4. CONTRAINDICATIONS:-
Anatomic factors
• Proximity to nerve bundles
• Second mandibular molar
• Maxillary sinus
Periodontal status
Medical factors
• Leukemia or neutropenia
• Uncontrolled diabetes
• Recent heart surgery
• Cancer
• Old/ill patients
Postponement of surgery
• Patient’s on anticoagulants
• Radiation therapy of jaw
• Surgeon’s skill
5. Ingle’s classification
Surgical drainage
Incision and drainage
Cortical trephination
Periradicular surgery
Curettage
Biopsy
Root-end preparation and filling
Corrective surgery
Perforation repair
Mechanical(iatrogenic)
Resorptive(internal & external)
Root resection
Hemisection
Replacement surgery
Implant surgery
Endodontic implants
Root form osseointegrated implants
6. Armamentarium:-
Sterile towels
2”*2” gauze
Local anesthetic equipment
Aspiration equipment
Irrigating syringes with sterile saline,stroko irrigator
Tweezers
Scalpel blades
Front surface mouth mirror
Probes:hooked,curved,angled
Locking cotton pliers
Periosteal and root-tip elevators
Flap retractors
Bone and periodontal curettes
Tissue forceps
Air impact hand piece
Surgical length carbide burs
Ultrasonic unit & surgical tips
Root end filling material carrier
Root end filling condensor
Suture materials, needles,& surgical scissor
Surgical operating microscope
Endodontic instruments for canal preparation and obturation may also be required.
11. Root end resection(apicoectomy)
Indications:-
Biological factors(60%):
Due to the persistent symptoms & the continued presence
of a periradicular lesion.
Technical factors(40%):
Due to the presence of intraradicular posts,crowned teeth
without posts,irreversible root canal filling materials &
procedural accidents.
Main purpose:
To eliminate the cause of persistent periradicular disease.
To provide good visulization & access to the periradicular
disease.
12. Instruments used:
Root is resected using any of the following burs:
No.51 straight fissure bur
Lindermann bone bur,multipurpose bur
Finishing done with multifluted carbide bur/fine diamond bur.
Extent of resection:
A 3mm apical tip should be removed so as to eliminate all
accessory canals & expose isthmus, which eliminates the
residual microorganisms.
Angle of resection:
10 degree or perpendicular to the long axis of the tooth.
This angulation decreases the no of dentinal tubules
communicating with periradicular regions & root canals.
It also helps in obtaining good cavity preparation.
Reduces the forces acting in apical region which prevents
fracture.
Creates better environment for healing.
13. The 45 bevel removes more root structure & increases the
probability of overlooking important lingual anatomy.
10 bevel conserves the root structure maintains a better
crown/root ratio & increases the ability to visualize
important lingual anatomy.
ROOT CONDITIONING:
Purpose..
Removes smear layer & improves the mechanical adhesion of
retrograde fillings.
Exposes the dentine tetra acetic-acid.
CONDITIONERS USED:
50% CITRIC-ACID-Ph,(not commonly used)
15-24% EDTA-Ph 7.3(best)
Tetracycline Hcl-Ph 1%
14. ROOT END PREPARATION:
Class-I cavity measuring a depth of 3mm along the long
axis of tooth.
An ultrasonic tip can be used to prepare a cavity without
risk of perforation.
It removes a smear layer.
For bonded restorations, the cavity is shallow & entire
resected surface is scalloped with deepest concavity at 1-
mm depth.
15. Retrograde filling:
It is placed in the apically resected root when canal is poorly
sealed from surrounding tissue.
This technique depends upon:
Accessibility of the root tip in operative side.
Presence of hazardous anatomic structure surrounding the
surgical site,location,cofiguration & accessibility of the apical
foramina in the resected root.
Filling materials to be used.
16. Maxillary anterior tooth whose root apex is adjacent to the
nasal fossa is in accessible because of root elongation or
lingual inclination require removal of more root structure &
more obliquely beveled preparation.
Following factors can affect root-end preparation:
I. Location of the apical foramen on a curved root.
II. No.,position & shape of foramina on the resected root apex.
III. Location of a foramen on the root surface such as occurs with
root perforation or a lateral canal.
The cavity in the beveled surface of the root is prepared for
a retrograde filling with small, round burs no.1/2,1,2
inverted cone burs no.,33 1/2,34/35.
Ideal preparation has smallest exposed surface at apex
while encompassing all formina & extends about 2-mm
inside the root canal.
17. The rationale for keeping the exposed surface of the filling
small & extending the filling deep into root to ensure an
adequate continual seal.
Because root resorption can occur around the cut apex, a small
deep restoration is less likely to result in marginal leakage or
becomes a loose foreign body in the periapical tissues.
18.
19. Apical seal:
The most successful seal reported consists of orthogradefilling
of gutta-percha & cement completing the obturation of the
canal to the root apex.
It is better tolerated & causes less periapical tissue toxicity than
most retrograde filling material.
Some materials used for a retrograde fillings are zinc & zinc-
free amalgam,cavit,polycarboxylate cements, zinc oxide
eugenol cements,silver cones & gold foil.
20. Technique of packing amalgam into a prepared cavity in
apical root tip follows:-
Debride the operative site,wipe & dry root tip,isolae the root
tip with sterile cotton pellets to prevent any seepage into the
cavity & to collect any excess amalgam particles that fall into
the wound during packing & condensation.
Place varnish over the prepared cavity.
Pack the amalgam into the cavity using a KG retrofilling
amalgam carrier, or a plastic instruments,PF/W3 acting as
amalgam carrier, condense the amalgam, with retrofilling
amalgam plugger,E-3.
Wipe & adopt the margins of amalgam to dentin with moist
cotton pellet.
Remove all the cotton pellets surrounding the root apex
cautiously to prevent amalgam particles trapped in the cotton
from falling into the surrounding tissues.
21. Irrigate the wound with sterile saline or anesthetic solution
and aspirate the solution to debride the wound site
Examine the root tip filling and surrounding tissue ,both
visually and radio graphically to ensure that the canals have
been properly sealed ,that the margins of amalgam to dentin
are well adapted and that no foreign body amalgam particles
or pathologic tissue debris remain in the wound site.
Completion of surgical procedures
When the rot apex has been sealed, the operative site is
debrided thoroughly.
A strong irrigating stream of saline/anesthetic solution is
flushed through & is aspirated from surgical area.
This procedure rids the wound of blood to make it ensure
that all pathologic tissue has been removed.
24. ROOT END FILLING MATERIALS
Requirements
Acc. to Garther & Dorn
Seals all bacteria within the canal to prevent leakage of bacteria
& their leakage of bacteria & their by-products into the
periradicular disease.
Non-toxic
Non-cariogenic
Biocompatible with the host tissue
Dimensionally stable
Insoluble in tissue fluids(non-resorbable )
Easy to use
Unaffected by moisture during setting
Radio opaque
Induces regeneration of PDL especially cementum.
