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Surgical Endodontics




9/15/2009            Endo 15       1
Modern concept of Endodontics has modified the approach to
treatment
 Attempting to determine the cause of persistent periradicular
    disease. Treatment is directed to eliminate the etiology.
    Which is the presence offbbacteria and microbial irritants
    in the root canal space.
 Microorganism can be survive in the well treated root canals,
    in dentinal tubules, canal irregularities, deltas and
    isthmus areas. If these completely entombed periradicular
    healing should be occur.
 Over extended RCT is not indicated for apical surgery but it
    will contributed to failure due to toxic material like
    formaldehyde
 Vertical root fracture

 9/15/2009                     Endo 15                           2
Radiolucencey
            In
   Radiograph




                            Orthograde     -Clean
                            Root filling   -Shape

Treatment of choice                        -Fill


9/15/2009             Endo 15                       3
When reading x-ray’s following should be considered
  *Natural foramina over the apex
  *Other pathological lesions
  *maxillary sinus


Treatment of choice
                                                    Stress
Orthograde Root filling
                                  Surgery
           failure                                  discomfort



     Reroot filling


           failure
   9/15/2009                    Endo 15                          4
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




9/15/2009                           Endo 15               5
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




 9/15/2009                         Endo 15                6
Medical history
     Well documented medical history is essential

            Rheumatic fever (Not contraindicated)
            Heart diseases
            Diabetes
            Blood dyscrasias
            Steroid therapy
            Impaired renal/hepatic function
            CVA




9/15/2009                      Endo 15              7
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)

  9/15/2009                             Endo 15                   8
(1) Incision and Drainage
        The only surgical procedure in acute inflammation

                  Antibiotics
                  Drainage through root canal
    Anaesthesia
              Local
                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 unit
  9/15/2009                        Endo 15                            9
(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 from
 the peri radicular tissue. Actually, Apicectomy by it self can’t
 resolve root canal failure .It should accompanied the retro seal.
 It is an adjunct for Orthograde root filling
 Success rate is less than implant
 a. Cannot seal all lateral canals
 b. Exposed areas of root canal material is greater there for long
    term success is also affected


              WASHINGTON STUDY
 9/15/2009                       Endo 15                             10
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 causing
.                                                 deficient apical seal,


    9/15/2009                             Endo 15                       11
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 …………….Apexogenasis
           Nonvital Ca(oH)2…………Apexification
                         Failure               Surgery
      Conventionally blocked apices
      E.g.,   Existing post in the root canal
                                   ---Redo- it/Surgery
9/15/2009                            Endo 15                    12
Surgical repair
             latrogenic E.g., Perforated Apex
             Pathological---Internal Resorption
                         ---External
            Treat with Ca(OH)2 in both occasions, it fails
                          Surgery
   Fracture apical 1/3 of root
   When biopsy is required
   Cost
   Cracked root / tooth
     persistent Cyst
     Treatment alternatives ?
     Diagnostic E.g., biopsy

9/15/2009                              Endo 15               13
Surgical Technique
            Analgesia
            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 up
9/15/2009                          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.     Local
      B.     General
      C.     Sedation
 9/15/2009                           Endo 15                        15
Local Anesthesia

             2% Lignocaine with 1:80,000 adrenaline
                              1:50,000 adrenaline
              [Analgesic & Haemostatic effect]


    Maxilla                       -Superior dental nerves
    Palate                          - Greater Palatine nerve
                                   - Long spheno palatine nerves
    Mandible                      -Inferior Dental Nerve
                                                 lN
                                  - Lingual Nerve

               Slow infiltration, 1-2ml per minute
 9/15/2009                         Endo 15                         16
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:
                                              -         mental
      Healthy Periodontal tissue              -         lingual, palate

   9/15/2009                       Endo 15                          17
Types of flaps

              1. Semilunar flap (Partsch incision)
              2. Sub marginal (Leubke-orchsenbain)
              3. Full mucoperioseteal

             ----triangular
             ----rectangular
             ----trapezoid
             ----envelope (Horizontal)




 9/15/2009                           Endo 15         18
Semilunar Flap
  Simple
     Easy to suture
Incision is drawn a semicircle from near the apex of the adjacent
tooth in Apical alveolar mucosa towards the gingival margins
around the area operated on, finishes at the apex of the tooth on the
other side. Margin of the flap should extent up to attach gingivael.

Disadvantages;


            Scarring
            May lie on unsupported bone if the lesion is larger than
            expected

9/15/2009                           Endo 15                            19
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 papilla
9/15/2009                              Endo 15   20
Reflection of flap

Vertical relieving incisions are placed firmly down the line angle
of the teeth on the either side of the operating teeth in to the
gingival Crevices taking in the gingival papilla.
Horizontal incision made along the gingival crevice
to 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 apex
     to be curetted
     -more local at this stage
     -uncover the apex
  9/15/2009                          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




  9/15/2009                        Endo 15                       23
Corrosion
Retrograde root filling
                                                     Long term success
            -apical area is cleaned with saline.     Apical inflammation
            -packed the cavity with wet gauze.       Mercury ?
            -dry with cotton wool.
            -Zinc free Amalgam is packed to the cavity.
                         Hill amalgam carrier.
                         KG retrograde carrier.

                                               Materials
                          super EBA                   Composite resin
                          IRM                         Diaket
                          Glass Ionomer cement        MTA
9/15/2009                            Endo 15                            24
9/15/2009   Endo 15   25
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 / smoking
 9/15/2009                       Endo 15               26
X-rays

                  Think twice before undertaking
                  difficult surgical procedure.
                  Consider carefully risk and benefits of
                  the surgical procedure.


                  If you do not have personal skills
                  always refer to someone with required
                  skills



Success 25%-90%


9/15/2009                 Endo 15                           27
Tooth which is able to be removed one piece
       atruamatically
       Curve root teeth not indicated
       Perio endo lesions
       Root fracture can be cement using dentine
       bonding




9/15/2009                 Endo 15                    28

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Endo note 15 surgical endodoic

  • 2. Modern concept of Endodontics has modified the approach to treatment Attempting to determine the cause of persistent periradicular disease. Treatment is directed to eliminate the etiology. Which is the presence offbbacteria and microbial irritants in the root canal space. Microorganism can be survive in the well treated root canals, in dentinal tubules, canal irregularities, deltas and isthmus areas. If these completely entombed periradicular healing should be occur. Over extended RCT is not indicated for apical surgery but it will contributed to failure due to toxic material like formaldehyde Vertical root fracture 9/15/2009 Endo 15 2
  • 3. Radiolucencey In Radiograph Orthograde -Clean Root filling -Shape Treatment of choice -Fill 9/15/2009 Endo 15 3
  • 4. When reading x-ray’s following should be considered *Natural foramina over the apex *Other pathological lesions *maxillary sinus Treatment of choice Stress Orthograde Root filling Surgery failure discomfort Reroot filling failure 9/15/2009 Endo 15 4
  • 5. 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 9/15/2009 Endo 15 5
  • 6. 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 9/15/2009 Endo 15 6
  • 7. Medical history Well documented medical history is essential Rheumatic fever (Not contraindicated) Heart diseases Diabetes Blood dyscrasias Steroid therapy Impaired renal/hepatic function CVA 9/15/2009 Endo 15 7
  • 8. 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) 9/15/2009 Endo 15 8
  • 9. (1) Incision and Drainage The only surgical procedure in acute inflammation Antibiotics Drainage through root canal Anaesthesia Local 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 unit 9/15/2009 Endo 15 9
  • 10. (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 from the peri radicular tissue. Actually, Apicectomy by it self can’t resolve root canal failure .It should accompanied the retro seal. It is an adjunct for Orthograde root filling Success rate is less than implant a. Cannot seal all lateral canals b. Exposed areas of root canal material is greater there for long term success is also affected WASHINGTON STUDY 9/15/2009 Endo 15 10
  • 11. 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 causing . deficient apical seal, 9/15/2009 Endo 15 11
  • 12. 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 …………….Apexogenasis Nonvital Ca(oH)2…………Apexification Failure Surgery Conventionally blocked apices E.g., Existing post in the root canal ---Redo- it/Surgery 9/15/2009 Endo 15 12
  • 13. Surgical repair latrogenic E.g., Perforated Apex Pathological---Internal Resorption ---External Treat with Ca(OH)2 in both occasions, it fails Surgery Fracture apical 1/3 of root When biopsy is required Cost Cracked root / tooth persistent Cyst Treatment alternatives ? Diagnostic E.g., biopsy 9/15/2009 Endo 15 13
  • 14. Surgical Technique Analgesia 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 up 9/15/2009 Endo 15 14
  • 15. 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. Local B. General C. Sedation 9/15/2009 Endo 15 15
  • 16. Local Anesthesia 2% Lignocaine with 1:80,000 adrenaline 1:50,000 adrenaline [Analgesic & Haemostatic effect] Maxilla -Superior dental nerves Palate - Greater Palatine nerve - Long spheno palatine nerves Mandible -Inferior Dental Nerve lN - Lingual Nerve Slow infiltration, 1-2ml per minute 9/15/2009 Endo 15 16
  • 17. 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: - mental Healthy Periodontal tissue - lingual, palate 9/15/2009 Endo 15 17
  • 18. Types of flaps 1. Semilunar flap (Partsch incision) 2. Sub marginal (Leubke-orchsenbain) 3. Full mucoperioseteal ----triangular ----rectangular ----trapezoid ----envelope (Horizontal) 9/15/2009 Endo 15 18
  • 19. Semilunar Flap Simple Easy to suture Incision is drawn a semicircle from near the apex of the adjacent tooth in Apical alveolar mucosa towards the gingival margins around the area operated on, finishes at the apex of the tooth on the other side. Margin of the flap should extent up to attach gingivael. Disadvantages; Scarring May lie on unsupported bone if the lesion is larger than expected 9/15/2009 Endo 15 19
  • 20. 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 papilla 9/15/2009 Endo 15 20
  • 21. Reflection of flap Vertical relieving incisions are placed firmly down the line angle of the teeth on the either side of the operating teeth in to the gingival Crevices taking in the gingival papilla. Horizontal incision made along the gingival crevice to join the vertical incision Blade is held in near vertical position Raised a good mucoperioseteal flap. 9/15/2009 Endo 15 21
  • 22. 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 apex to be curetted -more local at this stage -uncover the apex 9/15/2009 Endo 15 22
  • 23. 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 9/15/2009 Endo 15 23
  • 24. Corrosion Retrograde root filling Long term success -apical area is cleaned with saline. Apical inflammation -packed the cavity with wet gauze. Mercury ? -dry with cotton wool. -Zinc free Amalgam is packed to the cavity. Hill amalgam carrier. KG retrograde carrier. Materials super EBA Composite resin IRM Diaket Glass Ionomer cement MTA 9/15/2009 Endo 15 24
  • 25. 9/15/2009 Endo 15 25
  • 26. 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 / smoking 9/15/2009 Endo 15 26
  • 27. X-rays Think twice before undertaking difficult surgical procedure. Consider carefully risk and benefits of the surgical procedure. If you do not have personal skills always refer to someone with required skills Success 25%-90% 9/15/2009 Endo 15 27
  • 28. Tooth which is able to be removed one piece atruamatically Curve root teeth not indicated Perio endo lesions Root fracture can be cement using dentine bonding 9/15/2009 Endo 15 28