Surgical Endodontics1 / orthodontic courses by Indian dental academy

INTRODUCTION

It is generally accepted that non-surgical endodontics therapy

periapical inflammation or infection and allows teeth to be restored that

previously might have been extracted. However failures does occur in a

small percentage of cases. When confronted with such cases the clinician

should be prepared to initiate alternative procedures including surgery to

enhance the rate of success.

The scope of endodontic surgery has expanded beyond

apicocectomy to include crettage, radisectomy, replantation transplantation,

implantation, trephination, incision and drainage. Apicoectomy literally

means ‘Resection of the root apex’ but for many years it has been

injudiciously used to describe many types of endodontic surgical

procedures. At present the more acceptable term when referring to surgical

procedures performed around the root periradicular surgery. Chivian

suggested using the terminology non-surgical or conventional verses

surgical to describe the two endodontic procedures.

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.

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Later the procedure was refined and popularized by Hullihen in

1839.

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

amputation techniques and in 1919 Garvin demonstrated

retrofillings radiographically.

PATHWAYS BE CONSIDERED WHEN REVALUATING AN ENDODONTICALLY TREATED TOOTH

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:

1. Surgical drainage

a. Incision.

b. Trephination

2. Radicular surgery

a. Apical surgery

i. Currettage and biopsy.

ii. Apicoectomy.

iii. Retrofilling.

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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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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:

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.

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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.

Contra Indications for endodontic surgery

1. Indiscriminate surgery.

2. Poor systemic health.

3. Psychological impact.

4. Local anatomical considerations.

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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 Impact : Patients facing endodontic surgery may be terrified

by the suggestion of surgery to seek masochistic addiction to polysurgery

who is seeking the experience. Patients should be allowed to verbalize their

thought and fear are they have been informed of the operation.

Local Anatomical considerations : Short root length precludes apical root

resection if the grown root ratio should becomes so disproportionate as to

limit the useful future of the tooth.

Poor bony support : An advanced periodontal disease may well dissuade

one from endodontic surgery. On the other hand in these cases apical repair

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can be expected to develop within the 2 years following successful

endodontic treatment.

ANATOMIC CONSIDERATIONS

Maxilla Anterior Facial Region

- The lateral incisors are seldom close to the nasal

floor than the central incisors.

- The maxillary incisors and canines are often covered

with little or no labial cortical plate.

- The maxillary sinus is in close proximities to the

root apices. At times apices of the maxillary premolar and

molars may penetrate the sinus floor and establish a

communication between the periodontal ligament and

mucoperiosteal lining of 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 teeth.

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- 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:

- 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.

The mean vertical distance from the mesial root apex of first

mandibular molar to the superior border of the neurovascular bundle is

about 5.3mm.

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

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25° and the central beam directed superiorly, if in the second film the

mandibular canal waves 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

The surgical procedure should be described in detail, as should all

potential postoperative problems such as discomfort, swelling, bleeding,

brushing, maxillary anterior penetration and rare possibility of parasthesia.

- A hand drawn illustration is often useful.

- Alternative to surgery such as no treatment, tooth

extraction and referral should also put forward.

- Patient should be asked to sign that attest to them

understanding and treatment procedure, risk and fees.

PRE-OPERATIVE PREPARATION AND PREMEDICATION OF THE PATIENT

Antiseptic mouthwash : According to Loe, JPS 1970, chlorhexidine

gluconate reduces the levels of fracture in the oral cavity and plays a

important role in healing following endodontic surgery.

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Patient is instructed to rinse with the solution for 1 min twice daily

for 5 days. This regimen should begin the day before surgery.

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 effectively reduce apprehension and act as muscle

relaxants.

Diazepam, 5mg taken orally 30 minutes prior to treatment.

Narcotics can be effective premedication.

ARMAMENTARIUM

The suggested surgical set up for periapical surgery:

1. Anesthesia – lidocaine HCL 2%, epinephrine 1,80,000

2. Sterile cotton gauze.

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3. Periosteal elevator (molt 4 curette, the friedy).

4. Straight handpiece burs 2, 4, 6, 8, 33 ½ hand chisel, sterile saline,

handpiece, (st and CA) and microhead contra angle.

5. Surgical curettage.

6. Apical amalgam carrier, plastic instrument, amalgam plugger and

condenser.

7. Needle holder or hemostat, silk suture and scissors.

8. Surgical tray cotton pliers, explores, mirror etc.

Fiberoptic light source could be used, which is attach to surgical aspirators

or retractors.

Magnification of operative site using visors and loupes. Surgical

telescopes and microscopes also provide crisp undistorted images of

operating site.

High torque surgical drills are preferred to systems that rely on

compressed air as these motor engine driven system prevents the

phenomenon of cermicofacial subcutaneous air emphysema.

Haemostasis can be achieved by use of Nu gauge geefoam, bone wax or

other physical barriers.

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Cotton, cotton wool or gauze saturated with adrenaline are least desirable

materials as the residual cotton fibres left in the crypt provoke a latent

foreign body reaction.

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

promoes homeostasis by rapidly.

ANESTHESIA

[A solution of 2% lignocaine and 1;80,000 adrenaline is an effective

local Anesthetic in mirror oral surgery].

Buccal Infiltration

The specific target sites of infiltration injections are the

approximated levels of the root apices. Attempts to inject deeper tissue

may prove counter productive, because of the likelihood of injecting into

skeletal muscle.

Palatal infiltration

An increment of 0.3ml is sufficient.

Mandible

Conduction anesthetia, in which anesthetic solution is deposited

near the mandibular foramen is used for mandibular periapical surgery.

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FLAP DESIGN

Requirements of an ideal flap:

1. Base is the widest point of the flap : The need for the width at the

base is to afford sufficient circulation to the raised portion of the

flap so that the edges do not become ischemic and later slough.

2. Avoiding incision over a body defect.

3. Include the full extent of the lesion.

4. Avoid sharp corners : Tips of sharp corners have a tendency to

become ischemic before collateral circulation across the sutured

tissues becomes established.

5. Avoid incisions across a bony prominence : Usually found in the

maxillary cuspid region, since the mucosa covering the eminence is

thinner than that covering the interdental bone, less circulation is

available to provide nutrition to the edges of a flap placed on

eminence. Also, unesthetic scar formation develops.

6. Guarding against possible dehiscence : Maxillary molars and

bicuspids.

7. Avoid the mucogingival junction : The junction of the attached

gingiva and the alveolar mucosa had extremely friable tissues.

Incisions plced here take much longer time to heal.

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8. Flap should generally extend one or two teeth laterally : To

allow for relaxed retraction and prevent stretching and tearing of

tissue.

9. Care during retraction should be taken after the flap is opened the

tissue retracted from the underlying bone must be held away from

the surgical site.

10. A full thickness mucoperiosteal flap : should be raised to maintain

the integrity of the periosteum.

The basic flap designs used in endodontic surgery

1. Gingival Flap

Indications : Cervical resorptive defects.

Cervical area perforations.

Periodontal procedures.

Advantages : No vertical incision.

Ease of repositioning.

Disadvantages : Limited access and visibility.

Difficult to reflect and retract.

Predisposed to stretching and tearing.

Gingival attachment violated.

2. Seminar Flap : Esthetic crowns present

Trephination.

Reduces incision and reflection time.

Maintains integrity of gingival attachment.

Eliminates potential crystal bone loss.

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Disadvantages : Limited access and visibility.

Tendency to increase hemorrhage.

Crosses root eminences.

May not include entire lesion.

Predisposed to stretching and tearing.

Repositioning is difficult.

Healing is associated with scarring.

3. Triangular Flap :

Indications : Midroot perforation repair.

Periapical surgery.

- Posterior areas.

- Short roots.

Advantages : Easily modified

- Small relaxing incisions.

- Additional vertical incision.

- Extension of horizontal component.

Easily repositioned.

Maintains integrity of blood vessels.

Disadvantages : Limited access and visibility to longer roots.

Tension is created on retraction.

Vertical incision penetrates alveolar mucosa.

Gingival attachment severed.

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4. Ochesenbein luebke flap

Indications : Prosthetic crown present

Periapical surgery.

- Anterior region.

- Longer roots.

Wide band of attached gingiva.

Advantages : Ease of incision and reflection.

Enhanced visibility and access

Ease of repositioning.

Maintains integrity of gingival attachment.

- Prevents gingival recession.

- Avoids dehiscence.

- Prevents crestal bone loss.

Disadvantages : Horizontal component disrupts blood supply.

Vertical component crosses mucogingival junction and enter muscle tissue.

Difficult to alter if size of lesion misjudged.

5. Rectangular flapIndications : Periapical surgery.

- Multiple teeth.

- Large lesion.

- Long roots.

Lateral root repairs.

Advantages : Provides maximum access and visibility.

Reduces retraction tension.

Facilitates repositioning.

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Disadvantages : Reduced blood supply to the flap.

Increased incision and reflection time.

Gingival attachment violated.

- Gingival recession.

- Crystal bone loss.

- May uncover dehiscence.

Suturing more difficult.

6. Palatal Flaps : The need to reflect the lateral tissues of the

maxilla may be needed in certain cases. As in

any flap all rules for flap design are applicable

however, 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 first cuspid

and bicuspid to prevent severing of the

anastomose 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 the

teeth on the opposite side of the arch with

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a suture material.

7. Trapezoidal Flap :

Indications : Periapical surgery

- Multiple teeth.

- Large lesions.

- Long or short roots.

Advantages : Provides maximum access and visibility.

Reduces retraction tension.

Facilitates repositioning.

Blood supply to flap is maintained.

Disadvantages : Increased incision and reflection time.

Gingival attachment violated.

- Gingival recession.

- Crestal bone loss.

- May uncover dehiscence.

Suturing is more difficult.

SURGICAL TECHNIQUE

Vertical incision (Relieving, Relaxing) :

Incision should be continuous, linear and well defined.

Avoid repeated incisions.

Do not make an incision on bony prominence.

Intrasulcular incision:

Incision follows the contours of the labial surface of the teeth.

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Reflection

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.

A thin gauze may be used for reflection to prevent tearing on the

flap.

Retraction

Retraction is placed the bone firmly above the bony defect. The

reflected tissue should lie freely against the retraction and not be pushed or

pulled against lip or cheek.

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, Cavelle and Wedgewood],

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irreversible bone necrosis is realized when temperature exceeds 56°C. (A

small window is cut and a sterile broken off head of a bar is placed in the

depression, (sterile ruler) (window preparation).

Periradicular curettage:

Once apex has been located curette is performed with a sharp (Molt

4) / Goldman Fox- 3 curette. First the back side of a curette is used to

loosen the fibrous capsule from the wall. Then the loosened inflammatory

tissue is scooped out of the cavity with a curette.

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

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

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

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satisfactory, periapical curettage and removal of the pathologic tissue and

the extruded filling material will suffice.

The old concept that cementum must be curetted away is not based

on scientific fact. A biopsy of soft tissue curettements is recommended as a

safeguard.

Use of instruments that crush tissue, such as hemostats or needle

holders is discouraged. Instruments that pucture and grasp such as the allis

forceps are more favourable for the removal of sizeable specimens. The

tissue is placed in a specimen bottle of 10% formalin and sent to the

laboratory for diagnosis.

In case of excess gutta-percha overfilling. It can be removed with a

fast rotating No. 6 or 8 bur. The GP should be then burnished and

compressed back into the canal space with a ball burnisher.

Root end Resection:

Root end resection refers to the removal of the apical portion of the

root best accomplished by obliquely resecting the most apical portion of

the involved root with a large round bur size 702 or # 6 or # 8.

Reasons for RER

- This segment is known for anatomical variations

such as accessory canals, deltas and severe curve it is also the

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area in which operator errors such as zips, ledges and perforation

are likely to occur.

- Some apices close to the maxillary sinus, nasal

cavity and mental neurovascular bundle may require RER to

provide working room for apical curettment or place retrofilling.

By resecting the apex a buffer area of bone can fill in so the apex

is not in immediate proximity to the anatom entity.

Selden has described the endoantral syndrome caused by irritation

of an apex to the sinus even though the tooth was endodontically treated

and needed REP.

Matsura, Cummings has suggested that an apical resection of 2 to 3

mm to expose the canal and eliminate accessory canals 90° resection care

must be ensure that the resection is carried completely through the root

from buccal to lingual.

Root end preparation

Retropreparation is best done with a small round bur micro contra

angle handpiece. The canal can be located with a sharp explorer or morse

scaler.

The depth of penetration should be 2 to 3mm and in center of the

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

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structure and development of cracks upon condensation or dimensional

change of Ag amalgam.

A slot preparation is suggested by Matsura where access is limited.

The canal is located and prepared to a vertical length of 3 to 5 mm with a #

700 bur and straight handpiece. Retention is placed with a inverted cone

bur.

Ultrasonic Retropreparation

The pioneers in the field of ultrasonic cavity preparation under

enhanced visibility using a surgical operating microscope are Buchanan,

Carr, Rubinstein, Reuben and others.

Preparation is done with ultrasonic unit and special tips that are only

¼ mm in diameter and 3mm in length (about 1/10th the size of conventional

HP). The REP time is 1 to 2 minutes.

Retrofilling Materials

The most commonly used retrofilling materials 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

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structure. Before suture a radiograph should be taken to verify the removal

of filling particles. Reinjection of local anesthesia could help to control

bleeding and extend comfort to the patient.

Repositioning of the flap

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

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

the natural and incisional reference points are matched.

Harrison has recommended 2 to 3 minutes of compression to

develop a thin fibrin clot under the 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, increases chances of sutures to tear open

once the tissues swell.

Suturing needles traumatic (eyeless/swaged) needles which are

advantageous because of their reverse cutting edge.

- The needle should penetrate 2 to 3mm from wound

margin.

- Suture materials are divided as:

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1) Absorbable (digested by body enzymes).

2) Non-absorbable (walled off).

E.g., Absorbable Surgical gut (traps food).

Non absorbable Silk (ethicon).

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

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

should pass through the most dependent unattached tissue and the proceed

through the attached tissue and be tied. A puncture too close to the incision

can result in tearing of the tissue. A surgerons knot is most effective and

least likely to slip.

Sling suspensory or circumferential suturing is an effective

technique for maximum tissue adaptation. Because the lingual anchor is

lingual surface of the tooth. There is no tearing of the weaker lingual tissue

as the suture thread settle obstrusively against linguo-gingival surface of

the crown.

Interrupted sutures may also be placed.

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POSTOPERATIVE SEQUELAE

The following postoperative sequelae can occur after endodontic

surgery:

1) Swelling

Although swelling does not occur in all the cases, it is sufficiently

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

a minimum during operation.

- Effective method of reducing swelling is the

application of cold compress over the surgical area

for 20 minutes every hour post operative.

- Enzyme preparations and corticosteroids are used.

2) Pain

3) Ecchymosis

The discoloration of skin due to extravasation and breakdown of

blood in that are can travel along fascial planes and may appear near

angle of the jaw, under the eye, neck and even chest. These black and

blue marks usually disappear within 2 weeks.

4) Parasthesia

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Transient parasthesia sometimes lasts for a few days after root

resection in any part of the jaw. It is very rare in the maxilla.

5) Stitch Abscess

Possible causes are local laceration of tissue during suturing,

accumulation of food debris or irritation of suture material itself.

6) Hemorrhage

Secondary hemorrhage is quite usual following root resection. If

hemorrhage occurs time to time a cold compress is placed over the

site.

7) Perforation

Perforation of the antrum may occur postoperative in a maxillary

teeth from cuspid to molar. It is not a serious sequale unless foreign

bodies are introduced. a suitable flap is coated and sutured properly

followed by an antibiotic coverage.

8) Iatrogenic

When rarefaction of area is extrusive and intrusive it is always

possible to disrupt blood and nerve supply to the adjacent tooth. To

prevent this complication endodontic therapy should be initiated

prior to surgical.

POSTOPERATIVE MANAGEMENT OF THE PATIENT

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Preferably the instructions should written and explained to the

patient.

Ice pack and pressure

- Patient should be instructed to apply an ice pack over the surgical

site and firmly, but gently press the pack on the facial tissues.

- The pressure and reduction in temperature slows the flow of blood

promotes coagulation in severed vessels and ultimately decreases

post operative bleeding and swelling.

- Cold reduces sensitivity of peripheral nerves endings and acts as an

analgesic.

Application of moist heat

Application of moist heat on the surgical site is acceptable after 18

to 24 hours. Heat promotes the flood flows and enhances and inflammatory

response that is essential for wound healing during the first and second post

operative days.

Avoidance of activity

It should be instructed to retrain from strenuous activity for the

remainder of the day on which the surgery was performed. To prevent

tearing of the sutures patient is instructed.

1. Not raise the lip and look at the operated area.

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2. Do not brush in the opened area use mouthwashes.

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Diet

An adequate balanced diet, preferable soft foods such as eggs,

mashed potatoes, fruit juices, soap, malted milk.

Oral hygiene

Chlorhexidine mouthwash thrice daily for a week after the surgery.

Pain management

An analgesic maintenance dose of 400mg every 8 hourly for first 3

operative days.

Nacrotic through controversial can be prescribed hydrocodone

(7.5mg) with 750 mg paracetamol every 4 to 6 hours.

INCISION AND DRAINAGE

It is a standard procedure to drain an abscess. There are two

problems that accompany this procedure firstly, optimal to intervene and

secondly obtaining adequate local analgesia.

Ideally, the immediate area to be incised, the pointed area should

feel soft and fluctuant under the examiner’s fingertips. There should be a

fluid thrill that is when pressure is applied the feeling should be transmitted

through the fluid. The apex of the swelling may appear whitish or

yellowish. This is the ideal time to incise and drain.

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Learning the correct moment of surgical intervention is gained by

experience.

Some time a lesion may be in the indurated stage. In such cases the

patient is prescribed antibiotics and hot saline rinses half hourly to bring

the abscess to a head. But there is no thumb rule in the matter of incising

and draining while the lesion is still in indurated stage.

The second problem, that is of obtaining local analgesia exists

because:

1. It is difficult to establish profound analgesia for an inflamed and

abscessed area.

2. reluctance to inject into the area is because initially it is very painful

due to increase in fluid pressure by injecting into the region, but it

also unwise to risk the spread of infection by the pressure of

injection.

The following guidelines for administering anesthesia should be

followed:

- Topical anesthesia should be applied liberally followed by

conduction analgesia peripheral to the site of infection.

- Block anesthesia followed by conduction anesthesia is best.

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- A intramucosal wheal infiltration around the perimeter of the lesion

is given.

Armamentarium:

2” x 2” gauge sponges.

Three cotton swabs.

One scalpel with No. 11 blade.

One small curved haemostat.

One needle holder

One half curved cutting needle with 000 silk thread.

One suture scissors.

One aspirator tip.

Selection of rubber dam ‘T’ drain.

- Gauge is placed to catch the flow.

- Swab the area with disinfectant.

- Test the depth of anesthesia and perform a sweeping vertical

incision with a No. 11 scalpel through the most pointed area to the

bone and irrigate copiously with anaesthetic solution.

- Aspiate immediately.

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- Open the incised area widely by following out the tract with a

haemostat. Spread the handles of haemostat to separate the beaks.

- Place a T drain with the bar of the drain inside the incision.

- Suture the drain in place if necessary.

TREPHINATION

This surgical form is used to secure drainage and alleviate pain

when exudates in the cancellous bone is dammed up behind the cortical

plate.

The tremendous pressure leads to excruciating pain of an

intraosseous acute apical periodontitis or apical abscess. This intraosseous

pressure can be released and the area decompressed through trephination,

which provides a pathway to empty pus and other acid exudates.

After a good local anesthesia is obtained, a mini vertical incision

provides adequate access and landmark visualization.

- The focal area of lesion is pinpointed by examination and working

through the soft tissue cortical plate of bone is grossly removed with

a No. 8 bur to identify the root apex.

- The bone is then penetrated at the apex with a No.4 bur.

Trephination speeds relief and healing but may not be accompanied

by a great flow of exudates or pus.

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HEMISECTION

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

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

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

premolars.

Indications for hemisection:

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.

Contraindication for hemisection:

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

root would have inadequate support.

2. When bridge span is long, and the abutment tooth would rend

inadequate support.

3. When roots are fused.

Procedure

- The roots to be retained undergo endodontic therapy and the pulp

chamber is filled with amalgam.

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

entire half of the tooth will be extracted.

- A sharp cowhorn explorer or periodontal probe is used to identify

the buccal and lingual furcations.

- By first placing the tip of a high speed tapered tissue bur in the

furcation, the operator can effectively section the molar with

accuracy.

- An elevator should be wedged between the two halves and slightly

rotated to determine if the separation is complete.

- The pathologic half is then extracted with forceps or eased out with

an elevator. The socket area is lightly curetted and packed with bone

wax / gel foam.

This is followed by copious irrigation.

RADISECTOMY

Synonyms : Root amputation

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

This procedure is often done for periodontal reasons.

Indications for Radisectomy

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

when such treatment has failed.

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2. When untreatable furcation involvement is present and removal of

root will facilitate oral hygiene in that area.

3. When extensive loss of bone has occurred around one root of an

upper molar.

4. When a fractured root of an upper molar is present.

5. When a root has been perforated and root be treated endodontically.

6. When a root has been destroyed by extensive decay.

Contraindications:

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

root would have inadequate support.

2. When roots are fused.

Armamentarium:

- Surgical length or long shank fissure bur sizes 700, 701, 557 and

558.

- Long tapered fissure diamond stones – to smoothen retained tooth

segment.

- Elevators straight, apical elevators.

- Forceps upper / lower forceps, universal forceps.

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Endodontic therapy is completed prior to the surgical procedure:

- A flap need to be raised if root amputation performed on

periodontially involved teeth.

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

There are two method by root amputations can be performed :

1) Vertical cut method

- Utilizers a long shank, tapered fissure carbide bur in

airrotor to section through the entire crown and root

to the furca in gaining separation.

Advantages of vertical cut method:

1. Direct visualization of bur penetration 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 furca, to allow the

root to cleave along desirable angles.

4. Excellent visualization of furca after amputation.

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2) Horizontal cut preparation

Horizontal cut is 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.

Any occlusal forces over the amputated root will tend to put severe

stress from a undesirable direction on the remaining roots.

Amputation Procedures on Mandibular Molars

- Also known as bicuspidization.

Procedure

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

through furca from the buccal to lingual.

The rest of the procedure is as in vertical procedure is as in vertical

cut method for maxillary molars.

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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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CONTENTS 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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