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Periapical surgery

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periodantal surgery

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Periapical surgery

  1. 1. Endodontic SurgeryEndodontic Surgery
  2. 2. Endodontic Surgical ProceduresEndodontic Surgical Procedures  Incision and drainageIncision and drainage  Periapical curettagePeriapical curettage  ApicoectomyApicoectomy  Retrograde endodontic treatmentRetrograde endodontic treatment  Perforation repairPerforation repair  Root resectionRoot resection  Hemisection (± root removal)Hemisection (± root removal)  Exploratory surgeryExploratory surgery  Intentional replantationIntentional replantation
  3. 3. Endodontic Surgical ProceduresEndodontic Surgical Procedures  Incision and drainageIncision and drainage  Periapical curettagePeriapical curettage  ApicoectomyApicoectomy  Retrograde endodontic treatmentRetrograde endodontic treatment  Perforation repairPerforation repair  Root resectionRoot resection  Hemisection (± root removal)Hemisection (± root removal)  Exploratory surgeryExploratory surgery  Intentional replantationIntentional replantation
  4. 4. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
  5. 5. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required  Foreign body reaction with extruded materialForeign body reaction with extruded material
  6. 6. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required  Foreign body reaction with extruded materialForeign body reaction with extruded material  Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively)
  7. 7. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required  Foreign body reaction with extruded materialForeign body reaction with extruded material  Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively)  If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as:  Very long or wide post; Post not in line with canalVery long or wide post; Post not in line with canal  Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc  Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration
  8. 8. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required  Foreign body reaction with extruded materialForeign body reaction with extruded material  Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively)  If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as:  Very long or wide post; Post not in line with canalVery long or wide post; Post not in line with canal  Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc  Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration  Patient factorsPatient factors  Medical / dental condition, time, costs, recent crown, etc.Medical / dental condition, time, costs, recent crown, etc.
  9. 9. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Psychological aspectsPsychological aspects  Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery
  10. 10. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Psychological aspectsPsychological aspects  Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery  Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate  GrungGrung et alet al - 28% higher success if non-surgical- 28% higher success if non-surgical re-treatment was done prior to surgeryre-treatment was done prior to surgery
  11. 11. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Psychological aspectsPsychological aspects  Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery  Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate  GrungGrung et alet al - 28% higher success if non-surgical- 28% higher success if non-surgical re-treatment was done prior to surgeryre-treatment was done prior to surgery  Surgery is a “one visit” techniqueSurgery is a “one visit” technique  Can not disinfect the canal with irrigants and/or medicamentsCan not disinfect the canal with irrigants and/or medicaments
  12. 12. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material  Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well
  13. 13. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material  Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well  Surgery “entombs” bacteria rather than killing orSurgery “entombs” bacteria rather than killing or removing themremoving them  And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal
  14. 14. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material  Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well  Surgery “entombs” bacteria rather than killing orSurgery “entombs” bacteria rather than killing or removing themremoving them  And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal  Surgery does not remove the pathway of entry alongSurgery does not remove the pathway of entry along which the bacteria have entered & infected the toothwhich the bacteria have entered & infected the tooth  This is usually caries, a defective restoration, or a crackThis is usually caries, a defective restoration, or a crack
  15. 15. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Over-extended root filling materialsOver-extended root filling materials  Will not always cause a foreign body reactionWill not always cause a foreign body reaction  Hence, always watch and reassess over timeHence, always watch and reassess over time
  16. 16. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Over-extended root filling materialsOver-extended root filling materials  Will not always cause a foreign body reactionWill not always cause a foreign body reaction  Hence, always watch and reassess over timeHence, always watch and reassess over time  Large, well-defined radiolucenciesLarge, well-defined radiolucencies  Are not always cysts as often thought by many dentistsAre not always cysts as often thought by many dentists  Can be any form of periapical pathosisCan be any form of periapical pathosis  Size and borders indicate time & speed of developmentSize and borders indicate time & speed of development
  17. 17. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations  Potential post-operative sequelaePotential post-operative sequelae  Swelling and bruisingSwelling and bruising  InfectionInfection  Pain / discomfortPain / discomfort  Anaesthesia / ParaesthesiaAnaesthesia / Paraesthesia  Tissue discolourationTissue discolouration  ScarringScarring  Gingival recessionGingival recession  Loss of interdental papillaLoss of interdental papilla  Altered aestheticsAltered aesthetics
  18. 18. Possible Indications forPossible Indications for Periapical SurgeryPeriapical Surgery  ““It must be recognised that few trueIt must be recognised that few true indications exist for the endodonticindications exist for the endodontic surgical approach”surgical approach”  Gutman JL.Gutman JL. Surgical EndodonticsSurgical Endodontics 1991: 501991: 50
  19. 19. Endodontic SurgeryEndodontic Surgery
  20. 20. Endodontic Surgery - StagesEndodontic Surgery - Stages a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan b)b) Local AnaesthesiaLocal Anaesthesia c)c) Periosteal FlapPeriosteal Flap d)d) CurettageCurettage e)e) ApicoectomyApicoectomy f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment  Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling a)a) Wound Closure - suturesWound Closure - sutures b)b) Post-operative InstructionsPost-operative Instructions c)c) Follow-up & ReviewFollow-up & Review
  21. 21. Endodontic SurgeryEndodontic Surgery But first – some general principlesBut first – some general principles
  22. 22. Flap DesignsFlap Designs  Semi-LunarSemi-Lunar  Gingival crestGingival crest  TriangularTriangular  TrapezoidalTrapezoidal  GingivalGingival  Luebke-OschenbeinLuebke-Oschenbein
  23. 23. Semi-Lunar FlapSemi-Lunar Flap  In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva
  24. 24. Semi-Lunar FlapSemi-Lunar Flap  In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva  Poor accessPoor access  Incision often over the lesionIncision often over the lesion  Difficult moisture controlDifficult moisture control (haemorrhage)(haemorrhage)  Difficult to repositionDifficult to reposition  Uncomfortable during healingUncomfortable during healing  Leaves scarsLeaves scars
  25. 25. Semi-Lunar FlapSemi-Lunar Flap
  26. 26. Gingival FlapGingival Flap  Gingival crest incisionGingival crest incision  Extended horizontal incisionExtended horizontal incision  No vertical incisionNo vertical incision
  27. 27.  No access to apexNo access to apex  May be useful for coronalMay be useful for coronal third perforationsthird perforations  Used for palatal flapsUsed for palatal flaps  But difficult !But difficult ! Gingival FlapGingival Flap  Gingival crest incisionGingival crest incision  Extended horizontal incisionExtended horizontal incision  No vertical incisionNo vertical incision
  28. 28. Gingival FlapGingival Flap
  29. 29.  Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus  One vertical incisionOne vertical incision Triangular FlapTriangular Flap
  30. 30.  Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus  One vertical incisionOne vertical incision  ““First choice” flap for endodontic surgeryFirst choice” flap for endodontic surgery  Good accessGood access  Good visionGood vision  Good moisture controlGood moisture control  Heals without scarsHeals without scars  Easy to repositionEasy to reposition Triangular FlapTriangular Flap
  31. 31. Triangular FlapTriangular Flap
  32. 32. Triangular FlapTriangular Flap
  33. 33. Recall - 6 Months Triangular FlapTriangular Flap
  34. 34. Recall - 3 Months Triangular FlapTriangular Flap Recall - 6 Months
  35. 35.  Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus  Two vertical incisionsTwo vertical incisions Trapezoidal FlapTrapezoidal Flap
  36. 36.  Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus  Two vertical incisionsTwo vertical incisions  ““Second choice” for endodontic surgerySecond choice” for endodontic surgery Trapezoidal FlapTrapezoidal Flap
  37. 37.  Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus  Two vertical incisionsTwo vertical incisions  ““Second choice” for endodontic surgerySecond choice” for endodontic surgery  Begin as a triangular flap and then do 2Begin as a triangular flap and then do 2ndnd vertical incision if extra access requiredvertical incision if extra access required  Good access & visionGood access & vision  Good moisture controlGood moisture control  Heals without scarsHeals without scars  Easy to repositionEasy to reposition Trapezoidal FlapTrapezoidal Flap
  38. 38. Trapezoidal FlapTrapezoidal Flap
  39. 39. Trapezoidal FlapTrapezoidal Flap Recall - 6 Months
  40. 40. Luebke-Oschenbein FlapLuebke-Oschenbein Flap  Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva  3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin  Follows contours of the gingival marginFollows contours of the gingival margin
  41. 41. Luebke-Oschenbein FlapLuebke-Oschenbein Flap  Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva  3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin  Follows contours of the gingival marginFollows contours of the gingival margin  Vertical incisionsVertical incisions  1 or 21 or 2  Depends on howDepends on how much accessmuch access is requiredis required
  42. 42. Luebke-Oschenbein FlapLuebke-Oschenbein Flap  Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva  3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin  Follows contours of the gingival marginFollows contours of the gingival margin  Vertical incisionsVertical incisions  1 or 21 or 2  Depends on howDepends on how much accessmuch access is requiredis required  Little, if any, scarringLittle, if any, scarring
  43. 43. Luebke-Oschenbein FlapLuebke-Oschenbein Flap  Use for anterior teeth with crownsUse for anterior teeth with crowns  To avoid gingival recessionTo avoid gingival recession
  44. 44. Luebke-Oschenbein FlapLuebke-Oschenbein Flap
  45. 45. Luebke-Oschenbein FlapLuebke-Oschenbein Flap
  46. 46. Luebke-Oschenbein FlapLuebke-Oschenbein Flap Recall - 6 Months
  47. 47.  No. 15 - for periosteal flapsNo. 15 - for periosteal flaps  No. 11 - for incision and drainageNo. 11 - for incision and drainage  Stabbing actionStabbing action Scalpel BladesScalpel Blades
  48. 48. Scalpel BladesScalpel Blades
  49. 49. General Principles forGeneral Principles for Periosteal FlapsPeriosteal Flaps
  50. 50. General Principles forGeneral Principles for Periosteal FlapsPeriosteal Flaps
  51. 51. Apical BevelApical Bevel
  52. 52. Apical BevelApical Bevel
  53. 53. Apical BevelApical Bevel
  54. 54. Apical BevelApical Bevel
  55. 55. Apical BevelApical Bevel
  56. 56. Apical BevelApical Bevel
  57. 57. Apical BevelApical Bevel
  58. 58. Apical BevelApical Bevel
  59. 59. Apical BevelApical Bevel
  60. 60. Apical BevelApical Bevel
  61. 61. Micro-MirrorsMicro-Mirrors
  62. 62. CurettageCurettage TechniquesTechniques
  63. 63. Curettage TechniquesCurettage Techniques
  64. 64. Curettage TechniquesCurettage Techniques
  65. 65. Curettage TechniquesCurettage Techniques
  66. 66. Curettage TechniquesCurettage Techniques
  67. 67. Curettage TechniquesCurettage Techniques
  68. 68. RetrogradeRetrograde Filling MaterialsFilling Materials
  69. 69. Materials– Past and PresentMaterials– Past and Present  AmalgamAmalgam  CavitCavit  IRMIRM  Super-EBASuper-EBA  Composite resinsComposite resins  Gutta perchaGutta percha  Glass ionomersGlass ionomers  MTA (ProRoot)MTA (ProRoot)
  70. 70.  CorrosionCorrosion  Galvanism (with posts)Galvanism (with posts)  Tattoo on mucosaTattoo on mucosa  ExpansionExpansion  Dimensional changesDimensional changes  Marginal breakdownMarginal breakdown  Excess not absorbableExcess not absorbable  Mercury releaseMercury release  Difficult to condenseDifficult to condense  Condensation scatterCondensation scatter  Cavity largeCavity large  Undercuts neededUndercuts needed  Poor adaptation to wallsPoor adaptation to walls  No anti-bacterial actionNo anti-bacterial action  Difficult to remove forDifficult to remove for re-treatmentre-treatment Amalgam Disadvantages & Problems
  71. 71. Amalgam
  72. 72. Amalgam
  73. 73. Amalgam
  74. 74. Amalgam
  75. 75.  Poor tissue compatibilityPoor tissue compatibility  Due to continuous release of eugenolDue to continuous release of eugenol  Fibrosis of adjacent tissueFibrosis of adjacent tissue  SolubleSoluble  Large cavity requiredLarge cavity required  Difficult to handle materialDifficult to handle material  Esp. Super-EBAEsp. Super-EBA IRM + Super-EBA Disadvantages & Problems
  76. 76.  Low tissue toxicityLow tissue toxicity  Bone appositionBone apposition  Good sealing abilityGood sealing ability  Chemical bond to dentineChemical bond to dentine  RadiopaqueRadiopaque  Easy to mix & placeEasy to mix & place  Colour contrast to toothColour contrast to tooth  Short setting timeShort setting time  Moisture controlMoisture control  HaemorrhageHaemorrhage  Relatively largeRelatively large cavity requiredcavity required Glass Ionomer Advantages Disadvantages
  77. 77. Gutta Percha + Sealer  Low tissue toxicityLow tissue toxicity  Good sealing abilityGood sealing ability  RadiopaqueRadiopaque  Colour contrast to toothColour contrast to tooth  Conservative cavity onlyConservative cavity only  Anti-bacterial (sealer)Anti-bacterial (sealer) Advantages  Easy to mix & placeEasy to mix & place  Good physical propertiesGood physical properties  Satisfies requirements ofSatisfies requirements of root filling materialsroot filling materials  Proven and acceptableProven and acceptable material for RCF’s formaterial for RCF’s for over 120 yearsover 120 years
  78. 78. ReferenceReference FavourableFavourable Uncertain UnfavourableUncertain Unfavourable NordenramNordenram et alet al 19701970 56 %56 % 36 %36 % 8 %8 % HartyHarty et alet al 19701970 9090 -- 1010 RudRud et alet al 19721972 8383 1414 33 MalmströmMalmström et alet al 19821982 7474 1717 99 ForsellForsell et alet al 19881988 6868 2121 1111 AmagasaAmagasa et alet al 19891989 9595 -- 55 GrungGrung et alet al 19901990 8585 1414 11 FriedmanFriedman et alet al 19911991 7070 3030 -- RappRapp et alet al 19911991 5656 3333 1111 Abbott 1999Abbott 1999 92.392.3 4.24.2 3.53.5 Treatment Outcome StudiesTreatment Outcome Studies All re-treats after retro. amalgam
  79. 79. Endodontic SurgeryEndodontic Surgery -- with GP + AH26with GP + AH26
  80. 80. Endodontic Surgery - StagesEndodontic Surgery - Stages a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan b)b) Local AnaesthesiaLocal Anaesthesia c)c) Periosteal FlapPeriosteal Flap d)d) CurettageCurettage e)e) ApicoectomyApicoectomy f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment  Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling a)a) Wound Closure - suturesWound Closure - sutures b)b) Post-operative InstructionsPost-operative Instructions c)c) Follow-up & ReviewFollow-up & Review
  81. 81. ConsultationConsultation
  82. 82. Local AnaesthesiaLocal Anaesthesia
  83. 83. InstrumentsInstruments
  84. 84. Incision + Periosteal FlapIncision + Periosteal Flap
  85. 85. Bone Removal & CurettageBone Removal & Curettage
  86. 86. Retrograde Canal PreparationRetrograde Canal Preparation
  87. 87. Retrograde Canal PreparationRetrograde Canal Preparation
  88. 88. Retrograde Canal PreparationRetrograde Canal Preparation 
  89. 89. Retrograde Canal PreparationRetrograde Canal Preparation
  90. 90. Haemorrhage ControlHaemorrhage Control
  91. 91. Paper PointsPaper Points
  92. 92. Sealer - AH 26Sealer - AH 26
  93. 93. Gutta PerchaGutta Percha
  94. 94. Sealer - PlacementSealer - Placement
  95. 95. Retrograde Root FillingRetrograde Root Filling
  96. 96. Retrograde Root FillingRetrograde Root Filling
  97. 97. Retrograde Root FillingRetrograde Root Filling
  98. 98. Retrograde Root FillingRetrograde Root Filling
  99. 99. Retrograde Root FillingRetrograde Root Filling
  100. 100. Retrograde Root FillingRetrograde Root Filling
  101. 101. SuturingSuturing
  102. 102. Post-Operative InstructionsPost-Operative Instructions ALSO:ALSO: 1.1. Post-op RadiographPost-op Radiograph 2.2. Suture RemovalSuture Removal  4-5 days4-5 days 3.3. ReviewsReviews  3-4 months3-4 months  12 months12 months  3 years3 years
  103. 103. Pre-op
  104. 104. Mid-surgery
  105. 105. Review - 3 months
  106. 106. Review - 12 months
  107. 107. Review - 3 years
  108. 108. Post-op
  109. 109. Review - 8 years

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