Dr. Bhavik Miyani, Resident Doctor in Department of Oral and Maxillofacial Surgery, Narsinhbhai Patel Dental College and Hospital, Visnagar.

1. ENDODONTIC SURGERY
PRESENTED BY,
DR. BHAVIK MIYANI,
2nd YEAR PG,
DEPARTMENT OF OMFS,
VISNAGAR.
GUIDED BY,
DR. ANIL MANAGUTTI,
DR. SHAILESH MENAT,
DR. RUSHIT PATEL,
DR. JIGAR PATEL.
1

2. Introduction
 Over the past decade, periradicular surgery has
continued toevolve intoa precise, biologically based
adjunct to nonsurgical root canaltherapy.
 Although nonsurgical endodontic treatment gives
good results in mostcases, surgery may be indicated
for teeth with persistent periradicular pathoses that
have not responded to nonsurgicalapproaches.
2

3. History
 Over 1,500 years ago - Aetius, a Greek physician performed first recorded
endodonticsurgical procedure - incision and drainageof an acuteendodontic
abscess
 5000 BC – Sushruta – performed excision of palatalgrowth
 9th century – Abulcasis – performed surgical removal of epulis andCautery
procedure
 1728 - Pierre Fauchard - Replantation and Transplantationtechniques
 1845 - Hullihen - ‘Hullihen’s surgery’ or ‘Rhizodontrophy’ orTrephination
procedure
3

4. History
 1871 – Smith - First root endresection
 1880 – Brophy - Root end filling
 1881 - Claude Martin - Father of root endresection
 1884 – Farrar - Rootamputation
 Surgical operating microscopes –
- 1980’s - Endodonticmicrosurgery
 1990s – Dr. Gary Carrsurgical ultrasonic tips firstdesigned – Carr
tips
 1999 – Spartan/Obtura - Kim Surgical tips – Kistips
4

5. Definition
 A surgical procedure related to problem of the pulp less or
periodontallly involved tooth, requiring root amputationand
endodontictherapy.
(John I Ingle)
 Removal of tissuesotherthan thecontents of therootcanal space
to retain a tooth with pulpal and/orperiapical involvement.
(Franklin Weine)
5

6. Rationale
 Toremove thecausativeagentsof periradicularpathology.
 Torestore the periodontium toa stateof biologic and functional
health.
6

7. Objectives
 Toensure the placementof a properseal between the
periodontium and the root canalforamina.
7

8. Indications
Glick and Ingle
1. Need for surgicaldrainage
 Incision and drainage
 Trephination
2. Failed nonsurgical endodontic treatment
 Irretrievable root canalfilling,material
 Irretrievable intraradicularpost
3. Calcific metamorphosis of the pulpspace
4. Procedural errors
 Instrument fragmentation
 Non-negotiable ledging
 Root perforation
 Symptomatic overfilling
5. Anatomicvariations
 Rootdilaceration
 Apical rootfenestration
8

9. 6. Biopsy
7. Correctivesurgery
 Root resorptivedefects
 Rootcaries
 Root resection
 Hemi section
 Bicuspidization
8. Replacement surgery
 Replacement surgery
 Intentional replantation (extraction/replantation)
 Post-traumatic
 Implantsurgery
 Endodontic
 Osseo integrated
9

10. Relative Contraindications
1. Patient’s medical status
 Major system disorder – Cardiovascular, Respiratory, Digestive,
Hepatic, Renal, Immune, Skeleton-muscular
2. Anatomical considerations
 Nasal floor
 Maxillary sinus
 Proximity to neurovascular bundles of mandibular canal and
mental foramen
 limitations to adequate visual and mechanical access
3. Practitioner’s skill and experience
10

11. Surgical instruments
11

12. CLASSIFICATION (by Kim et al)
Based on sequence of use:
 Examination instruments
 Incision blades
 Elevation instruments
 Tissue retractioninstruments
 Curettage instruments
 Osteotomyinstruments
 Inspection instruments
 Retro fill carriers
 Retro fill Pluggers
 Miscellaneous instruments
 Suturing instruments
 Suction tips
 Irrigation instruments
 Ultrasonic instruments
 Surgical operating microscope
12

13. Examination Instruments
 Dental mirror
 Periodontal probe
 Endodontic explorer
 Micro explorer
Tip of microexplorer used to –
• Search for leak in root-end
filling
• Distinguish canal or craze
line from microfracture line
13

14. Incision blades
Bard Parker Blades:
 Microblade
 No. 15c
 No. 15
 No. 12
 No. 11
15C blade in use
Microblades
14

15. Elevation Instruments
Traditional Microsurgical
Enlarged tips of soft
tissue elevators
Molt’s curette (above)
Periosteal elevator No. 9 (below)
15

16. Tissue Retraction Instruments
 Arens tissueretractor
 Selden retractor
 University of Minnesotaretractor
Cats paw retractor
16

17. Curettage Instruments
•Minicurettes
•Mini jacquette 34/35
•Columbia 13- 14
•Miniendodontic curettes
•Minimolten curettes Enlarged tips of
minijacquettes and mini-
endodontic curettes
17

18. Osteotomy Instruments
Straight Handpiece
Microhead Handpiece
Impact air 45o handpiece with H161 Lindemann bone cutting bur
– instrument of choice for osteotomy 18

19.  No. 4 round bur
 No. 6 round bur
 No. 8 round bur
 No. 57 fissurebur
 Multipurpose bur
 Endo-Z bur
19

20. Inspection Instruments
Micro mirrors
Round and modified rectangular
Flexible neck
Stainless steel (top and bottom)
Scratch-free sapphire mirror surface
(centre two)
20

21. Retro fill Carriers
21

22. Retro fill Pluggers
22

23. Surgical Operating Microscope
Magnification Range = 2X - 32X
MAGNIFICATION RANGE
Low: 3 - 8 X
Medium: 10 – 16 X
High: 20 – 30 X
The surgical operating microscope was used first time in neurosurgery and ophthalmology in
1960
and Endodontic microsurgeries in 1980s
23

24. Advantages
 High magnification
 Surgical technique can be performedprecisely
and accurately
 Surgical technique can be easilyevaluated
 Fewer radiographs needed
 Video recordingspossible
 Reduces occupationalstress
24

25. Classification of Endodontic surgery
 Fisulative surgery
 Incision anddrainage
 Cortical trephination
 Decompression procedures
 Periradicularsurgery
 Curettage
 Root-end resection
 Root-end preparation
 Root-end filling
 Correctivesurgery
 Perforation repair
 Mechanical (iatrogenic)
 Resorptive
 Periodontal management
 Root resection
 Tooth resection
 Intentional replantation
25

26. Surgical Drainage :
Surgical drainage is indicated when purulentand/or
hemorrhagic exudates forms within the soft tissue
and the alveolarbone; a result of a symptomatic
Periradicularabscess.
 Surgical drainage maybe accomplished by;
 Incision and drainage (I and D)
 cortical Trephination
26

27. Incision And Drainage
Procedure
 Local anesthetic - Mepivacaine (low pKa)
 Horizontal incision with No.11 or 12 BP blade at the base ofthe
fluctuant area
 Frank et al - rubber dam drain to maintain the patency of thesurgical
opening.
 McDonald and Hovland - incision alone
 Gutmann and Harrison- use of drain is
Indicated in moderate to severe cellulitis and other
positive signs of an aggressive infective process.
27

28. INCISION AND DRAINAGE
28

29. Materialsused
 Iodoformgauze
 Rubberdam material -“H” or “Christmastree” shape.
 Penrosedrain
Penrose drain Serrated drain
29

30. 30

31. Trephination
Cortical trephination is a procedure involving the perforation of the
cortical plate to accomplish the release of pressure from the
accumulation of exudate within the alveolar bone.
 No 6 or 8 round bur
 Buccal approach
 The objective is to create a
pathway through the
cancellous bone to the vicinity
of the involved periradicular
tissues.
31

32. PERIRADICULAR SURGERY
32

33. Treatment planning for periradicular surgery
1. Presurgical patientmanagement
2. Need for profound local anesthesia andhemostasis
3. Management of softtissue
4. Management of hardtissues
5. Surgical access, both visual andoperative
6. Access to rootstructure
7. Periradicularcurettage
8. Root-end resection
9. Root endpreparation
10. Root-end restoration
11. Soft-tissue repositioning andsuturing
12. Postsurgical care
33

34. PRESURGICAL PATIENT MANAGEMENT
Patients medical status
 Proper history taking is first key forsuccessof any
surgical procedure.
 Patientshould beevaluated for majorsystem disorders
(cardiovascular, renal, hepatic, digestive, immune and
skeletal muscle) which may contraindicate or alter
approach tosurgery.
 Also premedication for patient in normal or in
presence of any of the above medical conditions
should begiven priorityand consulted with physician.
34

35. Patientpreparation
 Patient preparation starts with patient communication
regarding reason for surgery, risks involved, also factors
which improve prognosis forsuccessful outcomeof surgical
procedure.
 There may be necessity of premedication (sedatives or
hypnotics, systemic antibiotics) for patient in order to
improve accessibility also postsurgicalhealing.
 Presurgical mouth rinse with chlorhexidine gluconate
(Peridex) may improve surgical environment bydecreasing
tissue surface bacterialcontamination.
 Mouth rinse should be started aday before
surgery, immediately before surgery, and up to 4 to 5 days
post surgically. This reduces bacterial contamination of
surgical site and improve woundhealing.
35

36. Anaesthesia
 Local anaesthetic withvasoconstrictor
 Objectives:
 obtain profound and prolongedanaesthesia
 providegood hemostasis bothduring and afterthe surgical
procedure
 Selection based on:
 Medical status of thepatient
 Desired duration of anaesthesia
36

37. TYPES OF LOCAL ANALGESIA
 Topical analgesia (surfaceanalgesia)
 Sub mucosal infiltration
 Sub periosteal infiltration
 Nerve blockanalgesia
 Intra ligamentaryanalgesia.
 Intra osseousanalgesia.
2
1
3
6
5
4
37

38. TOPICAL ANALGESIA (SURFACE ANALGESIA)
 An anaesthetic is applied in a gel form to the intact
mucous membrane.
 It passes through the epidermis and makes the nerve
endings analgesic prior to administration of a deeper
or infiltration analgesic.
 Use-The surface analgesia prevents the pain of the
needle.
38

39. Treatment planning for periradicular surgery
1. Presurgical patientmanagement
2. Need for profound local anesthesia andhemostasis
3. Management of softtissue
4. Management of hardtissues
5. Surgical access, both visual andoperative
6. Access to rootstructure
7. Periradicularcurettage
8. Root-end resection
9. Root endpreparation
10. Root-end restoration
11. Soft-tissue repositioning andsuturing
12. Postsurgical care
39

40. Management of soft tissue
PRINCIPLES OF FLAP DESIGN
1. Making sure base of the flap should be wider than
the freeend.
2. Avoiding the incision overa bonydefect
3. Including the full extent of thelesion.
4. Avoiding sharpcorners
5. Avoiding incision across a bonyeminence
40

41. 6. Avoiding incision in the mucogingival junction.
7. Taking care during retraction.
8.Incision should be made with firm, continuous firm
strokeperpendicularto thecortical bone plate.
9.The sutured flap margin should rest on solidcortical
boneplate.
41

42. Classification
 Full thickness (Mucoperiosteal) - Epithelium + Connective tissue+
Periosteum
Partial thickness (Split) - Epithelium + Connectivetissue
 According to Gutmann & Harrison
Full mucoperiosteal Limited mucoperiosteal
Full mucoperiosteal flap – no attached
Gingiva around neck of crown
Limited mucoperiosteal showing -
Remaining attached gingiva 42

43.  Full mucoperiosteal flap
 Triangular
 Rectangular
 Trapezoidal
 Horizontal/Envelope
 Papilla base
 Limited mucoperiosteal
 Sub marginal curved/Semilunar
 Sub marginal scalloped rectangular/Luebke Ochsenbein
43

44. Advantages of Full Mucoperiosteal Flaps
1. Rapid wound healing
2. Good surgicalaccess
3. Minimal disruption of bloodsupply
4. Minimal untoward post-surgical sequelae
5. Optimal apical orientationand
6. Primary intentional healing.
Disadvantages
1. Loss of soft tissueattachment
2. Loss of crestal boneheight
3. Post surgical flapdislodgement
44

45. Advantages of limited mucoperiosteal flap
1. Marginal and interdental gingiva notinvolved
2. Unaltered soft tissue attachmentlevel
3. Crestal bone is notexposed
4. Adequate surgical accessand
5. Good would healing potential
Disadvantages
1. Disruption of blood supply to unflappedtissues
2. Flapshrinkage
3. Difficult flap re-approximation
4. Delayed secondary wound healing.
5. Limited apical orientation
45

46. TRIANGULAR FLAP
INDICATIONS:
 Mid root perforationrepair
 Periapical surgery in posteriorareaswith shortroots
ADVANTAGES:
○ Good wound healing
○ Minimal disruptionof vascularsupply to flapped tissue
○ Easeof flap re-approximation with minimum numberof
sutures
DISADVANTAGES:
○ Limited surgicalaccess
○ Difficult toexpose the rootapices of long teeth like maxillary and
mandibularcanines
○ Tension is created onretraction
46

47. 47

48. RECTANGULAR FLAP
INDICATIONS:
 Mandibularanteriors
 Multiple teeth
 Teeth with long roots like maxillarycanines
ADVANTAGES:
 Increased surgical access torootapex
 Reduces retractiontension
DISADVANTAGES:
 Difficulty in re-approximation of flapmargins
 Post surgical stabilization isdifficult
 Gingival attachmentviolated, gingival recession, crestal bone loss
mayoccur
48

49. 49

50. TRAPEZOIDAL FLAP
 Similar to rectangular except the 2 vertical incisions intersect the
horizontal incision atan obtuseangle → tocreatea broad based flap
with thevestibularpartwider than thesulcularportion
 Disadvantages:
 Angled incision – severs more vitalstructures
 More bleeding
 Disruption of vascularsupply to non-flapped tissues
 Shrinkage of flapped tissues
50

51. HORIZONTAL FLAP
 Horizontal intrasulcularincisionwith novertical releasing incision
 Limited applications - Limitedaccess
 Repairof cervical defects (rootperforations, resorption, caries)
 Hemi sections and Rootamputation
 ADVANTAGES:
 Ease of repositioning as novertical incision
 DISADVANTAGES:
 Limited access andvisibility
 Difficult to reflect andretract
 Predisposed to stretching andtearing
51

52. SUBMARGINAL CURVED/SEMILUNAR FLAP
ADVANTAGES
 Reduces incisionand
reflection time
 Maintain integrityof
gingival attachment
 Eliminates potential
crestal bone loss
INDICATION
1. Esthetic crownspresent
2. Trephination
DISADVANTAGES
 Limited access and visibility
 Tendency for increase
hemorrhage
 Crosses rooteminences
 May not include entire lesion
 Predisposed to stretching and
tearing
 Repositioning is difficult
 Healing is associated with scar
52

53. SUBMARGINAL SCALLOPED RECTANGULAR/
LUEBKE OCHSENBEIN FLAP
 Modification of rectangularflap
 Horizontal incision is placed in buccal/labial attached
gingiva & is scalloped - follows thecontourof marginal
gingiva
 INDICATIONS
 Prostheticcrowns
 Periradicular surgery of anteriorregion
 longerroots
53

54. ADVANTAGES
 Ease in incision and
reflection
 Enhanced visibility and
access
 Ease in repositioning
 Maintains integrity of
attachment
 Prevent gingival recession
 Avoid dehiscence
 Prevent crestal bone loss
DISADVANTAGE
 Horizontal component
disrupts blood supply
 Vertical componentscrosses
mucogingival junction and
may enter muscle tissue
 Difficult to alter if sizeof
lesion misjudged
54

55. INCISION
 Incisions for the majorityof mucoperiosteal flaps for
periradicularsurgerycan beaccomplished by ;
No.11, NO.12, No.15, No.15C, micro surgical blade.
55

56. FLAP REFLECTION
 Flap reflection is the process of separating thesoft tissue (Gingiva
Mucosaand Periosteum) from thesurfaceof thealveolar bone.
 Thisprocess should begin in thevertical incisiona few millimeter
apical tothe junctionof the horizontal and vertical incisions.
Periosteal elevatorforflap reflectionare ;
 No.1 and No.2 (Thompson Dental Manufacturing Co)
 No.2 (Union Bronch)
 No.9 (Union Bronch Co)
56

57. FLAP RETRACTION
 Processof holding in position the reflected soft tissues
 Provides visual and operativeaccess
 Tissueretractormustalways reston solid cortical bonewith firm
lightpressure
57

58. HARD TISSUE MANAGEMENT
Osteotomy
 Following reflectionand retraction of the mucoperiosteal
flap, surgical access must be made through thecortical bone to the
roots of theteeth.
 Methods to locate the rootapex
 Methylene bluedye
 Visual and tactilemethod(Barnes)
1. Rootstructuregenerally has ayellowish color
2. Roots does not bleed whenprobed
3. Roottexture in smoothand hard as opposed to thegranularand
porous nature of bone
4. Theroot is surrounded by the PDL
58

59. OPTIMAL OSTEOTOMY SIZE
 Traditional endodontic surgery - approximately 10 mmin
diameter.
 Should be just largeenough to manipulate ultrasonic tips freely
within the bonecrypt.
 Since the length of an ultrasonic tip is 3 mm, the ideal diameter
of an osteotomy is about4mm.
59

60. Periradicular curettage
A surgical procedure to remove diseased or reactivetissue
from alveolar bone in the periradicular area or lateral region
surrounding a pulp less tooth (AAE 1994)
 Purpose:
• To remove pathological periradicular tissues for visibility
and accessibility for treatment of apical root canal system
•To remove foreign material present in periradicular
tissues
60

61.  Toaccomplish removal of entire mass, the largest bone curette,
consistent with the size of the lesion, is placed between the soft
tissue mass and lateral wall of the bonycrypt with concavesurfaceof
curette facing thebone.
 Once soft tissue has been freed along the periphery of the lesion, the
bonecuretteshould be turned with concaveportion towards thesoft
tissue and used in scraping fashion to free tissue from deep walls of
bonycrypt.
61

62. Root End Resection
Indications
 Eliminating
 Anatomicalvariations
 Ledges
 Canal obstructions
 Resorptivedefects
 Perforationdefects
 Separated instruments
 Visualizeseal created by orthogradetreatmentand need forroot-
end seal
 Gain access to pathological tissue trapped along lingual surfaceof
root
62

63.  Ingle et al recommended the root end resection is best accomplished by
the No.702 tapered fissure bur or No.6 or No.8 round bur in a low speed
straight hand piece.
Lasers
 Komori and associatesevaluated the useof the Er:YAG laser forroot-end
resections:
 Er:YAG laser - smooth, clean, resected rootsurfaces freeof anysigns
of thermal damage.
INSTRUMENTS
63

64.  Moritz and associates
 CO2 laser treatment optimally prepares the resectedroot-end
surfacetoreceivea root-end filling
 seals the dentinaltubules
 eliminates niches for bacterialgrowth
 sterilizes the rootsurface
 Advantages of the laseruse:
 Absence of discomfort andvibrations
 Less chance forcontaminationof thesurgical site
 Reduced risk of trauma to adjacenttissue
64

65. Rationale for laser use in endodonticperiradicularsurgery includes
(Miserendino etal)
(1) improved homeostasisand concurrentvisualizationof the
operative field
(2) potential sterilizationof thecontaminated rootapex
(3) potential reduction in permeabilityof root-surfacedentin
(4) reduction of post-operativepain
(5) reduced risk of contamination of the surgical site through
eliminationof the useof aerosol-producing airturbine hand
pieces.
65

66. EXTENT OF APICAL RESECTION
66

67. BEVEL ANGLE
 Historically – 30-45o: togainvisual and operating access to the root tip for
resection, placement of retro filling materials, and inspection.
 Present - 90o Maximum= 10o degree bevel
Advantages:
•Exposes fewer dentinal tubules, thus preventing
excess leakage and contamination.
67

68. ROOT END PREPARATION
Purpose:
• Tocreateacavity toreceivea root-end filling.
Objective: It must be placed parallel to the long axis of the root.
Instruments Used:
 Small round or inverted coneburs
 Ultrasonictips
68

69. IDEAL ROOT END PREPARATION
 Theapical 3 mm of the rootcanal must be freshlycleaned and
shaped.
 The preparation must be parallel toand coincidentwith the
anatomic outlineof the pulp space.
 Adequateretention form must becreated.
 All isthmus tissue, when present, must beremoved.
 Remaining dentin walls must not beweakened.
69

70. Traditional root-end cavity preparation technique
 Miniaturecontra-angleorstraight hand piece
 Small round or inverted conebur.
 Class I cavity preparation along the long axis of the rootwithin the
confines of the rootcanal.
 Recommended depth - 2 to 3 mm being the mostcommonly
advocated. (Gutmann and Harrison)
 Disadvantage: Apical perforationdue todifficulty in aligning the bur
70

71.  Recently, speciallydesigned ultrasonicrootend preparation
instruments have beendeveloped.
 Ultrasonictips developed by De Gary Carr- Availablewith plain and
diamond coated tips.
 Kis Microsurgical Ultrasonic Instruments – The tips arecoated with
zirconium nitrite for faster dentin cutting with less ultrasonic
energy
71

72. Advantages of Ultrasonic tips over micro head burs
 Need for bevelingeliminated
 Tipstayscentered in rootand followscanal space
 ↓ chances of lingual orlateral root perforations
 Conserving greaterthicknessof rootcanal wall
 Betteraccess tosurgical areas, especiallydifficult toreach areas such as
lingual apices
 Deeper root-end preparationachieved
72

73.  Less dentinal tubulesexposed
 Cleanercavity than bur – smoother, less debrisand smear layer
 Ultra precise isthmuspreparations.
 Parallel canal walls preparation for betterretentionof filling
materials.
Drawbacks:
Creationof microcracks due tovibrationsproduced
73

74. RETROGRADE RESTORATIVE MATERIALS AND TECHNIQUES
Purpose:
Toseal theapex so that no bacteriaor bacterial by productscan enteror
leave from thecanal
Properties of ideal retrograde restorative materials:
 Well tolerated by periapical tissues
 Bactericidal orbacteriostatic
 Adhere to thetooth
 Dimensionallystable
 Readilyavailableand easy to handle
74

75.  Notstain teethorperiradiculartissue
 Noncorrosive
 Resistant todissolution
 Electrochemically inactive
 Promote Cementogenesis
 Radiopaque
75

76. Root End filing materials :
 Guttapercha
 Amalgam
 Cavit
 IRM
 Super EBA
 Glass Ionomer
 Compositeresins
 Carboxylatecements
 Zinc phosphatecements
 Zinc oxide eugenolcements
 Mineral trioxide aggregation(MTA)
76

77. The prognosis ultimately depends on factors such as:
 An accuratebevel
 Adequateaccess
 Homeostasis
 Accurate retrogradepreparation
 Accurate retrograderestoration
 Existent periodontaldisease
 Occlusal trauma
 Missed verticalfractures
 Quality of the orthogradefilling
 Individuals hostresponse.
77

78. SOFT TISSUE REPOSITIONING AND COMPRESSION
 Theelevated muco periosteumgentlyreplaced to itsoriginal position
with the incision lines approximated as closelyas possible.
 Typeof flap designwill affect theease of repositioning.
 Tissuecompression: Using a surgical gauze moistened with sterile
saline, gently apply firm pressure to the flapped tissue for 2 to 3
minutes (5 minutes forpalatal tissue) beforesuturing.
 Enhances intravascularclotting in thesevered blood vessels
78

79. SUTURING
Purpose: Toapproximatethe incised tissueand stabilize the flapped muco
periosteum until reattachmentoccurs.
CLASSIFICATION OF SUTURE MATERIALS
 Based on material:
Natural
Collagen
Gut
Silk
Syntheticfibers
Nylon
Polyester
Polyglactin
Polyglycolicacid
 Absorbency:
Nonabsorbable
Silk
Nylon
Absorbable
Polyester
Polyglactin
Polyglycolicacid
Collagen
Gut 79

80.  Size:
USP size: 3-0, 4-0, 5-0, 6-0.
The higherthe first number, thesmaller thediameterof the
suture material.
 Structure: Monofilament and Multifilament
Twisted and Braided
80

81. Silk Sutures: Non absorbable, multi filamentous, andbraided.
High capillaryeffect
Enhances movement of fluids and
microorganisms between fibers
Plaque accumulation on thefibers
Severe oral tissuereactions
Prevented by postoperative rinse withchlorhexidine
Advantage: Ease of manipulation
81

82. Gut:Collagen is the basic component of plain gut suture material
 derived from sheep or bovineintestines.
 Thecollagen is treated withdiluted formaldehyde to increase its
strength
 Shaped into the appropriate monofilamentsize.
 Gutsuturesareabsorbable in 10 days
Chromic gut: plain gut treated with chromium trioxide.
 delayed absorptionrate
 Gutsuture material is available in sterilepackets containing isopropyl
alcohol.
82

83. Polyglycolic Acid (PGA): made from fibers of polymerized glycolic acid-
absorbable. The rateof absorption is about 16 to 20 days.
 Multi-filament, braided and handling characteristicssimilartosilk.
 Firstsyntheticabsorbablesutureand it is manufactured as Dexon.
Polyglactin (PG): Developed by Craig and coworkers In1975
 Copolymerof lacticacid and glycolicacid
 Called polyglactin 910 (90 partsglycolic acid and 10 parts lacticacid).
 Suturesof polyglactin areabsorbable, braided and multi filament.
 Commercially available asVicryl
83

84. NEEDLES
 Needle with reversecutting edge (the cutting edge is on theoutside of the
curve) is preferable.
 Available in arcs of 1/4, 3/8, 1/2 and 5/8 of a circle, with the most useful
being the 3/8 and 1/2circle.
84

85. SINGLE INTERRUPTED SUTURE
SUTURING TECHNIQUES

86. INTERRUPTED LOOP (INTERDENTAL) SUTURE
86

87. POST OPERATIVE INSTRUCTIONS AND CARE
 Do not lift up lipor pull back thecheek to look at where the surgery was
done.
 A little bleeding from surgical is normal. This should only last fora few
hours.
 A little swelling and bruising face may be evidentwhich may last fora few
days.
 Do not drink alcohol oruse tobacco (smoke orchew) for the next 3 days.
 Havea good, soft dietand drink lots of liquids for the first few days after
surgery.
87

88.  Place an ice bag (cold) on face where the surgery was done. Leave it
on for 20 minutes and take it off for 20 minutes. Continue this for 6
to 8 hours.
 Take the prescribed medicines asrecommended.
 Rinse the mouth with 1 tablespoon of the chlorhexidine mouthwash
twice daily for 5days.
 Sutureremoval after5-7 days by thedental personnel only.
 Maintain postoperative follow up recall visits
 If any problemsexists informand visityourdentist immediately.
88

89. BARRIER MEMBRANE TECHNIQUES IN ENDODONTIC SURGERY
 Regeneration: is the replacementof destroyed tissuewith new tissue
formed by the cells of the same origin. This new tissue reacts in a
similar manneragainst pathologicstimuli as theoriginal tissues.
 Repair: is the restorationof thedestroyed tissue bydiseasewith new
tissue consisting of cells different from the original cells. These cells
reactdifferently from theoriginal cells against pathologicstimuli.
89

90. Materials used:
 GTR membrane
 Calciumsulphate
 Periosteal graft
 Platelet richplasma
 Tri calcium phosphate
Objective: To enhance the quality and quantity of bone regeneration
in the peripheral region and to accelerate bone growth in
circumscribed bonecavitiesafterendodonticsurgery.
90

91. GTR Membrane
Indication
 Through and through periapicallesion.
 Large periapical lesion
 Endo-perio lesion
Periapical lesion communicating with thealveolarcrest
Furcation involvementas a resultof perforation
Rootperforationwith bone loss toalveolarcrest
91

92. Advantages:
○ Barrier function in case of lack ofperiosteum.
○ Greaterconcentration of osteogenic cells in the healing area
○ High successrate.
Disadvantages:
○ Cost
○ Possibility of infection
○ Need fora second surgery (non resorbablematerialsonly)
○ Need for a space-maintaining device in largedefects
○ Problems in the application of thebarrier.
○ Operatorskill (e.g. , high surgical skill required whena palatal flap is
raised)
92

93. CALCIUM SULFATE
Indications :
 Post apicoectomy bonedefects
 Through and throughlesions
 Periapical lesions with furcationinvolvement
 Post surgical endo-periocommunications.
Advantages:
 Inexpensive
 No inflammatoryreaction
 Absence of post operativecomplications.
 Possibility of using the materialseven in asepticenvironment
 Ability toachievesecondaryclosureof soft tissueon theexposed material.
 Stabilization of blood clot.
 Adhesion to rootsurface.
 Biocompatible
 Completeabsorption.
93

94. PERIOSTEAL GRAFT AS BARRIER MATERIAL: (Kwan et al 1998)
Actions: 1. Periosteum
Osteo progenitorcells
Osteogenesis
2.Barrier for epithelialinfiltration
Indications: multifaceted endodontic- periodontic problems
Advantages:
○ Highlyvascular
○ Easily harvested
○ Configuration adjusted to shape of recipientsite
Disadvantages:
○ Profuse bleeding
○ Difficulty in obtaining the split thicknessgraft
94

95. Platelet rich plasma – Rich source of growth factors
Properties andAdvantages:
•Decreased intra operative and post operativebleeding
•Rapid soft tissuehealing
•Rapid vascularization
•Decreased post operativepain
•Osteoconductive
•Hemostaticproperties
•Safe
•Affordable
(Demiral et al JOE , 30 (11) , 2004)
PLATELET RICH PLASMA + TRI CALCIUM PHOSPHATE
95

96. Corrective surgery
 Correctivesurgery is categorized as surgery involving thecorrectionof
defects in the bodyof the roototherthan theapex.
 Corrective surgical procedure may be necessary as a result of
procedural accidents, resorption (internal orexternal), rootcaries, root
fracture, periodontaldisease.
Corrective surgery mayinvolve
 Rootresection.
 Hemi section.
 Intentional replantation.
96

97. ROOT AMPUTATION
Rootamputation proceduresarea logical way toeliminatea
weak, diseased root toallow the strongerroot(s) tosurvivewhen, if
retained together, they would collectivelyfail.
97

98.  Distance between pulpchamber floorand coronal aspectof the root
separation= 3mm (Minimum)
 2 mm allow forestablishmentof supracrestal attachmentapparatus
and 1 mm for placement of crownmargins
98

99. INDICATIONS FOR ROOT AMPUTATION:
(Rosenberg et al)
 Existence of periodontal bone loss to the extent that periodontal
therapy and patient maintenance do not sufficiently improve the
condition.
 Destructionof a root through resorptive processes, caries, or
mechanical perforations.
 Surgically inoperable roots thatarecalcified, contain separated
instruments, oraregrosslycurved.
 The fractureof one root thatdoes not involvetheother.
 Conditions that indicate the surgerywill be technically feasible to
perform and the prognosis isreasonable.
99

100. CONTRAINDICATIONS FOR ROOT AMPUTATIONS:
 Lack of necessaryosseoussupport forthe remaining rootorroots.
 Fused rootsorroots in unfavorableproximitytoeach other.
 Remaining rootorrootsendodontically inoperable.
 Lack of patient motivation toproperly perform home-care procedures.
100

101. HEMISECTION
 Hemi section is defined as separationof a multi rooted toothand
the removal of a root and the associated portion of the clinical
crown.
Sutures placedResected root
Deep periodontal pocket Flap raised
101

102. BISECTION OR “BICUSPIDIZATION”
Refers toadivisionof acrown that leave the two halves and
the respectiveroots.
 BS should be considered in mandibular molars in which
periodontal disease has invaded the bifurcation andrepair
of internal furcation perforation has beenunsuccessful.
 The furcation is then turned intoan interproximal space
where the tissue is more manageable by the patient
102

103. BICUSPIDIZATION
103

104. INTENTIONAL REPLANTATION
 Defined as theactof deliberately removing a toothand following
examination, diagnosis, endodontic manipulation and repair
returning the tooth into itsoriginal socket.
INDICATIONS
 Difficultaccess
 Anatomic limitations
 Perforation in areas notaccessible surgically.
 Failed apical surgery
 Apical surgery creatingdefect
 Accidental avulsion( unintentionalreplantation)
104

105. Contraindication
 Pre-existing moderate to severe periodontaldisease
 Curved and flared roots
 Non restorabletooth
 Missing interseptal bone
3 factors that directly affect the outcome of intentional
replantation.
 Extra oral time
 Keeping PDL cellsviable
 Minimizing damage to the cementum and pdl ligament cells
during elevation andextraction
105

106. Endodontic microsurgery
 DEFINITION
 A surgical procedureon exceptionallysmall and complex structures
with an operationmicroscope.
(Kim etal)
 The microscope has changed surgical endodontics froma “blind”
techniquetoone that is visuallydominated.
 Itenables thesurgeon toassess pathological changes moreprecisely
and to remove pathological lesions with far greater precision, thus
minimizing tissue damage duringsurgery.
106

107. Indications
 Failure of previous nonsurgical endodontictreatment
 Failure of previous endodonticsurgery
 Anatomicdeviation
 Procedural errors
Contraindication
 Periodontal health of thetooth
 Patient healthconsideration
 Surgeons skill andability
Hard tissue management
 Osteotomy: H161 lindermann bone cutter----- 8x to16x
 Periradicularcurettage: Columbia no 13 and no14 ---10x to 16x
 Apical resection: lindermann bur -----4xto8x
107

108. Comparison of traditional v/s microsurgery
Kim and Rubenstein, 2001
PROCEDURE TRADITIONAL MICRO-SURGERY
Identification of
apex
Difficult Precise
Osteotomy Large (=>10
mm)
Small (<5mm)
Root surface
inspection
None Always
Bevel angle Large (45o) Small (<10o)
Isthmus
identification
Nearly impossible Easy
Retro
preparation
Approximate Precise
Root end filling Imprecise Precise 108

109. SURGICAL SEQUELAE
Pain:
- Minimal and of shortduration, if the tissue management is adequate
- Long acting Localanesthetics
- Analgesics and Anti inflammatorydrugs
Swelling:
Causes:
○ Post surgicaledema
○ Hematoma
○ Infection
Management:
Inform patient
Reassurepatient
Cold packapplication
109

110. MANAGEMENT:
Cold pack application
Pressure packs: 2X 2 inch gauge orwet tea bag held with moderate pressure
for 10- 15 minutes.
If severe return to thedental clinic - Resuturing and use of hemostatics
(Tannic acid: hemostatic)
•Improper elevation and Retraction
•Incision into muscle attachment
•Inadequate suturing
•Trauma due to brushing, mastication
Bleeding
110

111. Ecchymosis
Discoloration of the facial or oral soft tissues caused
by extravasation and subsequent breakdown in the
subcutaneous tissue
Common in elderly patients with fragile capillaries
Causes:
•Bruising
•Soft tissue compression
Depends on: site
degree of trauma
complexion 111

112. CONCLUSION
Endodontic surgery is dynamic and it is
imperative that scientific investigation
continue, concepts ,techniques and materials
used in endodontic surgery must be continually
evaluated and modified and more emphasis
must be placed on the assessment of long-term
outcome
112

113. REFERENCE
 Pathways of the Pulp by Stephen Cohen, Richard C. Burns,7th,8th Edition
 Endodontics by John I. Ingle, Leif Bakland 5th Edition
 Microsurgery in Endodontics: Syngkuc Kim
 Surgical Endodontics: Guttman and Harrison: Mosby:1994.
 Contemporary surgical endodontics: Stockdale: 2 Edition
 Contemporary oral and maxillo facial surgery:Peterson: 5th Edition.
 Colour Atlas of surgical endodontics: Barnes
 Colour atlas of endodontic surgery:Loushine
 Microscopes in endodontics: DCNA: Syngkuc Kim, July; 41 (3)1997.
 Ultrasound real time imaging in the differential diagnosis of periapical lesions: Cotti
et al. IEJ; 36; 2003.
113