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Surgical Endodontics

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Modern concept of Endodontics has modified the approach totreatment

Attempting to determine the cause of persistent periradiculardisease. Treatment is directed to eliminate the etiology.Which is the presence offbbacteria and microbial irritantsin the root canal space.

Microorganism can be survive in the well treated root canals,in dentinal tubules, canal irregularities, deltas andisthmus areas. If these completely entombed periradicularhealing should be occur.

Over extended RCT is not indicated for apical surgery but itwill contributed to failure due to toxic material likeformaldehyde

Vertical root fracture

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Radiolucencey

In

Radiograph

Treatment of choice

Orthograde

Root filling

-Clean

-Shape

-Fill

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When reading x-ray’s following should be considered*Natural foramina over the apex

*Other pathological lesions

*maxillary sinus

Treatment of choiceStress

Orthograde Root filling

failure

Reroot filling

failure

Surgery

Endo 15

discomfort

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General indications for Endodontic surgery

1. Access to the root canal

2. To establish drainage

3. Need to seal the system

4. To repair any defect in the root

5. Surgical resection of multi-rooted teeth

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Surgical procedures in Endodontics

1. Incision to establish drainage

2. Periapical (Peri radicular) curettage

3. Apicectomy

4. Surgical repair of roots ( Corrective surgery )

5. Root amputation (Resection)

6. Hemi section

7. Intentional replantation

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Medical historyWell documented medical history is essential

Rheumatic fever (Not contraindicated)

Heart diseases

Diabetes

Blood dyscrasias

Steroid therapy

Impaired renal/hepatic function

CVA

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Contraindications ( Or Cautions )

Poor Psychological health / poor health

Post radiation therapy

Difficult accessibility

-Palatal roots

-Disto buccal root of upper 7 7

-Distal 7 ( External oblique ridge )Limited mouth opening

Poor periodontal support

No cortical plate

Very short roots

Beyond capabilities and experience

Anatomical structures in jeopardy ( nerve)

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(1) Incision and Drainage

The only surgical procedure in acute inflammation

Antibiotics

Drainage through root canal

AnaesthesiaLocal

Spray

Gel

Sub mucosal injection*Incise with bard parker No 11 blade or

*Aspirate with wide bore needle ABST

Extra oral drainage could be referred to a specialized unit9/15/2009 Endo 15

(2) Apicectomy & Retrograde apical seal

The term “Apicectomy” refers to only a stage of an operation

Objectives is to seal the canal system at the apical foramen fromthe peri radicular tissue. Actually, Apicectomy by it self can’tresolve root canal failure .It should accompanied the retro seal.

It is an adjunct for Orthograde root filling

Success rate is less than implanta. Cannot seal all lateral canals

b. Exposed areas of root canal material is greater there for longterm success is also affected

WASHINGTON STUDY

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.

Indications for Apicectomy

Retreatment of a failed root filling

*Retreatment of Orthograde is also failed

- Difficulty in removing filling

- Unfilled apical delta

- Original canal cannot be negotiated

- Filling Material has been extruded-with symptoms causingdeficient apical seal,

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Procedural difficulty-Aberrant Anatomy

E.g.,Maxillary molars, Lower incisors, lower premolars- Unusual root canal configuration

E.g., severe dilacerations-extensive Secondary dentine formation

E.g.,Ageing process,Calcification- FractureddIInstrument with symptoms- Open apex

Vital Ca(oH)2 …………….ApexogenasisNonvital Ca(oH)2…………Apexification

Failure

Conventionally blocked apices

Surgery

E.g., Existing post in the root canal

---Redo- it/Surgery9/15/2009 Endo 15 12

Surgery

Surgical repair

latrogenic E.g., Perforated Apex

Pathological---Internal Resorption

---External

Treat with Ca(OH)2 in both occasions, it fails

Fracture apical 1/3 of root

When biopsy is required

Cost

Cracked root / tooth

persistent CystTreatment alternatives ?Diagnostic E.g., biopsy

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Surgical TechniqueAnalgesia

Reflection of flap

Location of apex

Curettage of area

Resection of root

Retrograde cavity Preparation

Retrograde filling

Flap replacement

Post op instruction

Suture removal

Follow up9/15/2009 Endo 15 14

Analgesia

1. Anaesthesia

2. Haemostasis – Improved vision

- Less time

- Less blood loss

- Less post op discomfort

Failure to produce good anesthesia is a problem in apical surgery

A.

B.

C.

Local

General

Sedation9/15/2009 Endo 15 15

lN

Local Anesthesia

2% Lignocaine with 1:80,000 adrenaline

1:50,000 adrenaline

[Analgesic & Haemostatic effect]

Maxilla

Palate

Mandible

-Superior dental nerves

- Greater Palatine nerve

- Long spheno palatine nerves

-Inferior Dental Nerve

- Lingual Nerve

Slow infiltration, 1-2ml per minute9/15/2009 Endo 15 16

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Flap Designing

Adequate exposure

*Good surgical access

*Visualization

*Lightning

Adequate Blood supply – Avoid tissue necrosis

*Broad base - Adequate blood for margins

Edges of flap should rest on the bone

Clean incisions, it Should not cross -bony eminence e.g.;canine

-neurovascular bundle, ex:

Healthy Periodontal tissue

- mentallingual, palate

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Types of flaps

1. Semilunar flap (Partsch incision)

2. Sub marginal (Leubke-orchsenbain)

3. Full mucoperioseteal

----triangular

----rectangular

----trapezoid

----envelope (Horizontal)

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Semilunar FlapSimple

Easy to suture

Incision is drawn a semicircle from near the apex of the adjacenttooth in Apical alveolar mucosa towards the gingival marginsaround the area operated on, finishes at the apex of the tooth on theother side. Margin of the flap should extent up to attach gingivael.

Disadvantages;

Scarring

May lie on unsupported bone if the lesion is larger thanexpected

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Full mucoperioseteal flap

Excellent view

Excellent access

No scaring

Can be extended

Maintain intact vertical blood supply

Problems

-Time consuming

-flap reflection is difficult

-meticulous suturing is necessary

-Possible loss of interdental papilla9/15/2009 Endo 15 20

Reflection of flap

Vertical relieving incisions are placed firmly down the line angleof the teeth on the either side of the operating teeth in to thegingival Crevices taking in the gingival papilla.

Horizontal incision made along the gingival creviceto join the vertical incision

Blade is held in near vertical position

Raised a good mucoperioseteal flap.9/15/2009 Endo 15 21

Location of the apex-easy when perforated

-use radiographs

- rose head no 1 or tapered fissure bur/ISO 18-24

- priced off the cortical plate

- just exposed the apical area

- Copious irrigation

Curettage

-soft tissues around the apexto be curetted

-more local at this stage

-uncover the apex9/15/2009 Endo 15 22

Resection of root

Minimum amount of apex is shaved at 300- 450 to provide access to. the canal ?

Root beveled

Retrograde cavity preparation

-use small ½ or ¼ rose head round bur, ISO 008

- create a simple surface cavity

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CorrosionRetrograde root filling

-apical area is cleaned with saline.

-packed the cavity with wet gauze.

Long term success

Apical inflammation

Mercury ?

-dry with cotton wool.

-Zinc free Amalgam is packed to the cavity.

Hill amalgam carrier.

KG retrograde carrier.

Materials

super EBA

IRM

Glass Ionomer cement

Composite resin

Diaket

MTA9/15/2009 Endo 15 24

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Replacement of flap

-4/0 black silk

-vertical mattress

-Suture removalliin 5 days

Post operative period

Pain……………………………Analgesics

Antibiotics

Swelling……………………….ice bags, externally

Discomfort ……………………warm salt water mouth baths

chlorhexidine

Oozing ………………………..24h normal

Activities ………………………Avoid Alchohol / smoking9/15/2009 Endo 15

X-rays

Think twice before undertakingdifficult surgical procedure.

Consider carefully risk and benefits ofthe surgical procedure.

If you do not have personal skillsalways refer to someone with requiredskills

Success 25%-90%

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Tooth which is able to be removed one pieceatruamatically

Curve root teeth not indicatedPerio endo lesionsRoot fracture can be cement using dentinebonding

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