Re: Pain and Inflammation After Periapical Surgery

Apicectomy of lower molars via trephining

Access for apicectomy at the lower molars requires either bone resection or bone preservation using a bony lid.
The compact bone is considerably thick; a significant amount of bone must be removed to get to the root apices of the teeth. If avoidance of this bone loss is preferred, the bone-preserving bony lid method can be used instead. However, the access must be wide enough to work with diamond separating disks. Additionally, the bony lid must be chiseled, which patients under regional anesthesia will find extremely disagreeable. In order to minimize these disadvantages while still having the advantage of the bony lid, access to the lower molars can be gained via trephining.

Advantages:

bone-preserving method
easier surgical procedure than the traditional bony lid method
significant reduction of post-operative pain due to the shorter and easier operation technique
significantly quicker consolidation of the bone defect
Disadvantage:
The general disadvantage of a bony lid is the increased risk of infection (prophylactic antibiotic treatment may be required).
Risk of nerve damage if the nerve and root apices are situated close together.
poorer view of the surgical field than with the traditional bony lid method
Depending on the accessibility of the surgical area, the trephines can be operated using a handpiece or green right-angle attachment.
The position and size of the bony lid are determined by radiography. If the root distance is low, a burr diameter of 10 to 12 mm should be used. If the distance between the apexes is greater, trephination must be performed twice, once mesial and once distal to the apexes (approx. 4 to 6 mm diameter).
The bony lid is removed using an elevator. After completion of apicectomy, the bony lid is repositioned and secured in place with or without collagen, as needed.
This technique was evaluated in a prospective clinical study . Radiology did not reveal signs of insertion or dislocation of the cover in this group of patients. No case of damage to the inferior alveolar nerve was reported.
Bony lid approach (Khoury and Hensher 1987)
Used for apical root resection of mandibular molars
Procedure

A generous incision is made from the canine tooth to the wisdom tooth.
The corners of the planned window are marked using a rose-head burr.
Fine incisions are made through the compact bone to the cancellous bone with a diamond disk shielded to keep from damaging the flap.
The bony lid is then lifted with a chisel, removed completely and kept in physiological saline solution.
After resection and retrograde filling, the bony lid is repositioned and secured in the opening.
Advantage

significant reduction of bone loss
Disadvantages

An extensive incision is required.
The inferior alveolar nerve may lie buccal to the roots.
Infection and necrosis of the avascular, replanted bony lid is possible.