-Endodontic surgery is the management or prevention of
periradicular pathosis by a surgical approach. In general, this
includes abscess drainage, periapical surgery, corrective
surgery, intentional replantation, and root removal.
-Apiceoctomy,cutting of apex to accessary canal with sealing and removing the
necroting cementum which presented
-The aim of surgical endodontics is to prevent noxious substances from
within the root canal causing inﬂammation in the periodontal ligament
-The objective of surgical endodontics is to achieve a satisfactory seal of
the root canal and thus prevent noxious substances entering into the
.Teeth with active periapical inflammation, despite the
presence of a satisfactory endodontic therapy.
with pridectable Failure of RCT because of:
–1 Completely calcified root canal.
–2 Severely curved root canals.
–3 Presence of posts or cores in root canal.
–4 Breakage of small instrument in root canal or the
presence of irretrievable filling material.
3-Procedural errors of RCT due to:
–1 Foreign bodies driven in to periapical tissues.
–2 Perforation of inferior wall of pulpe chamber.
–3 Perforation of root.
–4 Fracture at apical third of tooth.
1-All conditions that could be considered contraindications for oral surgery concerning the
age of the patient and general health problems ,such as
severe cardiovascular diseases, leukemia, tuberculosis, etc.
2-Teeth with severe resorption of periodontal tissues
(deep periodontal pockets, great bone destruction)...
4-Teeth whose apices have a close relationship with
anatomic structures (such as maxillary
sinus, mandibular canal, mental foramen, incisive and
greater palatine foramen) and if causing injury to these
during the surgical procedure is considered probable
1-The Traditional Periapical surgery
2- Priapical Microsurgery
TRADITIONAL PERIAPICAL SURGERY
1-Apicoctomy with retrograde filling
2-Apicoctomy with orthrograde filling
1-Apicoctomy with retrograde filling
1-Antibiotic.A preoperative dose of penicillin V potassium (2.0 g) or
clindamycin (600 mg) 1 hour before surgery should be considered by the
3-Flap Design. There are three principal ﬂap designs for surgical endodontics
The semilunar design avoids the gingival margin, and
there is less risk of recession of the gingival tissues
after surgery . However, there are three main disadvantages:
● surgical access to the apical tissues may be
● it is often difﬁcult to ensure the incision line
ends up resting on bone
● the ﬂap sometimes results in wound
The three-sided ﬂap provides excellent access for most surgical endodontic procedures.
There should be no undue tension on the ﬂap while it is being retracted.
A modiﬁcation of the three-sided ﬂap leaves a 3- to 4-mm rim of gingival tissue in situ. This design
usually provides satisfactory access to the apical tissues
TWO SIDED FLAP
A relieving incision is made in the oral mucosa
of the buccal sulcus, and the incision is extended
around the gingival margin of the tooth to be treated
. is preferred wherever possible. An advantage of
this type of incision is the ease of repositioning of
the ﬂap after surgery. In most circumstances access
to the apical tissues is satisfactory. If access is not
sufﬁcient, the gingival margin incision can be
extended distally as far as is required, but failing
that, a second relieving incision may be used; the
ﬂap is now a three-sided design.
Full-thickness flap is raised with sharp elevator in firm contact with bone. Enough
tissue is raised to allow access and visibility to apical area.
A sharp probe is pushed through the buccal cortical plate to identify the pathological
cavity If there has been loss of buccal bone through pathological resorption
A medium size (5 or 6) round bur is then used to create a window in the buccal bone
and expose the apical tissues
5-CURETTAGE OF THE APICAL TISSUES
Curettage is undertaken to remove foreign bodies such as excess root-ﬁlling material
within the tissues. Any periapical soft tissue is removed with a curved excavator or a
Approximately one third of apex is removed with tapered bur.
The angle of the bur cut relative to the long axis of the tooth is generally 45° for maxillary
teeth and greater than 45° for mandibular teeth.
7-RETROGRADE CAVITY PREPARATION
A retrograde cavity approximately 2–3 mm deep is prepared in the cut surface of
the apex of the root to accommodate the root-end ﬁlling.
A head bur or ultrasonic cutting tip is used to cut retentive axial cavity walls to
contain the root-end ﬁlling
A root-end ﬁlling is inserted into the retrograde cavity preparation to seal the root
surface. Many dental materials have been used, amalgam, gutta percha, gold
foil, polycarboxylate cement, Intermediate Restorative Material (IRM®), Super
EBA® (ethoxybenzoic acid) cement, composite resin, glass ionomer cement.
Though expensive, mineral trioxide aggregate an ‘ideal’ root-end ﬁlling material.
2-Apicoctomy with orthrograde filling
Which is called the conventional apiceoctomy , it has the same principles of •
the retrograde one except there is no preparation of periapical area .they use
the guttapercha as a orthograde filling material but they found that this firstly
expand and then shrink so they not be recommended now day
The apicocurettage has the same principles of apiceoctomy with retrograde filling but it
is apiceoctomy without resection of the root tip.
It is beter to do apiceoctomy rather than apicocurettage because it will be apiceoctomy
at the end.
-Microsurgery is defined as a surgical procedure on exceptionally small and complex structures
with an operating microscope. The microscope enables the surgeon to assess pathological changes
more precisely and to remove pathological lesions with far greater precision,
thus minimizing tissue damage during the surgery.
-Endodontic microsurgery, as it is now
called, combines the magnification and illumination
provided by the microscope with the proper use of
new micro instruments
-The advantages of microsurgery include easier
identification of root apices , smaller osteotomies
and shallower resection. In addition, reveals
anatomical details such as isthmuses, canal fins,
micro fractures , and lateral canals. Combined
with the microscope, the ultrasonic instrument
permits conservative, coaxial root-end
preparations and precise root-end fillings
Semilunar flap, is no longer recommended because of inadequate access and scar formation
Second, the removal of sutures is done within 48 to 72 h, not a week
Third , new suture materials are monofilament, gauge 5 provide rapid healing
Fourth, the papilla base incision (PBI) has been developed to prevent loss of interdental
papilla height with sulcular incisions
Fifth , flap retraction during the surgery is facilitated The wider base of the flap was an unnecessary
by making a resting groove in the bone, especially procedure, and it creat a lasting scar.
during mandibular posterior surgery, to ensure
CLASSIFICATION OF ENDODONTIC MICROSURGICAL CASES
sulcular or mucogingival incisions were chosen
cotton pellets soaked in 0.1% epinephrine and/or ferric sulfate were applied topically as required
The tissue was gently reflected toward the apical area with Molten 2– 4 curette
Osteotomies were performed with an bone cutter in an Impact Air 45 handpiece . A curette
and a scaler were used for periradicular curettage. A 3-mm root tip with a 0- to 10-degree
bevel angle was sectioned with a 170-tapered fissure bur under copious
water-spray. Root-end preparation s extending 3 mm into the canal space along the long axis
of the root were made with ultrasonic tips driven by ultrasonic unit
Retrograde filling material
Amalgam was the first retrograde filling material used, replaced for the most
part by zinc oxide-containing materials such as IRMg and Super EBAg, and now
the most ideal material available is MTA. MTA is not only biocompatible but has
been shown to have the capability of inducing bone, dentin, and cementum
formation Consistent use of MTA resulted in regeneration of periapical tissue
including periodontal ligament and cementum.
Er:Yag lasers have been used for apical surgery.
The Er:YAG laser can make an incision for flap lifting. This laser
produces a wet incision (some bleeding) as opposed to a dry
incision (no bleeding) produced by current CO2 lasers.
Detoxification of the infected site by lasing directly on the bone – studies
have shown that Er:YAG laser energy effects on bone include bacterial
Ablation of alveolar bone tissue with the Er:YAG
laser can be used for remodelling, shaping and
ablation of necrotic bone.
Vaporisation of granulation tissue is efficient with the Er:YAG
laser, offering a lower risk of overheating the bone than that posed by
the current diode or CO2 lasers.
Root apex resection using the Er:YAG laser in contact mode and
preparation of the apex cavity for retrograde
Er:YAG laser causes no vibration and discomfort while cutting bone and dentin and less
damage to soft tissues and bone, as well as less contamination of surgical sites.
1-The Er:YAG system can be used for osteotomies and root resections but the
procedure requires more time than a preparation with burs.
2-While the Er:YAG laser may promote faster healing and more comfortable postoperative
results according to the manufacturer, the root-end preparation cannot be done with the
laser and the procedure still requires microsurgical ultrasonic preparation and filling.