Endo note 15 surgical endodoic


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Endo note 15 surgical endodoic

  1. 1. Surgical Endodontics9/15/2009 Endo 15 1
  2. 2. Modern concept of Endodontics has modified the approach totreatment Attempting to determine the cause of persistent periradicular disease. Treatment is directed to eliminate the etiology. Which is the presence offbbacteria and microbial irritants in the root canal space. Microorganism can be survive in the well treated root canals, in dentinal tubules, canal irregularities, deltas and isthmus areas. If these completely entombed periradicular healing should be occur. Over extended RCT is not indicated for apical surgery but it will contributed to failure due to toxic material like formaldehyde Vertical root fracture 9/15/2009 Endo 15 2
  3. 3. Radiolucencey In Radiograph Orthograde -Clean Root filling -ShapeTreatment of choice -Fill9/15/2009 Endo 15 3
  4. 4. When reading x-ray’s following should be considered *Natural foramina over the apex *Other pathological lesions *maxillary sinusTreatment of choice StressOrthograde Root filling Surgery failure discomfort Reroot filling failure 9/15/2009 Endo 15 4
  5. 5. General indications for Endodontic surgery 1. Access to the root canal 2. To establish drainage 3. Need to seal the system 4. To repair any defect in the root 5. Surgical resection of multi-rooted teeth9/15/2009 Endo 15 5
  6. 6. Surgical procedures in Endodontics 1. Incision to establish drainage 2. Periapical (Peri radicular) curettage 3. Apicectomy 4. Surgical repair of roots ( Corrective surgery ) 5. Root amputation (Resection) 6. Hemi section 7. Intentional replantation 9/15/2009 Endo 15 6
  7. 7. Medical history Well documented medical history is essential Rheumatic fever (Not contraindicated) Heart diseases Diabetes Blood dyscrasias Steroid therapy Impaired renal/hepatic function CVA9/15/2009 Endo 15 7
  8. 8. Contraindications ( Or Cautions ) Poor Psychological health / poor health Post radiation therapy Difficult accessibility -Palatal roots -Disto buccal root of upper 7 7 -Distal 7 ( External oblique ridge ) Limited mouth opening Poor periodontal support No cortical plate Very short roots Beyond capabilities and experience Anatomical structures in jeopardy ( nerve) 9/15/2009 Endo 15 8
  9. 9. (1) Incision and Drainage The only surgical procedure in acute inflammation Antibiotics Drainage through root canal Anaesthesia Local Spray Gel Sub mucosal injection *Incise with bard parker No 11 blade or *Aspirate with wide bore needle ABST Extra oral drainage could be referred to a specialized unit 9/15/2009 Endo 15 9
  10. 10. (2) Apicectomy & Retrograde apical sealThe term “Apicectomy” refers to only a stage of an operation Objectives is to seal the canal system at the apical foramen from the peri radicular tissue. Actually, Apicectomy by it self can’t resolve root canal failure .It should accompanied the retro seal. It is an adjunct for Orthograde root filling Success rate is less than implant a. Cannot seal all lateral canals b. Exposed areas of root canal material is greater there for long term success is also affected WASHINGTON STUDY 9/15/2009 Endo 15 10
  11. 11. Indications for Apicectomy Retreatment of a failed root filling*Retreatment of Orthograde is also failed - Difficulty in removing filling - Unfilled apical delta - Original canal cannot be negotiated - Filling Material has been extruded-with symptoms causing. deficient apical seal, 9/15/2009 Endo 15 11
  12. 12. Procedural difficulty -Aberrant Anatomy E.g.,Maxillary molars, Lower incisors, lower premolars - Unusual root canal configuration E.g., severe dilacerations -extensive Secondary dentine formation E.g.,Ageing process,Calcification - FractureddIInstrument with symptoms - Open apex Vital Ca(oH)2 …………….Apexogenasis Nonvital Ca(oH)2…………Apexification Failure Surgery Conventionally blocked apices E.g., Existing post in the root canal ---Redo- it/Surgery9/15/2009 Endo 15 12
  13. 13. Surgical repair latrogenic E.g., Perforated Apex Pathological---Internal Resorption ---External Treat with Ca(OH)2 in both occasions, it fails Surgery Fracture apical 1/3 of root When biopsy is required Cost Cracked root / tooth persistent Cyst Treatment alternatives ? Diagnostic E.g., biopsy9/15/2009 Endo 15 13
  14. 14. Surgical Technique Analgesia Reflection of flap Location of apex Curettage of area Resection of root Retrograde cavity Preparation Retrograde filling Flap replacement Post op instruction Suture removal Follow up9/15/2009 Endo 15 14
  15. 15. Analgesia 1. Anaesthesia 2. Haemostasis – Improved vision - Less time - Less blood loss - Less post op discomfortFailure to produce good anesthesia is a problem in apical surgery A. Local B. General C. Sedation 9/15/2009 Endo 15 15
  16. 16. Local Anesthesia 2% Lignocaine with 1:80,000 adrenaline 1:50,000 adrenaline [Analgesic & Haemostatic effect] Maxilla -Superior dental nerves Palate - Greater Palatine nerve - Long spheno palatine nerves Mandible -Inferior Dental Nerve lN - Lingual Nerve Slow infiltration, 1-2ml per minute 9/15/2009 Endo 15 16
  17. 17. Flap Designing Adequate exposure *Good surgical access *Visualization *Lightning Adequate Blood supply – Avoid tissue necrosis *Broad base - Adequate blood for margins Edges of flap should rest on the bone Clean incisions, it Should not cross -bony eminence e.g.;canine -neurovascular bundle, ex: - mental Healthy Periodontal tissue - lingual, palate 9/15/2009 Endo 15 17
  18. 18. Types of flaps 1. Semilunar flap (Partsch incision) 2. Sub marginal (Leubke-orchsenbain) 3. Full mucoperioseteal ----triangular ----rectangular ----trapezoid ----envelope (Horizontal) 9/15/2009 Endo 15 18
  19. 19. Semilunar Flap Simple Easy to sutureIncision is drawn a semicircle from near the apex of the adjacenttooth in Apical alveolar mucosa towards the gingival marginsaround the area operated on, finishes at the apex of the tooth on theother side. Margin of the flap should extent up to attach gingivael.Disadvantages; Scarring May lie on unsupported bone if the lesion is larger than expected9/15/2009 Endo 15 19
  20. 20. Full mucoperioseteal flap Excellent view Excellent access No scaring Can be extended Maintain intact vertical blood supplyProblems -Time consuming -flap reflection is difficult -meticulous suturing is necessary -Possible loss of interdental papilla9/15/2009 Endo 15 20
  21. 21. Reflection of flapVertical relieving incisions are placed firmly down the line angleof the teeth on the either side of the operating teeth in to thegingival Crevices taking in the gingival papilla.Horizontal incision made along the gingival creviceto join the vertical incisionBlade is held in near vertical positionRaised a good mucoperioseteal flap. 9/15/2009 Endo 15 21
  22. 22. Location of the apex -easy when perforated -use radiographs - rose head no 1 or tapered fissure bur/ISO 18-24 - priced off the cortical plate - just exposed the apical area - Copious irrigation Curettage -soft tissues around the apex to be curetted -more local at this stage -uncover the apex 9/15/2009 Endo 15 22
  23. 23. Resection of root Minimum amount of apex is shaved at 300- 450 to provide access to . the canal ? Root beveled Retrograde cavity preparation -use small ½ or ¼ rose head round bur, ISO 008 - create a simple surface cavity 9/15/2009 Endo 15 23
  24. 24. CorrosionRetrograde root filling Long term success -apical area is cleaned with saline. Apical inflammation -packed the cavity with wet gauze. Mercury ? -dry with cotton wool. -Zinc free Amalgam is packed to the cavity. Hill amalgam carrier. KG retrograde carrier. Materials super EBA Composite resin IRM Diaket Glass Ionomer cement MTA9/15/2009 Endo 15 24
  25. 25. 9/15/2009 Endo 15 25
  26. 26. Replacement of flap -4/0 black silk -vertical mattress -Suture removalliin 5 daysPost operative period Pain……………………………Analgesics Antibiotics Swelling……………………….ice bags, externally Discomfort ……………………warm salt water mouth baths chlorhexidine Oozing ………………………..24h normal Activities ………………………Avoid Alchohol / smoking 9/15/2009 Endo 15 26
  27. 27. X-rays Think twice before undertaking difficult surgical procedure. Consider carefully risk and benefits of the surgical procedure. If you do not have personal skills always refer to someone with required skillsSuccess 25%-90%9/15/2009 Endo 15 27
  28. 28. Tooth which is able to be removed one piece atruamatically Curve root teeth not indicated Perio endo lesions Root fracture can be cement using dentine bonding9/15/2009 Endo 15 28