Endodontic surgery most advancing and developing procedure

1. -FAZILATHUNNISA.A
CRRI

2.  INTRODUCTION
 DEFINITION
 INDICATION
 CONTRAINDICATION
 CLASSIFICATION
 SURGICAL DRAINAGE
 PERIRADICULAR SURGERY
 CORRECTIVE SURGERY
 REPLACEMENT SURGERY

3.  Over the past decade, periradicular surgery has continued to
evolve precise , biologically based adjunct to nonsurgical root
canal therapy .
 Although nonsurgical endodontic treatment gives good results
in most cases ,surgery may be indicated for teeth with
peristent periradicular pathoses that have not responded to
non surgical approaches.

4.  Endodontic surgery encompases surgical procedure
performed to remove the causative agents of periradicular
pathosis and to restore the periodontium to a state of a
biologic and functional health .

5. 1. Need for surgical drainage
2. Failed non surgical endodontic treatment
 Irretrievable root canal filling material
 Irretrievable intra-radicular post
3. Calcific metamorphosis of pulp space
4. Procedural Errors
a. Instrument fragmentation
b.Non negotiable ledging
c.Root perforation
d . Symptomatic overfilling

6. 5. Anatomic variations
a. Root dilacerations
b.Apical root fenestration
6. Biopsy
7. Conservative procedure
a. Root resorptive defects
b. Root caries
c. Root resection
d. Hemisection
e. Bicuspidation
8. Replacement surgery
a.Replacement Surgery
i.Intentional replantation
ii.posttraumatic
b.Implant surgery
i. Endodontic
ii.ossteointegrated.

7.  Poor periodontal health of the tooth
 Poor patient’s medical status
 Local anatomical factors like nasal floors ,
maxillary sinus , mandible canal and its
neurovascular bundle and mental force .

8.  SURGICAL DRAINAGE:
1.Incision and drainage ( I&D)
2. Cortical trephination (fistulative
surgery)
 PERIRADICULAR SURGERY
a. Curette
b. Biopsy
c. Root-end resection
d. Root-end preparation and filling

9.  Corrective Surgery
a. perforation repair
I. Mechanical ( Iatrogenic)
ii. Resorptive (internal and external)
b. Root resection
c. Hemi section
d. Bicuspidisation
 Replacement Surgery(extraction/replantation)
 Implant Surgery
1.Endodontic implants
2. Root –form osseointegrated implants

10.  Surgical drainage is indicated when purulent
and haemorrhagic exudate forms within the
softtissue or the alveolar bone forming
Periradicular Abscess
 Surgical drainage may be accomplished by:
i. incision and drainage (I&D) of the
soft tissue
ii.Trephination of the alveolar cortical
plate

11.  An incision should to be made through the
focal point of the localised swelling to
relieve pressure , eliminate exudate and
toxins and stimulate healing
 Caution should always exercised with hard ,
indurated swelling especially when
accompained by fever
 Incision into a diffuse or indurated swelling
before its localisation is often unsuccesful.

12.  The patient be placed on appropriate
systemic antibiotic therapy
 Instructed to use hot salt water “MOUTH
HOLDS’’(1/4 -1/2 tsp in a 10-12 oz glass of
hot water)in the swolling area to assist in
localisation of the swelling to a more
fluctuant
 Clinical situation should be monitored every
24 hours
 As the swelling has localised and a fluctuant
area has developed , surgical drainage should
be performed

13.  Nerve block injection is the preferable for
obtaining local anaesthesia
 When block is impractical ,anaesthesia will
be limited to infiltration
 When local anaesthesia is used , oral mucosa
should be dried and a topical anaesthetic is
placed
 Local anaesthetic should be deposited
peripheral to the swollen mucoperiosteal
tissue

14.  Incision should be HORIZONTAL and placed
at dependent base of the fluctuant area .
 The exudates should be aspirate and a
sample collected for bacteriologic culture
 Probing with curette or haemostat into the
incisional wound to release exudates
entrapped in tissue compartments will
facilitate a more effective result .

15.  Insertion of drain is only indicated when initial
drainage is limited incase presenting with
moderate to severe cellulitis and other positive
signs of an aggressive infective process.
 Material used:Iodoform gauze
Rubber dam material-H’ and
‘christmas tree’ shape
Penrose drain
 It may be sutured in placed for added retention
and should removed after 2-3 days .

17.  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 .
 No6 or 8 round bar
 Buccal approach
 A reamer or k type file
Is then passed into the cancellous
Bone into the vicnity of the
Periradicular tissue.

18. PERIRADICULAR SURGERY

19.  PRINCIPLES:
 Need for profound local anaesthesia and
haemostasis
 Management of soft tissue
 Management of hard tissue
 Surgical access,both visual and operative
 Access to root structure
 Periradicular curettage
 Root-end resection
 Root –end preparation
 Root –end filling
 Soft tissue repositioning and suturing
 Postsurgical care.

20.  ANTIINFLAMMATORY:
The patient (average weight of 150 lbs) take ibuprofen (400 mg) just
before surgery is recommended to minimise the postsurgical inflammatory
response.
 TRANQUILLISERS:
If patient is very anxious about the surgery , sublingual
triazolam or DIAZEPAM 10 mg taken 15-30 minutes before surgery.
 ANTIBIOTICS :
As stated previously , medically compromised patients must be
premedicated (eg with advanced diabetes , heart valve disease)
 ANTIBACTERIAL RINSE :
To reduce the oral microflora the patient instructed to
use a 0.12% CHLORHEXIDINE GLUCONATE mouth rinse the night before surgery
and morning of surgery and 1 hour before surgery .

21.  The injection of local anaesthetic agent that
contains a vasoconstrictor has two equally
important objective:
. To obtain profound and
prolonged anaesthesia
. To provide good haemostasis
both during surgical procedure
 HAEMOSTASIS:
Presurgical haemostasis
surgical haemostasis
postsurgical haemostasis .

22.  PRESURGICAL HAEMOSTASIS :
The choice of vasoconstrictor in the
local anaesthesic will have an effect on both duration of
anaesthesia and quality of hemorrhage control at the surgical
site .
 Vasopresser agents used in dentistry are direct acting
sympathomimetic amines that exert their action by
stimulating special receptor ( Alpha- and Beta- adenergic
receptors )on the smooth muscle cells in microcirculation of
various tissue
 EPINEPHRINE is the most effective and most widely used
vasoconstrictor agent in dental anaesthetics,

23.  Local haemostasis can be achieved by pressure technique of pressing cotton pellets or
gauze in the bony crypts
 Topical hemostatic agent:
A. MECHANICAL AGENTS:
Bone wax
B.CHEMICAL AGENTS :
Epinephrine saturated cotton pellets
other vasoconstrictors
Ferric sulphate solution
C.BIOLOGIC AGENTS
Thromobin USP
D.ABSORBABLE HEMOSTATIC
i. Intrinsic action
gelfoam
Absorable collagen
ii. EXTRINSIC ACTION
Surgicel
iii. MECHANICAL ACTION
Calcium sulphate

24.  After the flap is sutured, hemostasis is achieved by a ice –cold
wet sterilised gauze placed over the sutures to stabilise the
flap and control oozing of the blood from the surgical sites
 The gauze should be placed into the mucobuccal fold for
about one hour and an ice-pack should be applied to the
cheek 10 minutes on, 5 minutes off for 1- 2 hours.

25.  FULL MUCOPERIOSTEAL (sulcus full thickness flap)
. Triangular flaps ( one vertical releasing
incision)
. Rectangular flaps (two vertical releasing
incision)
. Trapezoidal flaps(broad-base rectangular)not
used
, Horizontal flaps(no vertical releasing
incision
 LIMITED MUCOPERIOSTEAL FLAP:
. Submarginal curved (semiluar)
. Submarginal scalloped rectangular(Lubeke-
ochsenbein) flap
. Free rectilinear submarginal flaps.

27.  Hard tissue management of periradicular surgery
involves four stages :
i. Osteotomy
ii. Curettage and biopsy
iii. Root-end resection
iv . Root –end retropreparation.

28.  Osteotomy is defined as the removal of facial
cortical plate to expose the root-end and must
be approached with a visualized 3D mental image
to ensure that it is made exactly over the apices.

29.  Periapical radiographs imaged perpendicular to
the roots from two different horizontal angles are
done to ascertain of the length and curvature of
the roots , position of the apices in relation to the
crown and number of roots
 The exact location of the apex determined by two
methods:
 Using the tooth length measurement obtained from a
Well angled radiograph .A small amount of radioopaque material is
placed and direct radiograph exposed
 Root surfaces generally has a yellowish colour
 Roots does not bleed
 Root texture is smooth and hard as opposed to
granular porous nature of bone
 The periodontal ligament that can be stained be
methylene blue dye surrounds root .

30.  Generation of heat is a major importance during
osseous tissue removal by bur as heating bone
tissue above 60 degree C in interruption of blood
flow and tissue necrosis
 The heat production can be minimised by
 LIQUID COOLANT during bone removal
i. dissipating the heat generated
ii. Keeping the cutting flutes of the instrument
free of debris
 LIQUID BRUSH STROKES with short, intermittent
cutting.

31.  Periradicular curretage involves removal of the
periradicular inflammatory tissue and is best
accomplished by using sharp surgical bone
curettes and angled periodontal curettes .

32.  INDICATIONS:
 BIOLOGIC FACTORS:
Persistent symptoms and continued presence of a periradicular
symptoms.
 TECHNICAL FACTORS:
a. Intra radicular posts
b. Crowned teeth without posts
c. Irretrievable root canal filling materials
d. procedural accidents
 Three important factors to be considered before performing
a root –end resection
1. INSTRUMENTATION
2. Extent of root end resection
3. Angle of root –end resection.

33.  INSTRUMENTATION:
Plain fissure bur and a low speed hand piece results in
the least gutta percha distortion
A smooth , flat resected root surface is preferred
clinically and may promote tissue healing
 EXTENT OF ROOT END RESECTION:
 Visual and operative access to the surgical site
 Anatomy of root
 Incidence of lateral canals and apical ramification at the
root end 3 mm significantly eliminates the major anatomic
entities
 Number of canals and their position in the root
 Need to place a retrofilling material surrounded by solid
dentine
 Presence and location of procedural error
 Presence and extent of periodontal defects
 Level of remaining crestal bone

34.  ANGLE OF ROOT END RESECTION:
The root end resection must be done perpendicular to
the long axis of the root .
In situation where a perpendicular bevel may not
possible as in the mesiolingual root of the mandibular first
molar 10 degree bevel can be used.

35.  PURPOSE: Retropreparation is to create a cavity to receive
a root-end filling
 Class -1 cavity preparation at least 3 mm into root dentine
with walls parallel to the anatomic outline of the pulp space
 FIVE Requirements
 Apical 3 mm of the root canal must be freshly
cleaned and shaped
 Preparation must be parallel to the anatomic
outline of the pulp space
 Adequate retention must be created
 All isthmus tissue must be removed
 Remaining dentine walls should not be weakned.

36.  TRADITIONAL RETROPREPARATION:
Involves use of either miniature contra –
angle or straight hand piece with a small round or inverted
cone bur
placed obliquely into the root , resulting in
risk of perforation and /or weakening of the dentine walls
TRADITIONAL
ULTRASONIC

37.  ULTRASONIC RETROPREPARATION:
 Solves the inadequacies of the traditional bur
preparation
 Ultrasonic microtips are very narrow in
diameter (one-tenth of a conventional
microhead handpiece)
 Produce smooth cutting with relatively the tips
are activated against the dentine wall of the
apical preparation
 ADVANTAGES:
 Better access especially in difficult to reach
areas (eg. Lingual apex)
 Debridement of the tissue debris
 Conservative preparation tracing the long axis
at a precise depth of 3mm
 Precise isthmus preparation

39.  PURPOSE: Provide a tight , biocompatible apical seal which prevents
the leakage of potential irritants from the root canal into the
periradicular tissue
 IDEAL PROPERTIES:
 Well tolerated by periapical tissue
 Adhere to the tooth structure
 Dimensionally stable
 Resistant to dissolution
 Promote cementogenesis
 Bacteriocidal or bacteriostatic
 Non corrosive
 Electrochemically inactive
 should not stain the tooth
 Readily available and easy to handle
 Allow adequate working time then set quickly
 Radioopaque

40.  RETROGRADE FILLING MATERIAL:
 Amalgam
 Gutta percha
 Gold foil
 Glass ionomers
 Zinc oxide eugenol
 Composite resins
 Mineral trioxide aggregate(MTA)
 INSTRUMENTS:
 Reverse fill carriers
 reverse fill pluggers
 Amalgam squeeze clothes
 Miniature reverse fill mirror
 Miniature head aspirator tips

41.  The elevated mucoperiosteum gently replaced to its original
position with the incision lines approximated as closely as
possible
 Tissue compression: using a surgical gauze moistened with
sterile saline gently apply firm pressure to the flapped tissue
2 to 3 minutes before suturing
 enhances intravascular clotting in the several blood vessels
 SUTURING: To approximate the incised tissue and stabilized
the flapped mucoperiosteum until reattachment occurs.

42.  Most like surgically sequelae include
 Pain
 Bleeding and swelling
 Ecchymosis
 Infection
 Transient paraesthesia
 Post operative instructions:
 Do not do any difficult activity for the rest of the day
 Good Diet and drink plenty of water
 Do not lift up the lip or pull back the cheek to look at where surgery
was done
 Place an ice bag
 After 8 hours ice bag should not be used
 Rinse the mouth with 1 table spoon of chlorhexidine mouthwash
two times a day
 Remove the suture after 2 days

43.  Corrective surgery involves the correction of defects in the body of the
root other than the
 Corrective surgery necessary for
 Procedural accidents
 Resorption
 Root caries
 Root fracture
 Periodontal disease
 classified
1. Perforationrepair
Mechanical
Resorptive and Root caries
2. Periodontal repair
Guided tissue regeneration
Root resection
Bicuspidisation

44.  Perforations are procedural accidents that can
occur during root canal or postspace preparation
 High potential areas of perforations are pulp
chamber , floor of the molars, distal aspect of
mesial root of mandibular molar and mesial buccal
root of maxillary molars
 Midroot perforation such as those resulting from
postspace preparation should be immediately
sealed internally , if possible calcium hydroxide
should be placed as an intracanal dressing

45.  In case of resportive defect that opens in to the
gingival sulcus . It is approachable from the buccal
or facial side a full mucoperiosteal flap is raised
and the extent is visualised
 If the defect extent into the pulp space a
temporary matrix (large gutta percha is placed into
the canal)
 After that the flap is repositioned and stabilised
with sutures and endodontic treatment can be
completed at the same or subsequent appointment

46.  Guided tissue (bone regeneration)
 Root resection/ Hemisection
 Bicuspidisation.

47.  This refers to the removal of one or more roots of a
multirooted tooth while others roots are retained
 logical way to eliminate a weak diseased root to allow the
stronger root to survive .

48.  Advantages
 Salvaging and retaining the two thirds or even one
Half of a tooth might add sufficient support to maintain arch
integrity
. The most posterior abutment retaining even half of the
tooth can avoid the need for removable prosthesis and
enable the patient to use fixed prosthesis or a splint
 INDICATIONS:
Existence of periodontal bone loss to the extent that
periodontal therapy and patient maintainence do not
sufficiently improve the condition
Destructive of a root through resorptive process,
caries or mechanical perforations
Fracture of one root that does not involve other.

49.  CONTRAINDICATIONS:
 Lack of necessary osseous support for the
remaining roots or root
. Fused root or roots in unfavourable proximity to
each other
. Remaining root or roots endodontically
inoperable
. Lack of patient motivation to properly perform
home care procedure.

50.  Bisection or bicuspidisation refers to a division of
the crown that leaves the two halves and their
respective root
 INDICATION:severe bone destruction in the
bifurcation but excellent support on the non
furcation area

51.  DEFINITION:
Intentional replantation as the act of deliberately
removing a tooth and a- after the examination, diagnosis
,endodontic manipulation and repair, returning the tooth to its
original socket.
 INDICATIONS:
 Difficult access
 Anatomic limitations
 Perforation in areas not access surgically
 Failed apical surgery
 Apical surgery creating defect
 Accidental avulsion

52.  CONTRAINDICATION:
 Preexisting moderate to severe periodontal
disease
 Curved and flared roots
 Non restorable tooth
 Missing interseptal bone
 3 factors that directly affect the outcome of intentional
replantation:
 Extraoral time
 Keeping PDL cells
 Minimizing damage to the cementum and pdl
ligament cells during elevation and extraction