When to Perform Surgery: One Indication

I get hundreds of email questions each week and I’m entering a new era in my life, as I enter my fourth decade in clinical endodontics.  With the travel and with the length of time I’ve been in the field, I have met countless individual and, of course, oftentimes this means a significant number of questions do arise.  I always have been faithful to answer each and every question, quite promptly, I might add.  However, with travel, sometimes it might take a week or two to get back to each person. 

So, more recently, I’m going to a blog format to answer these questions because I can be much more thorough and I think give more descriptions that might be useful than trying to plug it into an email and send it back. 

So, here we go.  Here is another question that came in, an international question, and the question has to do with surgery.  So, the colleague, I’m paraphrasing the question, but the colleague is saying that sometimes even after what he describes as thorough cleaning and shaping and filling root canal systems, that on large lesions, he says, that are cystic in appearance where there are huge radiolucencies noted in the bone, he has noticed after doing complete endodontics, that some of these do not resolve and require microsurgery. 

Well, you know, yes of course.  I don’t want to be condescending, but if you look at Bhashkar who probably wrote the definitive book on oral pathology, and I don’t remember exactly but I’m pretty close within a couple of percentage points… More or less he said that out of all endodontic lesions, you can say that about 50% of them were granulomatous lesions and about 50% were cystic.  It wasn’t exactly those numbers, but it was close. 

Presumably, granulomatous lesions would respond after careful cleaning, shaping and packing, and we would see the lesions resolve themselves on recall xrays.  So, when we took radiographs at 6 months, 1 year, 2 years, 5 years and over time, and even beyond those timelines I just gave, we would classically see the vast majority of all lesions would heal. 

Well, then this began to beg the question, if cystic lesions typically don’t heal and granulomatous lesions do, and if about half of them are cystic, how come the vast majority, high in the 90 percents, resolve following endodontics?  This goes to show that obviously, many cystic lesions do, in fact, heal after endodontics.

There has been a lot of literature and I’ll let the colleague do his own Googling, his own quest for knowledge, but if you Google ‘surgery’ and ‘cyst’ and ‘granulomatous tissue’ and all these kinds of things, you’ll find out that there are some lesions after careful concerted endodontics, where we’ve made a great access, we’ve negotiated the full length of the canal, we have a good deep shape, we have exchanged our irrigants through active irrigation, and we’ve used three-dimensional filling techniques… There are some lesions that still would not respond to those well-intended procedures.

In my own experience, having practiced for about 38 years, I don’t do a lot of surgery anymore, but I can remember back in the early 80s where I did an enormous amount of surgery. Basically, that was a very accepted protocol on cases that had been previously treated and were failing. 

With the advent of the microscope in 1988, that’s when I got my first microscope, and then along with MTA in the late 90s, mineral trioxide aggregate, we could start to do a lot of nonsurgical retreatments and repair many of these lesions that we used to flap and do surgery on.  So, my surgeries began to plummet with the introduction of the microscope, and with better armamentarium, and with better materials like MTA, a lot of the surgeries we didn’t do and virtually all the cases still have the capacity to heal. 

But, there would be on occasion, a large, large lesion, probably over a centimeter in diameter, and you would occasionally elevate a flap and when you would begin to enucleate this lesion from the osseous tissues, you would find out that oftentimes there was a clear exudate in a fluid-filled sac… classic cystic.  It could be encapsulated, the cyst, with fluid and you would realize that there’s no blood supply into these cystic lesions.  Therefore, there’s no capacity to heal.  That’s why some people even advocated a patency file during conventional treatment to theoretically puncture and collapse the cystic sac, and to initiate repair in that manner. 

So, sometimes surgery is necessary.  It has no indictment.  If the endodontics has been done carefully, with attention to detail, there’s no indictment that the work is deficient in some respect.  It simply means that you did what you would’ve done anyway and now to get the case to completely heal over time, surgery would be required. 

So, when we go in sometimes and pop these, I can also speak of the cholesteatoma, where you’ll get yellow, granulose bodies coming out of these fluid-filled sacs, and you begin to realize, quite humbly, chair-side, that there was nothing that endodontics was going to ever do to make this lesion heal through the tooth.  It would’ve required, ultimately, that procedure, through the tooth, plus surgical intervention, to get the desire result.

So, I hope this answers the question and the colleague can relax because from time to time, even after careful, conservative treatment, there will still be a need to have the ability to elevate a flap, do an osteotomy and then do an enucleation to rid these lesions of endodontic origin from their osseous crypts.  Thank you very much.