∗ Periradicular surgery, when indicated, should
be considered an extension of nonsurgical
treatment, because the underlying etiology
of the disease process and the objectives of
treatment are the same: prevention or
elimination of apical periodontitis.
∗ Surgical root canal treatment should not be
considered as somehow separate from
nonsurgical treatment, although the
instruments and techniques are obviously
The following conditions present problems that must often
require surgical intervention
Calcific metamorphosis, canal aberrations, bifurcations, secondary roots,
lateral canals, delta apexes and internal and external resorption
Irretrievable separated instrument; perforations; ledges; zips; strips;
Inadequate and nonretrievable filling material; and irremovable posts, silver
points, or gutta percha
Class III and IV crown fracture, root fracture , subluxated or luxated teeth ,
and alveolar fractures and /or displacement often demand the removal of
both soft and hard tissue before they can be repaired or replaced
Suspicious and /or nonhealing lesions, uncharacteristic signs and
symptoms, and responses peculiar to treatment require
exploratory examination and laboratory evaluation.
When regaining access to the canal or removing posts would risk a
perforation or root fracture and/or create a restorative problem, a surgical
approach may be more appropriate.
6-Expediency and convenience:
In lieu of multiple visits and an extended treatment plan for patients who
travel long distances ,have major time limitations ,require special medical
adjunctive therapy , or need treatment of multiple diseased teeth in the
same arch, endodontic surgery may be combined with conventional
methods to accelerate the treatment process.
Surgery is indicated when patients experiencing a superficial or deep
cellulites and/or severe and uncontrollable pain require an incision and
bone trephination to relieve the trapped pressure and/or fluids
In cases where conventional and adjunctive antibiotic therapy for
odoriferous , painful , and repeatedly problematic teeth have been
ineffective ,the periradicular area must be accessed to obtain a sample of
the exudates and lesions soft tissue (when present( .
Once obtained, this biopsy specimen can be forwarded to a qualified
pathology laboratory for identification of the microorganisms, a histologic
evaluation of the lesion, and a definitive diagnosis for an appropriate
(1) The patient’s medical status
(2) Anatomical considerations
)3(The practitioner’s skills and experience.
)4(Situations requiring professional judgment
-Uncooperative or unwilling patient
1. Fistulative surgery
a. Incision and drainage (I&D)
b. Cortical trephination
c. Decompression procedures
2. Periradicular surgery (primary focus of this chapter)
b. Root-end resection
c. Root-end preparation
d. Root-end filling
3. Corrective surgery
a. Perforation repair
i. Mechanical (iatrogenic)
b. Periodontal management
i. Root resection
ii. Tooth resection
c. Intentional replantation
CLASSIFICATION OF ENDODONTIC
To determine the patient medical and
OF THE PATIENT
To recognize, compensate for, or avoid prohibitive medical
)1(Major risk factor
Patients presenting with the following medical problems
should have treatment postponed until the condition has
been compensated for, has improved, is under control
or has been corrected and until the dentist has been
given a written release by the patient's attending physicians
The danger of this condition lies in the possibility of
sudden stroke, cardiovascular crisis, or
uncontrollable hemorrhage during treatment.
There is a danger of stress -related relaps,coagulant
antagonisms or hemorrhage during the procedure
The AHA (AMERICAN HEART ASSOCIATION) recommends
endocarditis prophylaxis for patients with the following
*High risk category:
-congenital heart disease
*Moderate risk patients:
-Most congenital cardiac malformation
-Rheumatic heart disease
-Mitral valve prolapse with valvar regurgitation
-Leukemia, Neutropenia and leukopenia
-May require hospitalization
-Anticoagulants should be discontinued only by the
patient's attending physicians
The loss of vascularity inhibits a normal inflammatory response which in turn impairs
Increase susceptibility to infection and delay healing
Antibiotic prophylaxis isn't indicated for dental patients with pins, plates and
-It is advisable to consider premedication in a small number of
patients who may be at increased risk of hematogenous total infection as
-Inflammtory arthropathion (Rheumatoid arthritis,SLE(
-Insulin dependant (TYPE I) diabetes
)2(MINOR RISK CONDITION
Caution should be used when treating patient presenting with the
following medical condition:
Patients are best served by preoperatively prescribing appropriate
hypotonic, sedativesor analgesics
-Asthmatic patient >>should be sedated Sever
-Emphysema >>> oxygenshould be administered throughout
As mitral valve damage, prolapse, stenosis and
pulmonary heart disease
-sedatives and prophylactic antibiotics should be
-blood pressure and pulse rate should be monitored
-consult the patient physician sedatives should be
-consult the patient physician
-operation performed only during mild trimester
-decrease anesthetic V.C
)All office personnel should be inoculated with hepatitis
*The patient must be thoroughly advised of the
benefits, risks, and other treatment options and
must be given an opportunity to ask questions.
*Premedication AS NSAID, Antibiotic, Chlorhexidine
-Administration of an NSAID, either before or up to 30
minutes after surgery, enhances postoperative
-Many types of NSAIDs are available, but ibuprofen
remains the usual standard for comparison. Ibuprofen
400 mg provides analgesia approximately equal to that
obtained with morphine 10 mg and significantly greater
than that from codeine 60 mg, tramadol 100 mg, or
acetaminophen 1000 mg
-The value of antibiotic prophylaxis before or after oral
surgery is controversial, and the current best
available evidence does not support the routine use of
prophylactic antibiotics for periradicular surgery
Chlorhexidine gluconate (0.12%) often is recommended
as a mouth rinse to reduce the number of surface
microorganisms in the surgical field, and its use may be
continued during the postoperative healing stage.
-Conscious sedation, either by an orally administered
sedative or by nitrous oxide/oxygen inhalation
analgesia, may be useful for patients who are anxious
about the surgical procedure or dental treatment
-A typical protocol is a single dose at bedtime the
evening before the procedure and a second dose 1 hour
before the start of surgery
-The following instruments are necessary for
performing an apicoectomy:
∗Microhead hand piece (straight and contra-angle) and
∗Special narrow periapical curette tips for preparation
of the periapical cavity
∗Apical retrograde micro-mirror and micro-explorers
∗Local anesthetic syringe and cartridges.
∗Miniaturized amalgam applicator for retrograde fillings
∗Narrow amalgam condensers
∗Scissors, needles and no. 3–0 and 4–0 sutures.
∗Metal endodontic ruler.
∗Gauze and cotton rolls/pellets.
∗Syringe for irrigating surgical field.
Comparison of microsurgical scalpel (top) to #15C surgical blade. Microsurgical
scalpels are particularly useful for the intrasulcular incision and for delicate dissection
of the interproximal papillae.
Microcondensers in assorted shapes and sizes for root-end filling
The microcondenser should be selected to fit the root-end
Comparison of standard #5 mouth mirror (top) to
diamond-coated micromirrors (CK Dental Specialties).
Micromirror used to inspect resected mesial root of a
mandibular first molar.
Retractors positioned to expose the surgical site
and protect adjacent soft tissues from injury.
Care must be taken to rest the retractors only
on bone, not on the reflected soft-tissue flap or
on the neurovascular bundle as it exits the
Teflon sleeve and plugger specially designed for placement
of MTA (DENTSPLY Tulsa Dental).
Messing gun–type syringe (CK Dental Specialties) can be
used for placement of various root-end filling materials.
Another delivery system designed specifically
placement (Roydent). Kit includes a variety of
tips for use in different areas of the mouth and a
single-use Teflon plunger.
Hard plastic block with notches of varying shapes and sizes (G.
Hartzell & Son). MTA is mixed on a glass slab to the consistency of
wet sand and then packed into a notch.
The applicator instrument is used to transfer the preformed plug of
MTA from the block to the root end
Special narrow periapical curette tips that may be
adapted to an ultrasonic device. They are used
forpreparation of the periapical cavity in areas with
Microhead handpiece compared to a
conventional handpiece. With this handpiece,
preparation of the periapical cavity is greatly
facilitated in areas with limited access
)1(Local anesthesia for surgery
)3(PERIRADICULAR CURETTAGE AND BIOPSY
)4(MANAGEMENT OF THE ROOT END
)5(ROOT-END CAVITY PREPARATION
)6(ROOT CANAL END FILLING PROCEDURES
)7(CLOSURE AND SUTURING
-Direct subperiosteal infiltration not only is ineffective but
also may be quite painful
-Standard infiltration may not be totally effective
-Regional block anesthesia techniques are preferred.
*Mandibular blocks for posterior areas
*bilateral mental blocks for the anterior mandible,
*posterior superior alveolar blocks for the posterior maxilla,
*infraorbital blocks for the premaxilla are preferred choices.
- These may be supplemented by regional infiltration.
)1(Local anesthesia for
-If regional block anesthesia is not sufficient, one of the
following methods may be used:
*The first technique is infiltration starting peripheral to the
*A second technique is the use of topical ethyl
-If none of these procedures work, the incision for drainage
may be done with intravenous sedation
Several general principles are important for
designing the access to a diseased region:
(1) The surgeon must have a thorough knowledge of the anatomic
structures in relation to each other, including tooth anatomy.
(2) The surgeon must be able to visualize the 3D nature of the
structures in the soft and hard tissue
(3) The trauma of the surgical procedure itself must be minimized
(4) The tissue and instruments must be manipulated within a limited
space, with the aim of removing diseased tissues and retaining
-INCISION AND REFLICTION
A vertical (rather than an angled) releasing incision severs
fewer vessels, reducing the possibility of hemorrhage. Also,
the blood supply to the tissue coronal to the incision is not
compromised, which prevents localized ischemia and
sloughing of these tissues
The following are general guidelines and
(1)Adequate blood supply to the reflected tissue is maintained
with a wide flap base.
(2) Incisions over bony defects or over the periradicular lesion
should be avoided; these might cause postsurgical soft tissue
fenestrations or nonunion of the incision.
(3) The flap should be designed for maximum access by avoiding
limited tissue reflection.
(The actual bone resorption is larger than the size observed
(4) Acute angles in the flap are avoided. Sharp corners are difficult
to reposition and suture and may become ischemic and slough,
resulting in delayed healing and possibly scar formation.
(5) Incisions and reflections include periosteum as part of the flap.
Any remaining pieces or tags of cellular nonreflected periosteum
will hemorrhage, compromising visibility.
(6) The interdental papilla must not be split(incised through). The
interdental papilla should be either fully included or excluded
from the flap; dividing may result in sloughing of the tissue.
(7) Vertical incisions must be extended to allow the
retractor to rest on bone and not crush portions of the flap.
(8) A minimal flap, which should include at least one tooth
on either side of the intended tooth, should be used.
(9) Combinations of vertical and horizontal incisions are used
to achieve various flap designs.
a. Full mucoperiosteal (intrasulcular incision including
the dental papilla or papillary based)
-Triangular: one vertical relieving incision
-Rectangular: two vertical relieving incisions
-Trapezoidal: two angled vertical relieving incisions
-Horizontal: no vertical relieving incision
b. Limited mucoperiosteal
-Curve submarginal (semilunar)
-Freeform rectilinear submarginal (Ochsenbein-Luebke)
TYPES OF FLAP
.Most commonly used
. One vertical releasing incision; can extend to rectangular flap
. Keep 2 teeth away from Pathosis
1. Excellent wound healing potential
2.Minimal disruption of vascular supply
3. Excellent visibility & access to defects
4. Good flap reapproximation
5. Easy to suture
1.More difficult to incise & reflect
2.May be limited access due to single releasing incision
3. Possible slight gingival recession
. Extension of triangular flap
. Two vertical releasing incisions
. Horizontal intrasulcular incision
. Use if increased reflection is needed
1. Enhanced surgical access
2. Excellent visibility
3. Excellent wound healing potential
4. Minimal disruption of vascular supply
5. Good to view dehiscenses & fenestrations
1. More difficult to incise & reflect
2. Possible gingival recession
3. More difficult wound closure than triangular flap
1. Does not involve marginal or interdental
gingiva nor expose crestal bone
2. Minimizes crestal bone loss & gingival recession
3. Easy flap reapproximation
1. Unable to extend flap if needed
2. Disruption of blood
supplty to marginal tissues; must rely on collateral
3. Limited mandibular use
4. Possible flap shrinkage & scarring
5. Limited visibility for root & crestal bone
. Full-thickness flap in alveolar mucosa at level of tooth apex
. Indication for long tooth only (max. canine)
. Seldom used due to poor access& scarring
. Hemostasis may be problem
1. Fast & easy to reflect; no exposure of crestal bone
2. Unaltered soft tissue attachment level
3. No involvement of marginal & interdental gingival
1. Poor access (least), excessive scarring & flap
2. Blood supply interruption to adjacent tissues
3. Limited use in mandible
4. Unable to extend; may cross bony cavity
. Intrasulcular horizontal incision without vertical release
. Not used for apical surgery
. Used for root resects, root amps, hemisections, repair of
cervical perfs. or resorptive defects
1. Good for perio-surgery
2. Can convert to rectangular flap if needed
1. Limited endo use
2. Not for apical surgery
3. No releasing incisions
The only flap designs indicated for palatal approach
surgery are the horizontal (envelope) and the
triangular, with the latter being preferred.
-A firm incision is made with a No. 15 or another
-To prevent tearing during reflection, the incision must
be made through periosteum to bone
-The tissue is reflected with a sharp periosteal
elevator beginning in the vertical incision and then
raising the horizontal component.
Incision and tissue
-Because periosteum is reflected as part of the flap, the elevator
must firmly contact bone as the tissue is peeled back, using firm
Elevator placed in the vertical incision for
the first step in undermining flap reflection.
-The tissue is reflected to a level that will provide adequate access
and visibility of the surgical site while allowing a retractor to be
placed on sound bone
Reflection of the triangular flap to expose the root-
-The main goals of tissue retraction are to provide a clear view
of the bony surgical site and to prevent further soft-tissue trauma.
-The general principles of retraction are
(1) Retractors should rest on solid cortical bone
(2) Firm but light pressure should be used
(3) Tearing, puncturing, and crushing of the soft tissue should be
)4(Sterile physiologic saline should be used periodically to
maintain hydration of the reflected tissue
)5(The retractor should be large enough to protect the retracted
soft tissue during surgical treatment
)6(If difficulty is encountered in stabilizing the retractor, a small
groove can be cut into the Cortical plate to support it.
- Biologic principles govern the removal of bone for
hard tissue access to diseased root ends:
1-healthy hard tissue must be preserved
2-heat generation during the process must be minimized
1-The shape and composition of the bur
(round fluted bur is better than fissure bur)
2- The rotational speed
(A high-speed handpiece that exhausts air from the base rather
than the cutting end is recommended to reduce the risk of air
3- The use of coolant
(essential to improve healing)
4- The pressure applied during cutting.
(gentle brushstroke technique)
-Factors determine the amount of heat
generated during bone removal:
-The root surface can be distinguished from the
surrounding osseous tissue in four ways:
(1) Root structure generally has a yellowish color,
(2) Roots do not bleed when probed,
(3) Root texture is smooth and hard as opposed to the
granular and porous nature of bone,
(4) It is surrounded by the periodontal ligament.
(5) methylene blue dye
-when the bone exposing a lesion is dense
misdirected penetration may lead to root
-bone length may be approximated from a prior radiograph
or an intracanal file measurement or digitalized from a
radiograph or guided by a radiograph of surgically placed
-curettage: To remove all pathologic tissue, foreign
bodies, and root and bone particles from periradicular
-Biopsy: To establish a definitive diagnosis by
removing a tissue specimen from its bed then
submitting it to an oral pathologist for a histologic
CURETTAGE AND BIOPSY
-Although the typical curette is shaped like a spoon and there is a
tendency to use it as such, the sharp edge created when its
concave surface faces bone makes it an extremely efficient cleaver.
-With the concave surface facing bone, the appropriate sized
curette is wedged between the soft tissue of the lesion and the
border of the window entry.
-The sharp edge of the instrument is kept in constant contact with
the bone as it penetrates the bone crypt.
-This cleaving motion easily strips the tissue from its bone
Under normal conditions, little or no resistance will be met and the
relatively soft tissue will easily disengage from the bone.
-Once the lesion is freed from the bone the curette can, with its
convex surface facing bone, be used as a spoon to easily lift and
remove the specimen from the crypt
-The walls of the bone cavity should appear smooth and free of all
-The specimen is immediately placed into a properly labeled biopsy
bottle for histologic evaluation.
1-When there is resistance to lesion tissue removal
,it usually means the granulation tissue is firmly attached to the
lingual aspect of the root surface. In this case ,it is better to gain un
confined access to the condition by widening the osseous widow
than to continue with a restricted ,laborious ,inefficient and time
consuming segmental curette.
2-When further resistance is met in the depth of
the crypt ,it generally indicates the lesion tissue has
perforated the lingual plate of bone and has communicated
with the palatal mucosa through the opening in the bone wall.
** This integration can be verified by placing a finger against
the lingual mucosa that approximates the lesion location and
physically feeling the curetting action within the depth of the
crypt. To avoid perforating the mucosa ,the innermost
segment of the lesion requires delicate dissection.
3-When resistance continues and periodontal
planning and scalpel dissection has been
unsuccessful in freeing the lesion , a 2-to 3- mm segment
of the apex should be resected ,and the tip and any adhering tissue
removed and included in the biopsy.
This technique is efficient and, because this root segment would
normally be removed during the apicoectomy procedure ,its loss is
of no consequence
4-Curetting large lesion often presents anesthesia
problems . when a patient complains of pain during curetting
of extensive lesion ,the procedure is stopped and the patient is
1-minimizes surgical time, surgical blood loss, and postoperative
hemorrhage and swelling.
2-enhances visibility and assessment of the root structure
3-ensures the appropriate environment for placement of the
current root-end filling materials and minimizes root-end filling
As CollaCote , CollaStat , Hemocollagene, and Instat
4-Bone Wax 5-Ferric Sulfate
6-Calcium Sulfate 7-Calcium Sulfate
8-Epinephrine Pellets 9-Cautery/Electrosurgery
Local hemostatic agents
The basis for periradicular surgery is two fold:
-The first objective is to remove the etiologic factor
- The second is to prevent recontamination of the periradicular
tissues once the etiologic agent has been removed. ( create an
environment conducive to regeneration of the periodontium—
that is, healing and regeneration of the alveolar bone,
periodontal ligament, and cementum overlying the root end
and root-end filling material.)
)4(MANAGEMENT OF THE
-Root-end resection of approximately 3mm involves beveling of
the apical portion of the root.
This step is often an integral part of periradicular surgery and serves
the following two purposes:
1. It removes the untreated apical portion of the root and enables
the operator to determine the cause of failure.
2. It provides a flat surface to prepare a root end cavity and pack it
with a root-end filling material.
-When roots with more than one main canal are resected, isthmus
tissue may be present, and the preparation should be modified to
include the isthmus area
- Reduction of an apically fenestrated root apex below the level of
the surrounding cortical bone allows remodeling of the bone over
the tooth structure.
-Apical sectioning is done with a tapered fissure bur in a high-
speed handpiece and copious sterile saline irrigation
The bevel should be made at approximately 45 degrees in a
faciallingual direction, with the least amount of bevel to give
maximum visibility to the root apex.
-From a biologic perspective, the most appropriate angle of root-end
resection is perpendicular to the long axis of the tooth .
-The conventional axiom for surface preparation of the resected
root end has been to produce a smooth, flat root surface without
sharp edges or spurs of root structure that might serve as irritants
during the healing process.
-smearing and shredding of the gutta-percha across the root face
occurred only when the handpiece was moved across the root face
in reverse direction in relation to the bur’s direction of rotation.
-Root surface conditioning removes the smear layer and
provides a surface conducive to mechanical adhesion and cellular
mechanisms for growth and attachment.
-Three solutions have been advocated for root surface
modification: citric acid, tetracycline, and ethylenediamine
tetraacetic acid (EDTA).
-All three solutions have enhanced fibroblast attachment to the
root surface in vitro. However, citric acid is the only solution tested
in an endodontic surgical application.
-The ideal preparation is a class I cavity prepared along the long
axis of the tooth to a depth of at least 3 mm
-Traditionally, a microhandpiece with a rotating bur has been
used, but with the advent of ultrasonic tips designed specifically
for this purpose root-end preparations now are most often
performed with the ultrasonic technique.
Diagram of a perpendicular root-end preparation and 3-mm-deep
cavity preparation along the long axis of the root
A root-end filling material should have the
1. Well sealing
2. Well tolerated by the periradicular tissue
4. Easily inserted
5. Unaffected by moisture
6. Radiographic visibility
7. Ability to allow regeneration of periradicular tissues
*Many materials have been used as root-end fillings,
-gutta-percha, - polycarboxylate cements,
-silver cones, amalgam, -Cavit (3M ESPE St. Paul,
-zinc phosphate cement, -gold foil
-Zinc oxide eugenol cements (IRM and SuperEBA),
-Glass ionomer cement -Diaket
-Composite resins (Retroplast), -Resin–glass ionomer
-Mineral trioxide aggregate (ProRoot-MTA).
Types of root-end filling
-good handling properties
-The apical seal depends on
the structure of gutta-percha ,
its degree of condensation,
and the nature and the amount
of sealer used
-there is atendency for its
margins to open when the
canal root interface is cut ,
heated or burnished
It has been the most widely used material
Its shrinkage lead to leakage
It produce corrosive byproduct
Mercury and tin contamination
A retentive designed cavity preparation is required
Tissue tattooing(not used anteriorly)
Scattered particles are not resorbable
(super EPA, IRM and CAVIT(
-have recently gained
popularity because they
don’t stain soft or hard
tissue and are
nongalvanic when placed
in contact with posts
-initial tissue irritation
)4(Dentine bonding agents
-they adapt better
-leak less than amalgam
-ineffective bond against
-all composites are
known to leak after
-chemically bond to the
-root preparation must be
-the seal is adversely
affected by moisture and
-The powder consists of fine
hydrophilic particles that set
in the presence of moisture
-Inability to flush the crypt
clean without washing out
-2-4 hrs setting time
)1(Surgical site should be isolated and aspirated of all
fluids and blood
)6(ROOT CANAL END FILLING
)2(The cavity preparation is flushed clean and thoroughly dried
with air blown through a 30-gauge short needle attached to a
)3(Test dryness and blood by short cut paper point
(4)For amalgam filling, 2 thin layer of cavity varnish should be
painted in the cavity
(5)For the gutta-percha, the cavity wall should be dressed with
)6(Microcondensers are used to vertically condense the
amalagam to minimize voids and maximize compaction
)7(All other filling materials including pastes, must be
mixed according to manufacturer's standards and carried to the
preparation by minicarriers or missing guns carvers
)8(Plugers of various angels and sizes are used to condense the
)9(All excess and flash should be curetted and aspirated from
the site with Lucas curette
)10(The borders should be examined under high magnification to
evaluate the interface seal
)11(The surface then should be burnished with a finishing bur
(12)The cavity is carefully inspected for flaws or loss of
marginal integrity by retromirrors
(13)Any gauze, pellets and or bone wax should be removed and
the surgical site should be cleaned
(14)A radiograph is finally taken to evaluate the filling
(1)The osteotomy site is gently curetted and irrigated with sterile
saline or water to remove any remnants of hemostatic agents and
(2)Some bleeding is encouraged at this point, because the
blood clot forms the initial scaffold for subsequent healing and repair.
(3)If indicated, grafting materials or barriers may be placed at this
(4)Slight undermining of the unreflected soft tissue adjacent to
the flap facilitates the placement of sutures.
(5)The flap is then repositioned
(6)When suturing is complete, chilled, sterile, moist cotton gauze is
again placed over the flap, and pressure is applied for 5 minutes.
(7)The patient is given a cold compress and instructed to hold it on the face in the
surgical area—on for 20 minutes then off for 20 minutes—for the rest of the day.
(8)The patient also is given verbal and written postoperative instructions
∗)Pressure to the area provides stability for the initial fibrin stage of clot formation
and reduced the possibility of excessive postoperative bleeding and hematoma
formation under the flap(
Gauze sponge moistened with saline and
applied to flap both before and after
-Sutures are classified as absorbable or nonabsorbable,
-size is designated by two Arabic numbers, one a zero, being separated by a hyphen
3-0, 4-0, 5-0, etc).
(The higher the first number, the smaller the diameter of the suture material).
-Suture material in size 5-0 is most commonly used, although some clinicians
preferslightly larger (4-0) or smaller (6-0) suture.
(Sutures smaller than 6-0 tend to cut through the relatively fragile oral tissues when
ied with the tension required to approximate wound margins).
Selection of the Suture Material
)1(Silk suture material
)2(Resorbable suture materials (plain gut and
)3(Suture materials with a smooth Teflon or
polybutilate coating (e.g., Tevdec and Ethibond,
)4(Synthetic monofilament suture materials (e.g.,
Supramid and Monocryl)
(5) Gortex (expanded PTEE-Teflon) sutures
Types of suturing
-Has been commonly used in dental surgery for decades and is both
inexpensive and easy to handle
but it tends to support bacterial growth and allows for a wicking
effect around the sutures , for these reasons, other materials are
preferable to silk
Silk suture material
-Are not routinely used for periradicular surgery
-May be indicated if the patient will be unavailable for the regular
suture-removal appointment (48 to 96 hours after surgery) or if
the suture will be used in areas of the mouth where access is very
-The primary problem with resorbable suture materials is the
variable rate of resorption; that is, sutures may weaken and
dissolve too soon or, more commonly, remain in the incision area
for longer than desired.
Resorbable suture materials
(plain gut and chromic gut(
-Are particularly well suited for use in periradicular surgery.
Suture materials with a smooth Teflon or
polybutilate coating (e.g., Tevdec and Ethibond,
-Are also commonly used
-These materials are easy to handle and do not promote bacterial
growth or wicking of oral fluids to the same extent as silk.
Synthetic monofilament suture materials
(e.g., Supramid and Monocryl(
Have many desirable properties but are more expensive than the
previously mentioned materials.
Gortex (expanded PTEE-Teflon)
*The final selection of an appropriate surgical needle is based on
a combination of factors including
-The location of the incision,
-The size and shape of the interdental embrasure,
- The flap design, and the suture technique planned.
*A needle with a reverse cutting edge (the cutting edge is on the
outside of the curve) is preferable
Conventional cutting needles are not recommended because the cutting edge
on the inside curvature tends to pull through the flap edge; reverse cutting
suture needles prevent suture material from tearing through surgical flaps.
As previously noted, NSAIDs generally are the preferred class of
drugs for managing postoperative pain
Ibuprofen (400 to 800 mg) or an equivalent
NSAID typically is given before or immediately after surgery and can
be continued for several days postoperatively as needed.
When additional pain relief is required, a narcotic such as codeine,
hydrocodone, or tramadol may be added to the standard
(This strategy may result in a synergistic effect, and therefore
greater pain relief, than would be expected with the separate
analgesic value of each drug).
1. Limit physical activity for the first 24 hours. Easy activity
is OK but be careful and do not bump your face where the surgery
was done. You should not drink any alcohol or use any tobacco
(smoke or chew) for the next 3 days.
2. It is important that you have a good diet and drink plenty
of liquids for the first few days after surgery. Juices, soups, and
other soft foods, like yogurt and puddings, are suggested. Liquid
meals, like Sego, Slender, and Carnation Instant Breakfast, can be
used. You can buy these at most food stores. Avoid carbonated
3. Do not brush in the area of the incision for first 3
days, then use a soft brush very carefully; use warm salt
water rinses (dilute 1/8 teaspoon salt per 8 oz glass of water)
and rinse for 1 minute swishing the surgical area every 2 hours
during the day. Continue rinses until 2 days after sutures removed.
4. Do not lift up your lip or pull back your cheek to
look where the surgery was done. This may loosen the stitches,
causing them to tear the gum tissue and start bleeding.
5. A little bleeding from where the surgery was done is normal.
This should only last for a few hours. You may also have a little
swelling and bruising of your face. This should only last for a few
6. Place an ice bag (cold) on your face where the surgery
was done. You should leave it on for 20 minutes and take it off for 20
minutes. You should do this for 6 to 8 hours. After 8 hours, the ice
bag (cold) should not be used. The next day after surgery, you can
put a soft, wet, hot towel on your face where the surgery was done.
Do this as often as you can for the next 2 to 3 days.
7.You should use the pain medicine you were given or
recommended to you, as needed.
8. Rinse your mouth with one tablespoon of the chlorhexidine
(Peridex) you were given or prescribed. This should be done two
times a day (once in the morning and once at night before going to
bed). You should do this for 5 days.
9. The stitches that were placed need to be taken out in a few
days (removed 2 to 4 days after surgery). You will be told when to
return. It is important that you come in to have this done!!
10. You will be coming back to the office several
times during the next few months so we can evaluate how you are
healing. These are very important visits and you should come in even
if everything feels OK.
11. If you have any problems or if you have any questions, you
should call the office. The office phone number is xxx-xxxx. If
you call after regular office hours or on the weekend, you will be
given instructions on how to page the doctor on call.
-Local anesthesia is rarely required, although application of a
topical anesthetic may be helpful, especially to releasing incisions
in nonkeratinized mucosa.
-Sharp suture scissors or a #12 scalpel blade can be
used to cut the sutures before they are removed with cotton pliers
or tissue forceps.
)9(POST SURGICAL EVALUATION AND
-A transient bacteremia can be expected after suture removal,
even when a preprocedural chlorhexidine mouth rinse is used.
-Antibiotic coverage should be considered only for patients at
high risk of developing bacterial endocarditis.
-If healing is progressing normally at the suture removal
appointment, the patient does not need to be seen again in the
office until the first scheduled recall examination, typically 3 to 12
months after surgery.
-Phone contact with the patient approximately 7 to 10 days after
suture removal is recommended to confirm the absence of
-Patients with questionable healing at the suture-removal
appointment should be reevaluated in the office in 7 to 10 days or
sooner if necessary.
Surgery involves the manipulation of both:
A-soft tissues (periosteum, gingiva, periodontal ligament, and alveola
B-hard tissues (dentin, cementum, and bone)
-connective tissue healing,
-and maturation and remodeling of both
connective tissue and bone
*)Clotting and inflammation consist of both chemical
and cellular phases. (
)A)SOFT TISSUE HEALING
1-The clotting mechanism is important because it is based on
the conversion of fibrinogen to fibrin; under pressure, the
clot should be a thin layer.
Failure of a clot to form results in leakage of blood into the wound
2-The inflammatory components of healing are a complex
network of both extrinsic and intrinsic elements
3-Initial epithelial healing consists of the formation of
the epithelial barrier, made up of layers of epithelial cells
that depend on the underlying connective tissue for nutrients.
This epithelial layer migrates along the fibrin surface until it
makes contact with epithelial cells from the opposite border of
the wound, forming an epithelial bridge.
4-The connective tissue component comes from
fibroblasts, which are differentiated from ectomesenchymal cells
and are attracted to the wound site by cellular and humoral
Adjacent blood vessels provide nutrients for the fibroblasts and
their precursors, which elaborate collagen, initially type III,
followed by type 1.
Macrophages are an important part of these processes.
5-As healing matures, there is a decrease in the amount of
inflammation and numbers of fibroblasts, accompanied by
deaggregation and reaggregation of collagen with
formation of collagen fibers into a more organized
As with soft tissue, the hard tissue response is based on the
fibroblast, which results in synthesis of ground substance,
cementum, and bone matrix formation .
New cementum deposition from cementoblasts begins
about 12 days after surgery; eventually a thin layer of cementum
may cover resected dentin and even certain root end filling
Complete periapical healing and
formation of cellular cementum
(arrows) adjacent to mineral trioxide
aggregate when it is used as a root-
end filling material in monkeys
Osseous healing begins by the proliferation of
endosteal cells into the coagulum of the wound site.
At 12 to 14 days, woven trabeculae and osteocytes appear, leading
to early maturation of the collagen matrix at about 30 days. This
process occurs from inside to outside, ending in the formation of
mature lamellar bone ,32-35 which is visible radiographically
A, Failed root canal treatment requiring surgery. B, The root
end is resected, and a cavity is prepared and is filled with MTA.
C, One-year recall shows complete healing
Postoperative pain typically peaks the day of surgery, and swelling
reaches its maximum 1 to 2 days after surgery.
As previously noted, good evidence supports the use of
prophylactic NSAID therapy and a long-acting local anesthetic to
reduce the magnitude and duration of postoperative pain.
MANAGEMENT OF SURGICAL
Patients should be advised that some postoperative oozing of
blood is normal, but significant bleeding is uncommon and may
Most bleeding can be controlled by applying steady pressure for 20
to 30 minutes, typically with a piece of moist cotton gauze or a tea
-Bleeding that persists requires attention by the clinician.
-Pressure to the area and injection of a local anesthetic containing
1:50,000 epinephrine are reasonable first steps.
-If bleeding continues, it may be necessary to remove the sutures and
search for a small severed blood vessel. (When located, the blood
vessel can be crushed or cauterized to control bleeding. Cauterization
may be performed with a heat source commonly used for warm
Local hemostatic agents, as previously described, may also be used.
Occasionally, a patient may require hospitalization and surgical
intervention to control bleeding, but this is an extremely rare event.
This condition is self-limiting and does not affect the prognosis.
Moist heat applied to the area may be helpful, although complete
resolution of the discoloration may take up to 2 weeks. Heat
should not be applied to the face during the first 24 hours after
(4) Sinus exposure
-Postoperative antibiotics and decongestants are often
recommended but this practice is controversial
-no evidence supports the routine use of antibiotics and
decongestants in these cases
The incidence of damage to the inferior alveolar nerve
after third molar surgery is approximately
1.3%, with only about 25% of these cases resulting in
Unless the nerve is resected during surgery, most
patients can be expected to return to normal sensation
within 3 to 4 months.
If the paresthesia does not show signs of resolving
within 10 to 12 weeks, referral and evaluation for
possible neuromicrosurgical repair should be
(6) postsurgical infections
Postsurgical infections are rare. For this reason, peritreatment
systemic antibiotic therapy is seldom required and is not considered
part of routine postsurgical care in healthy patients.
The most common causes of postsurgical infections following
periradicular surgery are the result of inadequate aseptic techniques
(These are under the direct control of the endodontic surgeon).
The clinical signs and symptoms of a postsurgical infection are
usually evident 36 to 48 hours after surgery.
The most common indications are progressively increasing pain and
Suppuration, elevated temperature, and lymphadenopathy may or
may not be present. Systemic antibiotic therapy should be initiated
immediately when indicated.
Chlorhexidine oral rinses should continue for 4 to 6 days following
surgery (2 to 3 days following suture removal).
(7) Staining of mucosa
due to amalgam that remained at the surgical field (amalgam tattoo)
(8) Healing disturbances
if the semilunar incision is made over the bony deficit or if the flap,
after reapproximation, is not positioned on healthy bone.
(9) Splattering of amalgam at the operation site
Due to inadequate apical isolation and improper manipulations for
removal of excess filling material
Extensive periapical lesion at maxillary right lateral
incisor. Indication for apicoectomy
Clinical photograph of case shown in
Arrow points to possible location of lesion
Surgical procedure for removal of periapical lesion, together
with apicoectomy at lateral incisor of maxilla. Incision for
creation of trapezoidal flap. a Diagrammatic illustration. b
Reflection of mucoperiosteum and exposure of labial alveolar
plate after elevation of flap. a Diagrammatic
illustration. b Clinical photograph
Removal of labial bone covering apical third of root. a
Diagrammatic illustration. b Clinical photograph
Removal of periapical lesion with hemostat and curette. a
Diagrammatic illustration. b Clinical photograph
Resection of apex with fissure bur and beveling at a 45°
angle. The resection faces the surgeon and is at a
distance of 2–3 mm from the root tip
Diagrammatic illustration (a) and clinical photograph (b)
showing beveled root of lateral incisor
Preparation of cavity at root tip of tooth usingmicrohead
handpiece. a Diagrammatic illustration. b Clinical photograph
Cavity created (inverted cone-shaped) where
filling material is to be placed. a Diagrammatic
b Clinical photograph
Placement of filling material in cavity of apex using miniaturized
amalgam applicator. a Diagrammatic
illustration. b Clinical photograph
Condensing of amalgam with narrow amalgam condenser. a
Diagrammatic illustration. b Clinical photograph
Diagrammatic illustration (a) and clinical photograph (b)
showing the apex of the tooth with retrograde
Operation site and placement of sutures. a
Diagrammatic illustration. b Clinical photograph
Radiograph taken before suturing of flap,which
shows retrograde amalgam filling
Radiograph of maxillary central incisor, showing
periapical lesion and unsatisfactory filling of the root canal
Surgical procedure for apicoectomy at maxillary left central incisor.
Semilunar incision made for flap.
a Diagrammatic illustration. b Clinical photograph
Reflection of flap and retraction with broad end of periosteal
elevator. a Diagrammatic illustration.
b Clinical photograph
Removal of bone covering apex of tooth. a Diagrammatic illustration. b
Exposing periapical lesion and apex of tooth together after removal of
respective buccal bone. a Diagrammatic
illustration. b Clinical photograph
Removal of periapical lesion with hemostat and periapical
curette. a Diagrammatic illustration. b Clinical
Resection of apex of tooth at a 45° angle. a Diagrammatic
illustration. b Clinical photograph
Preparation of cavity at apex with microhead handpiece. a
Diagrammatic illustration. b Clinical photograph
Diagrammatic illustration (a) and clinical photograph (b) showing
prepared cavity ready for placement of
Placement of filling at root tip with miniaturized amalgam applicator. a
Diagrammatic illustration. b Clinical
Condensing amalgam at periapical cavity with narrow amalgam
condenser. a Diagrammatic illustration.
b Clinical photograph
Operation site after placement of sutures. a Diagrammatic
illustration. b Clinical photograph
Periapical radiograph taken after suturing of flap, showing retrograde
-To evacuate exudate and purulence, which are potent and toxic
-Removal speeds healing and reduces discomfort resulting from the
irritants and from the buildup of pressure.
Performance of most intraoral incisions is generally within the ability
of general practitioners.
(1)Swelling originating from an acute apical abscess of pulpal
(2)Occasionally drainage is performed through the soft tissue even if
it has also been obtained through the tooth. The reason is that there
may be two (or more) separate, noncommunicating
abscesses-one at the apex and another in a submucosal location
or in ananatomic space
)3(Incising a fluctuant swelling releases purulence immediately and
provides rapid relief.
(1)Diffuse swellings are not usually
(2)Incised Patients with prolonged bleeding or clotting times
must be treated cautiously, and hematologic screening is often
(3)An abscess in an anatomic space may require more
involved treatment; the patient should be referred to an oral and
maxillofacial surgeon for an extraoral or aggressive intraoral incision
(1) Anesthesia (as discussed)
-The incision is made horizontally or vertically with
a No. 11, 12, or 15 blade.
-Vertical incisions are parallel with the major blood vessels and nerves
and leave very little scarring.
-The incision should be made firmly through periosteum to bone.
-If the swelling is fluctuant, pus usually
flows immediately, followed by blood. Occasionally, there is only a
serosanguineous exudate, which is acceptable.
-If the swelling is nonfluctuant, the predominant flow is hemorrhagic.
-A small closed hemostat may be placed in the incision and then
opened to enlarge the draining tract.
-The initial incision and subsequent enlargement usually provide the
-If a drain is necessary because of limited initial drainage, a self-
retentive I -shaped or "Christmas tree" drain cut from a rubber dam
or a piece of iodoform gauze is placed (suturing is optional) in the
-The drain should be removed after 2 to 3 days; if it is not sutured, the
patient may remove the drain at home.
These procedures are especially designed to correct
pathologic or iatrogenic entities (procedure errors) that have
damaged the root and are not correctable via the pulp space
Correction of root perforations often presents a more difficult
challenge than procedures that merely involve periradicular surgery.
Typically these accidents occur during access, canal preparation, or
restorative procedures (usually post placement).
(2) Resorptive Perforations
Resorptive root perforations typically occur as sequel to trauma or
internal bleaching procedures.
-the greatest potential for furcation perforations are the maxillary and
-When a perforation occurs in this area of the tooth, the initial attempt
at repair should be from an internal, nonsurgical approach.
-When surgery is necessary, a buccal
mucoperiosteal flap is reflected, the furcation bony defect is
curetted to remove any pathologic tissue, and the perforation site is
(2)Strip perforation: (in the cervical one-third of the Root)
-occur most frequently in the thin distal aspects of the mesial roots of
mandibular molars and the mesiobuccal roots of maxillary molars.
-Nonsurgical repair should be the first treatment option in these
-If surgical repair is deemed necessary, the perforation must be
accessed and visualized through a window created in the buccal
-If neither the nonsurgical nor surgical options are feasible, other
possible treatment options include root amputation,
hemisection, intentional replantation, or extraction
followed by the placement of a bridge or osseointegrated implant.
-is the removal of one or more roots of a multirooted tooth. The
involved root(s) is (are) separated at the junction of and into the
-performed in maxillary molars, but it can be performed in
is the surgical division of a multirooted tooth.
- In mandibular molars the tooth is divided buccolingually through
-In maxillary molars the cut is made mesiodistally, also through
The defective or periodontally involved root and its coronal crown are
-is a surgical division (as in hemisection, usually a mandibular molar),
but the crown and root of both halves are retained.
-If severe bone loss or destruction of tooth structure is confined
primarily to the furcation area, hemisection and furcal curettage may
allow retention of both halves
(Each half may be restored to approximate a bicuspid, hence the term
-The presence of severe bone
loss in a nonsurgical treatable
- Untreatable roots because
of broken instruments,
perforations, caries, resorption,
vertical fractures, or calcified
-Insufficient bony support for the
-Root fusion or proximity such that
root separation is not possible
-Strong abutment teeth available
(the involved tooth should be extracted
and a prosthesis fabricated)
-Inability to complete root canal
treatment on the remaining root(s)
- is performed by making an angled cut from the furcation to the
proximal aspect to separate the root from the crown.
-The crown remains intact, and the root is removed. Therefore, the
crown is cantilevered over the extracted root segment and
remains in contact with the approximating tooth.
A second approach is to use an angled vertical cut in which the crown
above the root to be amputated is recontoured, decreasing the
occlusal forces and making the procedure easier.
-As the crown is shaped, the bur is gradually angled into the root,
resulting in good anatomic contour.
- involves making a vertical cut through the crown into the
-This results in complete separation of the hemisected section (crown
and root) from the tooth segment that is retained.
- The defective half of the tooth is extracted.
-Furcation pathosis from
caries or fracture into furcation
ns-Deep furcation (thick floor of pulp
-Periodontal disease (each half must
be –periodontally sound)
-Inability to complete root canal treatment
on either half
- is performed after a vertical cut is made through the crown
into the furcation with a fissure bur. This procedure results in
complete separation of the roots and creation of two separate
After healing of tissues the teeth can be restored to form two
-These techniques may or may not require flap
reflection. Often, if the root is periodontally involved, it is
removed without a flap.
-If bony recontouring is indicated, a flap is necessary
before root resection is carried out.
-A sulcular flap design is often possible without a vertical
-when surgical access is very
limited or presents unacceptable
(Mandibular second molars are a
common example for this technique
because of the typically thick overlying
buccal bone, shallow vestibular depth,
and proximity of the root apices to the
-Teeth with flared or moderately
-the presence of periodontal
-The tooth should be extracted with minimal trauma to the tooth
(Ideally, elevators are not used, and the root surface is not engaged
-All instruments and materials for root-end preparation and filling
should be arranged before extraction to minimize extraoral
-The root surface must be kept moist by wrapping the root
with gauze soaked in a physiologic solution such as
Hank’s Balanced Salt Solution.
-After root-end preparation and filling (described
previously), the tooth is replanted, and the buccal bone is
-The patient may be instructed to bite on a cotton roll or
other semisolid object to help position the tooth properly in the
- Occlusal adjustment is indicated to minimize traumatic forces
on the tooth during the initial stage of healing.
-A splint may be applied, but this is often not necessary.
-The patient should eat a soft diet and avoid sticky foods,
candy, and chewing gum for at least 7 to 10 days.
∗A, The mandibular second molar
remained symptomatic after an
unsuccessful attempt was made
to negotiate the apical portion of
both mesial canals and to retrieve
the separated instrument from
one of the canals. Due to the
close proximity of the mandibular
canal to the apices of the roots of
the second molar, an intentional
replantation procedure was
recommended rather than
periapical surgery; B, Forcep
extraction; C, Root ends resected;
D, Tooth reimplanted; E, Acrylic
splint placed; F, Immediate
postoperative radiograph; G, Soft
tissues are healthy and tooth is
asymptomatic at the 6-month
follow-up; H, There has been a
reduction in the size of the
periapical radiolucent defect on
the 6-month follow-up radiograph.
*Varying results have been reported for root removal.
*Success depends on the following factors:
-Cutting and preparing the tooth without creating additional damage
-Good oral hygiene
-Development of caries (most common cause of failure)
-Excessive occlusal forces
-Poor restorative procedures
-Untreatable endodontic problems
∗-Periodontal disease (second most common cause of failure(