endodontic microsurgery


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endodontic microsurgery

  2. 2. CONTENTS • Introduction • Problems with traditional surgery • Changes in techniques • Definition of microsurgery • Birth of microsurgery • Triad of microsurgery • Comparison between traditional surgery and microsurgery • Classification of cases • Indication • Precaution • Patient evaluation and pre medication • Microsurgical instruments • Apical root resection • Conclusion • References
  3. 3. Introduction Preservation of the dentition and maintenance of function are the dental professional ultimate goals. More patients expect and demand that their teeth be saved and not extracted, which is reflected in the increase in endodontic treatments. The introduction of new instruments & devices to improve nonsurgical endodontic treatment has been explosive in the past decade.
  4. 4. Procedural errors such as broken instruments, have increased as endodontists familiarize themselves with this new equipment. Although retreatment can be performed more precisely & easily under the microscope & with new kinds of instruments, retreatment endodontics is still less successful than routine endodontic therapy. This has created an increase need for endodontic surgery, as patients & endodontists seek to save these teeth.
  5. 5. PROBLEMS WITH TRADITIONAL ENDODONTIC SURGERY Invasive procedure. Restricted access to the surgical site. Presence of anatomical structures (large blood vessels, maxillary sinus, mental foramen etc..) Lack of magnification & illumination. Poor success rate.
  6. 6. CHANGES IN SURGICAL TECHNIQUES The view that endodontic surgery is the last resort is based on past experience with unsuitable surgical instruments, inadequate vision within the surgical site & post operative complications and failures that often lead to extraction of the tooth. The introduction of the ultrasonics, microscopes and miniaturized instruments have made the endodontic surgery more predictable with increase in the success rate.
  7. 7. Microsurgery is defined as “a surgical procedure on exceptionally small & complex structures with an operating microscope.” The microscope enables the surgeon to assess pathologic changes more precisely and to remove pathological lesions with far greater precision, thus minimizing tissue damage during the surgery.
  8. 8. Birth late 1950s and early 1960s Concept used in neurosurgery & ophthalmology Today it is widely used in Microvascular Neurological Opthamological surgical procedures
  10. 10. Illumination & magnification are provided by surgical microscope. With bright focused light the surgeon can see every detail of the apical structures and can execute treatment more precisely. The third element of the triad is instrumentation. Conventional endodontic instruments are too large for endodontic microsurgery. Thus newer instruments are designed for this purpose ( ultrasonic tips, condensers, pluggers, micro mirrors etc.. ) in a miniature form.
  11. 11. COMPARISON
  12. 12. CLASSIFICATION OF ENDODONTIC MICROSURGICAL CASES Six classes Class A Class B Class C Class D Class E Class F
  13. 13. Class A Class B
  14. 14. Class C Class D
  15. 15. Class E Class F
  16. 16. INDICATIONS Failure of previous endodontic therapy
  17. 17. Anatomical deviations- tortuous roots, severe C-shaped canals, sharp angle bifurcations, severe calcifications.
  18. 18. Procedural errors- broken instruments not retrievable, overfilled/under filled canals with non resolving periapical pathology, ledges, blocks that are not negotiable, perforations.
  19. 19. PRECAUTIONS Anatomical factors- proximity to neurovascular bundles
  20. 20. Second mandibular molar area
  21. 21. Maxillary sinus Periodontal considerations- tooth mobility and periodontal pockets Medically compromised patients -Myocardial infarction -Anticoagulants -Radiation therapy -Uncontrolled diabetes
  22. 22. Patient evaluation and premedication Medical evaluation Oral evaluation Radiographic evaluation
  23. 23. Medical evaluation Thorough medical history of the patient necessary. Few medical contraindications like: • Advanced diabetes • Cardiovascular disorders • Hematological disorders Physician consultation before commencement of the surgery is essential.
  24. 24. Oral evaluation Pain & swelling are the symptoms that most often prompt a patient to seek endodontic treatment. Extraoral swelling or cellulitis alters the contour of the patient face. In such cases surgery should be postponed until the swelling has been resolved through administration of antibiotics. Surgery should not be attempted while an aggressive large hard swelling is present.
  25. 25. Intraoral inflammation & local mucosal swelling change the color & contour of the mucosa over the root surface. If swelling is present it should be palpated to determine its character. A soft fluctuant swelling indicates a local acute abscess that requires incision & drainage. If a fistula tract/sinus has developed in the mucosa, a gutta percha point is inserted along the tract until it meets resistance and a radiograph taken.
  26. 26. Sinus tract traced with gutta percha
  27. 27. The tooth should be checked for fractures & its periodontal condition assessed. Pocket depth, tooth mobility, radio graphical findings are important criteria for determining if endodontic surgery can be performed
  28. 28. Radiographic evaluation- Important tool Reveal relevant informations like Anatomical deviation Fractures Periradicular pathosis Root resorption Periodontal disease Changes in bone pattern Evidence of traumatic injury
  29. 29. Radiographic evaluation
  30. 30. Premedication They include: Anti-inflammatory drugs. Ex: Ibuprofen Tranquilizers . Ex: Valium Antibiotics. Ex: Amoxicillin Anti bacterial rinses. Ex: CHX
  31. 31. • Dr.Gary Carr – designer and manufacturer of first generation of microsurgical endodontic instruments. • Some microsurgical instruments are miniature versions of traditional surgical instruments. MICROSURGICAL INSTRUMENTS
  32. 32. Classified as-  Examination instruments: Mirror, periodontal probe, endodontic explorer
  33. 33. Micro explorer
  34. 34.  Incision and elevation instrument 15C Blade, handle, soft tissue or pereosteal elevators
  35. 35. Curettage instruments
  36. 36.  Inspection instruments
  37. 37.  Retro filling carrier and plugging instruments
  38. 38. Miscellaneous instruments
  39. 39.  Osteotomy instruments
  40. 40.  Suturing instruments
  41. 41. Tissue retraction instruments
  42. 42. The Groove Technique: a small narrow horizontal groove is made just above the mental foramen. A KP#1 retractor is firmly seated in the groove protecting the nerve during the osteotomy.
  43. 43. Stropko irrigator
  44. 44. Ultrasonic units
  45. 45. KiS Tips
  46. 46. SURGICAL MICROSCOPES Provide important benefits: • Surgical field can be inspected at high magnification so that minute details of anatomical structures ( lateral canal apex) can be identified & managed • Surgical techniques can be evaluated. • Fewer/no radiographs may be needed during surgery because the surgeon can inspect the apex or apices directly. • Video recordings of the procedure can be used for patient teaching • Communication with referring dentists • Occupational stresses can be reduced.
  47. 47. Low(4to8) Orientation, inspection of the surgical site, osteotomy, alignment of surgical tips, root-end preparation, and suturing Midrange (8to14) Most surgical procedures including hemostasis. Removal of granulation tissue, detection of root tips, apicoectomy, root-end preparation, root-end filling High (14 to 26) Inspection of resected root surface and root-end filling, observation of fine magnification procedures
  48. 48. Surgeon’s position
  49. 49. Chair side positions
  50. 50. Anesthesia and Hemostasis In surgical endodontics local anesthesia has 2 prime purposes • Profound anesthesia • Hemostasis Profound anesthesia of the surgical site is essential for patient comfort & working efficiency of the surgeon. Hemostasis is a prerequisite for microsurgery. In the past achieving effective hemostasis was a challenge. Many endodontic surgeons performed surgery in a pool of blood, guessing at anatomical landmarks & structures
  51. 51. Maxillary anesthesia
  52. 52. Mandibular anesthesia
  53. 53. Topical haemostatic agents Epinephrine pellets: Ex- • Racellets • Epidri pellets • Radri pellets
  54. 54. Other agents • Ferric sulfate (21%, 50%, 70%) • Calcium sulfate • Thrombin • Absorbable collagen • Bone wax • Gelfoam • Microfibrillar collagen hemostats
  55. 55. Flap designs Key concepts: • The sulcular full thickness flap is the design of choice for endodontic microsurgery. • For esthetic reasons the mucogingival flap is suitable for crowned anterior teeth. • The scalloped horizontal incision of the mucogingival flap provides a guide for correct repositioning of the flap • The semilunar flap has been found useful for incision & drainage only. • The rectangular flap is best suited for anterior teeth • Triangular flap with vertical incision at the mesial aspect of the flap is more suitable for posterior teeth.
  56. 56. Designs of flaps
  57. 57. APICAL ROOT RESECTION How much tip must be resected??? Determining how much root tip to resect depends on the incidence of lateral canals and apical ramifications of the root end. The authors examined this question by using Hess model of root anatomy. Using a computer system, the authors resected the roots at 1,2,3 & 4mm from the apex.
  58. 58. The relationship of resection level and canal ramifications eliminated in this canine apex.
  59. 59. Bevel angle?? Root resections must be performed perpendicular to the long axis of the root. Ignoring this rule is the most frequent mistake in apical resection. Resections not made at 90 * to the long axis result in an uneven or incomplete resection of the apex.
  60. 60. The minimal bevel angle provides 3 important advantages • Minimizes the removal of buccal plate, resulting in a more stable tooth and faster healing • It exposes fewer dentinal tubules, thus preventing excess leakage & contamination • It prevents a potential endodontic- periodontic communication.
  61. 61. The impact of different bevel angles, and the amount of lateral leakage through the exposed dentinal tubules to the REF (blue triangles). The red triangle in the 45 bevel would represent contaminated tubules left after such a resection
  62. 62. The correct positioning (left) forthe tooth long axis relative to the flooron the left. Positioning in this manner allows forthe resection to be ‘‘gravity driven,’’ dropping straight down toward the floor, making a right angle cut with regard to the facial-palatal direction. On the right, because the angle is incorrect, the osteotomy is largerand
  63. 63. The relationship of the root long axis and the microscope visual axis .If the microscope and, by extension, the surgeon are positioned in the same line as the long axis of the root at the selected resection site, then the line of resection will be parallel to the surgeon’s chest, an ergonomically reproducible path. This positioning will ensure the correct mesial-distal angulation. When a disparity exists, as shown on the right, the surgeon is
  64. 64. The correct inclination of the microscope and patient for maxillary anterior surgery. Position A and Movie 1 are for the resection; position B and Movie 2 are for the inspection,
  65. 65. The correct inclination of the microscope and patient for the maxillary posterior surgery. Position A and Movie 5 are for the resection; position B and Movie 6 are for the inspection, REP, and REF. Note the bow-tie effect on the resected root surface of this MB root.
  66. 66. The correct inclination of the microscope and patient for the mandibular anterior surgery. Position A and Movie 3 are for the resection; position B and Movie 4 are for inspection, REP,
  67. 67. The correct inclination of the microscope and patient for the mandibular posterior surgery. Position A and Movie 7 are for the resection; position B and Movie 8 are for the inspection, REP, and REF. Note the harvesting of the root apex after resection, and the 2 canals it demonstrates (one filled, one uninstrumented/filled).
  68. 68. Isthmus?? A narrow connection between two root canals & usually contains pulp tissue. It has been called as “corridor” by Green, “lateral connection” by Pinneda & “anastomosis” by Vertucci. “Isthmus” are found connecting two canals in one root 3 mm from the apex. Thus the isthmus is a part of the root canal system and not a separate entity. So it should be cleaned, shaped and filled as thoroughly as other canal spaces.
  69. 69. Retropreparation Microsurgical retro preparation techniques require the practiced use of ultrasonic tips & micro mirrors under the microscope. The use of surgical operation microscope with targeted illumination & magnification & development of microsurgical techniques have allowed dental surgeons to overcome the inadequacies & difficulties associated with traditional techniques
  70. 70. A perfect class I cavity can be made with a small instrument and bur. With the advent of ultrasonics, the procedures are more accurate and have greatly improved endodontic retro preparation. A study showed that ultrasonic procedures are 96% more successful than the traditional surgical procedures.
  71. 71. Advantages of ultrasonic tips over micro burs • Better access to surgical sites, especially difficult areas like lingual apices • Ultrasonic cleansing of tissue debris • Conservative preparations that follow the canal anatomy to a precise depth of 3 mm • Ultra precise isthmus preparations • Parallel canals walls preparation for better retention of filling materials
  72. 72. RETROFILLING MATERIALS Endodontic microsurgery has advanced to such a level of sophistication & precision that the demand for creating the ideal retrograde filling material is even greater than before. Various material are available • Amalgam ( Discarded) Cavit • Guttapercha Bone cement • Gold foil Super EBA • ZnOE MTA • GIC • IRM
  73. 73. Super EBA
  74. 74. MTA
  75. 75. Surgical sequelae & complications Key concepts • Pain • Hemorrhage • Swelling • Ecchymosis • Paresthesia • Maxillary sinus infringement • Lacerations • Infection
  76. 76. CONCLUSION The view that endodontic surgery is the last resort is based on past experience with unsuitable surgical instruments, inadequate vision within the surgical site & post operative complications and failures that often lead to extraction of the tooth. Fortunately, this era ended when ultrasonic & the microscope were introduced and when surgical instruments were miniaturized to accommodate the small scale needs of endodontic surgery.
  77. 77. Throughout the history of endodontics, never before have there been as many changes as in the last decade. In the past the endodontist was dependent on the textbook knowledge of tooth anatomy, his experience & tactile sense. There was nearly no visual guidance & no visual feedback. There is an immense difference between traditional endodontic surgery & microsurgery
  78. 78.  The concurrent development of microscopic techniques has resulted in a new understanding of the apical anatomy, better surgical & resection techniques, better patient response & greater treatment success. These developments have marked the beginning of the endodontic microsurgery era which looks promising & exciting.
  79. 79. REFERENCES - Color atlas of microsurgery in endodontics syngcuk kim - Essentials of Endodontic Microsurgery DCNA 2010 - Modern Endodontic Surgery Concepts and Practice: A Review JOE — Volume 32, Number 7, July 2006