hours before the operation.

Minimize the anxiety caused by the upcoming surgery will help sedatives: valerian, motherwort tincture.

Stages of tooth root resection, dental instruments and equipment

The algorithm for carrying out the considered manipulation is as follows:

Creation of a mucoperiosteal flap by cutting the gums. The operator uses a scalpel (in the presence of scars) or thrust.
Formation of a hole in the area of the apex of the tooth root using special burs with ball-shaped tips. This procedure is minimally invasive and painless.
Cleaning the bone from granulomas, foreign bodies (if any), filling material.
Turning sharp corners of the bone with a medical cutter.
Cutting off the apex from the root of the tooth. For these purposes, the surgeon uses a drill. Access is through the opening.
Removal of the apex of the root and cyst with tweezers. If necessary, the canals are filled. If the cystic formation is large, the cavity is filled with a synthetic bone substance (chips of the cortical plate or granules soaked in a special solution).
Suturing the wound surface; installation of drainage for several days.
Apply pressure bandage for 10 hours.
Applying an ice pack to the area to be operated on to reduce swelling.

Recommendations for patients after resection of the tooth root - can there be complications?

After this manipulation, to minimize the risk of complications, the patient should adhere to the following recommendations:

Antibiotic therapy (lincomycin, sumamed, azitral), regular mouth rinses antiseptic preparations(furacillin, iodinol, chlorhexidine). Such activities will save the wound surface from infection, help relieve inflammation and swelling.
Taking drugs that stop pain (Voltaren, Ketonal, Ketorol).
Abstinence from sports, heavy physical activity within 24 hours of the operation in question.
Exclusion from the diet for a day of cold, hot, spicy, salty foods and liquids (including garlic). During the first three months, the consumption of solid foods should be minimized. Those who are accustomed to chewing nuts with their teeth should give up their bad habit.
X-ray examination of the operated area a couple of months after resection of the apex of the tooth root.

This procedure may be fraught with the following exacerbations:

Bleeding, as a result of violation of the integrity of the walls of blood vessels. A similar phenomenon occurs during this operation rarely, but it can provoke posthemorrhagic anemia.
Damage to the nasal cavity, maxillary sinuses. This exacerbation is associated with the proximity of the teeth to the maxillary sinuses. Incisions during the operation in this case should be small, and all actions must be done very carefully.
Reappearance of the cyst. It is diagnosed with poor-quality cleaning of the wound surface or with poor drainage. This defect can be eliminated only through repeated manipulation.
Injury to the trigeminal nerve, which leads to severe and regular pain. Sometimes there may be a decrease in sensitivity to skin, mucous membrane. Such a defect is eliminated by a course of physiotherapeutic procedures, vitamin therapy.
Exacerbations of a purulent nature that appear against the background of ignoring the rules of asepsis during or after surgery.

One of the most common dental procedures is root resection.

This article describes the essence of the operation for the treatment of the root of the tooth, the conditions in which it is necessary and for whom it is contraindicated, the mechanism for its implementation, as well as the advantages and disadvantages. Particular attention is paid to the likely aggravation, rehabilitation and special cases of this manipulation.

What is a root apex resection?

Tooth cyst removal

Apicoectomy or resection of the apex of the tooth root is an operative solution that is aimed at eliminating the infection that has penetrated to the base of the root.

With this manipulation, the upper section of the tooth root is removed, as well as cystic neoplasms located in the upper region of the organ.

As a rule, an abscess is formed near the cyst, seals on the root of the tooth, which, if left untreated, have negative effects not only on the tooth, but on the entire body. They can be headaches, sinusitis, weakness.

Apicotomy is performed if for surgical treatment of inflammatory pathologies maxillofacial region, there is no direct access to the apex of the tooth root through the canal.

This manipulation is carried out in medical clinics by dentists, using the latest equipment and drugs with anesthetic properties.

Indications for the procedure

In professional practice, dentists often perform resection of the apex of the tooth root with canines and incisors.

Apicoectomy of the tooth root is resorted to when, according to indications, endodontic therapy methods are ineffective.

In professional practice, dentists often perform resection of the apex of the tooth root with canines and incisors.

As for multi-rooted teeth, their resection is less common due to the complexity of the manipulation.

In medical practice, there are certain conditions in which apicoectomy is prescribed:

Tumor-like formation of a large size in the region of the root of the tooth.
Installed crowns and filled dental canals.
Low-quality filling of tooth canals with filling material.
The presence of a metal pin in the tooth root.
Traumatic damage to the tooth in the third part from above.
The canals of the teeth are too tortuous.
Diagnosis of osteomyelitis.

Important! Apicotomy belongs to the category of rather complicated and painful methods of surgical therapy, requiring a long recovery. But, the main advantage of such treatment is the absence of removal of the diseased tooth and preservation of its root. This allows in the future to carry out its therapy and prosthetics using various techniques.

Preparatory stage

In order to prevent the occurrence of complications, at least two days before the operation, sanitation of the oral cavity is performed.

The duration of apicotomy is no more than an hour.

This is subject to the high professionalism of the surgeon and the proper preparation of the oral cavity for this type of surgical intervention.

To do this, in order to prevent the occurrence of complications, at least two days before the operation, the oral cavity is sanitized.

After the operated tooth is examined for the presence of sealed canals.

If necessary, its preliminary sealing is carried out, which consists of the following manipulations:

With the use of a drill-boron or extractor pulps, access to the channels is opened.
Through the use of a file, their cavities are cleaned, enlarged and disinfected.
Canals are sealed using pins or sellers. In this case, liquid cement should fill the entire cavity of the root canal to its apex.
A permanent filling or crown is placed.

Important! The essence of the preparatory stage before the operation is the high-quality filling of the dental canals. Depending on their clinical condition, the doctor determines the scope of the upcoming work.

How is the operation going?

An apicotomy consists of the following steps:

Anesthesia. A local one is used and is selected taking into account the location of the operated tooth. During resection of the root of the tooth in the upper jaw, infiltration anesthesia is used, while conduction anesthesia is performed on the lower mandible.
Operations. The technique of its implementation consists of the following manipulations:
- Opening of the soft tissues of the periodontium.
- Trepanation of the anterior wall of the alveolar process of the jaw, followed by exposure of the upper dental root.
- Cutting off the top of the root from the main body of the tooth with its subsequent extraction. Also, in the presence of cysts or foci of inflammation, they are removed.
  Important! If, after removal of the neoplasm, a large unfilled cavity remains in its place, its space is filled with bone tissue of synthetic origin. Such manipulations contribute to quick recovery natural bone tissue.
Suturing. The mucous membrane is sutured with sterile suture threads. At the same time, drains are inserted into the seams, ensuring the removal of the ichor from the wound. After that, a pressure bandage is applied to the lips for half a day. In order to prevent the formation of a hematoma from the side of the operated tooth root, cold is applied to the operated area.

Stages of resection of the apex of the tooth root

Does it hurt?

The operation is performed under local anesthesia and with strict observance of the technique of its implementation does not cause pain.

Many patients planning to do a root resection are interested in whether it hurts.

Apicoectomy is not an easy and very painful procedure that requires a long recovery. This manipulation is highly traumatic.

In the process of its implementation, not only the integrity of the periodontium is violated, but also the bone tissue of the maxillofacial complex.

Such changes require a long recovery. This is due to the physiological features of the structure of the oral cavity.

During an apicoectomy, pressure is exerted on the nerve endings located in the upper layers of the periodontium. The operation is performed under local anesthesia and with strict observance of the technique of its implementation does not cause pain.

But, after the end of the anesthesia, the sensitivity of the tissues returns completely. Therefore, for several days in the postoperative period, the appearance of pain of a different nature and intensity is observed. For their relief, analgesics are prescribed.

rehabilitation period

The rehabilitation period varies from several days to several weeks.

During this period, the use of special medicines for rinsing the mouth to avoid the development of infections.

An effective result is achieved when using decoctions from:

Pharmacy chamomile.
Hypericum.
Oak bark.

Natural medicines help relieve swelling and prevent the formation of abscesses at the site of granulomectomy.

If necessary, for drug treatment apply:

Antiseptic agents for local use.
Antibacterial drugs.
Immunostimulating drugs.
Analgesics.

Important! In order to prevent recurrence, it is recommended to undergo a control X-ray after apicotomy in 2 months.

Contraindications

Apicoectomy is not performed if there are the following pathological conditions and contraindications:

Periodontal disease of any degree of flow.
Periodontal inflammation.
The presence of a large tumor-like formation at the base of the tooth root.
Exposed cervical area of a problematic tooth with periodontal disease.
Cracks in the root of the tooth.
A large area of damage (60 percent or more) of the crown of the tooth.
Acute form of cardiovascular pathology.

Important! Performing dental surgeries, including resection of the apex of the tooth root during pregnancy, is allowed if there is a great threat to the woman's life. Experts recommend to refrain from such manipulations until the birth of the baby.

Advantages and disadvantages

Like any type of surgical intervention, resection of the apex of the tooth root has a number of positive and negative characteristics.

Among them, experts distinguish the following:

Advantages	Flaws
Belongs to the category of sparing dental procedures.	If the operation is performed incorrectly, the tooth root, which has become shorter, reduces the resistance of bone tissue to mechanical stress.
The operation lasts no more than an hour and does not require subsequent stationary monitoring.
The operation is performed using local anesthesia in the form of infiltration or conduction anesthesia.	The relatively high cost of this type of surgery.
Rapid disappearance of pain in the postoperative period.	The relatively high cost of this type of surgery.
With strict observance of all the rules of sanitation of the oral cavity, the likelihood of complications is minimal.	There is a minimal chance of developing a slight decrease in masticatory function.
The dental unit is preserved after the operation, performing its aesthetic and chewing functions.
If it is necessary to carry out prosthetics, the root remains an excellent basis for any type of prosthesis and implant.	The complexity of surgical intervention requires the presence of a highly professional surgeon for its implementation. This will avoid the development of complications.

Price

Pricing policy for different kinds dental services in different clinics is quite diverse. The price of resection of the apex of the tooth root in the medical centers of Moscow varies from 4000 to 21000.

This range is explained by the level of the clinic, the classification of the medical staff, the type of materials used, the complexity of the operation and the complex of manipulations included in this type of treatment.

Important! As a rule, the cost of an apicoectomy includes anesthesia, surgery and follow-up examinations. To determine the final cost, it is necessary to clarify the availability drug therapy v recovery period. You should also know whether the retrograde filling of the root canal, which is carried out in rare cases.

Possible complications and consequences

The high level of complexity of the operation, if its technique is not followed, provokes the development of serious complications. Their severity can be different: from the development of minor edema to loss of sensitivity.

Among them it is worth highlighting:

Important! Resection of the apex of the tooth root by an experienced surgeon will avoid the development of complications and significantly speed up the healing process.

Features of therapy

Consider the features of therapy:

In the oral cavity there is a huge number of pathological microorganisms, the activity of which often leads to infection of the gums, the spread of inflammatory processes.

In some cases, pathological formations appear on soft tissues (cysts, abscesses, fistulas, boils, etc.), which require immediate treatment.

In this article, we will consider one of the ways surgical treatment of these pathologies - resection (soft tissue or tooth). The procedure allows you to remove defects and foci of inflammation, while maintaining the health of the adjacent tooth.

Many patients are interested in what it is "resection of the apex of the tooth" and why it is prescribed.

Manipulation is an operation which is performed by a dental surgeon in the area of the tooth root. It allows you to amputate the affected areas of the root and block the inflammatory (infectious) process.

Tooth resection

As a rule, resection is prescribed in the case when the standard did not help. endodontic treatment, as the operation is very time-consuming and complicated. As a result, it is possible to preserve a healthy tooth and arch by removing a pathological formation without consequences and complications.

Most often, manipulation is prescribed in the case of diagnosing periodontitis and deep periodontal disease, as well as to remove cysts, abscesses, granulomas, fistulas, etc.

Also, the need for the procedure can be caused by defects in the root canals (perforation, changes in structure, poor-quality filling, fracture of the apex, etc.), the consequences of wearing prostheses and implants, a doctor’s mistake (a fragment of the instrument remained in the canal).

There are also contraindications to the operation:

periodontitis with tooth mobility;
periodontal disease (tooth necks are exposed);
tumor in the area of tooth growth.

When is resection necessary?

Let us consider in more detail when and why this procedure is used.

Stages of the operation

Dentists explain to patients that this is a gum and tooth resection, how long it lasts and what stages it includes.

The duration of the operation ranges from half an hour to an hour. Its duration is affected by the location of the formation and the tooth, the size of the capsule, the stage of the disease, and other factors.

Also, for the first few days, try to eat liquid food - soups, slimy cereals, mashed vegetables or chicken, dairy dishes.

Until the day the sutures are removed, the patient should take a vacation, avoid lifting weights, stressful situations, physical and psychological stress.

Complications after resection

Breakage of instruments in the cavity of the tooth is one of the reasons for the resection of the apex of the tooth root

As a rule, the consequences of resection of the apex of the tooth root ( Photo below) can occur for several reasons.

According to statistics, resection gives good results, and in most cases completely eliminates pathologies (infections, foreign bodies, granulomas and cysts, and other formations).

However, in some cases, serious postoperative complications are still possible, which will require expensive and lengthy treatment.

The operation is called resection of the root apex because one of the moments of this intervention is the removal of the root apex. In fact, the main goal of such an operation is to eliminate the periapical granulation focus that occurs in chronic periodontitis. Therefore, this operation is more correctly called a granulomectomy.

Indications for granulomectomy for chronic periodontitis and its consequences were greatly narrowed due to the method of treating chronic inflammatory periapical processes by obturating the root canal with filling material and introducing it with therapeutic purpose in the periapical region. In rare cases, granulomectomy is also performed in acute periodontitis, when it is necessary to avoid tooth extraction at all costs, and the possibility of treatment through the root canal is excluded due to the presence of solid filling material in the canal, an artificial tooth pin, or foreign body like a broken pulp extractor. This also includes cases of obstruction of the root canals due to their curvature. The tops of the teeth roots located in the cavity of the cyst are also resected.

Granulomectomy is an operation that allows you to save the tooth in the absence of large destruction by the pathological process of the near-apex section of the alveolus and its edge in the area of the resected tooth. The size of these destructions is established by means of an x-ray. When the alveolus is destroyed by the near-apex process by more than one third of the root length, resection of the root apex is contraindicated, since the resected tooth in these cases is not well-strengthened in the alveolus. If the edges of the alveolus are destroyed as a result of periodontal disease, resection of the root apex is indicated only for grade I atrophy of the alveolar edge.

With a combination of near-apex and marginal processes, it is necessary to carefully consider the indications for resection of the root apex. Much wider, despite the extensive destruction of the bone, it is possible to resect the root apex when preparing the tooth for fixed prosthetics. In these cases fixed prosthesis, fixed on neighboring teeth firmly seated in the alveolus, plays the role of a fixing splint for the resected tooth.

Before the operation, the tooth is processed and sealed. In some cases, the tooth has to be filled during the operation through the crown, or from the side of the surgical wound through the root stump.

Phosphate cement is the best filling material. After expansion and thorough disinfection of the canal, liquid cement is introduced into it so that it penetrates as far as possible beyond the root apex. To obtain the best filling results, a metal pin is sometimes inserted into the root canal until the cement hardens. In some cases, it is convenient to fill the canal between the injection of anesthetic liquid and the onset of anesthesia.

Filling the canal during the operation through the crown of the tooth provides control over the pushing of the filling material beyond the root apex, but lengthens the operation. When filling the root stump with an amalgam, after removing the top, the root canal is expanded from the side of the wound with a small bur in the form of an inverse cone approximately 2-3 mm deep, after which formed cavity filled with amalgam. The wound at this time is carefully drained with gauze napkins. Technically, this filling method is quite complicated, since the surgical field is filled with blood. The results with this method are the worst: the amalgam often falls out of the cavity prepared in the root, as a result of which a gingival fistula appears after the operation.

On the radiograph, such a metal filling that has fallen into the operating cavity resembles a pellet or a small fragment of a bullet. In some cases, filling the root with an amalgam through the wound is the only way to isolate the canal, for example, if there is a solid filling material at the mouth of the canal, an artificial tooth pin, etc.

The operation consists of a number of successive steps: 1) gum incision and formation of a mucoperiosteal flap; 2) trepanation of the wall of the alveolar process to expose the apex of the root; 3) root resection and curettage of the granulation focus; 4) suturing.

After the patient is properly prepared for the operation, the lip or cheek is retracted with blunt hooks and anesthesia is started. When resection of the root apex in the upper jaw, conduction anesthesia is recommended at the infraorbital foramen or tubercle of the upper jaw in combination with infiltration anesthesia to bleed the surgical field. In some cases, anesthesia of the dental plexus is sufficient. For resection of the root apex in the lower jaw, mandibular anesthesia should be used in combination with infiltration anesthesia. In order to form a mucoperiosteal flap, several types of incisions have been proposed. The most common and convenient is the arcuate incision according to Brocade (Fig. 36).

When resecting the tops of the roots of the lower premolars, an incision should be made at the level of the middle part of the root in order to avoid injury to the neurovascular bundle emerging from the mental foramen. When resecting the tops of the roots of the upper and lower canines, an incision should be made, slightly retreating from the transitional fold to the edge of the gum, so as not to injure the rich arterial and venous network in the area of the transitional fold.

The formation of a trapezoidal flap is indicated in cases where, in addition to resection of the root apex, intervention is required in the region of the edge of the alveolus (Fig. 37).

Rice. 36. Arcuate section according to Brocade.
Rice. 37. Trapezoidal section according to Novak - Peter. With this incision, the edge of the gum is damaged.

The formed mucoperiosteal flap should be wide enough and partially capture the area of adjacent teeth. After the incision, the mucous membrane with the periosteum is separated from the bone and the flap is pulled up with a hook.

The next stage of the operation - trepanation of the anterior wall of the alveolar process of the jaw to expose the root apex - is greatly facilitated if there is already an usura in this wall in the region of the root apex. In this case, it is sufficient to expand the bone defect with a grooved chisel, a large round bur or a milling cutter so that the root apex is completely exposed. If the anterior wall of the alveolar process does not yet have a usura, then it is necessary to establish the place where the bone trepanation will be performed. This moment of the operation is perhaps the most difficult for novice doctors: they do not immediately find the desired area to be trepanated, and therefore cause unnecessary trauma. Bone trepanation should be started 3-5 mm below the projection of the root apex along the borders of the alveolar eminence of the tooth to be operated on. A flat chisel removes the bone layer by layer along the boundaries of the alveolar eminence until a granulation tissue or root appears, which has a different color and density than the bone. After that, the formed bone defect is increased with a grooved chisel until the root apex is completely exposed and the inflammatory focus is widely opened. Usually, granulations surround the apex, therefore, in order to completely scrape them, it is more convenient to first resect the root. To do this, the top of the root is sawn off using a fissure bur. It is possible to start this removal of the tip by sawing the root with a fissure bur and finish with a light blow on the chisel inserted into the formed cut. Resection of the root apex using only a chisel and a hammer should not be done, as this can lead to crushing of the root or dislocation of it from the alveolus (Fig. 38). As a rule, it is necessary to resect the apex of the root at the level of the bottom of the granulation cavity, but still remove no more than a quarter of the length of the root. In some cases, experienced surgeons resect one third of the length of the root. After cutting off the top, it is removed from the wound with tweezers or a spoon and proceed to remove the granulations. They are scraped out with sharp spoons of various sizes, after which the bony edges of the wound and the amputation surface of the root are smoothed with a cutter. It is desirable that the amputation surface of the root has an inclination towards the vestibule of the mouth: this allows more careful control of the correct filling of the canal (Fig. 39). After that, the wound is again carefully scraped out with a spoon so that no fragments of bone or root remain in it. To do this, you can also wash the wound with hydrogen peroxide. The last act of the operation is suturing. The sutures are removed on the 6-7th day (Fig. 40).

Rice. 38. Resection of the root apex with a chisel.
Rice. 39. Resection of the root apex with a bur.

Rice. 40. Successive stages of granulomectomy.

The technique of resection of the root apex of individual teeth differs in some features. The upper first premolars have two roots in approximately 50% of cases. Therefore, when resecting the apex of a tooth that has two roots, it is necessary to check the number of canals. If during the operation a lumen of only one canal is detected, it is necessary to resect the existing interradicular septum between the buccal and palatine roots (about 2-3 mm thick). Only then is the palatine root exposed.

When resecting the tip of the second upper premolars, one should keep in mind the proximity of the tips of these teeth to the maxillary sinus. The latter can sometimes be preliminarily established using an x-ray. Sometimes the connection of the root apex with the maxillary sinus is established only during the operation. In these cases, the resection of the apex must be done with particular care so as not to push the resected root segment into the maxillary sinus. A healthy maxillary sinus opened during resection of the root apex is not probed or washed. In this case, the wound must be sewn up tightly.

Resection of the top of the roots of the first upper molars is rarely done, 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 is not difficult, since the roots of these teeth are located very close to the anterior wall of the alveolar process; resection of the apex of the palatine root, performed from the palatal side, is much more difficult. It is rarely necessary to resort to it, since the width of the canal of this root usually ensures the success of conservative methods of treatment. Root apex resection of second molars is rare.

When resecting the top of the roots of the lower premolars, one must remember the proximity of the neurovascular bundle emerging from the mental foramen.

Resection of the apex of the roots of the lower first molars is difficult due to the massiveness of the jaw and the proximity of the mandibular canal.

On the lower second and third molars, resection of the root apex is not performed.

Complications that occur after root resection: postoperative pain, bleeding, wound suppuration - are treated in the usual way. Some authors recommend applying a pressure bandage for 12 hours to reduce postoperative edema and hemorrhage. soft tissues persons in the area of operation. Best Action exerts cold (ice) during the first day after surgery.

In general, with proper consideration of indications and contraindications for resection of the root apex, with proper filling of the canal, with the correct technique of the operation and normal healing of the surgical wound, resection of the apex of the tooth is an operation that allows you to save the tooth for a long time.