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ENDODONTIC SURGERY   INDIAN DENTAL ACADEMY Leader in Continuing Dental Education   www.indiandentalacademy.com
INTRODUCTION   Over the years Endodontic surgery has seen great advancements due to the    advent of new technology.This ...
HISTORICAL PERSPECTIVE.   The first ever Endodontic surgical procedure    was incision & drainage,of an acute    endodont...
OBJECTIVE OF ENDODONTIC           SURGERY.   The surgery ensures the proper seal between    the Periodontium and the root...
INDICATIONS.   Need for surgical drainage.   Failed non surgical endo treatment.1.Irretrievable root canal filling mater...
  Biopsy Corrective Surgery1.Root Resorptive Defects.2.Root Caries.3.Root Resection.4.Hemisection.5.Bicuspidization. Re...
CONTRAINDICATIONS.   GENERAL CONTRAINDICATIONS1.MEDICALLY COMPROMISED PATIENTS:With active systemic    diseases such as D...
   LOCAL CONSIDERATIONS.1.LOCALISED ACUTE INFLAMMATION:Periapical Surgery is    contraindicated2.ANATOMIC CONSIDERATIONS:...
   PRE OPRERATIVE CONSULTATION    A necessary informed consent is to be taken from the    patient.Assurance should be giv...
SURGICAL DRAINAGE.   INDICATIONS:Purulent &/or hemorrhagic exudate forms within the soft tissue   or the alveolar bone as...
   INCISION-Surgical area should be isolated with sterile 2x2 gauze sponges.-Incision should be horizontal and placed at ...
CORTICAL TREPHINATION    It is a procedure involving the perforation of the central cortical plate to accomplish     the ...
www.indiandentalacademy.com
PERIRADICULAR SURGERY   Thoroughly trained dental practitioner and staff is necessary and    instruments ,equipment and s...
   CONCEPTS & PRINCIPALS OF PERIRADICULAR    SURGERY.1.Local anesthesia and Hemostasis2.Management of soft tissues.3.Mana...
 LOCAL ANESTHESIA & HEMOSTASIS: OBJECTIVES.1. To obtain profound and prolonged anesthesia.2. To provide good hemostasis ...
   SOFT TISSUE MANAGEMENT: -Surgeons goal must be to minimize the trauma to both the soft and hard   tissues involved in ...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
    INCISIONS:Accomplished by using 1 or 4 scalpel blades No11,12 ,15     and 15c.    -Horizontal incision should be made...
    FLAP RETRACTION: Process of holding in position the reflected soft     tissues.    -Accomplished by a tissue retracto...
     HARD TISSUE MANAGEMENT    -Following the reflection & retraction of the mucoperiosteal flap,surgical access must be ...
-Once the soft tissue has been freed along the periphery of the lesion, the      bone curette should be turned with the co...
www.indiandentalacademy.com
www.indiandentalacademy.com
   Angle of root end resection: In periradicular surgery should be 30-45    degrees from the long axis of the root facing...
   ROOT END PREPERATION-   OBJECTIVES:To create a cavity to receive a root canal filling.   PROCEDURE:-Surgical Hemosta...
   ROOT END FILLING: The purpose of the root end filling is to                                                           ...
   MTA-MINERAL TRIOXIDE AGGREGATE:    Presently used root end filling material    Composed of Calcium and phosphorus ions...
www.indiandentalacademy.com
   SMEAR LAYER REMOVAL:    -Irrigation with tetracyclin removes the smear layer.    -Doxycyclin can also be used because ...
    SOFT TISSUE REPOSITIONING & SUTURING     -Final step in periradicular surgical procedure are wound closure & soft    ...
     SUTURING:    -OBJECTIVE: Approximate the incised tissues and stabilize the flapped  mucoperiosteum until reattachmen...
POST SURGICAL CARE AFTER ENDO                    SURGERY   Two important components of post surgical care are 1.Genuine ex...
COMPLICATIONS & MANAGEMENT   BLEEDING AND SWELLING: Slight oozing of blood from several    microvessels may be evident fo...
  DISCOLORATION: Seen in the mucoperiosteal or facial tissues,is a result   of the breakdown of the blood that has leaked...
  ORAL HYGINE: Tooth brush in the surgical area should not be used as it   may dislodge the mucoperiosteum flap. -A cotto...
CORRECTIVE SURGERY.   Corrective surgery is categorized as surgery involving the correction of    defects in the body of ...
    PERFORATION REPAIR:    Perforation occuring on the mesial roots of the maxillary and mandibular    molars are usually...
    PERIODONTAL REPAIR:    GUIDED TISSUE REGENERATION: is a procedure used to regenerate     lost periodontal structures...
   ROOT BISECTION /    BICUSPIDIZATION :Refers to a    division of the crown that leaves the    two halves and their resp...
    SURGICAL CORRECTION OF THE RADICULAR LINGUAL GROOVE:     Radicular lingual groove commonly seen in the maxillary late...
4.)Non Surgical & surgical treatment have failed & symptoms / pathosis persists.5.)Visual access inadequate to perform roo...
8.)Extraction socket should be irrigated with normal saline and gently   suctioned to remove any blood clot that may have ...
IMPLANT SURGERY.  There are 2 types of endosteal implants:-1. Endodontic Implants.2. Osseointegrated implants/Endosseous ...
OSSEO INTEGRATED IMPLANTS. www.indiandentalacademy.com
  PROCEDURE: EXTRATION & CURETTMENT PROCEDURE : Tooth should be extracted   with as little trauma as possible. - It is i...
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     SUPPORTIVE THERAPY: Following immediate implant placement a      broad spectrum antibiotic such as Amoxyillin,Cephal...
CONCLUSION   A surgical approach to a failed root canal treatment should only be    considered when an orthograde approac...
www.indiandentalacademy.com
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Endodontic surgery / / rotary endodontic courses by indian dental academy

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Transcript of "Endodontic surgery / / rotary endodontic courses by indian dental academy"

  1. 1. ENDODONTIC SURGERY INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
  2. 2. INTRODUCTION Over the years Endodontic surgery has seen great advancements due to the advent of new technology.This field has progressed beyond Apicectomy (Root Resection,Root Amputation),to include periapical curettage,radiosectomy,replantation,implantation,trephination & incision for drainage. Root resection is the most common form of periapical surgery. The success rate of Endodontic surgery is high but it is used only in certain cases,when the normal conventional treatment has failed. www.indiandentalacademy.com
  3. 3. HISTORICAL PERSPECTIVE. The first ever Endodontic surgical procedure was incision & drainage,of an acute endodontic abcess performed by Aetius 1500yr ago in Greece. Abulcasis,Fauchard,Hullihan,Martin,Partisch & Black were the poineers who refined Endodontic surgery. www.indiandentalacademy.com
  4. 4. OBJECTIVE OF ENDODONTIC SURGERY. The surgery ensures the proper seal between the Periodontium and the root canal foramina. When this seal cannot be achieved satisfactorily by working through the canal system (orthograde filling), a surgical procedure permits visual and manipulative control of the area and placement of the seal through the surgical site. www.indiandentalacademy.com
  5. 5. INDICATIONS. Need for surgical drainage. Failed non surgical endo treatment.1.Irretrievable root canal filling material2.Irretrievable intraradicular post. Calcific Metamorphosis of the pulpal space. Procedural errors.1.Instrument Fragmentation2.Non negotiable ledging3.Root perforation4.Symptomatic Overfilling Anatomic variations1.Root Dilaccertions2.Apical root perforations. www.indiandentalacademy.com
  6. 6.  Biopsy Corrective Surgery1.Root Resorptive Defects.2.Root Caries.3.Root Resection.4.Hemisection.5.Bicuspidization. Replacement Surgery.1.Intentional Replantation.2.Post traumatic Implant surgery1.Endodontic2.Osseointegrated. www.indiandentalacademy.com
  7. 7. CONTRAINDICATIONS. GENERAL CONTRAINDICATIONS1.MEDICALLY COMPROMISED PATIENTS:With active systemic diseases such as Diabetis,Tuberculosis,Syplillis,Nephritis,Blood dyscrasis,Osteoradionecrosis or any other medical condition which restricts the surgicsl procedure.2.EMOTIONALLY DISTRESSED PATIENT:Psycologically weak patients who cannot withstand and cope with the surgical procedures.3.LIMITATIONS in the surgical skill and experience of the operator. www.indiandentalacademy.com
  8. 8.  LOCAL CONSIDERATIONS.1.LOCALISED ACUTE INFLAMMATION:Periapical Surgery is contraindicated2.ANATOMIC CONSIDERATIONS:Nasal floor,Maxillary sinus,Mandibular canal,Mental Foramen,Greater palatine vessels.3.INACCESIBLE SURGICAL SITES:Lingual surface of molars or external oblique ridge of the Mandible.4.TEETH WITH POOR PROGNOSIS. www.indiandentalacademy.com
  9. 9.  PRE OPRERATIVE CONSULTATION A necessary informed consent is to be taken from the patient.Assurance should be given to the patient that he will be treated expertly. PREMEDICATION. Pentobarbital and Secobarbital 50-150 mg 30min prior to the surgical procedure may be given orally IM/IV Tranquilizers like Meprobromate 400 mg 4 times daily for several days prior to tratment or Diazepam 5mg taken orally 30 min prior to treatment is effective. www.indiandentalacademy.com
  10. 10. SURGICAL DRAINAGE. INDICATIONS:Purulent &/or hemorrhagic exudate forms within the soft tissue or the alveolar bone as a result of a syptomatic periradicular abcess It is accomplished by1. Incision & Drainage of soft tissue.2. Trephination of Alveolar Cortical plate. INCISION & DRAINAGE. Incision should be made through the focal point of the localized swelling to relieve pressure,eliminate exudate and toxins and stimulate healing. LOCAL ANESTHESIA. Nerve block is the preferable method. Some blocks must be supplemented with the infiltration to obtain adequate anesthesia. Oral mucosa in the area to be injected should be dried with 2x2 gauze and a topical anesthetic placed. www.indiandentalacademy.com
  11. 11.  INCISION-Surgical area should be isolated with sterile 2x2 gauze sponges.-Incision should be horizontal and placed at the dependent base of the fluctuantarea.-Incision should be made using a scalpel and blade that is pointed such asNo11or No 12.-Exudate should be aspirated and if indicated a sample collected forBacteriologic culturing. PLACEMENT OF A DRAIN.-Made of either iodoform gauze or rubber dam material cut in an “H” or-Christmas tree shape.-Can be sutured in place for additional retention-Should be removed after 3-4 days. www.indiandentalacademy.com
  12. 12. CORTICAL TREPHINATION It is a procedure involving the perforation of the central cortical plate to accomplish the release of pressure from the accumulation of the exudate within the alveolar bone. INDICATIONS Patients who present with moderate to severe pain but with no intraoral or extraoral swelling. OBJECTIVES. To create a pathway through the cancellous bone to the vicinity of the involved periradicular tissues. PROCEDURE -An incision is made through the mucoperiosteal tissue and perforated through the cortical plate with a rotary instrument. -The most recommended site is at or near the root apex. -A reamer of K-type file is then passed through the cancellous bone into the vicinity of the periradicular tissues. - Cortical trephination is initiated from the buccal side and never from the palatal or lingual side. www.indiandentalacademy.com
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  14. 14. PERIRADICULAR SURGERY Thoroughly trained dental practitioner and staff is necessary and instruments ,equipment and supplies must be readily available in the treatment room. The potential for possible complications must be anticipated and incorporated into pre surgical planning. Good communication with the patient is essential for a thorough surgical preparation. A signed consent form must be taken from the patient prior to surgery. Pre surgical mouthrinse will improve the surgical environment as it decreases the bacterial contamination on the tissues,thereby reducing the inoculation of microorganisms into the surgical wounds. www.indiandentalacademy.com
  15. 15.  CONCEPTS & PRINCIPALS OF PERIRADICULAR SURGERY.1.Local anesthesia and Hemostasis2.Management of soft tissues.3.Management of Hard tissues.4.Surgical Access,both Visual and operative.5.Access to root structure.6.Periradicular Curettage.7.Root end resection.8.Root end preperation9.Root end filling10.Soft tissue repositioning and suturing.11.Post surgical care. www.indiandentalacademy.com
  16. 16.  LOCAL ANESTHESIA & HEMOSTASIS: OBJECTIVES.1. To obtain profound and prolonged anesthesia.2. To provide good hemostasis both during and after surgical procedure. SELECTION OF THE ANESTHEIC AGENT:Lidocaine Hydrochloride is the commonly used agent. SELECTION OF VASOCONSTRICTORS: Epinephrine is the commonly used. SITE OF INJECTION. www.indiandentalacademy.com
  17. 17.  SOFT TISSUE MANAGEMENT: -Surgeons goal must be to minimize the trauma to both the soft and hard tissues involved in the surgical procedure -Most of the periradicular procedure requires the raising of the mucoperiosteal flap. CLASSIFICATION OF SURGICAL FLAPS . 1.Full mucoperiosteal flap a.Triangular (one vertical relasing incision). b.Rectangular c.Trapezoidal d.Horizontal 2.Limited Mucoperiosteal flap. a.Submarginal curved b.Submarginal scalloped rectangular. www.indiandentalacademy.com
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  23. 23.  INCISIONS:Accomplished by using 1 or 4 scalpel blades No11,12 ,15 and 15c. -Horizontal incision should be made first followed by vertical releasing incisions,by holding the scalpel handle in a pen grasp,initial incision stroke must penetrate the mucosa & gingiva followed by a second that penetrates the periosteum to the surface of the cortical bone . FLAP REFLECTION: The process of separating the soft tissues from the surface of the alveolar bone.This process should begin in the vertical incision. -A periosteal elevator is used to elevate the periosteum &its superficial tissues from the cortical plate. -The periosteal elevator is inserted between the periosteum & bone,it is directed coronally. -This technique allows for all directive reflective forces to be applied to the periosteum & bone.It is referred to as undermining elevation. www.indiandentalacademy.com
  24. 24.  FLAP RETRACTION: Process of holding in position the reflected soft tissues. -Accomplished by a tissue retractor . -After retraction the periosteal surface of flap should be frequently irrigated with saline. www.indiandentalacademy.com
  25. 25.  HARD TISSUE MANAGEMENT -Following the reflection & retraction of the mucoperiosteal flap,surgical access must be made through the cortical bone to the roots of the teeth. - Cutting of osseous tissue with a No 6 or No 8 round bur produces less inflammation and results in smoother cut surface and a shorter healing time PERIRADICULAR CURETTAGE. -Removal of periradicular inflammatory tissue is accomplised by sharp surgical bone curettes & angled periodontal curettes. -A local anesthetic with a vasoconstrictor is injected into the soft tissue mass. -Largest bone curette is placed between the soft tissue mass and the lateral wall of the bony crypt with the concave surface of the curette facing the bone. -Pressure should be applied around the lateral margins of the lesion. www.indiandentalacademy.com
  26. 26. -Once the soft tissue has been freed along the periphery of the lesion, the bone curette should be turned with the concave portion toward the soft tissue and used in a scrapping fashion,to free the soft tissue from the deep walls of the bony crypt. ROOT END RESECTION : INDICATIONS1. Biologic –Persistent symptoms -Presence of a periradicular lesion2. Technical-Interradicular posts -Crowned teeth without posts. -Irretrievable root canal filling materials. -Procedural accidents. INSTRUMENTATION: Ingle et al recommended the use of No 702 tapered fissure bur or No 6 or No 8 round bur in the low speed straight handpiece. EXTENT OF ROOT END RESECTION :Root should be resected to the level of healthy bone since the portion of the root that extended into the diseased tissue was infected and the cementum was necrotic. www.indiandentalacademy.com
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  29. 29.  Angle of root end resection: In periradicular surgery should be 30-45 degrees from the long axis of the root facing toward the buccal or facial aspect of the root ,to provide enhanced visibility to the resected root end & operative access to enable the surgeon to accomplish a root end preparation with a bur in low speed handpiece. Once the desired extent & bevel of the root end resection have been achieved the face of the resected root surface should be carefully examined to verify that complete circumferential resection resection has been accomplished. This can be accomplished by a fine,sharp explorer around the periphery of the resected root surface. If incomplete resection is in doubt,some amount of Methylene blue is applied to the root surface for 5-10 sec. After this area has been irrigated with sterile saline,the periodontal ligament will appear dark blue thereby highlighting the root outline. www.indiandentalacademy.com
  30. 30.  ROOT END PREPERATION- OBJECTIVES:To create a cavity to receive a root canal filling. PROCEDURE:-Surgical Hemostasis is achieved bt the use of hemostatic agents like Bone wax,Epinephrine,Ferric sulfate,Thrombin,Calcium Sulfate,Gelatin,Absorbable collagen. -Preparation of Class1 cavity down the long axis of the root within the confines of the root canal using either a small round or inverted cone bur in a contra-angle or straight handpiece. -Recommended depth of the preparation ranged from 1-5mm . ULTRASONIC ROOT END PREPERATION:Use of ultrasonics in root end preperation has become very popular and has many advantages over the traditional bur type preparation. ADVANTAGES: 1.Smaller preparation 2. Less need for a root end bevelling 3. Deeper preperation . 4. More parallel walls for better retention www.indiandentalacademy.com
  31. 31.  ROOT END FILLING: The purpose of the root end filling is to . establish a seal between the root canal space and the periapical tissue IDEAL REQUISITES FOR ROOT END FILLING MATERIALS : 1. Prevent the leakage of Bacteria and their byproducts into periradicular tissues. 2. Non toxic 3. Non cariogenic. 4. Bio compatible. 5. Insoluble in tissue fluids. 6. Dimensionally stable. 7. Easy to use. 8. Radio opaque. : MATERIALS USED Gutta percha,Amalgam,Cavit,Intermediate restorative material(IRM),Super EBA,Glass ionomer,Composite resins, Carboxylate cements,Zinc Phosphate cement,Zinc oxide eugenol&Mineral trioxide aggregate(MTA). www.indiandentalacademy.com
  32. 32.  MTA-MINERAL TRIOXIDE AGGREGATE: Presently used root end filling material Composed of Calcium and phosphorus ions derived primarily from tri- calcium silicate,tri-calcium aluminate,tri-calcium oxide & silicate oxide. Its pH when set is 12.5 & setting time is 2 hrs and 45 min. Compressive strength of MTA is reported to be 40 MPa ,immediately after setting & increases to 70 MPa after 21 days. It has superior sealing ability to that of Super EBA & is less cytotoxic than Amalgam, IRM and Super EBA www.indiandentalacademy.com
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  34. 34.  SMEAR LAYER REMOVAL: -Irrigation with tetracyclin removes the smear layer. -Doxycyclin can also be used because of its long lasting effect on root surface. -Currently available materials are intermediate restorative material,Super EBA & MTAD. PLACEMENT & FINISHING OF ROOT END FILLINGS. -Depends on the type of filling material used. -Amalgam may be carried to the root end preparation with a small K-G carrier. -Zinc oxide Eugenol cements are attached to the back side of a spoon excavator or the tip of a plastic instrument or Hollenbeck carver & placed into the root end preparation. - MTA is placed by using the back side of a small spoon excavator or by using a amalgam carrier. www.indiandentalacademy.com
  35. 35.  SOFT TISSUE REPOSITIONING & SUTURING -Final step in periradicular surgical procedure are wound closure & soft tissue stabilization. REPOSITIONING & COMPRESSION. -The elevated mucoperiosteal tissue should be gently replaced to the original position with the incision lines approximated as closely as possible. -Using a surgical gauze,slightly moistened with sterile saline,gentle but firm pressure should be applied to the flapped tissue for 2-3 min before suturing. -Tissue compression both before & after suturing not only enhances intravascular clotting in the severed blood vessels but also approximate the wound edges. www.indiandentalacademy.com
  36. 36.  SUTURING: -OBJECTIVE: Approximate the incised tissues and stabilize the flapped mucoperiosteum until reattachment occurs.-SUTURE MATERIALS: Synthetic fibers like nylon,polyester,polygalactin and polyglycolic acid. Collagen ,Gut and silk. -NEEDLE SELECTION.:Needle with a reverse cutting edge.-SUTURING TECHNIQUES:Various suturing techniques can be used like1.Single Interrupted suture2.Interrupted loop suture –most prefered for better flap adaptation.3.Vertical Mattress suture4.Single sling suture www.indiandentalacademy.com
  37. 37. POST SURGICAL CARE AFTER ENDO SURGERY Two important components of post surgical care are 1.Genuine expression of concern and reassurance to the patient regarding both their physical and emotional experience. 2.Good patient communication. INSTRUCTIONS OF POST OPERATIVE CARE: 1.Do not do any difficult activity for the rest of the day. 2.Do not consume alcohol or use of tobacco for the next 3 days. 3.Have a good diet and drink lots of liquids for first few days after surgery. 4.Do not lift up the lip or pull back the cheeks to look at where the surgery is done,this may pull the stitches and cause bleeding. 5.An ice bag can be placed on the face where surgery was done for 20 min for every 6- 8 hrs. 6.Pain relievers should be used 7.Mouth should be rinsed with one tablespoon of chlorhexidine mouthwash 2 times a day for 5 days. www.indiandentalacademy.com
  38. 38. COMPLICATIONS & MANAGEMENT BLEEDING AND SWELLING: Slight oozing of blood from several microvessels may be evident for several hours following surgery. - Proper compression of surgical flap,application of the ice pack with firm pressure to the facial area over the surgical site. -Ice pack should be applied in 20 min in an on and off cycle,should be repeated for 6-8 hrs. -If minor bleeding persists for more than 12 hrs following surgery it can be managed by the patient with proper home care. -Patient should be instructed to slightly moisten a gauze pad and place it over the bleeding site while applying firm pressure. -If the home treatment fails then the dentist should be consulted. -A local anesthetic agent containing 1: 50,000 epinephrine must be injected and tissue compression is applied to the bleeding area. -Application of moist heat over the surgical site is recommended and should begin until 24 hrs following surgery. www.indiandentalacademy.com
  39. 39.  DISCOLORATION: Seen in the mucoperiosteal or facial tissues,is a result of the breakdown of the blood that has leaked into the surrounding tissues -Requires no treatment. -In patients with echymosis,application of moist heat may be beneficial for upto 2 weeks following surgery. -Heat promotes fluid exchange and speeds resorption of discoloring agents from the tissue. PAIN: Long acting local anesthetic agents such as Bupivacine or Etidocaine provide 6-8 hrs of local anesthesia and upto 10hrs of local analgesia. -They can either be used in surgery or in conjunction with Lidocaine 1:50,000 epinephrine or at the conclusion of a surgical procedure. INFECTION: The clinical signs and symptoms of post surgical infection are evident within 36-48 hrs after the surgery. -Most common indications are increased pain and swelling. -Systemic antibiotics like Penicillin V dosage is 1.0g as an initial dose,followed by a maintenence dose of 500mg for 3-4 hrs. -If patient is allergic to penicillin,clindamycin initial dose of 600mg followed by a maintenance dose of 150-300mg depending on age & wt of the pt for every 8 hrs. www.indiandentalacademy.com
  40. 40.  ORAL HYGINE: Tooth brush in the surgical area should not be used as it may dislodge the mucoperiosteum flap. -A cotton swab soaked with Chlorhexidine oral rinse or 3% Hydrogen Peroxide remove debris should be used twice daily for 4-6 days. SUTURE REMOVAL: -Suture and the surrounding mucosa should be cleaned with a cotton swab containing a mild disinfectant followed by H2O2. -A topical anesthetic should also be applied with a swab at the surgical site. -Sharp pointed scissors are used to cut the suture material,followed by grasping the knotted portion with cotton plies. www.indiandentalacademy.com
  41. 41. CORRECTIVE SURGERY. Corrective surgery is categorized as surgery involving the correction of defects in the body of the root other than the apex. INDICATIONS:1.Resorption (internal & external). 2.Procedural accidents. 3.Root Caries. 4.Root Fracture 5.Periodontal Disease. Reparative defects of the root and associated procedure are classified as follows: 1.Perforation repair a.)Mechanical b.)Resorptive /Caries. 2.Periodontal repair a.) Guided tissue regeneration b.)Root Resection/Hemisection. c.)Surgical correction of the radicular lingual groove. www.indiandentalacademy.com
  42. 42.  PERFORATION REPAIR: Perforation occuring on the mesial roots of the maxillary and mandibular molars are usually managed by the intentional replantation,root resection or hemisection. Midroot Perforations should be sealed internally if possible or calcium hydroxide should be placed as an intracanal dressing & sealed at a subsequent appointment. If the perforation is located in the apical third of a root,a root end resection,extending to the point of the perforation and a root end filling should be considered. RESORPTION:If a resorptive defect opens into the gingival sulcus & if the approach can be made from the buccal or facial side,a full mucoperiosteal flap should be raised and the extent of the defect established. If the resorption defect has not extended into the pulp space,it should be restored with a suitable material such as amalgam,composite resin or glass inonomer cements. www.indiandentalacademy.com
  43. 43.  PERIODONTAL REPAIR: GUIDED TISSUE REGENERATION: is a procedure used to regenerate lost periodontal structures through different tissue response. -It consists of placing barriers of different types to cover the bone and periodontal ligament thus separating them from the gingival epithelium -The memberane is removed after 5 weeks. MATERIALS USED FOR GTR: NON RESORBABLE :Millipore filler paper,Polytetrafluoroethylene membrane,Rubber dam,Teflon membranes. RESORBABLE: Natural Collagen,Synthetic-Polylactic acid & Glycolic acid,Acetyl tributylcitrate resorbable Membrane. ROOT RESECTION/HEMISECTION: Root resection:Removal of a entire root forms a multirooted tooth leaving the clinical crown intact. Hemisection:Seperation of a multirooted tooth & the removal of a root & the associated portion of the clinical crown. www.indiandentalacademy.com
  44. 44.  ROOT BISECTION / BICUSPIDIZATION :Refers to a division of the crown that leaves the two halves and their respective roots -Should be considered in mandibular molars in which periodontal disease has invaded the bifurcation and when repair of internal furcation perforatins have been unsucessful www.indiandentalacademy.com
  45. 45.  SURGICAL CORRECTION OF THE RADICULAR LINGUAL GROOVE: Radicular lingual groove commonly seen in the maxillary lateral & central incisors,this developemental defect in the root formation precludes the deposition of cementum in the groove,hence it prevents periodontal ligament attachment. -The groove then causes a narrow perodontal pocket that can lead to retroinfection of the pulp. PROCEDURE:Following palatal surgical exposure of the defect,the groove is eliminated by grinding it away with the round burs or diamond points. REPLACEMENT SURGERY: INTENTIONAL REPLANTATION: Extration and replacement of the tooth into its alveolus after the corrective procedure has been done. INDICATIONS: 1.) Inadequate interocclusal space to perform non surgical endodontic treatment 2.) Non surgical treatment is not feasible because of canal obstruction i.e. Calcifications of the pulp space,posts,seperated instruments. 3.) Surgical approach for periradicular surgery is not practical because of limiting anatomic factors i.e risk of parasthesia because of proximity of root apices to the mandibular canal; or mental foramen. www.indiandentalacademy.com
  46. 46. 4.)Non Surgical & surgical treatment have failed & symptoms / pathosis persists.5.)Visual access inadequate to perform root end resection & root end filling.6.)Root defects (Resorption,Perforation.) STEPS IN EXTRATION / REPLANTATION:1.)Following incision of the periodontal fibres with a No.15 scalpel blade,tooth to be extracted.2.)Appropriate forceps are chosen and beaks are wrapped with a sterile gauze sponge that is saturated with normal saline or Hanks Balanced Salt Solution.3.)Following extraction tooth should be held with a forceps,protected by saturated gauze.4.)Roots of the tooth should be thoroughly examined for the presence of root fractures,perforations or resorptions.5.)Root surfaces should be constantly bathed with either normal saline or Hanks Balanced salt sol during the time the tooth is out of its socket.6.)If no root fractures are evident & the prognosis for replantation appear positive,root defects should be repaired with an appropriate material.7.)If root end resection is indicated it should be done with a plain fissure bur in a high speed handpiece under constant irrigation www.indiandentalacademy.com
  47. 47. 8.)Extraction socket should be irrigated with normal saline and gently suctioned to remove any blood clot that may have formed.9.)Tooth is then carefully returned to its socket.10.)A rolled gauze sponge should be placed on the occlusal aspect of the tooth and the patient instructed to bite down foe 5 min so that the interocclusal force will seat the tooth into the socket.11.)If excessive mobility is evident then splinting is suggested.12.)In case of a posterior tooth stabilization may be achieved by placing a figure -8 suture over the occlusal surface of the tooth.13.)Patient should be seen 7-14 days following replantation to evaluate tooth mobility and removal of stabilizers.14.)Post surgical evaluation is recommended at 2,6 & 12 months following surgery. www.indiandentalacademy.com
  48. 48. IMPLANT SURGERY. There are 2 types of endosteal implants:-1. Endodontic Implants.2. Osseointegrated implants/Endosseous implants. ENDODONTIC IMPLANTS: A metallic implant extending through the root canal of a tooth into periapical bone structure,thereby lengthening the root of a pulpless tooth. INDICATIONS: 1. For stabilizing periodontally weakened bridge abutment. 2. When adjacent teeth are poor abutments. 3. Incisor which is hard to restore. OSSEOINTEGRATED IMPLANTS: A direct anchorage of an implant by the formation of bony tissue around it without growth of fibrous tissue at the bone implant interface. www.indiandentalacademy.com
  49. 49. OSSEO INTEGRATED IMPLANTS. www.indiandentalacademy.com
  50. 50.  PROCEDURE: EXTRATION & CURETTMENT PROCEDURE : Tooth should be extracted with as little trauma as possible. - It is important to retain the cortical bone buccal & lingual to the extraction socket. -All soft tissue should be removed from the bony crypt with curettes. IMPLANT PLACEMENT: Implant apex should be stabilized in at least 3-4 mm of bone & the implant head should be positioned to confirm to either the central fossa,in posterior teeth or the cingulum in anterior teeth or screw retained prosthesis. - For cement retained anterior prosthesis the implant head should be placed in line with the incisal edge of the adjacent teeth. BONE GRAFT & MEMBRANE PLACEMENT :Demineralised freezed dried bone allograft is commonly used. - Bone graft material is hydrated with sterile saline and packed into the void. SOFT TISSUE CLOSURE :Primary closure is the closure of choice ,when it is not possible a non resorbable membrane is used. www.indiandentalacademy.com
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  52. 52.  SUPPORTIVE THERAPY: Following immediate implant placement a broad spectrum antibiotic such as Amoxyillin,Cephalexin or Clindamycin is prescribed for a period of 7-14 days. - Suture remain in place for 2 weeks and those cases that contain a membrane be monitored every 2 weeks until the membrane is removed. www.indiandentalacademy.com
  53. 53. CONCLUSION A surgical approach to a failed root canal treatment should only be considered when an orthograde approach is not possible. The reason for failure should be carefully diagnosed before surgery is prescribed . www.indiandentalacademy.com
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