endodontic Surgery /certified fixed orthodontic courses by Indian dental academy

ENDODONTIC
SURGERY

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

A surgical approach to a failed root canal
treatment should only be considered when
an orthograde approach is not possible.
The reason for failure should be carefully
diagnosed before surgery is prescribed.


OBJECTIVE:
 As in all endodontic procedures, the objective of
periapical surgery is to ensure the placements of
proper seal between the periodontium and the root
canal foramina.
 When this seal cannot be achieved satisfactorily by
working through the canal system (orthograde
filling), a surgical procedure permits visual and
manipulative control of the area and placement of
the seal through the surgical site.


CASE 1

This tooth has been
obturated with silver
points,
and subsequently
received periradicular
surgery.
The correct treatment
should have been
orthograde retreatment
and conventional
obturation


CASE 2

This case requires
complete dismantling
and orthograde
retreatments.
Periradicular surgery
is unlikely to be
successful

Inadequate
fillings

INDICATIONS:
 Any condition a obstruction that prevents direct access
to the apical third of the canal, such as:
Anatomic : calcifications, curvatures, bifurcations,

dens in dente & pulp stones.
Iatrogenic : ridging, blockage from debris, broken
instruments, old root canal fillings and
cemented posts


 Periradicular disease associated with a
foreign body: overfilled canals,
excessive cement in the
periodontium, broken
instruments proceeding into
the apical tissue, and loose
retrograde fillings.


 Apical perforation : Any perforation that cannot be
sealed properly by a filling with in the canal, a
one that prevents the proper filling of the
anatomic canal & perforation.
 Incomplete apexogenesis with “blunder buss” a
other apices that do not respond to apical
closure procedures and all in adequately sealed
with an orthograde filling.


Persistent & recurring
exacerbations during non
surgical treatment as
persistent, un explainable  Horizontally
pain after completion of fractured root tip
non surgical treatment. with Periradicular
 Treatment of any tooth disease.
with a suspicious lesion  Failure to heal
that requires a diagnostic following skilled non
biopsy. surgical endodontic
treatment.


 Excessively large and intruding periapical lesion:
Marsupilization and decompression may be
the preferred treatment.
 Destruction of apical constricture of root
canal due to uncontrolled instrumentation
that results in an apical foramen that cannot
be adequately sealed with an orthograde
filling.


CONTRAINDICATION:
 The Contraindication to Periapical surgery are listed
in the following sections:
General Consideration:
 Medically compromised a “brittle” patient a patient
with an active systemic disease such as uncontrolled
diabetes tuberculosis, syphillis, nephritis, blood
dyscrasia a osteoradionecrosis.
 Emotionally distressed patient: a patient unable
psychologically to with stand as cope with any
surgical procedure.
 Limitations in the surgical skill and experience of the
operator.

Local considerations :
 Localized acute inflammation: where as emergency procedure
such as incision and derange or trephination may be
indicated, elective periapical surgery should be avoided.
 Anatomic considerations: procedures that penetrate the
mandibular canal, maxillary sinus, mental foramen, floor
of the nares, or that serves the grater palatine blood
vessels should be avoided when ever possible.


 In accessible surgical sites: inaccessible
position and location of root apices,
especially in posterior teeth, and
the need to gain access to the
surgical site through dense layers
of bone.


 Teeth with poor prognosis : short rooted teeth,
teeth with advanced periodontal disease,
vertically fractured teeth, non-strategic a
un-restorable teeth should not be considered
for periapical surgery.
 Finally, periapical surgery should not be
considered as a cure – all to compensate for
inadequate techniques.

Pre operative consultation:

A proper preoperative consultation is an
essential part of the total surgical experience
for both the patient and the clinician.
 Informed consent: prior to any treatment you
must be informed & understand.
 What will be done

 How it will be done

 Why it will be done

 What constitutes a successful result.
 How likely are your chances of attaining success.
 What alternative treatments are available to you.
 What risk you may encounter.

Generally:
 Surgical Endodontics is a painless procedure.
 Treatment is usually accomplished in the dental
chair, use in the same kind of anesthesia as for fillings


Reactions can occur after treatment such as:
 Sore tooth and gum (pain)
 swelling, varying from slight to large
 black & blue marks
 paraesthesia : a numbness or tingling sensation
that persists in the treatment area, mainly the low
jaw, but usually disappears in time.
 Routine instruction will be given to patient immediately
following surgical instrument treatment, regarding home
care, diet & medication.


 PREMEDICATION
 Premedication becomes necessary when a patient
remains overly anxious & un affected by the
preoperative consultation.
 The premedication drugs selected should reduce
anxiety, enhance the anesthetic to be administered, and
favorably reduce salivation, bleeding, a secondary
infection (antibiotics).


 Short acting barbiturates, such as pento barbital
(Nembutal) and seco barbital (seconal ) are frequently
used for sedation.
 Tranquillizes are effective drugs for surgical
premedication because they reduce apprehension.
 Narcotics can be effective premedication but they are
given infrequently to the ambulatory patient because of
their lasting effect.


SURGICAL INSTRUMENTS AND MATERIALS:
 A surgical set up should consist of al sterile
instruments and materials needed to complete
the contemplated procedure.
 A suggested surgical set up for periapical
procedures follows:
Anesthesia: Aspirating syringe, disposable
needle, and several caepules of desired local
anesthesia such as lidocaine HCL, 2%
epinephrine 1:50,000
Isolation of the operative site: sterile 2 x 2
cotton gauze squares, and cotton pellets or
racellets (alcohol sponges or topical antiseptic

Incision: Bard – parker handle No 15 blade, and
periodontal probe (to help determine flap
design).
Flap elevation & retraction: Periosteal elevator (union
broach no: 9)
Penetration & removal of cortical bone plate, root resection, and
prepration for retrograde filling in the root apex: Asserted
S.H (straight hand piece ) bur no 2, 4, 6, 8,
33½ , 34, 558, 701, 702 hand chisel ( Hu-friedy
No.1), + sterile saline or anesthetic solution for
use as a coolant and for debridement, hand
piece (straight or contra angle) and micro head

Curettage : Goldman fox No 3 curette, #
surgical excavator ( Hu-friedy no.9 or no.11)
Retrograde filling : apical amalgam carrier, plastic
instrument, apical amalgam plugger, and
amalgam.
Suturing : Needle holder or hemostat, 3-0 or 4-
0 silk suture on an atraumatic needle [ atraloc x
– 8 needles & 3-0 silk suture, FS-2 needles & 4-
0 silk suture ] & scissors.
Surgical tray : cotton pliers, explorer mirror, &
cotton or racellets.

CLASSIFICATION OF ENDODONTIC SURGICAL
PROCEDURES
 Surgical Drainage:
 Incision and drainage
 Cortical trephination (fistulative surgery)
 Periradicular surgery:
 Curettage
 Biopsy
 Root end resection
 Root end preparation and filling
 Corrective surgery
 Perforation repair.
 Root resection
 Hemisection

 Replacement Surgery:
 Extraction / Replantation
 Implant Surgery:
 Endodontic implants
 Root form Osseo-integrated implants.


TYPES OF INCISIONS & FLAPS
 Horizontal: A simple horizontal incision is often
used because of the natural contour of the maxilla
& mandible.
Semilunar / curved / elliptical flap: It is a curved
horizontal incision with convex portion of the incision
towards the gingival crest.
Indications:
 Used when it is desirable to mandible the attached
gingiva around the margin


 It is important that there should be 2 to 3 mm of
distances from the base of the gingival sulcus to the
incision.
A modified incision that follows the general bone
contour is often used to avoid the labial frenum.

Advantages:
 Simple and easy to reflect
 Once reflected the operator is close to the apex of
involved tooth, provides access to apex without
impinging on the tissues.


 Gingival attachment is not disturbed and
marginal gingiva does not receed while healing. .
 Patient can maintain good oral hygiene.

Disadvantages:
 Restricted access with limited visibility.
 Chances of tracing the corner of incision while
attempting to improve the access.
 if the incision is over the bony defect it may
result in dehiscence and scar formation.
 flap use is limited by the presence of muscle
attachment, canine or other bony prominence.

 Single vertical incision / triangular flap:
Indications:
 Indicated for surgery involving the short rooted teeth
(usually single).
 Incision is made with the root eminences of teeth.
Advantages:
 Provides grater access & visibilities.
 Affords a view of periodontal defects a bony
penetrations.
 Heals with minimal scar formation.

Disadvantages:
 Difficult to retract.
 Vertical & Horizontal incision must be
lengthy to gain access.
 Double vertical incision / Trapezoidal flap:
Two oblique incisions are made and entire
flap is retracted towards the vestibule.
Advantages:
 Good accessibility.
 Convenient for teeth with long roots.
 Convenient for curetting more then one
root & large lesions.

Disadvantages:
 Loss of gingival attachment.
 Envelope / Gingival flap:
 used mainly for posterior mandibular and
palatal surgery.
 Grater relaxation of the flap can be
achieved giving incisions around the necks of
all teeth in a quadrant.
 A relaxing incision can be added at either
end of the flap if the access is still not
adequate. www.indiandentalacademy.com

Luebke – Ochsenbein flap / scalloped
flap :
 It is named after Leuebke an endodontist and
ochsenbein a periodontist who together
designed the flap.


 It is a modified semilunar flap in which a
scalloped horizontal incision is made in the
attached gingiva with accompanying vertical
incisions.
 Scalloped flap is produced by first making a
continuous scalloped incision in the firm
attached gingiva parallel to the free gingival
groove.
 At both ends vertical oblique relaxation
incisions are made.
 Scalloped incision should be 3-4 mm short of

Advantages:
 Greater access and visibility.
 Decreases the possibility of placing the
incision over the periapical defect.
 Flap is easily displaced and sutured.
 marginal gingiva is not disturbed, so there is
no gingival recession.

Disadvantages:
 Misjudgment of the size of the lesion
resulting in incision crossing the osseous
defect. www.indiandentalacademy.com

Trephination


TREPHINATION


Trephination
Trephination

ROOT END SURGERY


RETROGRADE FILLING
 A retrograde filling is placed in the apically resorted
root when the canal is poorly scaled from the
surrounding tissue.
 The technique used for resection and retrograde filling
depends on the accessibility of the root tip in the
operative site, the presence of hazardous anatomic
structures surrounding the surgical site. The
configuration, location and accessibility of the apical
foramina to be used.
 The root is beveled to achieve the access needed to fill
all the foramina present on the resected root surface


Materials Used:
 Zinc & Zinc free amalgam – widely used.
 ZOE cements
 Cavit
 Polycorboxylate cement
 Glass ionomer cement
 Composite filings
 Zinc phosphate cement
 Silver cones
 Gold foil.

Apical seal:
 The filling at the interface of the canal and
periapical tissues should seal the root canal
from the surrounding tissue.
Technique:
 The cavity in the bevelled surface of the
root is prepared for a retrograde filling with
small, round burs followed by inverted cone
burs.
 The ideal preparation has the smallest
exposed surface at the apex while
encompassing all foramina and extends about

.
Technique of root resection : (root amputation)
 Administration of local anesthesia.
 Probe the area to determine the extent and outline
of alveolar bone destruction among the root to be
removed.
 Elevate the mucoperiosteal flap.
 With the contraangle hand piece and cross cut bur
severe the root where it joins the crown and
remove the root.
 With a stone or diamond point smooth the resected
root stumps and contour the tooth.

ROOT AMPUTATION


HEMISECTION:

DEFINITION:
 Procedure in which one root and its
corresponding crown portion is cut and removed.


INDICATIONS:
 When the periodontal involvement of one root
is severe.
 When loss of bone is extensive in the furcation
area.
 When caries involves much of the roots.
Contraindications:
 Similar to radisectomy.
Technique:
 It involves the same technique as that is used
for root resection.
The retained mesial and distal halves serves as abutment for
 In this procedure, half of the crow is removed

HEMISECTION:


.
BICUSPIDIZATION / BISECTION:
TECHNIQUE:
 Molar is cut into two separate mesial and distal
portion without the removal of any part of the
root or crown.
 It is performed when the mandibular molar
exhibit proper anatomic features and stability.
 Molar with divergent roots and bone loss
restricted to buccal areas all ideal for
bicuspidization.
 The tunnel like effect of the furcation
involvement www.indiandentalacademy.com creating two
is eliminated by

BICUSPIDIZATION /
BISECTION:


Complications of Endodontic Surgery:
1) Swelling
2) Pain
3) Echymosis
4) Paraesthesia
5) Stitch abscess
6) Hemorrhage
7) Perforation
8) Iatrogenic damage to adjacent teeth.
9) Incision failure.

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endodontic Surgery /certified fixed orthodontic courses by Indian dental academy

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