HISTORY

Endodontic surgery was first recorded 1500 years ago when AETIUS, excised an acute apical absess with s all scalpel! "U##I"E$ in 1%&' stated( )*a+e an incision through the gu , along the entire length of the fang,! gu s,! This was a refine ent o.er AEITUS! The other contributors were /arror 01%%123 4hein 01%'523 6!7! 8lac+ 01%%92 and 6ar.in 01'1'2! :U44E$T#;, endodontic surgery is predictable, and often necessary procedure which is generally accepted! Surgical procedures play an extre ely i portant role in the anage ent of endodontic proble s! As failure does occur in a s all percent of cases which are non< surgically treat ent with con.entional endodontic therapy, Then apply a reasted fig - bruised raisins to the

clinicians should be prepared to initiate alternati.e procedures, including surgery to enhance the rate of success! $e.ertheless, 64=SS*A$ stated that, it is indicated in fewer than 5> of all endodontic patients! The success rate of endodontic surgery, howe.er is high, fro 5&> to ''>! ?E4SS=$ reported a successful result following root resection in 5&> of @9 teeth! S=**E4 reported '5> of success rate in resected eases! ?"I##I?S A *AB*A$ clai ed ''> success rate in 900 cases! 64=SS*A$ A$C =#EIT reported '0 to ''> of success rate! Confusion in Terminology / Misnomers ! )Apicectomy, was the ter years to describe used inDudicrously for ore than ore than 100 root

any types of endodontic surgical procedures!

The ter inology has been

odified to

ore accurately

describe the specific procedures enco passed under the heading )Surgical Endodontics ! At ?resent E )"eriradicular Surgery, is ore acceptable ter

when referring to surgical procedures perfor ed around the root! Root End Resection3 )Apicetomy, =ld Ter re o.al of the apical portion of the root! Root End #illing E describes the procedure of placing a filling into a prepared apex! )Placement of retro-filling / reverse filling , E *icro er and gra atically incorrect! < is used to describe the

Endodontic Surgery$ Is defined as a surgical procedure related to proble s of the pulpless - periodontally E in.ol.ed tooth reFuiring root a putation and endodontic therapy! I! Endodontic Surgical Tec%ni&ues can 'e Classified as follo(s$ 0:lassification by Ingle2! i2 Surgical Crainage

&

0a2 Incision 0b2 Trephination

ii2 4adicular Surgery (A) Apical Surgery 1! :urettage A 8iopsy 0?eriapical surgery2 @!Apicoecto y &! Intentional 4eplantation @! 4oot resection &! "e isection 1! 8isection II! Anot%er Classification$ 12 Surgical Crianage Trephination Incision (B) Corrective Surgery 1! *iscellaneous correcti.e

@2 4adicular surgery Apical surgery < :urettage and biopsy *echanical Corrective surgery < ?erforati.e repair 4esorpti.e < ?eriodontal repair < < Apicoecto y 4etrofilling &2 4eplace ent surgery 4eplant surgery 5 Endosteal i plant surgery 6T4 4esection

Intentional

?ost trau atic

Endodontic =sseointegrated

*ost endodontic proble s can be treated - retreated by con.entional therapy and peri<radicular surgery should not be considered a panacea when endodontic proble s arise! :lean, well obturated canals are the biological basis of endodontic success! If the canal ter inus can be reached through a coronal access, then these are the pathways to be considered!
Endodontically Treated Toot%

Failure
$o Access ;es ;es :onsiderations Surgery 4: treat ent 4ecall ?oor 4estorati.e $eed

Success
E.aluate fill $o 6ood

$o treat ent

If the canal ter inus through the coronal access ca.ity is i possible, a surgical approach should be considered! E.en then, the pulp cha ber and as uch of the root canal0s2 as

possible, should be instru ented and obturated before surgery to reduce the critical concentration of the irritant within the root

canal syste

and con.entionally close off portals of exit that

exist coronal to the apex! These are .ery few contraindications to ?a surgery! < < < < ?sychological - syste ic proble s of the patients! The practitioners experience - expertise in the procedures! Inaccessibility! Anato ical proble s i!e! unusual bone root

configurations! Anatomical Considerations$ Surgical procedures to anterior teeth are generally unco plicated and uninhibited! Gith the exception of the nasal spine and the rare nasal fistula! In the posterior region the following critical structures to root apices difficult! ?roxi ity of the ental fora en to the apices of olar! andibular a+e access

pre olar at ti es to the first

 A thic+ external obliFue ridge E in the @nd and &rd olar region 0trau atic and difficult2!

andibular

0In such cases the apex of a tooth is located in the center - lingual aspect of the the .estibule andibule, the thic+ cortical plate and the shallowness of a+e access to the apex difficult and trau a2! andibular canal( o.ing inferiorly in relation to the

The location of the

0If the radiograph shows canal

root apices, the canal is lingual to the apices! If it o.es upwards on the roots, it is buccal to the apices! o.e ent of the canal indicates that it is in close

*ini al

proxi ity to the apices2! 0I *adi *2 *esial root apex E to the superior border of the neuro.ascular bundle is about 5!& The !

axillary sinus in close proxi ity to the root apices! olar E axillary unication

?re olar,

0*ay penetrate the sinus floor and establish a co between the periodontal and the

ucoperiosteal lining of the sinus2!

A pro inent Hygo atic process that i pedes surgical access to the rest of the axillary olar teeth! olar that is closely

A palatal root of the first and @nd aligned with the greater palatine fora ina!

6ood<Fuality radiographs are essential if a critical assess ent of the position, location and angulation for root apices and of local anato ical structures is to be of .alue before surgery! COMM)*ICATIO* +ITH "ATIE*T$ < The surgical procedure should be described in details, as should all potential postoperati.e proble s such as disco fort, swelling, bleeding, brushing, possibility of paraesthesia! < < A hand drawn illustration is often useful! Alternati.e to surgery such as no treat ent, tooth extraction and referral should also put forward! < ?atient should be as+ed to sign that at tests to their understanding and acceptance of procedure, ris+s and fees! axillary antru penetration and rare

'

"REO"ERATI,E "RE"ARATIO* A*- "REME-ICATIO* O# THE "ATIE*T$ Antiseptic outhwash( According to #eo I?S 1'50,

chlorehexidine gluconate 0!@> reduces the le.els of bacteria in the oral ca.ity and play an i portant role in healing following endodontic surgery! < ?atient is instructed to rinse the solution for 1 twice daily for one wee+ prior to the surgery! AC*I$IST4ATI=$ =/ non<steroidal anti<infla atory drugs inute

before the surgical procedures helps to reduce post<operati.e pain and swelling! Ibuprofen exerts its effect by initiating the enHy e cyclo< oxygenase and pre.ents the for ation of infla atory ediators! A

dose of 900 g to @ hours 8efore surgery! And 100 g E 1 hours postoperati.ely! "owe.er the Ibuprofen causes: < *ild gastrointestinal irritation 0so should be ta+en with food2! 10 axi u daily dose should not exceed E &@00 g!

Contraindicated: < In patients with peptic ulcer!

"ARACETAMO.$ is an acceptable alternati.e for patients who need to a.oid ibuprofen, but it exhibits an anti<infla atory dyna ics!

SHORT ACTI*/ 0AR0IT)RATES$ such as pentobarbital and secobarbital are freFuently used for sedation, oral ad inistration is co on, 50<150 g, &0 inutes prior to the surgical treat ent! uscle ost

TransFuiliHers effecti.ely reduce apprehension and act as relaxants! CiaHepa E 5 g E orally E &0

inutes prior to the treat ent

narcotics can be effecti.e pre edication! ARMAME*TARI)M The suggested surgical setup for periapical surgery( 12 Anaesthesia E lidocaine, epinephrine! @2 Sterile cotton gauge E @x@! &2 ?eriosteal ele.ator! 12 Straight handpiece burs E @, 1, 9, %, && J hand chisel, sterile saline, handpiece 0st and :A2 and 52 Surgical curette! 11 icrohead contra<angle!

92 Apical a alga

carrier, plastic instru entation, a alga

plugger and condenser! 52 $eedle holder - he ostat, sil+ suture and scissors! %2 Surgical tray cotton pliers, explores, irror etc!

IM"RO,E- ,ISI0I.ITY$ < /iberoptic light source could be used, which is attached to surgical aspirators - retractors! < < *agnification of operati.e site using .isors and loupes! Surgical telescropes and icroscopes also pro.ide cresp

and undistorted i ages of operating site! < "igh tongue surgical drills are preferred E as they pre.ent subcutaneous air e physe a! HAEMOSTASIS$ < The inDection of a local anesthesia into the oral tissues before ?a surgery has @ i portant purposes( < < Anaesthesia! "ae ostasis!

1@

A*AESTHESIA I* )""ER 1A+$ < #ignocaine 0between @ and 1 l2 containing 1(50,000 adrenaline 0@> lignocaine E 1(%0,000 adrenaline is effecti.e local anaesthetic in I*#I.TRATIO*$ < < The approxi ated le.els of the root apices 0buccally2! Atte pts to inDect deeper tissues ay pro.e counter inor oral surgery2!

producti.e, because of the li+elihood of inDecting into s+eletal uscle 0because receptors are presents and causes .asodilatation2 increased bleeding rather than hae ostasis! "A.ATA. I*#I.TRATIO*$ < An incre ent of 0!& l is sufficient! Along with ner.e bloc+s! MA*-I0.E$ #ignocaine with 1(%0,000 adrenaline for( < < < Infiltration al.eolar bloc+! 8uccal n bloc+! #ingual infiltration<K

1&

#ignocaine with 1(50,000 adrenaline not used for palatal inDections E IS:"AE*IA! "AC2I*/$ < ?ac+ing foreign agents into the bony ca.ity is a contro.ersial < ethod of producing hae ostasis!

:otton, cotton wool- gauge saturated with adrenaline are least desirable aterials 0the fibres left in the crypt cause E argins

latent foreign body reaction, if trapped along the of the root end filling E i pair the apical seal2! < Agents li+e 6E#/=A* SU46I:E#
0Infla atory treat ent

are ad.ocated as local hae ostatic agents

:=##A?#U6 8=$E GAB

if left in the surgical site2

< <

:ollaplug 08ioco patible and excessi.e cost2! 15!5> ferric sulphate 0astringent2! ust be

G"ATE7E4, hae ostatic techniFue is chosen, bleeding re<established before E reapproxi ating and suturing flap! S)R/ICA. "ROCE-)RE < /lap design! 11

<

Exposure of the site! Incision /lap reflection /lap retraction =steoto y

< < < < <

:urettage and biopsy! Apicoecto y! 4etropreparation! 4etro<filling! /lap closure! /lap repositioning! Suturing!

/E*ERA. "RI*CI".ES #OR #.A" -ESI/*$ 1! lying on bone! @! Extend the flap so as to allow design to be wider at base for better .ascularity! &! adeFuate 1! Include adDacent J nor al teeth in flap for echanical accessibility and .isibility! Always place flap o.er sound bone! A.oid bony defects as flap in these areas will undergo necrosis! 15 Incision should be placed in a single fir stro+e

5!

A.oid placing incision lines o.er areas of bony pro inences as strations! ucosa here is .ery thin and can undergo fine

9! al.eolar Dunction! 5! %!

Co not extend incision beyond attached gingi.a to ucosa E As healing ta+es longer at the al.eolar ucosa

A.oid sharp

argins!

Ghile raising flap care should be ta+en to include full thic+ness flap including periosteu !

THE

0ASIC

#.A"

-ESI/*S

)SE-

I*

E*-O-O*TIC

S)R/ERY C)RRE*T.Y ARE$ < < < < < < < < < 6ingi.al flap! Se ilunar flap 0cur.ed flap2! Triangular flap 0single .ertical flap2! =chesenbein cueb+e flap! 4ectangular flap! *ini.ertical flap! TrapeHoidal flap! *odified flap! ?alatal flap!

19

Triangular flap / single 3ertical$ Indications: < < *idroot perforation repair! ?eriapical surgery! ?ost areas! Short roots! Advantages: < Easily odified! S all relaxing incision Additional .ertical incision! Extension of horiHontal co ponents! < < Easily repositioned! *aintains integrity of blood supply!

Disadvantages: < < < < #i ited access and .isibility to long roots! Tension created on retraction! 7ertical incision penetrate al.eolar 6ingi.al attach ent ser.ed! ucosa!

15

OCHEE*0EI*4.)E02E #.A" / SCA..O"EIndications: < < ?rosthetic crowns present! ?eriapical surgery! Anterior region! #onger roots < Advantages: < < < < Ease in incision and reflection! Enhanced .isibility and access! Ease in repositioning! *aintains gingi.al attach ent! ?re.ents recession! A.oids dehiscences! ?re.ents crestal bone loss! Disadvantages: < < tissue! < Cifficult to alter if siHe of lesion isDudged! "oriHontal co ponent disrupts blood supply! 7ertical co ponents crosses *6T and ay enter uscle Gide band of attached gingi.a!

1%

Rectangular flap / -ou'le 3ertical Indications: < ?eriapical surgery! *ultiple teeth! #arge lesions! #ong - short roots! < < Advantages: < < < ?ro.ides axi u access and .isibility! #ateral root repairs! /ull length root .isualiHed!

4educe retraction tension! /acilitates repositioning!

Disadvantages: < < < < Cecreases because to the flap! Increases incision and reflection TI*: 6ingi.al attach ent .iolates! Suturing is difficult!

Trape5iodal flap / -ou'le 3ertical$ Indications, Advantages and disadvantages: < Si ilar to rectangular flap!

1'

/ingi3al flap$ Indications: < < < Advantages: < < $o .ertical incision! Ease of repositioning! :er.ical resorpti.e defects! :er.ical area perforations! ?eriodontal procedures!

Disadvantages: < < < < #i ited access and .isibility! Cifficult to reflect and retract! Stretching and tearing! 6ingi.al attach ent .iolated!

SEMI.)*AR #.A" / C)R,EIndications: < < Advantages: < < < 4educes incision and reflection ti e! *aintaining integrity of gingi.al attach ent! Eli inates crestal bone loss! @0 Esthetic crowns present! Trephination!

Disadvantages: < < < < < < < Mini vertical Indications: < Advantages: < < < Cecreased tissue da age! 6ood healing! #ess .essels and ner.es are rest! Trephination! #i ited access and .isibility! Increases he orrhage! :rosses root e inences! *ay not include entire lesion! Stretching and tearing! 4epositioning is difficult! "ealing is associated with scarring!

Disadvantages: < Cecreased .isibility and accessibility!

"A.ATA. #.A"$ Indicated: < =.erextended palatal obturation - perforation!

@1

4e.iew for( < < Advantages: < < =f sling suture! It holds the palatal flap in operating position and increase access and .isibility! *axillary sinus! 4oot length!

Disadvantages: < < < < :ri ping of the tough palatal tissue! Cecreased 8S! #eads to necrosis! Sloughing of the flap!

After t%e surgical site is e6posed 'y$ Incision, flap reflection, retraction, the clinicians can consider the any ad.ances in endodontic surgical techniFues and their practice in order to ensure The following aspects are( < < "ard tissue anage ent - osteoto y! ore predictable results! aterials into

4oot end resection and preparation - apicecoto y!

@@

< <

4oot end filling

aterials!

?ostoperati.e care of the patient!

#.A" -ESI/* e!uire"ents of an ideal flap: 12 Should allow good .isual and @2 6ood .ascularity wide base! &2 Should be placed on sound bone on no bony defects! 12 Should be so placed such that adDacent 1<@ teeth be included in flap design! 52 Incisions should not be placed o.er bony pro inences! 92 A.oid sharp corners! 52 A.oid placing extending o.er *:I at it ta+es longer li its heal! %2 8ase is the widest point of the flap( The need for the width at the base is to afford sufficient circulation to the raise portion of the flap so that the edges do not beco e ische ic and later slough! '2 A.oiding incision o.er a bony defect! 102Include the full extent of the lesion! @& echanical accessibility!

112A.oid sharp corners( Tips of sharp corners ha.e a tendency to beco e ische ic before collateral circulation across the sutured tissues beco es established! 1@2A.oid incisions across a bony pro inence( Usually found in the axillary cuspid lesion, since the ucosa co.ering the e inence

is thinner than that co.ering the e inence is thinner than that co.ering the interdental bone, less circulation is a.ailable to pro.ide nutrition to the edges of a flap placed on e inence! Also, unesthetic scar for ation de.elops! 1&26uarding against possible dehiscence( *axillary bicuspids! 112A.oid the ucogingi.al Dunction( The Dunction of the attached ucosa has extre ely friable tissues! uch longer ti e to heal! olars and

gingi.a and the al.eolar Incisions placed here ta+e

152/lap should generally extend one or two teeth laterally to allow for relaxed retraction and pre.ent stretching and tearing of tissue! 192:are during retraction should be ta+en after the flap is opened the tissue retracted fro the surgical site! the underlying bone ust be held away fro

@1

152A full thic+ness

ucoperiosteal flap should be raised to

aintain

the integrity of the periosteu ! The basic flap designs used in endodontic surgery currently are( #$ %ingival flap Indications( < < < Ad.antages( < < $o .ertical incision! Ease of repositioning! :er.ical resorpti.e defects! :er.ical area perforations! ?eriodontal procedures!

Cisad.antages( < < < < #i ited access and .isibility! Cifficult to reflect and retract! ?redisposed to stretching and tearing! 6ingi.al attach ent .iolated!

&$ Se"ilunar flap (curved flap): Indications( < < Esthetic crowns present! Trephination! @5

Ad.antages( < < < 4educes incision and reflection ti e! *aintains integrity of gingi.al attach ent! Eli inates potential crestal bone loss!

Cisad.antages( < < < < < < < #i ited access and .isibility! ?redisposed to stretching and tearing! Tendency to increase he orrhage! :rosses root e inences! 4epositioning is difficult! *ay not include entire lesion! "ealing is associated with scarring!

'$ (riangular flap (single cervical flap): :onsists of a single .ertical incision and a horiHontal cre.icular incision! 7ertical incision is placed @ teeth away fro Extends fro affected tooth!

ucobuccal Dunction obliFuely to a point to interest

the gingi.al interproxi ally at '0L! The horiHontal incision is placed cre.icularly to for accessibility! the base of the flap for adeFuate .isibility and

@9

In case of greater accessibility another .ertical relining incision is placed distally! Indications( 1! In case of @! Short roots! &! ?osterior teeth! < :an be easily odified by id root perforations 0resorption -caries2!

i! Including relaxing .ertical incisor! ii! Extending horiHontal incisors! iii! :an be easily repositioned! i.! 6ood .ascularity < aintain!

:an not be utiliHed for in case of longer roots i! Tension on retractor! ii! In.ol.es al.eolar ucosa E healing decay!

iii! 6ingingi.al attach ent altered! Ad.antages( < Easily odified!

S all relaxing incisions! Additional .ertical incision! Extension of horiHontal co ponent! < < Easily repositioned! *aintains integrity of blood .essels! @5

Cisad.antages( < < < < #i ited access and .isibility to longer roots! Tension is created on retraction! 7ertical incision penetrates al.eolar 6ingi.al attach ent se.ered! ucosa!

)$ *c+senbein lueb,e flap scalloped$ The horiHontal scalloped incision is placed on pre olar attached gingi.a! 7ertical incisions are then extended bac+ into al.eolar Indicated in cases of( 1! Esthetic crowns! @! Gide band of attached gingi.a present! &! #ong roots, wide lesions! Indications: < < ?rosthetic crown present! ?eriapical surgery! Anterior region 0 axillary2! #onger roots! < Ad.antages( < 6ood .isibility and accessibility! @% Gide band of attached gingi.a! ucosa!

< < < < < < <

?reser.es attached gingi.al health! ?re.ents recession! ?re.ents crestal bone loss! $o scar tissue for ation! #onger ti e for reflection and retraction! In.ol.es al.eolar 8lood supply ucosa hence relaxation is delayed!

ay be co pro ised!

Cisad.antages( < < "oriHontal co ponent disrupts blood supply! 7ertical co ponent crosses enter < uscle tissue! isDudged! ucogingi.al Dunction and

Cifficult to alter if siHe of lesion

-$

ectangular flap: This flap is usually carried out when(

1! *ultiple teeth are in.ol.ed! @! #arge periapical lesions! &! teeth with long roots! < < < 6ood accessibility and .isibility! 7iolation of gingi.al attach ent! :re.icular bone loss!

@'

Ad.antages( < < < < Increased reflection and retraction ti e! 7ascularity co pro ised! /lap undergoes recession! Cifficult to reposition!

Cisad.antages( < Suturing is difficult!

.$ Mini vertical flap: This flap in.ol.es a single .ertical incision proxi al to the in.ol.ed apex! Indicated in cases of trephination( < < < #ess tissue da age! 7isibility and accessibility reduced! 6ood healing as less .essels and ser.ed one cut!

/$ 0alatal flaps: The need to reflect the palatal tissues of the axilla ay be

needed in certain cases! As in any flap all rules for flap design are applicable howe.er, the rich .ascular supply of the palatal area pro.ides for excellent healing in ost instances!

&0

<

?alatal flap is prepared with a scalloped incision around the gingi.al argins!

<

4elaxing incisions are generally placed between the first cuspid and bicuspid to pre.ent se.ering of the anato ose of incisi.e and palatine .essels!

Cistal incision is placed distal to second

olar on the

axillary

tuberosity to pre.ent se.ering the greater palatine .essels! < The free end of the flap could be tied the teeth on the opposite side of the arch with a suture 1$ (rape2oidal flap: To there rectangular flap but with added obliFueness of the .ertical incision! Indicated in cases of( 1! *ultiple teeth in.ol.e ent! @! #arge periapical lesions! &! #ong - short roots! Ad.antages( 1! 8etter .isibility and accessibility! aterial!

&1

@! 8lood

supply

is

co pro ised

as

large

nu ber

of

ucoperiosteal .essels are intererupted E increased hae o a! &! /lap undergoes extraction, shrin+age! 1! 6ingi.al attach ent is co pro ised! 5! :restal bone co pro ised! 9! 4ecession seen! 5! Cifficult to approxi ate! %! Increased reflection and retraction ti e!

*odified trapeHoidal flap by 7neeland 1<@ gingi.a a scalloped incision 0horiHontal is gi.en to

of

crest of

aintain the

cre.icular gingi.a intact fora en healing! The horiHontal incision gi.en is a re.erse be.el incision fro is reflected! 1! Incision allows pri ary healing to ta+e placed as incision is attached gingi.a i!e! rich in collagen fibres! @! :an be easily repositioned! &! Suturing done only on .ertical incision lines! here a full thic+ness ucoperiosteal flap

&@

Surgical Tec%ni&ue$ i) Incision

7ertical incision 0relie.ing, relaxing2 < < < Incision should be continuous, linear and well defined! A.oid treated incisions! Co not a+e an incision on bony pro inence!

Intrasulcular incision < Incision follows the contours of the labial surface of the teeth! ii2 eflection E U8E:= $o! @ double ended periosteal ele.ator, periosteal ele.ator < olt curette, "u friedy!

4eflection is initiated with a sharp con.ex end of a no! 1 olt curette or the "u friedy curette!

<

The ele.ators are used to reflect both the periosteu !

ucosa and

< <

The ele.ator always on the bone and ne.er on the flap! A thin gauHe on the flap! && ay be used for reflection to pre.ent tearing

iii)

etraction: 4etraction is placed on the bony fir ly abo.e the bony defect!

The reflected tissue should lie freely against the retractor and not be pushed or pulled against lip or chee+! The siHe of the retractor should secret the siHe of the flap! Too s all retractions will allow the tissue to flap o.er whereas too large retractors will trau atiHe the surrounding tissues! S all retractors E periosteal ele.ator! #arge E anistin, *innesota "anchan! Hard tissue management$ The a.erage thic+ness of bone o.erlying the andibular first olar is 1!@ ! esial root of the

To penetrate this thic+ cortical bone a rotating $o! 1 extra length surgical bur ounted in a high speed I pact hand piece 0?alisades

Cental2 should be introduced slowly! This handpiece has an angled head that facilitates surgical entry and .isibility and does not blow air or oil into surgical site! :opious irrigation with a sterile physiological saline should acco pany all atte pts to re o.e bone! 0according to /ister and 6ross, :a.elle and Gedgewood2 irre.ersible bone necroses is realiHed when te perature exceeds 59L:! 0A s all window is cut and a sterile &1

bro+en off head of a bar is placed in the depression, 0sterile ruler2 0window preparation2! iv) Curettage and biopsy: =nce apex has been located curettage is perfor ed with a sharp 0*olt 12 - 6old an /ox<& curette! /irst the bac+ side of a curette is used to loosen the fibrous capsule fro infla the wall! Then the loosened

atory tissue is scooped out of the ca.ity with a curette or using

Allis tissue holding forceps! It is suggested that the soft tissue of the lesions surrounding the root should be curetted in toto! "owe.er, this is not always possible or practical, especially if the lesions in.ol.es the of adDacent teeth is in Deopardy, or the The old concept that ce entu axillary antru , .itality

andibular .essels! ust be curetted away is not

based on scientific fact! A biopsy of soft tissue curette ents is reco ended as a safeguard! Use of instru ents that crush tissue, such as he ostats or needle holders is discouraged! Instru ents that puncture and grasp such as the allis forceps are ore fa.ourable for the re o.al of siHeable speci ens!

The tissue is placed in a speci en bottle of 10> for alin and sent to the laboratory for diagnosis! &5

In case of excess gutta<percha o.erfilling exists! It can be re o.ed with a fast rotating $o! 9 or % bur! The 6? should be then burnished and co pressed bac+ in the canal space with a ball burnisher! v) Apicoecto"y: 4oot end resection refers to the re o.al of the apical portion of the root best acco plished by obliFuely resecting the ost apical

portion of the in.ol.ed root with a large round bur siHe 50@ or M 9 or M %! easons for 3 : a2 This seg ent is +nown for anato ical .ariations such as accessory canals, deltas and se.ere cur.e it is also the area in which operator errors such as Hips, ledges and perforation are li+ely to occur! b2 So e apices close to the ental neuro.ascular bundle wor+ing roo axillary sinus, nasal ca.ity and ay reFuire 4E4 to pro.ide

for apical curett ent or place retrofilling! 8y

resecting the apex a buffer area of bone can fill in so the apex is not in i ediate proxi ity to the anato ic entity!

&9

Selden has described the endoantral syndro e caused by irritation of an apex to the sinus e.en though the tooth was endodontically treated and needed 4E4! *atsura, :u & care ings has suggested that an apical resection of @ to

to expose the canal and eli inate accessory canals '0L resection ust be ensure that the resection is carried co pletely through the buccal to lingual! icroscopic ultrasonic tips E ?reparation has a inutes with continuous irrigation to cool the

root fro

?reparation with 5<& depth in @<&

surface and

axi iHe cutting!

"igh speed burs are used to resect the root end! A lingual<to<labial be.el angled at &0 to 15L to the coronal aspect of the tooth E 0enhances surgical .isibility and accessibility2! vi) oot end preparation: 4etropreparation is best done with a s all round bur icro contra

angle handpiece! The canal can be located with a sharp explorer or orse scaler! The depth of penetration should be @ to & root! #ateral o.er preparation and in center of the

ay result in a wea+ening of the apical &5

root structure and de.elop ent of crac+s upon condensation or di ensional change of Ag a alga A slot preparation is suggested by *atsura where access is li ited! The canal is located and prepared to a .ertical length of & to 5 with a M 500 bur and straight handpiece! 4etention is placed with a

in.erted cone bur! Ultrasonic 4etropreparation( Sonically- ultrasonically dri.es icrosurgical retrotrips because co 1''0Ns! The pioneers in the field of ultrasonic ca.ity preparation under enhanced .isibility using a surgical operating :arr, 4ubinstein, 4euben and others! ?reparation is done with ultrasonic unit and special tips that are only O in dia eter and & in length 0about 1-10 th the siHe of icroscope are 8uchanan, only a.ailable in the early

con.entional "?2! The 4E? ti e is 1 to @ inutes! :a?=1 ce ent is a ixture of @

:a ?=1 co pounds E o.erextend, one basic E when co bined sets to for vii) hydroxyapatite! etrofilling "aterials:

&%

.iii2

The

ost co

only used retrofilling

aterials are

I4*, Super E8A ce ent, A alga , Petac sil.er glass iono er ce ent! A alga is carried to the apex with a s all P<6

retrofilling carrier siHed for retropreparations! S all P<6 retrofilling caries! *essings gun *essings gun to place a alga in deeper hand to reach areas!

Cr! 4ay onds carrier and condensor caries and condensor retrofilling instru ent de.eloped by Cr! 4ay ond! *icroscopic endodontic surgeries carried out using operating icroscopes first proposed by( < < < < Ad.antages( < < < < Surgical Tiny M Exists of accessory canals! Isth uses! icroscope E it re.eals( 8uchanan :arr 4ubinstein! 4euben!

&'

<

/ins preparation done with pieHoelecitric ultrasonic units and special!

The ad.ent of s all

icroscopic surgical

irrors and ultrasonic

root end preparation techniFues has enabled the cut in so e cases to be reduced to 0L! If the obturation coronal to the defect has been perfor ed satisfactorily, it ay be appropriate to resect only the unacceptable

seg ent of the root and not place a root end filling! 0If the apical gutta<percha is seen, it can be well burnished to the resected root tip2! 8ut if there is e.er any doubt about the Fuality of the apical seal a root end filling should be used! i4) 5lap closure /ollowing retrofilling procedure, the bone wax or ferric sulfate is re o.ed and the surgical site is thoroughly debrided with irrigating solution to re o.e any loose particles of filling aterials bone or root

structure! 8efore suture a radiograph should be ta+en to .erify the re o.al of filling particles! 4einDection of local anesthesia could help to control bleeding and extend co fort to the patient!

10

epositioning of t+e flap: The flap is closed by gently placing the ost apical portion of the

flap first! The flap is s oothed to place with a @ x @ gauge sponge so that th natural and incisional reference points are "arrison has reco ended @ to & atched!

inutes of co pression to

de.elop a thin fibrin clot under the flap! 4) Suturing The function of the suture is to secure the flap in its original or desired position! Sutures that are tightly placed co pro ise circulation, increase changes of sutures to tear open once the tissues swell! Suturing needles trau atic 0eyeless - swaged2 needles which are ad.antageous because of their re.erse cutting edge! The needle should penetrate @ to & Suture aterials are di.ided as( fro wound argin!

1! Absorbable 0digested by body enHy es2! @! $on<absorbable E 0Galled off2! E!g! Absorbable Surgical gut 0traps food23 $on<absorbable Sil+ 0Ethicon2! 11

The flap is gently replaced and s oothened into position with a @x@ gauge sponge until the incisional reference points suture should pass through the atch! The first

ost dependent unattached tissue and the

proceed through the attached tissue and be tied! A puncture too close to the incision can result in teasing of the tissue! A surgeons +not is effecti.e and least li+ely to slip! Sling suspensory or circu ferential suturing is an effecti.e techniFue for axi u tissue adaptation! 8ecause the lingual anchor is ost

lingual surface of the tooth! There is no tearing of the wea+er lingual tissue as the suture thread settle obstrusi.ely against linguo<gingi.al surface of the crown! "ostoperati3e Se&uelae The following postoperati.e seFuelae can occur after endodontic surgery! #) S6elling: Although swelling does not occur in all the cases, it is sufficiently co to a on to warrant e.ery effort to pre.ent it, such as by +eeping trau a ini u during operation!

1@

<

Effecti.e

ethod of reducing swelling is the application of inutes e.ery hour

cold co press o.er the surgical area for @0 postoperati.e! < &) ')

EnHy e preparations and corticosteroids are used! 0ain$ 3cc+y"osis The discoloration of s+in due to extra.asation and bra+down of

blood in that area can tra.el along fascial planes and

ay appear near

angle of the Daw, under the eye, nec+ and e.en chest! These bac+ and blue )) ar+s usually disappear within @ wee+s! 0arast+esia: Transparent parasthesia so eti es lasts for a few days after root resection in any part of the Daw! It is .ery rare in the -) Stitc+ abscess ?ossible causes are local laceration of tissue during suturing accu ulation of food debris or irritation of suture aterial itself! axilla!

1&

.)

7e"orr+age Secondary he orrhage is Fuite usual following root resection! If

he orrhage occurs ti e to ti e a cold co press is placed o.er the site! /) 0erforation ?erforation of the antru teeth fro cusp to ay occur postoperati.e in a axillary

olar! It is not a serious seFuale unless foreign bodies

are introduced! A suitable flap is coated and sutured properly followed by an antibiotic co.erage! 1) Iatrogenic Ghen rarefaction of area is extensi.e and intrusi.e it is always possible to disrupt blood and ner.e supply to the adDacent tooth! To pre.ent this co plication endodontic therapy should be initiated prior to surgical and Ad3ances in Endodontic Surgeries 1! Use of icroscopy and ultrasonic technology for retro

preparations! @! Use of carr surgical icro irror 0*icrons & diagra in

different shapes and angulations2! This

irror allows to chec+ for

11

co pleteness of canal wall preparation and re o.al of old fillings! &! Use of specialiHed carriers and pluggers to carry and condense the retrofilling 1! Super E8A is aterial! aterial of choice caused with $o! 1@ poor E inute pluggers 0@5 diagra ,

exca.ator condensed with burnished and tri 5! Surgical

ed and finished!

icroscope allows is deotaping for post surgery patient ade by a icro co puter .ideo

education .ideoprints can be printer!

Causes for inade&uate apical seal according to Carr$ 1! InadeFuate extent of apical preparation in a buccal<lingual direction! @! Apical preparation not in the long axis of the cnal! &! InadeFuate retention! 1! /ailures to re o.e isth us in between canals! These failures can be o.erco ed by surgeries! 15 icroscopic endodontic

"OSTO"ERATI,E MA*A/EME*T O# THE "ATIE*T ?referably the instructions should written and explained to the patient! Ice pac, and pressure: < ?atient should be instructed to apply an ice pac+ o.er the surgical site and fir ly, but gently press the pac+ on the facial tissues! < The pressures and reduction in te perature slows the flow of blood pro otes coagulation in se.ered .essels and ulti ately decreases post<operati.e bleeding and swelling! < :old reduces sensiti.ity of peripheral ner.es endings and acts as an analgesic! Application of moist %eat$ Application of oist heat on the surgical site is acceptable after

1% to @1 hours! "eat pro otes the flood flows and enhances an infla atory response that is essential for wound healing during the

first and second postoperati.e days!

19

A3oidance of acti3ity$ It should be instructed to restrain fro strenuous acti.ity for the

re ainder of the day on which the surgery was perfor ed! To pre.ent tearing of the sutures patient is instructed! 1! $o a raise the lip and loo+ at the operated area! @! Co not brush in the operated area use Diet: An adeFuate balanced diet, preferable soft foods such as eggs, ashed potatoes fruit Duices, soap, *ral +ygiene: :hlorhexidine surgery! "ain management 7 At 8 le3els$ An analgesic & operati.e days! $arcotic though contro.ersial can be prescribed hydrocodone 05!5 g2 with 550 g paraceta ol e.ery 1 to 9 hours! aintenance dose of 100 g e.ery % hourly for first outhwash thrice daily for a wee+ after the alted il+! outhwashes!

15

Incision and -rainage$ It is a standard procedure to drain an abscess! There are two proble s that acco pany this procedure firstly, opti al ti e to inter.ene and secondly obtaining adeFuate local analgesic! Ideally, the i ediate area to be incised, the pointed area should

feel soft and fluctuant under the exa inerNs fingertips! There should be a fluid thrill that is when pressure is applied the feeling should be trans itted through the fluid! The apex of the swelling whitish or yellowish! This is the ideal ti e to incise and drain! #earning the correct experience! So eti e a lesion ay be in the indurated stage! In such cases o ent of surgical inter.ention is gained by ay appear

the patient is prescribed antibiotics and hot saline rinses half hourly to bring the abscess to a head! 8ut there is not thu b rule in the incising and draining while the lesions is still in indurated stage! The second proble , that is obtaining local analgesia exists because( 1! It is difficult to establish profound analgesia for an infla ed and abscessed area! 1% atter of

@! 4eluctance to inDect into the area is because initially it is .ery painful due to increase in fluid pressure by inDecting into the region, but it also unwise to ris+ the spread of infection by the pressure of inDection! #A can be of & types( < < < Short acting E procaing @<& hours! Inter ediate acting E ?rilocaine, #ignocaine &<5 hours! #ong acting E Eliodocaine, bupi.ocaine %<10 hours! odulating pain at :$S! 8y use of

&! Acting on :$S by pre.ents opoids li+e

orphine, iodine 90<1@0 g, pestidine,

(reat"ent of pain < < < ?reoperati.e AICS or conclusteroids! #ong acting #A :entrally acting opoids!

The following guidelines for ad inistering anesthesia should be followed( < Topical anesthesia should be applied liberally followed by conduction analgesia peripheral to the site of infection! < 8loc+ anesthesia followed by conduction anesthesia is best! 1'

<

A intra ucosal wheal infiltration around the peri eter of the lesion is gi.en!

Armamentarium$ @Q x @Q gauge sponges! Three cotton swabs! =ne scalpel with $o!11 blade! =ne s all cur.ed hae ostat! =ne needle holder! =ne half cur.ed cutting needle with 000 sil+ thread! =ne suture scissors! =ne aspirator tip! Selection rubber da < < < RTN drain!

6auge is placed to catch the flow! Swab the area with disinfectant! Test the depth of anesthesia and perfor .ertical incision with a $o!11 scalpel through the a sweeping

ost pointed area

to the bone and irrigate copiously with anaesthetic solution! < Aspirate i ediately!

50

<

=pen the incised area widely by following out the tract with a hae ostat! Spread the handles of hae ostat to separate the bea+s!

< incision! <

?lace a T drain with the bar of the drain inside the

Suture the drain in place if necessary!

HEMISECTIO* "e isection refers to sectioning of the crown a olar tooth, with

either the re o.al of half of the crown and its supporting root structure or the retention of both hal.es, to be used after reshaping and splinting as two pre olars! Indications for +e"isection: 1! Ghen periodontal in.ol.e ent of one root is se.ere! @! Ghen loss of bone is extensi.e in furcation area! &! Ghen caries in.ol.es uch of the root!

Contraindication for %emisection$ 1! Ghen loss of bone in.ol.es ore than one root, and the

re aining root would ha.e inadeFuate support!

51

@! Ghen bridge span is long, and the abut ent tooth would rend inadeFuate support! &! Ghen roots are fused!

"rocedure$ < The roots to be retained undergo endodontic therapy and the pulp cha ber is filled with a alga ! < $o filling aterial is placed into the root to be re o.ed,

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! < 8y first placing the tip of a high speed tapered fissure bur in the furcation, the operator can effecti.ely section the accuracy! < An ele.ator should be wedged between the two hal.es and slightly rotated to deter ine if the separation is co plete! olar with

5@

<

The pathologic half is then extracted with forceps or eased out with an ele.ator! The soc+et area is lightly curetted and pac+ed with bone wax -gel foa ! This is followed by copious irrigation!

5&

TRE"HI*ATIO* This surgical for is used to secure drainage and alle.iate pain ed up behind the cortical

when exudates in the cancellous bone is da plate!

The tre endous pressure leads to excruciating pain of an intraosseous acute apical periodontitis or apical abscess! This intraosseous pressure can be released and the area deco pressed through trephination, which pro.ides a pathway to e pty pus and other acid exudates! After a good local anesthesia is obtained, a ini .ertical incision

pro.ides adeFuate access and land ar+ .isualiHation! < The focal area of lesions is pinpointed by exa ination, and wor+ing through the soft tissue cortical plate of bone is grossly re o.ed with a $o! % bur to identify the root apex! < The bone is then penetrated at the apex with a no! 1 bur! ay not be

Trephination speeds relief and healing, but acco panied by a great flow of exudates or pus!

51

8icuspidation( carried out when only furcation area is in.ol.ed and re aining tooth structure is nor al! In such cases the tooth usually co.er andibular olars are split in half buccolingually at furcation

area to gi.e @ pre olars which are recontoured and capped to allow proper cleaning at interdental area! RA-ISECTOMY Synony ous ( 4oot A putation 4adisecto y denotes the re o.al of one or This procedure is often done for periodontal reasons! Indications for adisecto"y: 1! Ghen endodontic treat ent of one root is technically i possible or when such treat ent has failed! @! Ghen untreatable furcation in.ol.e ent is present and re o.al of root will facilitate oral hygiene in that area! &! Ghen extensi.e loss of bone has occurred around one root of an upper olar! olar is present! ore roots of olar!

1! Ghen a fractured root of an upper

55

5! Ghen a root has been perforated and root be treated endodontically! 9! Ghen a root has been destroyed by extensi.e decay! Contraindications: 1! Ghen loss of bone in.ol.es ore than one root and the re aining

root would ha.e inadeFuate support! @! Ghen roots are fused! Armamentarium$ < Surgical length or long shan+ fissure bur siHes 500, 501, 555 and 55%! < #ong tapered fissure dia ond stones E to s oothen retained tooth seg ent! < < Ele.ators straight, apical ele.ators! /orceps upper - lower forceps!

Endodontic therapy is co pleted prior to the surgical procedure( < A flap need not be raised if root a putation perfor ed on periodontally in.ol.ed teeth!

59

<

A flap has to reflected if the teeth is periodontally in.ol.ed!

There are two

ethods by root a putations can be perfor ed(

#$ 8ertical cut "et+od: UtiliHes a long shan+, tapered fissure carbide bur in airrotor to section through the entire crown and root to the furca in gaining separation! Advantages of vertical cut "et+od: 1! Cirect .isualiHation of bur penetration to ensure that preparation will be in the correct position! @! 4e o.al of that portion of the crown that is o.er the root to pre.ent undesirable postoperati.e occlusal forces! &! ?osition of each cut, based on the anato y of the furca, to allow the root to clea.e along desirable angles! 1! Excellent .isualiHation of furca after a putation! @! "oriHontal cut preparation! "oriHontal cut is altered in the preparation! 55 ade through the tooth without the crown being

:utting the tooth in this crown and the al.eolar debris!

anner lea.es a deep trough between the

ucosa which is ob.ious trap for food and

Any occlusal forces o.er the a putated root will tend to put se.ere stress fro a undesirable direction on the re aining roots!

A"putation procedures on "andibular "olars: < "rocedure$ A gently cur.e is through furca fro ade in a siHe 10 sil.er cone and inserted it Also +nown as bicuspidiHation!

the buccal to lingual!

The rest of the procedure is as in .ertical procedure is an in .ertical cut ethod for axillary olars!

Storage "edia: 1! "8SS @! 7taspan E decreased incidence of root resorption after re i plantation!

5%

Correcti3e surgeries$ 1! ?erforati.e repairif in coronal &rd of root can be sealed using Super E8A! < If in iddle &rd and co unicating with periodontiu

then 4:T followed by pac+ing canal with :a0="2@ to pro ote ce entogenesis! < If the resorpti.e defecti.e is co unicating to oral ca.ity

then a connecti.e radicular surgery has to be perfor ed! < a alga setting2! @! ?eriodontal repair( 6uided tissue regeneration( This is based on the principle of place ent of a banus epithelial e brane that pre.ent 4aised flap E perfor 4:T fil up resorpti.e site using

- Super E8A 0Then obdurate canal co pletely in next

igration and down growth of Dunctional epitheliu

into healing periodontiu ! Thus allows blood clot to undergo regeneration in a stable en.iron ent with the proliferation of indifferent esenchy al cells to for fibroblasts, ce ento and

osteoblasts! Thus allowing plug fil s to get reattached onto the surface of a new ce entu ! These barrier e branes ay be

5'

resorbable or non<resorbable 0has to be re o.ed after 9 wee+s2 of banner e brane cortex!

Endodontic Implants$ It is a etallic extension of the root with the obDect of increasing!

1! The root to crown ratio! @! To gi.e the tooth stability in the arch! Endo i plants are useful for the treat ent of( 1! ?eriodontally in.ol.ed teeth reFuiring stabiliHation! @! Trans.erse root M in.ol.ing loss of the apical frag ent - the presence of @ frag ent that cannot be aligned! &! ?athologic resorption of the root apex incident to chronic abscess! 1! A pulpless tooth with an unusually short root! 5! Internal resorption affecting the integrity and strength of the root! 9! A tooth in which additional root length is desired for i pro.ing its al.eolar support! The success of an Endodontic i plant depends on(

90

 ?roper case selection and close adherence to the following criteria! $or al root anato y without cur.ature - defelctions! Al.eolar bone is sufficient for retention and stability of both the tooth and the i plant! Contraindicated: 1! Ghen ultiple incisors are periodontally in.ol.ed and the

adDacent teeth would ser.e as satisfactory abut ent! @! Ghen anato ic structures are close to the apex! &! The inclination of the tooth! 1! h-o bleeding proble s! 5! h-o bone infection 0 onth-any extre ities2! 9! h-o rheu atic heart disease, diabetes and other syste ic illness! The disad.antages of Endo i plants, which can result in failure( ?oor apical seal resulting in ?a rarefaction around the root apex! Extrusion of excessi.e sealer!

91

 ?erforation of the lateral root surface - perforation of a cur.ed root near the root apex! A structurally wea+ened tooth! #i itations ( 8ecause of the local anato ic factors!

Instruments$ Special instru ents and filling successful outco e( 12 Extra long 010 2 rea ers in standardiHed siHe 50 to 110! aterials are reFuired for the

@2 Special intraosseous drill! &2 Standard chro e<cobalt endodontic i plant siHes 50 to 110! Tec%ni&ue$ Anaesthetic the tooth and in.ol.ed area with a local anaesthetic! 4ubber da is applied!

Access preparation, enlarge ent and irrigation of the root canal is carried out!

9@

 #arger and wider access preparation in the clinical crown<to< acco odate the place ent of the rigid i plant )straight line,!

In addition, the root canal should be enlarged to at least the siHe of a $o! 90 instru ent! A ar+er is then set on the 10 rea er at a le.el eFui.alent to

the length of the tooth plus the nu ber of <<<< the i plant will extend beyond the root apex! Thus the bone is rea ed to the desired length! Irrigate with anaesthetic solution - saline as $a=:l the ?a tissue2! Irrigation E debrides the canal, controls hae orrhage! Cry the canal with sterile absorbent points! Select the i plant to the least eFui.alent instru ent used, score it lightly to the desired G# 0occlusal tip to cancellous bone2! I plant ust fit tightly and ust penetrate the bone to the ay irritate

prepared length!

9&

I plant E should be tried out!

ust fit at the apical fora en! If not adDust ents of the tip and then

ade by cutting of the i plant 1

Gith the help of a plugger seat the i plant during ce entation! Then the coronal portion is replaced by crown - post<type crown 0seat the i plant to the le.el corresponding to the idroot, so as

to pro.ide sufficient space to ce ent post<core crown later! 4eplantation - rei plantation is the insertion of a tooth in its soc+et after its co plete a.ulsion resulting fro trau atic inDury!

Intentional replant( is the intentional re o.al of a tooth and its reinsertion into the soc+et after orthograde obturation and resection of the root tips, resection of the root tips followed by retrograde obturation teeth! Transplantation is re o.al of a tooth - tooth bud fro and transplanting it into another soc+et! Autotransplantation /ro one soc+et to another /ro Allotransplantation one person to another one soc+et

Soc+et of the sa e person ' types of "aterials are used: 91

< < <

*etals! :era ics! ?oly ers and co posites!

95

Metals: < < < < Stainless steel! :o<:r<*o! Ti A Ti<Al .anadiu ! *etal with surface coating! 8ioglass Alu iniu =@

"ydroxyapatite $on reacti.e Conclusion Peeping in

ind, the degree of difficulty and co plexity of

endodontic cases we are currently challenged to treat de and all our resources to include surgical endodontics!

99