Surgical Endodontics / orthodontic courses by Indian dental academy

Introduction

The scope of endodontic surgery has expanded beyond apicocectomy to

include periapical curettage, redisectomy, replantation transplantation,

implantation, trephination, incision for drainage and root submergence.

The term apicoectomy meant the resection of the root apex, surgical

procedures performed around the root is termed as periradicular surgery.

Failure may occur in small percentage of cases with non-surgical

endodontics therapy that eliminates periapical inflammation or infection and

allows teeth to be retained in a free healthy state, when confronted with such

cases the clinician should be prepared to initiate alternative procedure including

surgery to enhance the rate of success.

History according to Ingle

Endodontic surgery has first recorded 1500 years ago when Aeticus, a

Greek physician dentist excised an acute apical abscess with a small

scalpel.

Later the procedure was refined and popularized by Hullihen in 1839.

Fawas (1884), Rhein (1894) and G.V. Black (1886) described root

amputation techniques and in 1919 Garvin demonstrated retrofillings

radiographically.

Classification

Endodontic surgery encompasses surgical procedures performed to

remove the causative agents to radicular and periradicular disease and to restore

these tissue to functional health. It can be classified as follows:

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1. Surgical drainage

a. Incision.

b. Trephination

2. Radicular surgery

a. Apical surgery

i. Currettage and biopsy.

ii. Apicoectomy.

iii. Retrofilling.

b. Corrective surgery

i. Perforative repair Mechanical

Resorptive

ii. Periodontal repair GTR

Resection

3. Replacement surgery

a. Replant surgery Intentional

Post traumatic

b. Endosteal implant surgery Endodontic

Osseointegrated

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According to Grossman periapical surgery can be classified as:

1. Root resection or apical curettage following an orthograde filling.

Either in one stage that is, immediate root resection, or in tow stages,

in which multiple appointments separate non surgical and surgical

procedures.

2. Orthograde filling during root resection or periapical curettage.

3. Root resection and retrograde filling.

4. Root resection and retrograde filling following an orthograde filling

(in one stage or two procedures).

Indications and Contra Indications

Clean well obturated canals are the biological basis of endodontic

success marked improvements in the non surgical techniques have improved

the success rate, however if cleaning of the canal terminus root canal access is

impossible, (a surgical approach should be considered) whenever a root canal

cant be filled properly with an orthograde filling endodontic surgery should be

considered.

A classical characterization of specific indication and contraindication

has developed by Leubke, Glick, and Ingle. Based on the classifications.

Indications of endodontic surgery (Grossman)

1. Any condition or obstruction that prevents direct access to the apical

third of the canal such as:

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a. Anatomic – calcifications, curvatures, bifurcations dens in dente

and pulpstones.

b. Iatrogenic – ledging blockage from debris, broken instruments

old root canal fillings and cemented posts.

2. Periradicular disease associated with a foreign body, overfilled canals,

broken instruments protruding into apical tissue and loose retrograde

fillings.

3. Apical perforations: any perforation that can’t be sealed properly by a

filling within the canal.

4. Incomplete apexogenesis with blunderbus or other apices that do not

respond to apical closure procedure.

5. Horizontally fractured root tip with periradicular disease.

6. Failure to heal following non surgical endodontic treatment.

7. Persistant and recurring exaggeration during non-surgical treatment or

persistant, unexplainable pain after completion of non surgical

treatment.

8. Treatment of any tooth with a suspicious lesion that requires a

diagnostic biopsy.

9. Excessively large and intruding periapical lesion.

10. Destruction of apical constricture of root canal due to uncontrolled

instrumentation.

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Contra Indications for endodontic surgery

1. Indiscriminate surgery.

2. Poor systemic health.

3. Psychological impact.

4. Local anatomical considerations.

Indiscriminate surgery : Endodontic surgeries should not be a cover up for

every endodontic case or a cover up for the skill in non surgical endo

technique.

Surgeries are not simply indicated because a periadicular lesion is

present at the time of treatment, is because a large lesion is present or because

the clinician believes a lesion may become cystic.

Poor systemic health : A complete medical history is mandatory. If a question

exists about the patients health, medical consultation must be sought with the

patients physician. Contraindications include blood dyscrasias is neurological

problems, terminal illeness, diabetes, heart diseases, pregnancy in first and

third trimestor.

Psychological emotionally distressed patient, a patient unable

psychologically to withstand or cope with any surgical procedure.

Limitations in the surgical skill and experience of the operators

Local Considerations

1. Localized acute inflammation, whereas emergency procedure such as

incision and drainage or trephination may be indicated, elective

periapical surgery should be avoided.

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2. Anatomical considerations, procedures that penetrate the mandibular

canal, maxillary sinus, mental foramen, floor of the noses or that sever

the greater palatine blood vessels should be avoided whenever possible.

3. Inaccessible surgical sites, inaccessible position and location of root

apices especially in posterior teeth and the need to gain access to the

surgical sites third dense layers of bone, such as the lingual surface of

molars or the external oblique ridge of the mandible may preclude a

successful result.

4. Teeth with a poor prognosis short rooted teeth, with a advanced

periodontal disease, vertically fractured teeth, non strategic and

understorable teeth should not be considered for periapical surgery.

5. Finally, peripical surgery should not be considered as a cureall to

compensate for inadequate technique that resulted in failure to heal,

surgical treatment of teeth should not be done for experience alone.

Anatomical considerations

Maxilla

- The maxillary incisors and the alveolar process are

closely related to the floor of the nose.

- A combination of short alveolar process and long roots

allows the incisor apices to contact either bony plane of the nasal

floor.

- The lateral incisors however are seldom or close to the

nasal floor as are the central incisors.

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- The canine occupies a “neutral position” between the

maxillary sinus and the nasal cavity and has no intimate relationship

to either cavity.

- The maxillary incisors and canines are often covered

with little or no labial cortical plate.

- Second premolar are closer to the maxillary sinus wall

wherever molars sometimes reach the floor and at times protrude

into the sinus.

- Although the maxillary sinus membrane perforation

usually doesn’t cause postoperative problems, care must be taken to

prevent root tips, bone or other foreign bodies being inadvertently

pushed into the sinus.

- A prominent zygomatic process may impede surgical

access to the root of a maxillary molar tooth.

- A palatal root of the first or second molar that is closely

aligned with the greater palatine foramen. The position and course of

the palatine bundle must be carefully determined when placing a

palatal approach to the palatal root. To avoid vessels, palatal access

is gained by reflecting a flap created by making a vertical incision

between the premolars and a short distal releasing incision of the

tuberosity.

Mandible

- In gaining surgical access and isolating the apex of the

lower incisors, one must take care that the lingual alveolar plate is

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not also perforated anterior alveolar process is quite narrow in

labiolingual dimension.

- Proximity of the mental foramen to the apices of

mandibular premolars and on occasion to the first molar.

- Thick external oblique ridge in the second and third

mandibular molar region.

- The mandibular canal doesn’t interface with surgical

access except when a shallow mandibular process is associated with

long roots.

Knowledge of the most common location of a major nerve, such as the

inferior alveolar nerve in the mandibular canal, is of critical importance it

allows better control of the surgery and less likelihood of postoperative

parasthesia.

- Litter and associates found the average vertical distance

from the upper border of the mandibular canal of the apices of the

second molar and the first molar to be 3.5 and 5.4 mm respectively.

- Access for mandibular endodontic surgery from the

lingual aspect is extremely clumsy and unnecessary. Damage to the

lingual nerve or artery may occur, as well as the possibility of

confronting a wide mylohyoid ridge.

The buccolingual position of the canal can be determined by comparing

a IOPA exposed at right exposed at right angle to the long axis of the tooth

with a second radiograph exposed at a vertical angulation of 25° and the central

beam directed superiorly, if in the second film the mandibular canal waves

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inferiorly in relation to the roots apices, the canal is lingual in the apices, if it

moves upwards on the roots it is buccal, is the apices minimal movement of

canal indicates that it is in close proximity to the apices.

Pre-operative consultation with the patient

A proper preoperative consultation is an essential part of the total

surgical experience for both the patient and the clinician. The procedure should

be described in detail as should are potential postoperative problems such as

discomfort, swelling, bleeding, brushing, maxillary anterior penetration and

rare possibility of parasthesia.

Patient should be asked to sign that attest to them understanding and

treatment procedure, risk and fees.

Pre-operative preparation and medication

Premedication becomes necessary when a patient remains overly

anxious and unaffected by the pre-operative consultation. The premedication

drugs selected should reduce anxiety, enhance the anesthetic to be

administered, and favourably reduce salivation (antisialagues), bleeding

(epinephrine) or secondary infection (antibiotics).

Antiseptic mouthwash

Chlorhexidine gluconate reduces the levels of fracture in the oral cavity

and plays a important role in healing following endodontic surgery, for this

patient is instructed to rinse with the solution for 1 min twice daily for 5 days.

This regimen should begin the day before surgery.

Non steroidal anti-inflammatory drugs

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Administration of non-steroidal anti-inflammatory drugs before the

surgical procedure helps to reduce postoperative pain and swelling.

Ibuprofen enacts its effects by inhibiting the enzyme cycle-oxygenase

and preventing the formation of inflammatory mediators. Its analgesic and anti-

inflammatory properties result from inhibition of peripheral prostaglandin

synthesis. A loading dose of 600mg 2 hours before surgery, and 400mg every 4

hours postoperatively is advised short acting barbiturates, such as pentobarbital

and secobarbital are frequently used for sedation. Commonly administered

orally, 50, 150mg / 30 min prior to the surgical treatment.

Tranquilizers are effective drugs for surgical premedication because

they reduce apherhension, are sedatives and act as miracle relaxants. Either

meprobamite, 400mg – 4 times daily for several days prior to treatment or

diazepam (valium) 5mg taken orally 36 min prior to treatment is an effective

tranquilizer and relaxant.

Improving visibility

Endodontic surgical procedures are delicate and precise. The quality of

endodontic surgery improves dramatically when the surgical fields in well

illuminated, magnified and bleeding is controlled.

Illumination

Using specially designed clips fibre-optic cable can attached directly to

surgical retraction and aspiration, head lamps are also available with quartz

bulbs clipped to surgical telescopes and operating from either direct current or

battery pack.

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Surgical microscopes with a light source aimed directly at the site

provide by far the best method of illumination.

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Magnification

Magnification of the operative site makes it easier to differentiate root

from bone to locate the entire root surface during root end resection to locate

unfilled root canal systems and to better visualize root and preparations and

fillings.

Visors and loupes

Many inexpensive visors and loupes are available and provide

magnification from 1.7 upto 14.

Telescopes : are available with magnification capabilities between f2 and f8,

some models are attached to a headband, but in the most popular models the

optics are affixed to specially designed spectacles.

Telescopes can be obtained with varied fields of vision (standard,

widefield, expanded field and extended range). Wide field magnification is

becoming the most popular choice among endodontic surgeons.

Microscopes

Surgical microscopes provide magnification levels of between f4 and

f40 after features such as through the lens fibre-optic illumination, 300m

magnification foot pedal focusing and accessory optics for dental assistants.

Although these scopes provide crisp undistorted images proficiency in their use

demands time and patience.

Surgical instruments and materials

A surgical setup should consists of all sterile instruments and materials

needed to complete the contemplated procedure, too few instruments cause

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consternation for the surgeon who cannot efficiently and effectively complete

the task. Too many instruments lead to confusion and hesitation, the operator

can supplement or replace any instrument listed to accommodate personal

preference.

Surgical setup for periapical procedures

1. Anaesthesia, aspirating syinge, disposable needle and several capsules

of desired local anaesthesia such as lidocaine hydrochloride, 2%

epinephrine 1:50,000.

2. Isolation of the operative site. Sterile 1x2 cotton gauge squares, and

cotton pellets (alcohol sponges or topical antiseptic solution should be

available to swap the operative site).

3. Incision : Band parker handle, No. 15 blade and periodontal probe (to

help determine flap design).

4. Flap Elevation and retraction, periosteal elevator.

5. Penetration and removal of cortical bone plate, root resection and

preparation for retrograde filling is the root apex. Assorbed straight hand

piece burs had chisel, sterile saline or anaesthetic solutions for use as a

coolant and for debridement.

6. Curettage Goldman for #3 curett, surgical excavator Hu-Fiendly No.-9

or No.-11.

7. Retrograde filling apical amalgam carrier, plastic instrument, apical

amalgam plugger.

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8. Suturing, needle holder or hemostat, 3-0 or 4-0 silk suture on an a

traumatic needle and scissors.

9. Surgical tray, cotton pliers, explorer, mirror and cotton or racellets.

Haemostasis can be achieved by use of alugauage, gel form, bone wax

or other physical barriers, cotton, cotton roll or gauge saturated with adrenaline

are least desirable materials as the residual cotton fibres left in the crypt

provoke a latent foreign body resection.

Astringents such as 15.5% ferric sulphate burnished into a area of

fleeding promotes haemostasis rapidly.

Anesthesia

A solution of lignocaine containing adrenaline 1:100,000 is used for a

block, and lignocaine containing adrenaline 1:50,000 is used for infiltration.

Infiltration anesthesia, using a aspirating syringe is adequate for most

maxillary periapical surgery.

The anesthetic is injected subperiosteally over the operative site, attempt

to inject deeper tissue may prove counter productive because of likelihood of

injecting into skeletal muscle for additional anesthesia during the surgical

procedure, the anesthetic can be injected directly into the bony madullary

spaces inside the open wound.

Conduction anesthesia, in which the anesthetic solution is deposited near

the mandibular foramen is used for mandibular periapical surgery.

The infraorbital injection, posterior superior alveolar block is rarely

needed for elective periapical surgery used only in emergency situations to

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avoid inspiriting needles and depositing anesthetic solution into acutely

inflamed and swollen tissue.

Flap design

Certain cardinal principles that apply to all flap design are:

1. The base of the flap should wider than the free end, to ensure adequate

circulation into the flap.

2. The sutured flap margins should rests on solid cortical bone plate.

3. Incisions should be made with a finer, continuous stroke, perpendicular

to the cortical bone plate the periosteum retracted with the flap, that is a

full thickness flap of mucoperiosteum.

4. The flap should be designed with continuous curvatures between the

horizontal and vertical incisions to avoid sharp angles that tear.

5. A sinus tract when present should be included in the flap.

6. Releasing incisions should be made between the bony eminences

because tissue even such structures is thin and stretches and tears when

sutured.

7. Properly designed, a retracted flap can be held in position with passive

pressure by means of a periosteal elevator pressed against underlying

solid bone.

8. Flap should generally extend one or two teeth laterally to allow for

relaxed retraction and prevent stretching and tearing.

9. Avoid incision over a bony defect.

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The basic flap designs used in endodontic surgery

1. Gingival flap : indicated in cervical area perforations, advantage is no

vertical incision, ease of repositioning disadvantage of limited access

and visibility difficult to reflect.

2. Semilunar flap : when no underlying periodontal problems are present

esthetic crowns present, trephination. The horizontal component of this

flap rests on alveolar bone structure at least 3mm apical to the gingival

crest and ends in the attached gingiva. Reduces incision and reflection

time, maintains integrity of gingival attachment, eliminates potential

crestal bone loss disadvantage of limited access and visibility crosses

root eminences may not include active lesion healing is associated with

scarring.

3. Triangular flap : Indicated in midroot perforation repair, periapical

surgery involving posterior areas and short roots has advantage of easily

modifying with small retracting incisions, additional vertical incision

and extension of horizontal component.

Disadvantages of limited access and visibility to longer roots, tension is

created on retraction, gingival attachment severed.

4. Rectangular flap : Useful in periapical surgery involving multiple

teeth, large lesion, longer roots. Can get maximum access and visibility,

reduces retraction tension, facilities repositioning. Disadvantage reduces

blood supply to the flap increased incision and reflection time, interface

with gingival attachment causing gingival recession, crestal bone loss

may uncover dehiscene and suturing is more difficult.

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5. Palatal flaps : the rich vascular supply of the palatal area provides for

excellent healing in most instances, palatal flap is prepared with a

scalloped incision around the gingival margins. Relaxing incisions are

generally placed between the cuspid and bicuspid to prevent severing of

the anastomosis of incisive and palatine vessels.

Distal incision is placed distal to second molar on the maxillary

tuberosity to prevent severing the greater palatine vessels.

The free end of the flap could be tied to the teeth on the opposite side of

the arch with a suture material.

6. Ochesenbein-luke flap : Indicated in periapical surgery involving the

anterior regimen, longer roots, prosthetic crown present with wide band

of attached gingiva advantage is in placing incision and reflection with

enhanced visibility and access case of prepositioning, maintains

intergrity of gingival attachment. Prevents gingival recession, avoid

dehiscence prevents crestal bone loss.

Difficult to alter if size of the lesion misjudged, horizontal component

disrupts blood supply, vertical component crosses microgingival junction and

enter muscle tissues.

7. Rectangular, Trapezoidal flap : Indicated where maximum access and

visibility is required like in case of multiple teeth, large tension etc.

Surgical Techniques

Vertical incision may be relieving or relaxing incision, should be

continuous, linear and well defined. Avoid repeated incisions, do not make an

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incision on bony prominence. Intrasulcular invasion follows the contour of the

labial surface of the teeth.

Reflection

Is initiated with a sharp curves end of a No. 4 molt curette or the Hu

friedly curette. The elevators are used to reflect both the mucous and

periosteum. The elevator always on the bone and never on the flap.

Hard tissue management

The average thickness of the bone overlying the mesial root of the

mandibular first molar is 4.2mm.

To penetrate the thick cortical bone a rotating No. 6 extra length surgical

bur mounted in a high speed impact hand piece should be introduced slowly.

This hand piece has an angled head that facilities easy entry and visibility and

doesn’t blow air or oil into the surgical site. Copious irrigation with a sterile

saline accompany all attempts to remove bone, [according to Fisher and Gross,

Cuelle and Wedgehood], irreversible bone necrosis is realized when

temperature exceeds 56°C.

A window is cut which is created by preparing an openings in the bone

with a long, round bur, S.H. No. 4 or 6. Two of the opening penetrate the

cortical plate adjacent to the mesial and distal sides of the root near its apical

third. The 3rd openings are connected with a superficial cut by means and tissue

burs, that is S.H. No. 701 or 702. A hand chisel Hu-Friedz No. 1 is used to

elevate and to remove the cut bone of preparation of “the window” and

exposure of the periapical tissue.

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Frequently, especially in the maxillary anterior region, the cortical bone

can be penetrated with hand chisels or hand trephines alone. Penetrating the

periapical tissue with hand instruments is more efficient than with burs, is less

likely to gauge the root and is less frightening for the patient. The window can

be extended by hand chisels.

To determine the locale of the window use the radiograph as a “road

mp”. The radiographic tooth length and root anatomy can be measured and

transferred to the mouth for orientation. The osseous topographic features

overlying the root, that is through in the mesial and distal aspects of the root

itself, are useful.

A radiographic marker, such as a small piece of gutta-percha, can be

placed on the cortical bone over the projected site of the root apex, and a

radiograph can be exposed in the usual marker. This method is accurate for

determining which str is immediately beneath the marker, and it is accessibility

is limited and orientation is uncertains.

Periapical curettage and root resection

Once apex has been located curette and remove all the pathologic soft

tissue surrounding the root down to the hard surrouding bone with a Goldman-

Rd No.3 curette or a surgical excavator. If complete curettage is obstructed by

the presence of the root, the tip should be reduced carefully by shaving if about

1-3 mm with a tapered fissure no. 70C, until the granulation tissue can be

removed for biopsy.

It is suggested that the soft tissue of the lesion surrounding the root

should be curetted in total. However this is not always possible or practical,

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especially if the lesion involves the maxillary antrum viability of the adjacent

teeth is jeopardy, or the mandibular vessels.

Occassionally, the root and apex are difficult to localize even after

removing the cortical bone. The root can be distinguished from its surrounding

by its color, morphologic features, and hardness. Root structure is harder that

the soft cancellous bone with a defined anatomic outline and a different color

when viewed in a washed and debrided operative field, Cambruzzi and

associate described use of methylene blue to identify and isolate root apex.

The decision to resect the apical tip depends on the quality of the seal

between the root canal and the surrounding periodontium. If the seal is

satisfactory, periapical curettage and removal of the pathologic tissue and the

extruded filling material will suffice.

The old concept of always resecting a root tip is no longer valid. A root

is resected when canals cant be properly obturated, such as an obturation inside

the canal, other indication for root resection are:

1. Root perforation.

2. Apical root fracture.

3. Pathologic root defects.

- Any anatomic factors that prevent the proper preparation

and sealing of the canal such as calcified, bifurcated, or lateral and

accessory canals.

High-speed fissure burs are used to resect the root end. A lingual-to-

labial bevel angled at 30-45°C to the coronal aspect of the tooth and in line of

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sight. The advent of small microscopic surgical mirrors and ultrasonic root end

preparation techniques are enabled the cut in some cases to be reduced to 0°.

Root end preparation

The basic preparation for a root end filling is best done with a small

round bur micro contra angle handpiece. The canal can be located with a sharp

explorer or horse scaler.

The depth preparation should be 2 to 3 mm and in center of the root.

Lateral over preparation may result in a weakening of the apical root structure

and development of cracks upon condensation or dimensional change of silver

amalgam.

A slot preparation is suggested where access is limited. The canal is

located and prepared to a vertical length of 3 to 5 mm with a no. 700 bur and

straight handpiece. Retention is placed with a inverted bur.

The most commonly used retrofilling material are IRM super EBA

cement, amalgam, ketac silver glass ionomer cement.

Flap closure

Following retrofilling procedure, the bone wax or ferric sulfate is

removed and the surgical site is thoroughly debrided with irrigating solution to

remove any loose particle of filling material, bone or root structure. Before

suture a radiograph should be taken to verify the removal of filling particles.

Reinjection of local anesthetic could help to control bleeding and extend

comfort to the patient.

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Repositioning of flap

The flap is closed by gently placing the most apical position of the flap

first. The flap is smoothened to place with a 2 x 2 gauge sponge so that the

natural and incisional reference points are matched.

Hamision has recommended 2 to 3 minutes of compression to develop a

thin fabrin clot under flap.

Suturing

The function of the suture is to secure the flap in its original or desired

position.

Sutures that are tightly placed compromise circulation, increase changes

of sutures to tear open once the tissues swell.

Suturing needles traumatic (eyeless Kuaged), needles which are

advantageous because of their reverse cutting edge.

- The needle should penetrate 2 to 3 mm from wound margin.

- Suture materials are divided as:

1. Absorbable (disposed by body enzymes).

2. Nonabsorbable (walled off)

E.g. : Absorbable – surgical gut (traps food)

Nonabsorbable – Silk (ethicon)

The flap is gently replaced and smoothened into position with a 2x2

gauge sponge until the incisional reference points match. The first suture

should pass through the most dependent unattached tissue and the incision can

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result in teasing of the tissue. A surgeons knot that is most effective and less

likely to slip.

Sling suspensory or circumferential suturing is an effective technique for

maximum tissue adaptation. Interrupted sutures may also be placed.

Post-operative sequelae

The following post-operative sequelae can occur after endodontic

surgery.

1. Swelling

Although swelling doesn’t occur in all the cases, it is sufficiently

common to warrant every effect to prevent it, such as by keeping trauma to a

minimum during operation.

Effective method for reducing swelling is the application of control

compress over the surgical area for 20 min. every hour post operatively.

Enzyme preparations and corticosteroids are used but are not

recommended for routine use.

2. Pain

Pain is usually minor complaint and can generally be controlled with

mild analgesics.

3. Echymosis

Discoloration of the skin from extravasation and breakdown of blood in

that area, and can travel along facial tissue planes and may appear near the

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angle of the jaw, under the eye, these “black-and blue” marks usually disappear

within 2 weeks.

4. Parasthesia

A transient parasthesia sometimes lasts from a few days to a few weeks

after root resection in any part of the jaw more likely to occur resection of teeth

in the mandible patient should be advised of this possibility before the

operation.

5. Stitch abscess

Occasionally a stitch abscess develops. Possible causes are; local

laceration of tissue during suturing, accumulations of food debris at the site of

suturing, typing the knot in the line of incisions or irritation by the suture

material itself.

6. Hemorrhage

Secondly hemorrhage is seldom observed when occur, a breakdown of

the blood clot should be suspected. If cold compresses do not stop the bleeding

an injection should be made into the area, wound should be reopened, irrigated

with local anesthetic solution, and sutured.

7. Perforation

Perforation of the antrum may occur postoperatively in any of the

maxillary teeth from cuspid to molar, it is not serious, provided no foreign

bodies are introduced, a blood clot forms and a suitable flap has been coated

and sutured properly, a prophyactic antibiotic should be considered.

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8. Iatrogenic

When the area of rarefaction is extensive and intrusive it is always

possible to disrupt the blood and nerve supply to adjacent teeth during

curettage. To prevent this complication root canal treatment and filling may be

done first.

Post surgical instructions

1. The patient should be instructed to apply an ice pack for 20-30 min.

each has the first day.

2. The patient should be raise the lip or engage in extended conversion

because such activity can tear out the sutures.

3. Should avoid brushing the teeth near the surgical site; the sutures can

ripped out inadvertently by the toothbrush.

4. A softer or semisolid diet, should be prescribed for the first few days,

after eating the patient should debride the wound by flushing it with a

saline or bicarbonate soda mouthwash.

5. Post-operative pain can be controlled with mild analgesics.

6. No unwanted, antibiotics should be prescribed, antibiotic of choice is

penicillin V, orally administered 1000mg to start, followed by 500mg 4

times daily for 3 to 4 days.

For penicillin allergic patient is erythomycin 500mg initially, then

250mg every 6 hr for 3 to 4 days.

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Additional instructions

1. In case of bleeding apply constant steady pressure, using an ice pack on

the face over the surgical site for 20-30 min.

2. In the event of an emergency, call the dentist.

3. Recall approximately 1 day later for suture removal.

Repair

The initial repairs occur across the margins of the line of incision.

Healing by first intension usually occurs within 5 days, healing takes place

across the incisional margin, the length of the incisions is not a factor, if the

suture fails or tear, then healing will occur with the fixation of granulation

tissue (second intention) lasting 4 to 6 weeks.

Repairs of periapical tissue is usually complete within a year, and

progressive repair should be noticeable on a radiographs 6 months after the

operation.

Additional surgical procedures

At times, the endodontist is called on to perform other related surgical

procedures by modifying and applying the previously described techniques

using the surgical skills and knowledge needed for periapical surgery.

Incision and drainage

When the build up of exudates penetrates the cortical plate, swelling

occur and pain diminishes, if the swelling persists, that is it localize into a soft,

fluctuant, palpable mass it should be drained by the quick, sharp thrust of the

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scalpel that the center of the soft, fluctuant mass down to the solid cortical bone

plate after attaining anesthesia (Hilton method).

Trephination

A procedure used to relieve pain, the cortical bone is perforated by

engine-driven or hand operated terpine, to release the build up of pressure and

exudates around the root apex of a tooth.

Trephination will afford emergency relief because, in effect an artificial

sinus that is prepared through which trapped exudates in the bone is released.

The site must be anesthetized, an incision made to expose and penetrate

the bone through the cortical plate with a large, round bur No. 4-8, and with a

sterile coolant. The path of penetration must be a direct line to the periapical

tissue surrouding the root apex, any deviation can cause repairable damage to

the root itself, such as from penetration into the mandibular canal or mental

foramen. Trephination is therefore used infrequently as a means of pain

control.

Hemisection and Radisectomy

Radisectomy denotes the removal of one or more roots of a molar.

Hemisection refers to sectioning of the crown of a molar tooth, with

either the removal of half the crown and its supporting root structure or

the retention of both halves to be used after reshaping and splinting as

two premolars.

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Indications for radisectomy

1. When periodontal involvement of one root is severe.

a. Untreatable furcation involvement.

b. Extensive loss of bone has occurred.

2. When endodontic treatment of one root is technically impossible or

when such treatment has failed.

3. When root has been destroyed by extensive caries.

4. Fractured root of an upper molar.

Contraindications

1. When loss of bone involves more than one root and the remaining would

have inadequate support.

2. When bridge span is long and the abutment tooth would read inadequate

support.

3. When roots are fused.

Armamentarium

- Surgical length of long shank fissure bur sizes 700, 701, 557, 588.

- Long tapered fissure diamond strokes to smoothen retained tooth

segment.

- Elevator – straight, apical elevator.

- Forceps – upper/lower forceps, universal forceps.

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- Endodontic treatment should proceed root treatment.

- A flap need not be raised if root amputation performed on

periodontally not involved teeth.

- A flap has to be reflected if the teeth is periodontally involved.

There are two methods by root amputations can be performed:

1. Vertical cut method : utilize a long shank, tapered fissure carbide bur in

airotor to section through the entire crown and root to the furcea in

gaining separation.

Advantages of vertical cut method

1. Direct visualization of bur penetrates to ensure that preparation will be

in the correct position.

2. Removal of that portion of the crown that is over the root to prevent

undesirable postoperative occlusal forces.

3. Position of each cut, based on the anatomy of the furcea, to allow the

root to cleave along desirable angles.

4. Excellent visualization of furcea after amputation.

2. Horizontal cut preparation

Horizontal cut made through the tooth without the crown being altered

in the preparation.

Cutting the tooth in this manner leaves a deep trough between the crown

and the alveolar mucosa which is obvious trap for food and debris.

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Any occlusal forces over the amputed root will be tend to put severe

stress from a undersirable direction on the remaining roots.

(Amputation procedures on mandibular molars also known as

bucispidation).

Procedure

A gentle curve is made in a 40 silver cone and inserted it through furca

from the buccal to lingual.

The rest of the procedure is as in vertical procedure for maxillary molar.

Indications for hemisecton

1. When periodontal involvement of one root is severe.

2. When loss of bone is extensive in furcation area.

3. When caries involves much of the root.

Contraindications are similar to that for radisectomy

Procedure

- The roots to be retained undergo endodontic therapy and

the pulp chamber is filled with amalgam.

- No filling material is placed into the root to be removed

for that entire half of the tooth will be extracted.

- A sharp contour explorer or periodontal probe is used to

identify the buccal and lingual furcations.

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- By first placing the tip of a high speed tapered fissure

bur in the furcation, the operator can effectively section the molar

with usually.

- An elevator should be wedged between the two halves

and slightly rotated to differentiate if the separation is complete.

- The pathologic half is extracted with forceps or eased

out with an elevator.

- The socket area, is lightly curetted and packed with bone

wax/gelform.

- This is followed by copious irrigation.

Summary and Conclusion

All endodontic procedures should ensure the placement of a proper seal

between the periodontium and the root canal foramina. When this seal can’t be

achieved satisfactorily by working through the canal system, a surgical

procedure presents visual and manipulative control of the area and placement

of the seal through the surgical site.

When failure occurs in non-surgical endodontic therapy the clinician

should be prepared to initiate alternative procedure including surgery to

enhance the rate of success.

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SURGICAL ENDODONTICS

CONTENTSContents

Introduction

History

Classification

Indication and Contraindication

Anatomic Considerations

Preoperative Consultation with the patient

Preoperative preparation and Premedication of the patient

Armamentarium

Flap Design

Surgical technique

Suturing

Postoperative sequelae

Postoperative management of the patient

Summary & Conclusion

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