CONTRAINDICATIONS:- Anatomic factors • Proximity to nerve bundles • Second mandibular molar • Maxillary sinus Periodontal status Medical factors • Leukemia or neutropenia • Uncontrolled diabetes • Recent heart surgery • Cancer • Old/ill patients Postponement of surgery • Patient’s on anticoagulants • Radiation therapy of jaw • Surgeon’s skill
Ingle’s classification Surgical drainage Incision and drainage Cortical trephination Periradicular surgery Curettage Biopsy Root-end preparation and filling Corrective surgery Perforation repair Mechanical(iatrogenic) Resorptive(internal & external) Root resection Hemisection Replacement surgery Implant surgery Endodontic implants Root form osseointegrated implants
Armamentarium:- Sterile towels 2”*2” gauze Local anesthetic equipment Aspiration equipment Irrigating syringes with sterile saline,stroko irrigator Tweezers Scalpel blades Front surface mouth mirror Probes:hooked,curved,angled Locking cotton pliers Periosteal and root-tip elevators Flap retractors Bone and periodontal curettes Tissue forceps Air impact hand piece Surgical length carbide burs Ultrasonic unit & surgical tips Root end filling material carrier Root end filling condensor Suture materials, needles,& surgical scissor Surgical operating microscope Endodontic instruments for canal preparation and obturation may also be required.
Root end resection(apicoectomy) Indications:- Biological factors(60%): Due to the persistent symptoms & the continued presence of a periradicular lesion. Technical factors(40%): Due to the presence of intraradicular posts,crowned teeth without posts,irreversible root canal filling materials & procedural accidents. Main purpose: To eliminate the cause of persistent periradicular disease. To provide good visulization & access to the periradicular disease.
Instruments used: Root is resected using any of the following burs: No.51 straight fissure bur Lindermann bone bur,multipurpose bur Finishing done with multifluted carbide bur/fine diamond bur.Extent of resection: A 3mm apical tip should be removed so as to eliminate allaccessory canals & expose isthmus, which eliminates theresidual microorganisms.Angle of resection:10 degree or perpendicular to the long axis of the tooth.This angulation decreases the no of dentinal tubulescommunicating with periradicular regions & root canals.It also helps in obtaining good cavity preparation.Reduces the forces acting in apical region which preventsfracture.Creates better environment for healing.
The 45 bevel removes more root structure & increases theprobability of overlooking important lingual anatomy.10 bevel conserves the root structure maintains a bettercrown/root ratio & increases the ability to visualizeimportant lingual anatomy. ROOT CONDITIONING:Purpose..Removes smear layer & improves the mechanical adhesion ofretrograde fillings.Exposes the dentine tetra acetic-acid. CONDITIONERS USED: 50% CITRIC-ACID-Ph,(not commonly used) 15-24% EDTA-Ph 7.3(best) Tetracycline Hcl-Ph 1%
ROOT END PREPARATION:Class-I cavity measuring a depth of 3mm along the longaxis of tooth.An ultrasonic tip can be used to prepare a cavity withoutrisk of perforation.It removes a smear layer.For bonded restorations, the cavity is shallow & entireresected surface is scalloped with deepest concavity at 1-mm depth.
Retrograde filling: It is placed in the apically resected root when canal is poorlysealed from surrounding tissue.This technique depends upon:Accessibility of the root tip in operative side.Presence of hazardous anatomic structure surrounding thesurgical site,location,cofiguration & accessibility of the apicalforamina in the resected root.Filling materials to be used.
Maxillary anterior tooth whose root apex is adjacent to thenasal fossa is in accessible because of root elongation orlingual inclination require removal of more root structure &more obliquely beveled preparation.Following factors can affect root-end preparation:I. Location of the apical foramen on a curved root.II. No.,position & shape of foramina on the resected root apex.III. Location of a foramen on the root surface such as occurs with root perforation or a lateral canal. The cavity in the beveled surface of the root is prepared for a retrograde filling with small, round burs no.1/2,1,2 inverted cone burs no.,33 1/2,34/35. Ideal preparation has smallest exposed surface at apex while encompassing all formina & extends about 2-mm inside the root canal.
The rationale for keeping the exposed surface of the fillingsmall & extending the filling deep into root to ensure anadequate continual seal.Because root resorption can occur around the cut apex, a smalldeep restoration is less likely to result in marginal leakage orbecomes a loose foreign body in the periapical tissues.
Apical seal:The most successful seal reported consists of orthogradefillingof gutta-percha & cement completing the obturation of thecanal to the root apex.It is better tolerated & causes less periapical tissue toxicity thanmost retrograde filling material.Some materials used for a retrograde fillings are zinc & zinc-free amalgam,cavit,polycarboxylate cements, zinc oxideeugenol cements,silver cones & gold foil.
Technique of packing amalgam into a prepared cavity in apical root tip follows:-Debride the operative site,wipe & dry root tip,isolae the roottip with sterile cotton pellets to prevent any seepage into thecavity & to collect any excess amalgam particles that fall intothe wound during packing & condensation.Place varnish over the prepared cavity.Pack the amalgam into the cavity using a KG retrofillingamalgam carrier, or a plastic instruments,PF/W3 acting asamalgam carrier, condense the amalgam, with retrofillingamalgam plugger,E-3.Wipe & adopt the margins of amalgam to dentin with moistcotton pellet.Remove all the cotton pellets surrounding the root apexcautiously to prevent amalgam particles trapped in the cottonfrom falling into the surrounding tissues.
Irrigate the wound with sterile saline or anesthetic solutionand aspirate the solution to debride the wound site Examine the root tip filling and surrounding tissue ,bothvisually and radio graphically to ensure that the canals havebeen properly sealed ,that the margins of amalgam to dentinare well adapted and that no foreign body amalgam particlesor pathologic tissue debris remain in the wound site. Completion of surgical procedures When the rot apex has been sealed, the operative site isdebrided thoroughly. A strong irrigating stream of saline/anesthetic solution isflushed through & is aspirated from surgical area. This procedure rids the wound of blood to make it ensurethat all pathologic tissue has been removed.
Post operative complications:SwellingPainEcchymosisParesthesiaStitch abscessHemorrhagePerforationIatrogenicIncision failure
ROOT END FILLING MATERIALS Requirements Acc. to Garther & Dorn Seals all bacteria within the canal to prevent leakage of bacteria & their leakage of bacteria & their by-products into the periradicular disease. Non-toxic Non-cariogenic Biocompatible with the host tissue Dimensionally stable Insoluble in tissue fluids(non-resorbable ) Easy to use Unaffected by moisture during setting Radio opaque Induces regeneration of PDL especially cementum.