This presentation of mine is a brief overview of surgical management of root canal treatment failure . The non surgical approach is already explained in other presentation.

1. Dr. Hamza
Department of Operative Dentistry
Armed Forces Institute of Dentistry
National University of Medical Sciences,
Pakistan.

2.  Emergency surgery
 incision and drainage
 trephination
 Biopsy
 Periapical surgery for root-end management
 Corrective surgery
 perforation repair
 root resection
 hemisection
 Intentional replantation for root-end management or corrective
surgery
 Regenerative procedures
 Decompression

3.  Incision and drainage
 This procedure consists of the creation of a
surgical opening in the oral mucosa for the
purpose of releasing pus and exudate and is
a relatively minor procedure
 However, when the swelling extends to the
tissue spaces with an extraoral component,
this may result in life threatening situations,
such as occlusion of the airway
 Cellulitis is a symptomatic oedematous
inflammatory process that spreads diffusely
through the fascial planes This infection
demands immediate treatment with both
antibiotic and analgesic medication and
establishment of drainage if at all possible

4.  Trephination
 This is the surgical perforation of the alveolar
cortical plate to release accumulated
periradicular tissue exudate
 This procedure is used in cases where the
absence of any obvious intra- or extraoral
swelling prevents drainage causing intense
pain; the purpose of the procedure is to aid
release of inflammatory exudate through
perforation of the cortical plate
 The procedure may involve the use of
trephine burs or be as simple as the
puncturing of the cortical plate with a sterile
finger spreader
 Mishaps can occur with the use of burs and
damage to the tooth may require surgical
correction
 These procedures are performed when
drainage through the root canal is not
possible or evident
 Antibiotics are required only when there is
systemic involvement

5.  The purpose of taking a biopsy is to
establish a definitive diagnosis by
histological examination.
 It involves the surgical removal of a soft
and/or hard tissue specimen for
histological evaluation
 The value of routine histopathological
examination during endodontic surgical
procedures must not be underestimated.
 The taking of a routine biopsy during
periradicular surgical procedures has come
to be accepted as the standard of care,
particularly given the reduced frequency of
surgery and, therefore, higher chance of
non-endodontic pathoses.
 Correct handling of the removed tissue is
central to the formation of an accurate
histological diagnosis

6.  Recovered tissue must be placed immediately in a 10%
formalin solution and sent with complete relevant details
to the pathology laboratory
 A biopsy request should include:
 a history of the case, including patient details
 a clinical description of the lesion
 a gross description of the biopsied tissue including size,
location, duration, colour, texture, consistency and
radiographic appearance
 a provisional diagnosis
 Biopsies are usually excisional or incisional
 Excisional biopsy is used to remove the lesion in its
entirety and may, therefore also be therapeutic
 An incisional biopsy is only used to establish a diagnosis
and would be rarely used in endodontic procedures

7.  The periapical surgery procedure includes curettage of the
lesion, root-end resection, root-end cavity preparation and
root-end filling
 As a preliminary procedure for all periapical surgery, a tissue
flap must be reflected
 Careful and considered soft tissue management greatly
enhances the prognosis of the surgical procedure and
improves the postoperative wound healing

8.  The main considerations (for the surgeon) governing flap design are
good access and vision, while minimizing trauma to the soft tissues
during retraction
 The design (for the patient) should ensure good blood supply to the
flap, avoid damage to the surrounding structures and facilitate primary
wound closure
 The flap design should include the tooth to be treated and, only if
necessary, one or more teeth on
 either side; a balance must be struck between the risk of postoperative
gingival recession and good surgical access
 It is always preferable to extend the flap further than to attempt to work
in a restricted field
 Factors which influence the extent of the flap include position of the
mental nerve, muscle and fraenal attachments, root and bony
eminences and large bony defects

9.  Full and limited mucoperiosteal
flaps are used in endodontic
surgery and differ from
periodontal surgery flaps in only
involving healthy marginal tissue
 Mucoperiosteal flaps consist of the
periosteum along with the
overlying alveolar mucosa and
gingival tissues
 Flap names are designated
according to their shape & include
 Triangular
 Rectangular
 semilunar
 Submarginal
 Papilla-base
 Palatal

10.  Flaps with vertical relieving incisions are less likely to
produce excessive bleeding because of the orientation of the
submucosal vasculature , although this only confers a slight
advantage
 Incision lines should always be placed so that wound closure is
on sound bone
 Buccal flaps are most commonly used to gain access to the
periradicular tissues; however, a palatal approach may be
indicated for gaining access to palatal roots or defects
 The only indications for lingual flap reflection are crown
lengthening procedures or if repair of a coronal, lingually
located defect is planned

11.  These include
 trapezoid
 Rectangular
 triangular
 The vertical component of the trapezoid flap is
angulated, cutting across the vasculature and was
traditionally in very common use; it is useful for
reflecting a flap based on a single tooth where
potential for recession associated with adjacent
crowned teeth is to be avoided
 Rectangular and triangular flap appear to be
the most commonly taught, based on blood vessel
alignment, but clinical experience suggests no
obvious difference in healing compared with
trapezoid flaps

12.  The triangular flap has the advantage of
flexibility as the flap may either be extended
or converted into a rectangular one if
necessary
 It is created by the use of an intrasulcular
and relieving incision
 The relieving incision is started in alveolar
mucosa, passes through the attached and
marginal gingivae and ends on the mesial or
distal aspect of the teeth
 The gingival papillae should not be incised,
this will facilitate repositioning of the flap
and prevent sloughing of the papillae

13.  Elevation of the flap should commence in the attached
gingivae of the vertical incision
 The advantages of the full flaps include provision of good
access to the root tissues , ease of reflection and
repositioning and provision for excellent healing, usually
without scarring, thereby minimizing postoperative pain and
swelling
 The only disadvantage of these flaps is the possibility of
postoperative gingival recession
 This has been shown to be minimal with the correct
handling of the tissues and is more likely to occur with thin
marginal tissues

14. • These flap designs eliminate the need
to disturb the gingival margins
especially those around restorations
where recession would be most
noticeable
• They include
• The semilunar
• Submarginal (Oschenbein Leubke)
• The papilla-base flaps
• The semilunar flap is created by
cutting a semilunar shaped incision in
the alveolar mucosa
• The access provided is limited and

15.  The submarginal flap consists
of two vertical and a scalloped
horizontal incision in the
attached gingivae, which
follows the outline of the
gingival margin (Leubke-
Ochsenbein)
 It must be noted that the
required width of the attached
gingivae is 3–5 mm
 The papilla-base flap involves
vertical releasing incision(s)
along with a shallow incision in
the base of the papilla and a
second incision directed to the
crestal bone
 This creates a split thickness
flap in the area of the papilla

16.  These limited flap designs may be appropriate
(advantageous) when recession may lead to exposure of the
crown margin

17.  Elevation of the flap must be
performed with care in order to
avoid damage to the tissues
 Elevation is commenced in the
vertical incision and away from the
gingival margin, in the attached
gingivae

18.  Care for the reflected soft tissues is essential to
good postoperative wound healing
 The operator must ensure that the retractor is
placed firmly on the bone avoiding pinching of any
soft tissue
 Frequent saline irrigation of the surgical site
prevents dehydration of the flap and the tissue tags
attached to the teeth, encouraging optimum
healing
 In the mandibular premolar region, the mental
nerve should be identified and protected with a
retractor

19.  Access to the periapical tissues and root-
end is gained by removing the overlying
alveolar bone, unless the lesion has already
breached the cortical plate
 If the cortical plate is intact, measurements
from radiographs or from working lengths
obtained during a nonsurgical treatment
must be used to estimate the position of
the root apices
 In conjunction with copious sterile
irrigation a rear-venting surgical
handpiece is used to remove the bone
with a gentle brushing motion

20.  Large round tungsten–carbide burs have been
shown to be most suitable for safe bone
removal
 Excessive heating of the bone via the use of
excessive pressure on the rotating instrument,
excessive depth of cutting, inadequate cooling
or the use of the wrong cutting instrument can
result in stagnation of the local bone
circulation and eventual tissue necrosis
 Caution must be exercised at all times not to
damage adjacent teeth and soft tissues

21.  This has been defined as a surgical procedure to remove
diseased or reactive tissue and/or foreign material from the
periradicular bone surrounding the root of an endodontically
treated tooth
 Some clinicians argue that resection of the root-end can
facilitate curettage as access to the palatal/lingual surfaces is
improved, however, it is always better to curette first and
resect later so that clear sight of the root end is obtained
during resection
 All curetted tissue must be
removed and sent for
histopathological examination

22.  The residual infection is most likely to
reside in the anatomical complexities
in the apical 3 mm of the root, it is
often recommended that the apical 3
mm of the root-end be removed as a
matter of routine
 The root should be resected
perpendicular to its long axis
 Such a resection angle reduces the
number of dentinal tubules exposed,
decreasing the communication
pathways between the canal system
and periradicular tissues

23.  Visualization of the root-end outline can
be enhanced by staining it with a 1%
solution of methylene blue dye
 The root-end should be carefully inspected
for anatomical details, fractures and
incomplete resection
 Identification of the canal anatomy and, in
particular isthmi, facilitates the correct
extension of the root-end preparation.

24. Multipurpose bur
Lindemann
Bur

25.  The rationale for preparation
and filling of the root-end is to
debride the canal system and seal
off any residual intracanal
infection
 The rationale for placement of a
root-end filling is to prevent
egress of any residual intracanal
microorganisms and/or their
products into the periradicular
tissues

26.  The apical seal is all important in apical surgery, even more
so than in conventional root-canal treatment
 A “double seal” consisting of the physical barrier provided
by the root-end filling material, as well as a biological seal
formed by regeneration of the periodontal apparatus over the
resected root face is the ideal outcome
 This has been shown to be achievable with the root-end
filling materials available today, such as Diaket (Fig. 9.63)
and MTA (Fig. 9.64).

27.  The ideal root-end cavity should
be prepared along the axis of the
root, have near parallel walls, be at
least 3 mm deep and encompass the
root canal anatomy
 The introduction of ultrasonic
root-end tips has revolutionized
root-end preparation (Figs 9.65,
9.66)
 The smaller size of the ultrasonic
hand-piece and the angulation of
the root-end tips allow better access

28.  The flap should be repositioned and held in place under gentle
compression for a few minutes with damp gauze
 Once all the sutures have been placed, the flap should be
compressed again with digital pressure for approximately 5–10
minutes
 The rationale for this procedure is to encourage formation of as
thin a clot as possible
 If this is not achieved, complications including infection, scar
tissue formation, swelling and bruising may occur
 The importance of good oral hygiene must be emphasized to the
patient

29.  Monofilamentous sutures, such as nylon, polyester and
expanded polytetrafluoroethylene have many advantages
 They tend to be strong, easy to handle and see, non-
allergenic and available in a number of sizes
 Animal studies indicate that the wound reaches the major
part of its strength after 36 hours, and it has been suggested
that sutures can be removed after 2–3 days postoperatively

30.  When suturing the tissues, it is
important to ensure that the flap is
not under tension
 The horizontal incision is usually
sutured first
 The technique most commonly
used in endodontic surgery
involves the use of interrupted
sutures
 The single sling suture, vertical
mattress suture and the anchor
suture may also be used

31.  The ideal root-end cavity should be
prepared along the axis of the root,
 have near parallel walls, be at least 3
mm deep and encompass the root
canal anatomy
 The introduction of ultrasonic root-
end tips has revolutionized root-end
preparation
 The smaller size of the ultrasonic
hand-piece and the angulation of the
root-end tips allow better access

32.  A recognized complication of root-end preparation was
perforation of the lingual aspect of the root when
conventional surgical hand-pieces were used in conjunction
with 45° bevels
 This iatrogenic complication is less likely when
ultrasonically energized root-end preparation tips are used
instead

33.  Administration of adequate amounts of
vasopressor agents contained in the local
analgesic carpules will usually ensure good
haemostasis, which will be maintained
throughout the procedure provided that the
procedure is completed within a reasonable
time frame
 After this “window of opportunity”
control of the blood flow is lost and a
massive increase in bleeding occurs due to
the “rebound phenomenon”

34.  A number of locally applied haemostatic agents are available
for use during the surgical procedure
 Racellets® (adrenaline (norepinephrine) impregnated cotton
pellets) (Fig. 9.68)
 ferric sulphate (Fig.9.69) (e.g. Cutrol)
 Bone wax
 Oxidized cellulose (Surgicel®) (Fig. 9.70)
 gelatine-based foam (Gelfoam)
 Bovine-derived collagen (Collacote® or Collaplug®)

35.  The ideal root-end filling material should be
biocompatible, antibacterial, easy to place and
remove, radiopaque, dimensionally stable,
adhere to the root canal wall, insoluble and
induce regeneration of the periradicular tissues
 Root end filling materials used are
 MTA (see Fig. 9.28a)
 Super ethoxybenzoic acid (EBA) (Fig. 9.73)
 Intermediate restorative material (IRM) (Fig.
9.74)
 Gutta-percha
 Diaket (Fig. 9.75)
 Composite resin
 Glass ionomer cement