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Dr. Amit T. Suryawanshi 
Oral and Maxillofacial Surgeon 
Pune, India 
Contact details : 
Email ID - amitsuryawanshi999@gma...
 Introduction 
 Definition 
 History 
 Indication 
 Contraindication 
 Classification of Endo. surgeries 
1.Trephina...
Introduction 
Surgical intervention is required where endodontic 
treatment has failed and tooth is to be retained rather ...
Definition- 
Surgical endodontics is defined as,” Removal of tissues 
other than the contents of root canal to retain a to...
History 
Surgical endodontics is not a recent innovation. 
Trephination and incision and drainage are being done 
since an...
Root amputation was first introduced by Black and 
Inlitch in 1886 , then was dealt by Younger (1894) 
and Guerini (1909) ...
INDICATIONS 
1. Need for surgical drainage 
2. Failed endodontic treatment 
1. Irretrievable root canal filling material 
...
5. Symptomatic overfilling. 
6. Anatomic variations. 
A. Root dilaceration. 
B. Apical root fenestration. 
7. Biopsy. 
8. ...
CONTRAINDICATIONS 
 Poor systemic health. 
 Local anatomical considerations 
 Poor periodontal status. 
 Short root le...
 Success of surgical treatment over non-surgical 
treatment. 
 Medical history 
 Periodontal evaluation 
 Patient’s mo...
CLASSIFICATION OF ENDODONTIC SURGICAL 
PROCEDURES 
I. Surgical drainage 
1. Incision and drainage 
2. Cortical trephinatio...
5. Corrective surgery 
i. Perforation repair 
a. Mechanical (iatrogenic) 
b. Resorptive (internal and external) 
ii. Root ...
 In most cases drainage through the canal is all 
that is needed to treat the periradicular abcess 
of pulpal origin but ...
Incisions and flaps 
PRINCIPLES OF DESIGN-Principles 
and guidelines are applied to the location and 
extent of incision. ...
PRINCIPLES: 
 1. Avoid severing vessels and nerves 
 2. Make incisions far away from the surgical 
area to ensure that t...
4. The base of the flap should be the widest 
portion to maintain proper circulation. 
5. There should be no sharp angles ...
7. Maintain the integrity of the interdental 
papillae. 
8. Use sharp instruments to avoid tearing the 
mucoperiosteum. 
9...
11. Incise in the attached gingiva for 
semilunar flaps.
NOTE: 
“More trauma results from short incision rather 
than long incision”.
 Vertical incision 
 Sulcular incision 
 Semilunar incision 
 Modified semilunar incision 
 Ochsenbein-Leubke incisio...
Classification of Flaps: 
1. Full mucoperiosteal flaps: 
(a) Triangular (one vertical releasing incision) 
(b) Rectangular...
Full Mucoperiosteal Flaps. 
TRIANGULAR FLAP. 
 The triangular flap is formed by a intrasulcular 
incision and one vertica...
 ADVANTAGES: 
 Good wound healing as there is minimal disruption 
of the vascular supply to the flapped tissue, 
 
 Ea...
 Additional access can be easily obtained by placement 
of a distal releasing incision. 
 It is recommended for maxillar...
RECTANGULAR FLAP: 
 The rectangular flap is formed by an intrasulcular and 
two vertical releasing incisions.
 ADVANTAGES: 
 Increased surgical access to the root apex. 
 This flap design is especially useful for mandibular 
ante...
 TRAPEZOIDAL FLAP: 
 Similar to the rectangular flap with the exception that 
the two vertical releasing incisions meet ...
 Trapezoidal Flap ctnd….. 
 The angled vertical releasing incisions are designed 
to create a broad-based flap with the ...
 Trapezoidal Flap ctnd….. 
 Since the blood vessels and collagen fibers in the 
mucoperiosteal tissues are oriented in a...
 Trapezoidal Flap ctnd….. 
 This will result in more bleeding, a disruption of 
the vascular supply to the unflapped tis...
Limited Mucoperiosteal Flaps: 
 Submarginal Curved (Semilunar) Flap: 
 The submarginal or semilunar flap is formed by a ...
 The incision begins in the alveolar mucosa extending 
into the attached gingiva and then curves back into 
the alveolar ...
Submarginal scalloped rectangular (Luebke-ochsenbein) 
flap: 
 The submarginal scalloped rectangular flap is a 
modificat...
 ADVANTAGES: 
 It does not involve the marginal or interdental gingiva 
and the crestal bone is not exposed. 
 DISADVAN...
 FLAP REFLECTION: 
 Flap reflection is the process of separating the soft 
tissues (mucosa and periosteum) from the surf...
 After reflection of the attached gingival tissues, 
elevation is continued more apically lifting the 
alveolar mucosa al...
 Hard tissue management in endodontic surgery 
involves 3 stages: 
1.Trephination 
2.Periradicular curretage 
3. Periradi...
 OSTEOTOMY: 
 Osteotomy is the removal of some portion of the 
cortical plate to expose the root end. 
 Clinician shoul...
 When a root prominence or eminence in the 
cortical plate is present, the root angulation and 
position are more easily ...
 When the cortical plate is intact, locate the body of 
the root coronal to the apex where the bone covering 
the root is...
 Barnes identified four ways by which the root 
surface can be distinguished from the 
surrounding osseous tissue: 
 
 ...
 Definition- It is the perforation made through the 
cortical plate or apical foramen to accomplish the 
release of press...
 Small incision is made over the periapical 
region .flap is reflected and bone is 
examined. 
 Radiograph is taken with...
 CORTICAL TREPHENATION: 
 Perforation of the cortical plate to accomplish the 
release of pressure from the accumulation...
 The treatment of choice for these patients is 
drainage through the root canal system (apical 
trephination) whenever po...
 PERIRADICULAR CURETTAGE: 
 Involves removal of the periradicular inflammatory 
tissue and is best accomplished by using...
 Entire tissue mass is removed by inserting the 
bone curette, between the soft tissue mass 
and the lateral wall of the ...
Once the soft tissue lesion has been freed 
along with the periphery, the bone curette 
should be turned with the concave ...
 Periradicular Surgery 
 ROOT-END RESECTION (APICOECTOMY) 
 Historically, many authors have advocated 
periradicular cu...
 INDICATIONS: 
 These indications may be classified as, 
1) Biological 
2) Technical. 
Biologic factors: 
 Persistent s...
Technical factors: 
Periapical infection in teeth with… 
 Radicular posts, 
 Crowned teeth without posts, 
 Irretrievab...
 There are three important factors for the 
surgeon to consider before performing a 
root-end resection: 
(1) Instrumenta...
 1.Instrumentation: 
 Ingle et al. recommended that root-end resection 
is best accomplished by the use of tapered 
fiss...
 NOTE: 
 “Plain fissure burs, at high and low speed, 
produce the smoothest resected root 
surface”.
 2.Extent of the Root-End Resection: 
 Earlier, it was believed that it is necessary to 
resect the root at the level of...
Average length of root resection is 3mm which 
is considered enough to eliminate the source 
of infection. 
 however surg...
4. Need to place a root-end filling surrounded 
by solid dentin. 
5. Presence and location of procedural error 
6. Presenc...
 NOTE: 
“Conservation of tooth structure during 
root-end resection is desirable; however, 
conservation should not compr...
 3.Angle of Root-End Resection. 
 It should be 30 ° -45 ° from the line 
perpendicular to the long axis of 
the tooth fa...
 NOTE: 
 Recent literature states that beveling of root end 
results in opening of dentinal tubules on the 
resected roo...
Root-End Preparation: 
The purpose of a root-end preparation 
in periradicular surgery is to create a 
cavity to receive a...
Root-End Filling: 
 The purpose of a root-end filling is to establish a 
seal between the root canal space and the periap...
 Root-End Filling Materials: 
Numerous materials have been suggested 
for use as root-end fillings, including: 
Amalgam, ...
 REPOSITIONING AND SUTURING: 
 Several authors have compared the effects of 
continuous and interrupted suture technique...
1. Ask not to drink alcohol or use any form of tobacco. 
2.. Ask not to lift up the lip or pull back the cheek to 
look at...
4. Place an ice bag (cold) on face where surgery was 
done. Leave it on for 20 minutes and take it off for 
20 minutes. Do...
 CONCLUSION : 
 During the last 20 years, endodontics has 
encountered dramatic shift in the use of 
periradicular surge...
 Text book of endodontics, Ingle 5th edition. 
 Textbook of oral & maxillofacial surgery By 
Daniel M. Laskin. Vol.2 
 ...
Thank you
Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi,  Oral Surgeon, Pune
Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi,  Oral Surgeon, Pune
Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi,  Oral Surgeon, Pune
Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi,  Oral Surgeon, Pune
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Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi, Oral Surgeon, Pune

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Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best.

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Surgical endodontics (Apicectomy) by Dr. Amit T. Suryawanshi, Oral Surgeon, Pune

  1. 1. Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune, India Contact details : Email ID - amitsuryawanshi999@gmail.com Mobile No - 9405622455
  2. 2.  Introduction  Definition  History  Indication  Contraindication  Classification of Endo. surgeries 1.Trephination 2.Periradicular curretage 3. Periradicular surgery (i) Root end resection (Apicectomy) (ii) Root end preparation & filling Conclusion
  3. 3. Introduction Surgical intervention is required where endodontic treatment has failed and tooth is to be retained rather than extracted. The percentage of success of endodontic treatment has been consistently high but failures may arise due to infection, poor access cavity preparation, inadequate instrumentation, obturation, missed canals and coronal leakage. So if this happens, Surgical endodontics is needed to save the tooth.
  4. 4. Definition- Surgical endodontics is defined as,” Removal of tissues other than the contents of root canal to retain a tooth with pulpal or periapical involvement”
  5. 5. History Surgical endodontics is not a recent innovation. Trephination and incision and drainage are being done since ancient times. In 11th century, first case of endodontic surgery was performed by Abulcasis. Root end resection (Apicectomy ) was first documented in 1871 and apicectomy with retrograde cavity preparation and filling with amalgum was documented in 1890.
  6. 6. Root amputation was first introduced by Black and Inlitch in 1886 , then was dealt by Younger (1894) and Guerini (1909) In 1930, indications for endodontic surgery were proposed. In 1940, Triangular flap was first described by Fischer. Neumann and Eikan descibed Trapezoidal flap in 1940. Semilunar incision was first described by Partsch hence it is also known as Partsch incision.
  7. 7. INDICATIONS 1. Need for surgical drainage 2. Failed endodontic treatment 1. Irretrievable root canal filling material 2. Irretrievable intraradicular post 3. Calcification of the pulp space 4. Procedural errors 1. Instrument fragmentation 2. Non-negotiable ledging 3. Root perforation
  8. 8. 5. Symptomatic overfilling. 6. Anatomic variations. A. Root dilaceration. B. Apical root fenestration. 7. Biopsy. 8. Corrective surgery. 1. Root resorptive defects 2. Root caries 3. Root resection 4. Hemi-section 5. Bi-cuspidization
  9. 9. CONTRAINDICATIONS  Poor systemic health.  Local anatomical considerations  Poor periodontal status.  Short root length.  Acute infection.  Non restorable teeth
  10. 10.  Success of surgical treatment over non-surgical treatment.  Medical history  Periodontal evaluation  Patient’s motivation  Informed consent
  11. 11. CLASSIFICATION OF ENDODONTIC SURGICAL PROCEDURES I. Surgical drainage 1. Incision and drainage 2. Cortical trephination (fistulative surgery) II. Periradicular surgery 1. Curettage 2. Biopsy 3. Root-end resection 4. Root-end preparation and filling
  12. 12. 5. Corrective surgery i. Perforation repair a. Mechanical (iatrogenic) b. Resorptive (internal and external) ii. Root resection iii. Hemisection & Bi-cuspidization III. Replacement surgery i. Replantation IV. Implant surgery 1. Endodontic implants 2. Root-form osseointegrated implants
  13. 13.  In most cases drainage through the canal is all that is needed to treat the periradicular abcess of pulpal origin but there are times, when invasion of anatomic spaces has extended to a point that does not allow drainage through the tooth, and effectively remove the pus then It becomes mandatory to incise and drain the abcess.
  14. 14. Incisions and flaps PRINCIPLES OF DESIGN-Principles and guidelines are applied to the location and extent of incision. Why should one follow the principles ??? “The adherence to these principles will ensure that the flapped soft tissues will fit snugly in their original position and will properly cover the osseous wound site and provide an adequate vascular bed for healing”
  15. 15. PRINCIPLES:  1. Avoid severing vessels and nerves  2. Make incisions far away from the surgical area to ensure that the wound margins are over sound bone and there is room for adjustments when unexpected extensions are necessary. 3. Design the flap so that there is adequate visibility without overexposure of bone.
  16. 16. 4. The base of the flap should be the widest portion to maintain proper circulation. 5. There should be no sharp angles on the flap 6. Vertical or oblique incision should not be over root eminence. It is best to incise in the trough.
  17. 17. 7. Maintain the integrity of the interdental papillae. 8. Use sharp instruments to avoid tearing the mucoperiosteum. 9. Be gentle with the flap. 10. Do not incise close to the gingival sulcus while using a horizontal or semilunar incison
  18. 18. 11. Incise in the attached gingiva for semilunar flaps.
  19. 19. NOTE: “More trauma results from short incision rather than long incision”.
  20. 20.  Vertical incision  Sulcular incision  Semilunar incision  Modified semilunar incision  Ochsenbein-Leubke incision
  21. 21. Classification of Flaps: 1. Full mucoperiosteal flaps: (a) Triangular (one vertical releasing incision) (b) Rectangular (two vertical releasing incisions) (c) Trapezoidal (broad-based rectangular) 2. Limited mucoperiosteal flaps (a) Submarginal curved (semilunar) (b) Submarginal scalloped rectangular (Ochsenbein- Luebke)
  22. 22. Full Mucoperiosteal Flaps. TRIANGULAR FLAP.  The triangular flap is formed by a intrasulcular incision and one vertical releasing incision.
  23. 23.  ADVANTAGES:  Good wound healing as there is minimal disruption of the vascular supply to the flapped tissue,   Ease of flap reapproximation, with a minimal number of sutures required.  DISADVANTAGE:  It provides Limited surgical access because of the single vertical releasing incision.  Difficult to expose the root apices of long teeth (eg, maxillary cuspids and mandibular incisors.)
  24. 24.  Additional access can be easily obtained by placement of a distal releasing incision.  It is recommended for maxillary incisors and posterior teeth.  “It is the only recommended flap design for mandibular posterior teeth”.
  25. 25. RECTANGULAR FLAP:  The rectangular flap is formed by an intrasulcular and two vertical releasing incisions.
  26. 26.  ADVANTAGES:  Increased surgical access to the root apex.  This flap design is especially useful for mandibular anterior teeth, multiple teeth, and teeth with long roots, such as maxillary canines.  DISADVANTAGES:  Difficulty in reapproximation of the flap margins and wound closure.  Postsurgical stabilization is also more difficult as the flapped tissues are held in position solely by the sutures. This results in a greater potential for postsurgical flap dislodgment.  This flap design is not recommended for posterior teeth.
  27. 27.  TRAPEZOIDAL FLAP:  Similar to the rectangular flap with the exception that the two vertical releasing incisions meet intrasulcular incision at an obtuse angle.
  28. 28.  Trapezoidal Flap ctnd…..  The angled vertical releasing incisions are designed to create a broad-based flap with the vestibular portion being wider than the sulcular portion.  Flap design is made on the assumption that it will provide a better blood supply to the flapped tissues.
  29. 29.  Trapezoidal Flap ctnd…..  Since the blood vessels and collagen fibers in the mucoperiosteal tissues are oriented in a vertical direction, the angled vertical releasing incisions will severe more of these structures.
  30. 30.  Trapezoidal Flap ctnd…..  This will result in more bleeding, a disruption of the vascular supply to the unflapped tissues, and shrinkage of the flapped tissues.
  31. 31. Limited Mucoperiosteal Flaps:  Submarginal Curved (Semilunar) Flap:  The submarginal or semilunar flap is formed by a curved incision in the alveolar mucosa and the attached gingiva.
  32. 32.  The incision begins in the alveolar mucosa extending into the attached gingiva and then curves back into the alveolar mucosa.  Advantages – No advantages  Disadvantages- 1. Poor surgical access 2. Poor wound healing  “This flap design is not recommended for periradicular surgery”.
  33. 33. Submarginal scalloped rectangular (Luebke-ochsenbein) flap:  The submarginal scalloped rectangular flap is a modification of the rectangular flap in which the horizontal incision is not placed in the gingival sulcus but in the buccal or labial attached gingiva.
  34. 34.  ADVANTAGES:  It does not involve the marginal or interdental gingiva and the crestal bone is not exposed.  DISADVANTAGES:  Vertically oriented blood vessels and collagen fibers are severed, resulting in more bleeding and a greater potential for flap shrinkage, delayed healing, and scar formation.
  35. 35.  FLAP REFLECTION:  Flap reflection is the process of separating the soft tissues (mucosa and periosteum) from the surface of the bone.  The periosteal elevator is used gently to elevate the periosteum and its superficial tissues from the cortical plate.
  36. 36.  After reflection of the attached gingival tissues, elevation is continued more apically lifting the alveolar mucosa along with periosteum until adequate surgical access is obtained.  A thin gauze may be used for reflection to prevent tearing of the flap.
  37. 37.  Hard tissue management in endodontic surgery involves 3 stages: 1.Trephination 2.Periradicular curretage 3. Periradicular surgery (i) Root end resection (Apicectomy) (ii) Root end preparation & filling
  38. 38.  OSTEOTOMY:  Osteotomy is the removal of some portion of the cortical plate to expose the root end.  Clinician should precisely locate the root end.  A number of factors should be considered to determine the location of the bony window.  The angle of the crown to the root should be assessed.
  39. 39.  When a root prominence or eminence in the cortical plate is present, the root angulation and position are more easily determined.  Measurement of the entire tooth length on well-angled radiograph and transferred to the surgical site by the use of a sterile millimeter ruler.
  40. 40.  When the cortical plate is intact, locate the body of the root coronal to the apex where the bone covering the root is thinner.  Once the root has been located and identified, the bone covering the root is slowly and carefully removed with light brush strokes, working in an apical direction until the root apex is identified.
  41. 41.  Barnes identified four ways by which the root surface can be distinguished from the surrounding osseous tissue:   (1) Root structure generally has a yellowish color,  (2) Roots do not bleed when probed,  (3) Root texture is smooth and hard as  compared to the granular and porous  nature of bone, and  (4) The root is surrounded by the periodontal  ligament.
  42. 42.  Definition- It is the perforation made through the cortical plate or apical foramen to accomplish the release of pressure in the periapical area from the accumulation of exudate within the alveolar bone.  Indications-  This technique is employed in cases of periapical abcess in which there is no swelling or drainage but much pain.
  43. 43.  Small incision is made over the periapical region .flap is reflected and bone is examined.  Radiograph is taken with radiopaque marker for confirmation. So that there is no chance of penetration in the wrong area.
  44. 44.  CORTICAL TREPHENATION:  Perforation of the cortical plate to accomplish the release of pressure from the accumulation of exudate within the alveolar bone.
  45. 45.  The treatment of choice for these patients is drainage through the root canal system (apical trephination) whenever possible.  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.  The decision about whether to perform apical or cortical trephination is based primarily on clinical judgment regarding the urgency of obtaining drainage.
  46. 46.  PERIRADICULAR CURETTAGE:  Involves removal of the periradicular inflammatory tissue and is best accomplished by using various sizes and shapes of sharp surgical bone curettes and angled periodontal curettes.
  47. 47.  Entire tissue mass is removed by inserting the bone curette, between the soft tissue mass and the lateral wall of the bony crypt with the concave surface of the curette facing the bone.
  48. 48. Once the soft tissue lesion has been freed along with the periphery, the bone curette should be turned with the concave portion toward the soft tissue and used in a scraping manner to free the tissue from the deep walls of the bony crypt.
  49. 49.  Periradicular Surgery  ROOT-END RESECTION (APICOECTOMY)  Historically, many authors have advocated periradicular curettage as the definitive treatment in endodontic surgery without root-end resection.  Their rationale was to maintain a cemental covering on the root surface and to maintain as much root length as possible for tooth stability.
  50. 50.  INDICATIONS:  These indications may be classified as, 1) Biological 2) Technical. Biologic factors:  Persistent symptoms,  Persistent periradicular lesion.
  51. 51. Technical factors: Periapical infection in teeth with…  Radicular posts,  Crowned teeth without posts,  Irretrievable root canal filling materials,  Procedural accidents.
  52. 52.  There are three important factors for the surgeon to consider before performing a root-end resection: (1) Instrumentation, (2) Extent of the root end resection, (3) Angle of the resection.
  53. 53.  1.Instrumentation:  Ingle et al. recommended that root-end resection is best accomplished by the use of tapered fissure bur or round bur in a low-speed straight handpiece.  Gutmann and Harrison, have suggested the use of a high-speed handpiece and a surgical length plain fissure bur.
  54. 54.  NOTE:  “Plain fissure burs, at high and low speed, produce the smoothest resected root surface”.
  55. 55.  2.Extent of the Root-End Resection:  Earlier, it was believed that it is necessary to resect the root at the level of healthy bone.
  56. 56. Average length of root resection is 3mm which is considered enough to eliminate the source of infection.  however surgeon must evaluate the patient on an individual basis. 1. Visual and operative access to the surgical site 2. Anatomy of the root (shape, length, curvature). 3. Number of canals and their position in the root
  57. 57. 4. Need to place a root-end filling surrounded by solid dentin. 5. Presence and location of procedural error 6. Presence and extent of periodontal defects.
  58. 58.  NOTE: “Conservation of tooth structure during root-end resection is desirable; however, conservation should not compromise the goals of the surgical procedure”.
  59. 59.  3.Angle of Root-End Resection.  It should be 30 ° -45 ° from the line perpendicular to the long axis of the tooth facing toward the buccal or facial aspect of the root.  The purpose is to provide enhanced visibility to the root end and operative access to accomplish a root end preparation.
  60. 60.  NOTE:  Recent literature states that beveling of root end results in opening of dentinal tubules on the resected root surface that may communicate with the root canal space and result in apical leakage, even when a root end filling has been placed.
  61. 61. Root-End Preparation: The purpose of a root-end preparation in periradicular surgery is to create a cavity to receive a root-end filling. It is performed by the use of small round or inverted cone burs and straight low-speed handpiece. It should be done parallel to the long axis of the root.
  62. 62. Root-End Filling:  The purpose of a root-end filling is to establish a seal between the root canal space and the periapical tissues.  Suitable root-end filling material should be, (1) Able to prevent leakage of bacteria and their biproducts into the periradicular tissues, (2) Nontoxic & Noncarcinogenic, (3) Biocompatible with the host tissues, (4) Insoluble in tissue fluids, (5) Dimensionally stable, (6) Unaffected by moisture during setting, (7) Easy to use
  63. 63.  Root-End Filling Materials: Numerous materials have been suggested for use as root-end fillings, including: Amalgam,  Gutta-percha,  Glass ionomers,  Composite resins,  Carboxylate cements,  Zinc phosphate cements,  Zinc oxide–eugenol cements,  Mineral tri-oxide aggregate (MTA).
  64. 64.  REPOSITIONING AND SUTURING:  Several authors have compared the effects of continuous and interrupted suture techniques.  Their findings indicate that the interrupted suturing technique provides better flap adaptation than does the continuous technique and, therefore, is the recommended technique, and the most commonly used, for endodontic surgery.
  65. 65. 1. Ask not to drink alcohol or use any form of tobacco. 2.. Ask not to lift up the lip or pull back the cheek to look at where surgery was done. This may pull the sutures and cause bleeding. 3. A little bleeding from the surgical site is normal. This should only last for a few hours. There may be little swelling of the face. This should only last for a few days.
  66. 66. 4. Place an ice bag (cold) on face where surgery was done. Leave it on for 20 minutes and take it off for 20 minutes. Do this for 6 to 8 hours. 5. After 8 hours, the ice bag should not be used. The day after surgery, warm saline gargle. Do this as often as possible for the next 2 to 3 days. Advice for warm saline gargle. 7. Rinse the mouth with 1 tablespoon of chlorhexidine mouthwash two times a day, once in the morning and once at night for 5 days. 8. Recall for removal of sutures after 7 days,
  67. 67.  CONCLUSION :  During the last 20 years, endodontics has encountered dramatic shift in the use of periradicular surgery.  Previously, periradicular surgery was commonly considered as the treatment of choice when nonsurgical treatment had failed but nowadays periradicular surgery has become very selective in contemporary dental practice.
  68. 68.  Text book of endodontics, Ingle 5th edition.  Textbook of oral & maxillofacial surgery By Daniel M. Laskin. Vol.2  Text book of endodontics, Nisha Garg.  Text book of endodontics By Grossman.  Text book of Surgical endodontics, Guttman
  69. 69. Thank you

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