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POSTGRADUATE DEPARTMENT OF CONSERVATIVE
DENTISTRY AND ENDODONTICS
UNDER GUIDANCE OF :-
Prof. Dr Riyaz Farooq (HOD)
Dr Aamir Rashid (Asst. Prof.)
Dr Fayaz Ahmed (lecturer)
Presenter- Ashish Choudhary
Part I: Basics
“Surgery is the first and the highest
division of the healing art, pure in
itself, perpetual in its applicability,
a working product of heaven and
sure of fame on earth" - Sushruta
Instruments & operatory setup
Soft tissue access
Hard tissue access
Historical aspects to endodontic
Rationale of endodontic surgery
HISTORICAL ASPECT TO ENDODONTIC
A Mandible in Egypt from the 4th dynasty (2900 to 2750
BC) contained holes, that could have been made for relief of
The first recorded endodontic
surgical procedure was the incision
and drainage of an acute endodontic
abscess performed by Aetius, a Greek
physician–dentist, over 1,500 years.
11th century – Abulcasis
1561 – Pare
1712 – Fauchard
1756 – Pfaff
1768 – Berdmore
1778 – Hunter
1839 – Harris recommended the
use of ‘lancet or sharp, pointed
knife’ to puncture the tumour on
1845 – Hullihan operation or rhizodontropy (making a hole
through the gum, the outer edge of the alveolar process, and the
root of the tooth into the nerve cavity and the opening into the
blood vessels of the nerves)
1843 – Desirabode was the first to report root-end resection later
Magitot follwed him in 1860’s and 1870’s
1880 – Brophy reported root-end resection with
immediate root canal fill and management of the
apical filling in a patient with extraoral fistula
Sir G. V. Black
G. V. Black in 1886, Farrar in 1884
and Grayston in 1887 also recommended
for amputation of roots in neglected long
1890’s – Carl Partsch, a surgeon turned
dentist, from Germany developed root-end
resection techniques under chloroform and
1895 – 1900’s: Partsch I
and Partsch II methods
Partsch I method – vertical incision directly over the root and
pack the surgical area with iodoform to stop hemorrhage
Partsch II method – complete cyst removal followed by a form
of immediate soft tissue apposition and suturing.
1910 - William Hunter promulgated
the focal infection theory.
1915 – Neumann provided the first detailed
anatomical description of the relationships of
the mandibular roots to both osseous and
Sir William Hunter
1926 – Neumann proposed a split thickness flap, which in design
is known as the modern day Oschenbein-Luebke flap
1935 – Karl Peter classified the
position of the inferior alveolar
canal relative to the molar root, in
addition to providing descriptive
relationships of the maxillary
sinus and its size and position
relative to the roots of maxillary
1958- Messings gun
1960- Digital Optical Microscopes
1950’s- Development of
1993- MTA as root end filling
Classifications of Endodontic surgery
1. Root resection or apical curettage following an orthograde
filling, either in one stage or in 2 steps.
2. Orthograde filling during root resection or periapical curettage
3. Root resection & retrograde filling
4. Root resection & retrograde filling following an orthograde
filling( 1 or 2 stage procedure)
1. Incision and drainage
2. Cortical trephination
1. Endodontic implants
2. Root-form osseointegrated
3. Root-end resection
4. Root-end preparation and filling
5. Corrective surgery
1. Perforation repair
a. Mechanical (iatrogenic)
b. Resorptive (internal and
2. Root resection
Cohen and Burns:
Class A Class B Class C
Class D Class E Class F
- Root-end resection
- Root-end preparation
- Incision and Drainage
- Cortical trephination
- Perforative repair
- Periodontal management
- Intentional replantation
Surgery for root
Incision for drainage
Rationale for surgical endodontic
Nowdays, multiple treatment planning options are available for
root treated teeth that develop recurrent periapical pathosis or have
periapical lesions that fail to heal following adequate root canal
“Surgery is always the second best. If you can do something
else, its better”
- John Kirklin
Non surgical retreatment or surgical intervention???
success of endodontic therapy ranges from 53 to 98% when
performed the first time, while that for retreatment cases with
periapical lesion is lower
Scand J Dent Res 1979;87:217–24. J Endod 2004;30:1– 4.
Int Endod J 1998;31:155– 60.
Endod Topics 2003;6:114 –34.
GOOD ENDO !!!
POOR ENDO !!!
Go for surgrical
Specific indications for periradicular surgery today
Ingle; 6th edition
Failure of nonsurgical retreatment (treatment has been
rendered at least two times)
Failure of nonsurgical (initial) treatment and retreatment is
not possible or practical or would not achieve a better result, or
When a biopsy is necessary
“ It is paramount that these indications must be in the best interests of
patient, within the skills of clinician, and reflective of biological pinciples
of endodontic therapy”
What about Resurgery???
35.7% healed successfully after resurgery,
26.3% healed with uncertain results and
38% did not heal at the one-year follow-up.
J. Peterson & J. L. Gutmann
International Endodontic Journal, 34, 169–175, 2001
Reasons for failure:
Unsatisfactory preparation at the apical end
Advancing marginal periodontitis
Coronal leakage through faulty restorations
Anatomic aberrations that were not addressed during surgery
Iatrogenic damage to tooth or periodontium
intervention alone is
NEVER an option here
Need for surgical drainage
Failed nonsurgical endodontic
1. Irretrievable root canal filling
2. Irretrievable intraradicular post
3. Calcific metamorphosis of the
4. Procedural errors
5. Anatomic variations
Apical root fenestration
1. Root resorptive defects
2. Root caries
3. Root resection
A. Replacement surgery
1. Intentional replantation
B. Implant surgery
Need for surgical drainage
Surgical drainage is indicated when purulent and/or hemorrhagic exudate forms
within the soft tissue or the alveolar bone as a result of a symptomatic peri-
Surgical drainage may be accomplished by
(1) Incision and drainage (I &D) of the soft tissue or
(2) Trephination of the alveolar cortical plate.
An incision should be made through the focal point of the localized swelling to
relieve pressure, eliminate exudate and toxins, and stimulate healing.
Cortical trephination is a procedure involving the perforation of the cortical
plate to accomplish the release of pressure from the accumulation of exudate
within the alveolar bone.
Apical trephination involves penetration of the apical foramen with a small
endodontic file and enlarging the apical opening to a size No. 20 or No. 25 file to
allow drainage from the periradicular lesion into the canal space.
Failed nonsurgical endodontic treatment
Result from incomplete removal of intracanal irritants &
lack of complete obturation.
Persistently enlarging or newly developing radiolucencies
associated with previously filled canals are a sign of
Teeth with vital pulp with
Panoramic radiograph shows
the extent of this lesion
Biospy revealed the
presence of keratocytes
Close proximity to mental
foramen favours intention
Tooth replantedTooth extracted
Initial RCT Sinus tract persists Symptoms persisted
& apical resection
Replantation completed 3 months follow up
1. Indiscrimate surgery
2. Poor systemic health
3. Psychological impact on the patient
4. Local anatomic factors
Poor Systemic Health
Complete medical history
Patients with such diseases as leukemia or neutropenia
in active state, severely diabetic patients, patients who
have recently had heart surgery or cancer surgery & older
ill patients are exceptions.
Consideration should be given to patients on
anticoagulant medicines (eg., Coumadin); radiation
treatment of the jaw; in pregnancy.
Local factors factors which make operation difficult
may also delay healing
surgical inaccessibility short root lengths missing cortical bone
poor bone support proximity to neurovascular bundles, maxillary sinus
Shallow vestibule thick alveolar bone
average location was 16 mm inferior to the
cementoenamel junction (CEJ) of the second
premolar, although the range was 8 to 21 mm,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85:457, 1998.
Cone-beam computed tomography (CBCT) imaging can be very useful
Periapical radiographs taken from two vertical
angulations, 0 degrees (parallel technique) and −20 degrees, may help
determine the buccolingual position of the canal.
average vertical distance from the superior border of
the mandibular canal to the distal root apex of the
mandibular second molar is approximately 3.5 mm.
This increases gradually to approximately 6.2 mm for
the mesial root of the mandibular first molar and to 4.7
mm for the second premolar
Perforation of the sinus during surgery is fairly
common (10% to 50%)
Int J Oral Maxillofac Surg 28:192, 1999.
Int J Oral Surg 3:386, 1974. J Endod 24:260, 1998.
Even without periradicular pathosis, the distance
between the root apices of the maxillary posterior teeth
and the maxillary sinus sometimes is less than 1 mm
Int Endod J 35:127, 2002
Fortunately, perforation of the maxillary sinus rarely results in
long-term postoperative problems
No difference in healing compared with similar surgical
procedures without sinus exposure.
membrane usually regenerates, and a thin layer of new bone often forms
over the root end, although osseous regeneration is less predictable
Dent Clin North Am 41:563, 1997. 549.
If the maxillary sinus is entered during surgery, special care must be taken
to prevent infected root fragments and debris from entering the sinus. (Telfa
use of orascope or endoscope, in case of displacement of
root tip in sinus
role of vertical releasing incision
reached from either a buccal (transantral) or palatal
Take care of anterior palatine artery while
taking the palatal approach
ligation of the external carotid artery may be
necessary, if artery is severed
An acrylic surgical stent may be fabricated before surgery to assist
repositioning of the flap and help prevent pooling of blood under the flap.
Anterior maxilla & mandible:
access to the root apex in some patients may be unexpectedly difficult
because of long roots, a shallow vestibule, or lingual inclination of the roots
Surgery of upper centrals: presence of incisive canal & its contents.
Periradicular surgery on mandibular incisors often is more challenging than
The combination of lingual root inclination, a shallow vestibule, and a
prominent mental protuberance all can increase the degree of difficulty, as can
proximity to adjacent roots and the need for perpendicular root-end resection
and preparation to include a possible missed lingual canal.
PATIENT PREPARATION FOR
Informed Consent Issues Specific to Surgery
patient must be thoroughly advised of the benefits, risks, and other
treatment options and must be given an opportunity to ask questions.
Although the incidence of serious complications related to surgical
procedures is very low, patients should be advised of any risks unique to
Prompt attention to any surgical complications and thorough follow-
up are essential from a medicolegal standpoint.
Administration of an NSAID, either before or up to 30 minutes after
surgery, enhances postoperative analgesia
The combination of preoperative administration of an NSAID and
use of a long-acting local anesthetic may be particularly helpful for
reducing postoperative pain.
Ibuprofen 400 mg provides analgesia approximately equal to that
obtained with morphine 10 mg and significantly greater than that from
codeine 60 mg, tramadol 100 mg, or acetaminophen 1000 mg
Oral Maxillofac Surg 47:464,1989.
J Am Dent Assoc 108:598,1984.
McQuay H, Moore R: An evidence based resource for pain relief, Oxford, 1998, Oxford University Press.
The analgesic effectiveness of ibuprofen tends to level off
at about the 400 mg level (ceiling effect), although a slight
increase in analgesic potential may be expected in doses up
to 800 mg.
The current best available evidence does not support the routine use
of prophylactic antibiotics for periradicular surgery.
Evid Based Dent 7:72, 2006.
For most patients, the risks of indiscriminate antibiotic therapy are
believed to be greater than the potential benefits. J Am Dent Assoc 131:366, 2000.
Although routine use of prophylactic antibiotics for periradicular
surgery is not currently recommended, clinical judgment is
important in determining exceptions to the general rule.
For example, immunocompromised, diabetic patients, may be good
candidates for prophylactic antibiotic coverage.
Chlorhexidine gluconate (0.12%) often is recommended as a mouth
rinse to reduce the number of surface microorganisms in the surgical
field, and its use may be continued during the postoperative healing
stage. American Dental Association, 2008.
either by an orally administered sedative or by nitrous oxide/oxygen
inhalation analgesia, may be useful for patients who are anxious about
the surgical procedure or dental treatment in general.
Benzodiazepines with a short half-life are particularly useful
A typical protocol is a single dose at bedtime the evening before the
procedure and a second dose 1 hour before the start of surgery.
In appropriate doses, benzodiazepines and similar drugs may allow
for a more relaxed patient and thus a less stressful surgical experience
for both patient and surgeon.
INSTRUMENTS AND OPERATORY SETUP
Left to right (left section
Small round micromirror,
medium oval micromirror,
handle for microscalpel,
surgical suction tip.
Top to bottom(main
section of tray):
Carr #1 retractor,
Carr #2 retractor,
Ruddle R elevator,
Ruddle L elevator,
Basic tray setup for initial surgical access.
Instrument tray for root-end filling and suturing
Left to right (left
section of tray):
micro tissue forceps
Top to bottom (main
section of tray):
right &left SuperEBA
Placing & Plugging
anterior,left & right
Comparison of microsurgical scalpel (top)
to #15C surgical blade.
Microsurgical scalpels are particularly
useful for the intrasulcular incision and
for delicate dissection of the
Microcondensers in assorted shapes and sizes for root-end filling.
Comparison of standard #5 mouth mirror to diamond-coated
Retractors used in periradicular surgery.
Top to bottom, EHR-1, ER 2, and ER-1
(equivalent to Carr #2 and #1 retractors)
Placement of root end filling material
Teflon sleeve and plugger especially
designed for placement of MTA
Messing gun–type syringe
Kit includes a variety of tips for use in
different areas of the mouth and a
single-use Teflon plunger
Hard plastic block
with notches of
Surgeon, assistant, and patient positioned for initiation of surgery.
The patient should be given tinted goggles or some other form of eye
protection before the procedure is begun.
LOCAL ANESTHESIA FOR
Local anesthetics for periradicular surgeries:
Prolonged duration of action,
Low toxicity & allergic potential,
Excellent diffusion rate
increased ability to penetrate
long duration of effect
postoperative pain control
Once anesthesia is established, hemostasis in the soft
tissues can be enhanced by infiltration with anesthetic
solutions containing vasoconstrictors (epinephrine) in conc.
of 1:50,000 Anesth Pain Control Dent 2:223-226, 1993)
The local anesthetic is first slowly deposited in the buccal root apex
area of the alveolar mucosa at the surgical site and extended two or
three teeth on either side of the site.
Usually palatal or lingual infiltration is also required, although this
requires a much smaller amount of local anesthetic
After the injections for anesthesia, the surgeon should wait at least 10
minutes before making the first incision.
because it is composed of loose connective tissue with large
interstitial spaces which allow painless injections and rapid diffusion
throughout the mucosal tissues.
Why in submucosa why not in gingival
To regain loss of anesthesia during surgery….
Providing supplemental infiltration anesthesia is difficult after a
full thickness flap has been reflected
A supplemental block injection may be useful for mandibular teeth
and maxillary posterior teeth.
In the maxillary anterior area, a palatal approach to
the anterior middle superior nerve may be helpful
The key to this approach is slow injection of approximately 1 ml of
local anesthetic in the area of the first and second maxillary premolars,
midway between the gingival crest and the palatal midline.
An intraosseous injection also may be used to regain lost anesthesia,
but even when it is effective, the area of local anesthesia often is smaller
than desired for a surgical procedure.
As a last resort, the procedure can be terminated short of
completion, and the patient can be rescheduled for surgery under
sedation or general anesthesia.
Surgeon must have a thorough knowledge of the anatomic
structures in relation to each other, including tooth anatomy.
must be able to visualize the 3D nature of the structures in the soft
and hard tissue
trauma of the surgical procedure itself must be minimized, which
includes the preservation of tooth and supporting structures.
Tissue and instruments must be manipulated within a limited space,
with the aim of removing diseased tissues and retaining healthy tissues.
surgeon must take into consideration various anatomic features,
such as frenum-muscle attachments, the width of attached gingiva,
papillary height and width, bone eminence, and crown margins.
Incision should be made parallel to the
supraperiosteal vessels in the attached gingiva
No cuts should be made across frenum and
incision should be placed directly
over healthy bone.
incision should not be placed
superior to a bony eminence.
dental papilla should be included or
excluded but not dissected.
incision should extend from the depth of
the vestibular sulcus to the midpoint between
the dental papilla and the horizontal aspect of
the buccal gingival sulcus.
This incision extends from the gingival sulcus through the PDL fibers
and terminates at the crestal bone of the alveolar bone proper.
passes in a buccolingual direction adjacent to each tooth of the dental
papilla and includes the midcol region of each dental papilla.
entire dental papilla is completely mobilized.
Intrasulcular incision that includes the dental
shallow first incision at the base of
the papilla and a second incision
directed to the crestal bone
Submarginal or Ochsenbein-Luebke flap….
Incision must be placed at least 2 mm from the
depth of the gingival sulcus.
To include or exclude dental papilla???
papillary-based incision resulted in rapid recession free healing.
In contrast, complete mobilization of the papilla led to a
marked loss of papillary height.
use of the papillary-based incision in aesthetically sensitive
regions could help prevent papillary recession and surgicalcleft,
or double papilla.
Lancet 1:264, 1966.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 91:700, 2001.
midroot perforation repair
- posterior area
- short roots
- small relaxing incision
- additional vertical incision
- extension of horizontal components
maintains the integrity of blood supply
tension creates on retraction
gingival attachment severed
- multiple teeth
- large lesions
- long or short roots
lateral root repairs
maximum access & visibilty
reduces retraction tension
reduced blood supply to flap
increased incision & reflection time
gingival attachment violated
- gingival recession
- crestal bone loss
- may uncover dehiscence
suturing is more difficult
cervical resorptive defects
cervical area perforations
no vertical incision
ease of repositioning
limited access & visibiltiy
difficult to reflect & retract
predisposed to streching & tearing
gingival attachment violated
esthetic crowns present
reduces incision & reflection time
maintains integrity of gingival
eliminates potential crestal bone loss
limited access & visibiltiy
predisposed to streching & tearing
tendency for increase hemorhaging
crosses root eminences
may not include entie lesion
repositioning is difficult
healing is associated with scarring
Ochsenbein-luebke flap… Indications
esthetic crowns present
- anterior region
- long roots
wide band of attached gingiva
ease in incision & reflection
enhanced visibilty & access
ease in repositioning
maintains integrity of
Horizontal component disrupts blood supply
vertical component crosses mucogingival
difficult to alter if size of lesion misjudged
Clinical case of submarginal flap…..
Periodontal probing Submarginal incision
Flap reflection Flap repositioned & sutured
process of separating the soft tissues (gingiva, mucosa, and
periosteum) from the surface of the alveolar bone.
Concept of “undermining elevation”
allows all of the direct reflective forces to be applied to the
periosteum and the bone.
process of holding in position the
reflected soft tissues.
general principles to be followed….
Retractors should rest on solid cortical bone
firm but light pressure should be used
tearing, puncturing, and crushing of the soft tissue should be avoided;
sterile physiologic saline should be used periodically to maintain
hydration of the reflected tissue;
retractor should be large enough to protect the retracted soft tissue during
2 biological considerations….
healthy hard tissue must be preserved
heat generation during the process must be minimized.
Temperature increases above normal body temperature in osseous
tissues are detrimental.
Two critical factors determine the degree of injury:
how long it remains
how high the temperature is
Temp. rise (°C)
blood flow initially increases>40°C
46 °C for 2 min blood flow stagnates
deactivates alkaline phosphatase
47-50 °C for 1 min
reduces bone formation and is
associated with irreversible cellular
damage and fatty cell infiltration
Scand J Plast Reconstr Surg 18:261, 1984 J Bone Joint Surg Am 54:297, 1972.
Ann Intern Med 67:183, 1967 Lancet 1:264, 1966
At temperatures above 109° F (42.5° C), for every 1° C
elevation in temperature, the exposure time for the same biologic
effect decreases by a factor of approximately 2.
Temperatures above 117° F (47° C) maintained for 1 minute produce
effects similar to those at 118° F (48° C) applied for 30 seconds.
Temperatures above 127° F (53° C) applied for less than 1 second can
adversely affect osteogenesis
Int J Oral Surg 11:115, 1982. J Prosthet Dent 50:101, 1983.
Acta Orthop Scand 55:629, 1984. Scand J Plast Reconstr Surg 18:261, 1984.
Several factors determine the amount of heat generated during
bone removal, including the shape the bur, the rotational speed,
the use of coolant, and the pressure applied during cutting.
Shape & Composition of the bur
gentle brushstroke action
Do not use diamond bur
Use of coolant
If an appropriate irrigant is not used, temperatures can exceed those
known to impair bone healing (delayed up to 3 wks)
Coolant reach the cutting surface.
Pressure applied during cutting
Temperatures can rise above 212° F (100° C) when excess
pressure is applied during cutting.
A high-speed handpiece that exhausts
air from the base rather than the cutting
end is recommended to reduce the risk of
Sometimes, natural root fenestration is present, or in other cases,
the cortical bone may be very thin, and probing with a small
sharp curette will allow penetration of cortical bone.
In presence of dense bone, it is best to approach the
entry level by one of the following methods:
1. Length of the root measured from a well angled
radiograph,& transferring it to surgical site with
help of a sterile ruler.
2. Comparing a radiograph taken of a small piece of
sterilized gutta-percha or lead foil that has been
placed in a small hole drilled at the approximate
root tip location.
Barnes identified four ways in which the root surface
can be distinguished from the surrounding osseous
(1) root structure generally has a yellowish color
(2) roots do not bleed when probed
(3) root texture is smooth and hard as opposed to
the granular and porous nature of bone, and
(4) root is surrounded by the periodontal ligament.
Some authors advocate the use of methylene blue
dye to aid in the identification of the periodontal
Appropriate hemostasis during surgery minimizes surgical
time, surgical blood loss, and postoperative hemorrhage and
Hemostatic agents, generally aid coagulation by inducing rapid
development of an occlusive clot, either by exerting a physical
tamponade action or by enhancing the clotting mechanism and
vasoconstriction (or both).
Thorough review of the patient’s body systems and medical history
Review of the patient’s medications, both prescribed and over-the-
counter (OTC) drugs, is essential.
The patient’s vital signs (i.e., blood pressure, heart rate, and
respiratory rate) should be assessed.
Anxiety and stress can be alleviated with planning, sedation, and
profound local anesthesia.
achieve hemostasis through stimulation of
platelet adhesion, platelet aggregation and release
reaction, activation of factor XII (Hageman
factor),and mechanical tamponade by the
structure that forms at the collagen-blood/wound
Osseous regeneration in the presence of collagen typically proceeds
uneventfully, without a foreign body reaction.
Collagen-based materials can be difficult to apply to the bony crypt
because they adhere to wet surfaces.
J Oral Maxillofac Surg 50:608, 1992.
It is primarily a physical hemostatic
agent which acts as a barrier to blood
and then becomes a sticky mass that
serves as an artificial coagulum.
Surgicel is retained in the surgical wound & healing is retarded,
with little evidence of resorption of the material at 120 days.
gelatin-based sponge that is water insoluble and
Stimulates the intrinsic clotting pathway by promoting
platelet disintegration and the subsequent release of
thromboplastin and thrombin
nonabsorbable product composed of
88% beeswax & 12% isopropyl palmitate
retards bone healing and predisposes the surgical site to infection
necrotizing agent with an extremely low pH.
agglutination of blood proteins (forms plugs that
occludes the capillary orifices)
used for osteotomies smaller than 5mm
application to wound sites has resulted in tissue
necrosis for up to 2 weeks, differences in the degree
of epidermal maturation, and tattoo formation
Hemihydrate Medical -grade calcium sulphate (CS) acts as a
hemostatic agent by mechanically blocking open vessels
It is resorbed by body in 2-3 weeks
CS pellet is left in bony cavity, where it acts as a barrier to faster
growing soft tissues & may aid in bone regeneration by providing
matrix for osteoblasts: Bone inductive agent.
Used for osteotomies larger than 5mm
Racemic epinephrine cotton pellets (Racellet #3;
Pascal Co, Bellevue, WA) contain an average of 0.55
mg of racemic epinephrine hydrochloride per
pellet, half of which is the pharmacologically active
Cautery stops the flow of blood through coagulation of blood
and tissue protein, leaving an eschar that the body attempts to
The effect of cautery in the bony crypt during periradicular surgery
has not been studied to date
The detrimental effect of applying heat to bone is proportional to
both temperature and the duration of application.