Endodontic surgery

Dr. Arnab Saha

Sr. Lecturer in OMFS , GNIDSR
 Introductions
• Periradicular Surgical Procedures:-
• Periradicular surgery (PRS) is a generic term for treatment that encompasses
three main categories of surgical endodontic procedures:--
• 1. Periapical curettage of persistent periradicular disease, including removal
of the root apex (rootend resection) and retrograde filling of the root canal---
APICOECTOMY
• 2. Surgical repair of root surface irregularities such as external root resorption
defects or iatrogenic perforations.
• 3. Root resection of posterior teeth to remove diseased roots and retention of
roots suitable for further coronal restoration.

• the primary objective of all these surgical therapies is to repair any underlying
defect thereby facilitating regeneration of local dentoalveolar tissues.
 History
• first published description of a periradicular surgical procedure found by the
authors was in 1890.
• Dr Rhein---- describe the technique known today as “through-and-through”
apicoectomy as follows.----“Usually the operation presented no difficulty
and, except in the region of the antrum or mental foramen, no dangerous
anatomical points were involved. The instruments required were a sharp
spear-shaped drill to open through the process and root, and a new fissure-
bur, which, following the drill and worked laterally, severs the root. As a
rule, no anaesthetic was required…”
• ---- “To fill the root or roots, excise the diseased portion, following with a
vigorous use of the bur in the surrounding pathological tissue. If the
operation were performed under aseptic conditions and the parts kept so
until the wound was entirely healed, an immediate and radical cure resulted.”
Initial clinical establishment
• Periodontal status
• occlusal responsibility
• Presence of local infection, swelling, sinus
tracts
• Caries status of the teeth
 Why periapical surgery??

• An apicectomy is indicated when conventional nonsurgical root canal treatment

(NSRCT), with an orthograde root canal filling, has failed or is impractical & the
tooth is associated with clinical symptoms or signs of continuing periradicular
disease (PRD).
• surgical root canal procedures should not be considered as the primary treatment
option to treat teeth with associated apical pathology --- If orthograde treatment has
failed, the reason for failure should be diagnosed and, whenever possible, NSRCT
retreatment attempted.
• Surgery has been demonstrated to be more commonly performed if there are
persisting symptoms and/or progression of the periradicular lesion and in teeth
restored with post and core crowns.
 Periradicular disease lesions and
outcomes

• Associations have been made between failed root canal treatment and missing
adjacent teeth, greater plaque accumulation, the degree of marginal bone support,
a history of trauma to the treated tooth, the lack of postoperative coronal
restoration, and older patients.

• current evidence clearly identifies that the most significant factor influencing the
successful outcome of NSRCT is the presence and magnitude of a PRD lesion
prior to commencing treatment.

• it is only gradually being recognized and accepted that the host’s immune
response is an important factor in the outcome of endodontic treatment, this
having previously been largely ignored.
 Microflora of the PRD lesion
• controversy as to whether the PRD lesion per se is sterile or whether
microorganisms invade and inhabit the inflamed tissue.
• Recent investigations have reinforced the conjecture that PRD tissue contains
bacteria.
• 90% of PRD lesions contain cultivable bacteria. Nevertheless, microbes are
frequently found in only very small numbers within the lesion.
• Furthermore, only a small percentage of PRD tissue has been shown to
contain bacteria within the body of the lesion.
 Apicectomy procedures:-
• In 1970, Harty et al. published a report of 1016 periradicular surgery cases claiming a
success rate of 90%--almost 30% of their cases did not return for recall.

• two other papers published during that time, using amalgam retrograde fillings,
established prognoses following apicectomy procedures of only 59–70%.

• In 1992, Frank et al. observed that in cases where amalgam had been used as the
retrograde filling material the success rate was less than 56%.

• When using magnification and ultrasonic root-end preparation, Taschiere et al.

recorded successful outcomes in over 92% of their PRS cases.

• Employing current surgical techniques Tsesis et al, observed complete healing in 91%
of cases , in comparison to successful outcome in only 44% of cases where traditional
surgical methods were used for PRS.
• In teeth with failing root canal treatment and persisting periradicular
lesions, NSRCT retreatment is generally regarded as the treatment of
choice as this has a higher success rate than surgical procedures.

• In certain clinical situations root canal retreatment may not be feasible---

• Teeth restored with large post-core crowns may suffer root fracture on
attempting post removal and some teeth may have inaccessible canals. ----
-

According to the Royal College of Surgeons of England guidelines,

periradicular surgery may therefore be the preferred treatment option in
these cases.
• The surgical procedure aims to remove the necrotic and infected dental
root apex, curettage and remove the periradicular lesion, and seal off the
apical aspect of the root canal.
• Indeed, the apical seal of the root canal with a retrograde root filling has
been demonstrated to be a major factor towards the successful outcome
of PRS.
• several significant advances in endodontic surgical procedures over the
past decade.
• These include the development of improved root-end filling materials such
as ----
• a)mineral trioxide aggregate (MTA),
b)the introduction of magnification, and
c)the use of ultrasonics in root-end preparation
 Local anatomic considerations
Mandible:-
• PRS in the mandible,--- consideration must be given to the path of the inferior dental nerve bundle
in the mandibular canal, --- which lies in close proximity to the root apices.
• position of the mental nerve exiting through the mental foramen, --- which lies between the apices
of the lower premolars.
• If a vertical relieving incision is required when gaining access to posterior mandibular teeth, it
should be made over the mandibular canine, having carefully palpated the mental foramen.
• a more distal incision is prescribed for PRS to the molar teeth, then care must be taken to avoid the
facial artery as it crosses the border of the mandible adjacent to the first molar.
• The further posterior the tooth, the denser the overlying bone will be and the neurovascular bundle
will be closer to the root apices.
• Access to second mandibular molars may be so difficult as to preclude surgery.
• A degree of difficulty may also be experienced when attempting to access lower incisor roots.
• A shallow sulcus, especially when coupled with a prominent mandibular protuberance, together
with the lingual inclination of the roots may make access to the root apices extremely difficult.
• As 40% of lower incisors have two root canals, these difficulties may preclude adequate resection
and retrograde filling of the root apex which may ultimately lead to treatment failure.
 Maxilla:-
• principle anatomic consideration when performing PRS in the maxilla relates to the----
maxillary sinus.
• As the floor of the sinus may be only 1 or 2 mm above the root apices of the posterior
dentition, -- the risk of perforation when disease is present is relatively high.
• If preoperative assessment suggest that exposure of the sinus during surgery is a
possibility--- then incisions should be designed to ensure that the operation site can
be completely closed with a mucoperiosteal flap.
• Considerable care must be taken to prevent debris from entering the sinus during the
procedure and, if adhered to, postoperative sinus related problems may be avoided.

• other consideration in the maxilla-- relates to the position of the palatal root apices.
• impossible to access these from a buccal approach,--thereby necessitating a palatal
flap.
• the greater palatine artery may restrict the size of flap raised and access can be
difficult.
• Furthermore, replacement of palatal flaps can be challenging due to the concave
shape of the palate and the potential for blood pooling beneath the flap.
• A surgical stent for postoperative use may be prepared in advance should such
problems be anticipated
 Root and root canal morphology
• it is now accepted that root canal systems have
much greater complexity at the level of root
resection than previously recognized.
• root apex frequently possesses multiple portals of
exit
• West demonstrated that 100% of failed root canal
specimens had unfilled or underfilled portals of exit
at the apical area.
• Therefore, at least 3 mm of the root apex should be
removed to ensure the best possible chance of
successful retrograde obturation of all portals of
exit.
• The angle of resection should be as close to
horizontal as possible. •3D (CBCT) imaging is now becoming established
• The serious flaw in the traditional method of root in preoperativ assessment for PRS.
resection at an angle of 45 degree. •The detail provided by 3D CBCT imaging in
diagnosing the precise size and location of
resorption defects or periradicular pathology is
greatly beneficial over conventional radiography—
preventing trauma to important structures
 Armamentarium
The following instruments are necessary for performingan apicoectomy:
1. Microhead handpiece (straight and contra-angle) and microbur .
2. Special narrow periapical curette tips for preparation of the periapical cavity .
3. Apical retrograde micro-mirror and micro-explorers.
4. Local anesthetic syringe and cartridges.
5. Scalpel handle. 6. Scalpel blade (no. 15). 7. Mirror. 8. Periosteal elevator.
9. Cotton pliers. 10. Small hemostat. 11. Suction tips (small, large). 12. Irrigation receptacle.
13. Needle holder. 14. Retractors. 15. Periodontal curette. 16. Periapical curette.
• 17. Appropriate burs (round, fissure, inverted cone).
• 18. Miniaturized amalgam applicator for retrograde fillings .
• 19.Narrow amalgam condensers .
• 20. Scissors, needles and no. 3–0 and 4–0 sutures.
• 21. Metal endodontic ruler.
• 22.Gauze and cotton rolls/pellets.
• 23.Syringe for irrigating surgical field.
• 24.Saline solution.
Surgical Technique
The procedure for apicoectomy includes the following
steps:

1. Designing of flap.

2. Localization of apex, exposure of the periapical area

and removal of pathological tissue.

3. Resection of apex of tooth.

4. Retrograde filling, if deemed necessary.

5. Wound cleansing and suturing

 Flap design and soft tissue management
– introduction
•Before a decision is made on the design of the surgical flap in any patient,
careful assessment of the periodontal tissues and restoration margins is
essential.

•Inflamed, swollen gingivae with associated bleeding on probing indicate

the presence of plaque-related microbial disease. ---This should be
addressed before
treatment or postoperative outcomes may be compromised.

•Cause-related periodontal therapy may be supplemented with a 0.2%

chlorhexidine gluconate mouthrinse twice daily (after brushing) for 1 week
before and 1 week following the surgical procedure.

•This will significantly reduce the accumulation of plaque and enhance

tissue healing.
• Flap design depends on various factors, which mainly
include position of the tooth, presence of a periodontal
pocket, presence of a prosthetic restoration, and the
extent of the periapical lesion.

• Traditionally, three mucosal flap designs have been

described: semilunar, rectangular, and submarginal,
triangular, and trapezoidal.
 Semilunar flap
• The semilunar flap is indicated for surgical procedures of
limited extent and is usually created at the anterior region of
the maxilla, which is where most apicoectomies are
performed.
• In order to ensure optimal wound healing, the incision must
be made at a distance from the presumed borders of the bony
defect, so that the flap is repositioned over healthy bone.
• The semilunar flap, where a curved incision is made over the
root apices in the alveolar tissues, can no longer be advocated
in endodontic surgery for a number of reasons.
• The semilunar incision frequently lies over the bony defect
following the surgical procedure;

• the incision--- severs an excessively large number of blood

vessels which run vertically through the tissues &

• the natural elastic and muscle fibers tend to stretch the

wound margins making approximation difficult, with delayed
healing and impaired esthetics.
• The rectangular flap comprises two vertical
relieving incisions with a horizontal marginal
incision.
• Conversely, a triangular flap has only one The rectangular flap
relieving incision.

• However, this creates difficulty in accessing the

apical tissues without applying excessive
pressure to the flap which may result in tearing
of the tissues.
• Therefore the additional relieving incision may
be favoured to create a rectangular flap.
• Although easily repositioned, the disadvantage
of this flap design is === the potential for
gingival recession and exposure of restoration
margins.
• It is important that the relieving incisions are
placed on to sound bone.
• Referred to as the Ochsenbein-Luebke The submarginal flap
flap, the vertical relieving incisions of the
rectangular flap are commenced
approximately 2 mm from the gingival
sulcus and the horizontal incision is
made in the attached gingivae, in a
scalloped pattern to follow the natural
tissue contours.

• used where there is a good width of

attached gingiva to preserve the blood
supply and integrity of the remaining
tissue.

• Any failure here and resultant necrosis

of the residual attached gingiva will have
catastrophic esthetic outcomes.
• It must be noted that the pathological lesion, which has perforated the bone and has
become attached to the periosteum , must be separated from the flap with a scalpel.

• In case of a fistula, the fistulous tract must also be excised near the bone, because, if it
is excised at the mucosa, then there is risk of even greater perforation, resulting in
disturbances of the healing process.

• When the apicoectomy is performed at the anterior region (e.g., maxillary lateral
incisor) and there is an extensive bony defect near the alveolar crest the surgical
procedure is performed using a trapezoidal flap.

• The incision for creating the flap begins at the mesial aspect of the central incisor and,
after continuing around the cervical lines of the teeth, ends at the distal aspect of the
canine. With a periosteal elevator, the mucoperiosteum is then carefully reflected
upwards.
 Flap reflection
• Whichever flap design is selected, care should be taken to retract the entire
mucoperiosteal tissue without damage.
• Starting at a vertical relieving incision, the periosteum and mucosal tissue
should be elevated as one piece, bearing in mind that the surface of the
underlying cortical plate may be uneven.
• The flap should be elevated towards the attached gingivae, with microsurgical
instruments being used for gentle elevation of the gingival and papillary
tissues.
• The flap should extend well above the anticipated position of the root apex to
facilitate unhindered access to the surgical site without stretching or
traumatizing the retracted tissues.
• Hard and soft tissues should be kept moist by regular irrigation with sterile
normal saline throughout the operation.
 Hard tissue management:-Localization and Exposure of Apex.
• Access to the root apex is frequently facilitated through a perforation of the
cortical plate created by a sinus draining from the periradicular lesion.
• Once the flap has been raised sufficiently, the defect is identified and used as a
landmark for bone removal.
• In those cases where such a perforation has not occurred, location can be more
difficult.
• Clues may be found in that root tissue is harder than bone, cannot be marked with
a probe, is more yellow and does not bleed.
• Occasionally, a methylene blue dye may be used to outline the root surface as it
will stain the periodontal ligament.
• Careful assessment of the root length from preoperative radiographs prior to bone
removal will help in locating the root apex.
• When the buccal bone remains completely intact, then the root tip may be located with a
radiograph.

• More specifically, after taking a radiograph, the length of the root is determined with a
sterilized endodontic file or metal endodontic ruler.
• The length measured is then transferred to the surgical field, determining the exact position of
the root tip.
• Afterwards,with a round bur and a steady stream of saline solution, the bone covering the root
tip is removed peripherally, creating an osseous window until the apex of the tooth is
exposed.
• If the overlying bone is thin and the pathological lesion is large, the osseous window is
enlarged with a blunt bur or a rongeur.
• Enough bone is removed until easy access to the entire lesion is permitted.
• A curette is then used to remove pathological tissue and every foreign body or filling material,
while resection of the root tip follows.
 Resection of Apex of Tooth.
• The apex is resected (2–3mmof the total root length) with a narrow fissure
bur and beveled at a 45° angle to the long axis of the tooth .

• For the best possible visualization of the root tip the beveled surface must
be facing the dental surgeon.

• After this procedure, the cavity is inspected and all pathological tissue is
meticulously removed by curettage, especially in the area behind the apex
of the tooth.

• If the entire root canal is not completely filled with filling material or if the
seal is inadequate, then retrograde filling is deemed necessary.
• After beveling of the apex and curettage of periapical tissues, gauze impregnated with
adrenaline to minimize bleeding is placed in the bony defect.

• A microhead handpiece with a narrow round microbur is then used to prepare a cavity
approximately 2 mm long, with a diameter slightly larger than that of the root canal.

• The cavity may be enlarged at its base using an inverted cone-shaped bur to undercut the
preparation for better retention of the filling material.

• During preparation of the cavity, the dentist must pay careful attention to the width of the
cavity, which must be as narrow as possible, because there is a risk of weakening the root tip
and causing a fracture (which may not even be perceived) during condensing.
• After drying the bone cavity with gauze or a cotton pellet, sterile gauze is packed
inside the bone deficit and around the apex of the tooth, in such a way that only
the prepared cavity of the root end is exposed.

• Splattering of amalgam is thus avoided at the periapical region.

• The amalgam is placed inside the cavity with the miniaturized amalgam applicator
and is condensed with the narrow amalgam condenser
 Wound Cleansing and Suturing of
Flap.
• After placement of the amalgam, the gauze is carefully removed from the
bony defect and, after copious irrigation with saline solution

• a radiographic examination is performed to determine if there is amalgam

splattering in the surrounding tissues.

• The flap is repositioned and interrupted sutures are placed .

• Healing of the periapical area is checked every 6–12months

radiographically, until ossification of the cavity is ascertained.

• In order to evaluate the result, a preoperative radiograph is necessary,

which will be compared to the postoperative radiographs later.
 Complications

• The most common perioperative and postoperative complications

that may occur during and after the surgical procedure, respectively,
are:
• Damage to the anatomic structures in case of penetration of the nasal
cavity, maxillary sinus and mandibular canal with the bur.
• Bleeding from the greater palatine artery during apicoectomy of
palatal root.
• Splattering of amalgam at the operation site, due to inadequate apical
isolation and improper manipulations for removal of excess filling
material.
• Staining ofmucosa due to amalgam that remained at the surgical field
(amalgam tattoo)
• Healing disturbances, if the semilunar incision is made over the bony
deficit or if the flap, after reapproximation, is not positioned on healthy
bone.
• Dislodged filling material due to superficial placement, as a result of
insufficient preparation of apical cavity

• Incomplete root resection, due to insufficient access or visualization and

misjudged length of root.

• As a result, the apical portion of the root remains in position and the
retrograde filling is placed improperly, with all the resulting consequences.