Endodontic surgery / / rotary endodontic courses by indian dental academy

ENDODONTIC
SURGERY

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

INTRODUCTION

 Over the years Endodontic surgery has seen great advancements due to the
advent of new technology.This field has progressed beyond Apicectomy
(Root Resection,Root Amputation),to include periapical
curettage,radiosectomy,replantation,implantation,trephination & incision
for drainage.
 Root resection is the most common form of periapical surgery.
 The success rate of Endodontic surgery is high but it is used only in certain
cases,when the normal conventional treatment has failed.


HISTORICAL PERSPECTIVE.
 The first ever Endodontic surgical procedure
was incision & drainage,of an acute
endodontic abcess performed by Aetius
1500yr ago in Greece.
 Abulcasis,Fauchard,Hullihan,Martin,Partisch
& Black were the poineers who refined
Endodontic surgery.


OBJECTIVE OF ENDODONTIC
SURGERY.
 The surgery ensures the proper seal between
the Periodontium and the root canal foramina.
 When this seal cannot be achieved
satisfactorily by working through the canal
system (orthograde filling), a surgical
procedure permits visual and manipulative
control of the area and placement of the seal
through the surgical site.


INDICATIONS.
 Need for surgical drainage.
 Failed non surgical endo treatment.
1.Irretrievable root canal filling material
2.Irretrievable intraradicular post.
 Calcific Metamorphosis of the pulpal space.
 Procedural errors.
1.Instrument Fragmentation
2.Non negotiable ledging
3.Root perforation
4.Symptomatic Overfilling
 Anatomic variations
1.Root Dilaccertions
2.Apical root perforations.


 Biopsy
 Corrective Surgery

1.Root Resorptive Defects.
2.Root Caries.
3.Root Resection.
4.Hemisection.
5.Bicuspidization.
 Replacement Surgery.

1.Intentional Replantation.
2.Post traumatic
 Implant surgery

1.Endodontic
2.Osseointegrated.


CONTRAINDICATIONS.
 GENERAL CONTRAINDICATIONS
1.MEDICALLY COMPROMISED PATIENTS:With active systemic
diseases such as Diabetis,Tuberculosis,Syplillis,Nephritis,Blood
dyscrasis,Osteoradionecrosis or any other medical condition which restricts
the surgicsl procedure.
2.EMOTIONALLY DISTRESSED PATIENT:Psycologically weak
patients who cannot withstand and cope with the surgical procedures.
3.LIMITATIONS in the surgical skill and experience of the operator.


 LOCAL CONSIDERATIONS.
1.LOCALISED ACUTE INFLAMMATION:Periapical Surgery is
contraindicated
2.ANATOMIC CONSIDERATIONS:Nasal floor,Maxillary
sinus,Mandibular canal,Mental Foramen,Greater palatine vessels.
3.INACCESIBLE SURGICAL SITES:Lingual surface of molars or
external oblique ridge of the Mandible.
4.TEETH WITH POOR PROGNOSIS.


 PRE OPRERATIVE CONSULTATION
A necessary informed consent is to be taken from the
patient.Assurance should be given to the patient that he will be
treated expertly.
 PREMEDICATION.
Pentobarbital and Secobarbital 50-150 mg 30min prior to the
surgical procedure may be given orally IM/IV
Tranquilizers like Meprobromate 400 mg 4 times daily for
several days prior to tratment or Diazepam 5mg taken orally
30 min prior to treatment is effective.


SURGICAL DRAINAGE.
 INDICATIONS:Purulent &/or hemorrhagic exudate forms within the soft tissue
or the alveolar bone as a result of a syptomatic periradicular abcess
 It is accomplished by
1. Incision & Drainage of soft tissue.
2. Trephination of Alveolar Cortical plate.
 INCISION & DRAINAGE.
Incision should be made through the focal point of the localized swelling to relieve
pressure,eliminate exudate and toxins and stimulate healing.
 LOCAL ANESTHESIA.
Nerve block is the preferable method.
Some blocks must be supplemented with the infiltration to obtain adequate
anesthesia.
Oral mucosa in the area to be injected should be dried with 2x2 gauze and a topical
anesthetic placed.


 INCISION
-Surgical area should be isolated with sterile 2x2 gauze sponges.
-Incision should be horizontal and placed at the dependent base of the fluctuant
area.
-Incision should be made using a scalpel and blade that is pointed such as
No11or No 12.
-Exudate should be aspirated and if indicated a sample collected for
Bacteriologic culturing.
 PLACEMENT OF A DRAIN.
-Made of either iodoform gauze or rubber dam material cut in an “H” or
-Christmas tree shape.
-Can be sutured in place for additional retention
-Should be removed after 3-4 days.


CORTICAL TREPHINATION
 It is a procedure involving the perforation of the central cortical plate to accomplish
the release of pressure from the accumulation of the exudate within the alveolar
bone.
 INDICATIONS
Patients who present with moderate to severe pain but with no intraoral or
extraoral swelling.
 OBJECTIVES.
To create a pathway through the cancellous bone to the vicinity of the involved
periradicular tissues.
 PROCEDURE
-An incision is made through the mucoperiosteal tissue and perforated through the
cortical plate with a rotary instrument.
-The most recommended site is at or near the root apex.
-A reamer of K-type file is then passed through the cancellous bone into the vicinity
of the periradicular tissues.
- Cortical trephination is initiated from the buccal side and never from the palatal or
lingual side.

PERIRADICULAR SURGERY
 Thoroughly trained dental practitioner and staff is necessary and
instruments ,equipment and supplies must be readily available in the
treatment room.
 The potential for possible complications must be anticipated and
incorporated into pre surgical planning.
 Good communication with the patient is essential for a thorough surgical
preparation.
 A signed consent form must be taken from the patient prior to surgery.
 Pre surgical mouthrinse will improve the surgical environment as it
decreases the bacterial contamination on the tissues,thereby reducing the
inoculation of microorganisms into the surgical wounds.


 CONCEPTS & PRINCIPALS OF PERIRADICULAR
SURGERY.
1.Local anesthesia and Hemostasis
2.Management of soft tissues.
3.Management of Hard tissues.
4.Surgical Access,both Visual and operative.
5.Access to root structure.
6.Periradicular Curettage.
7.Root end resection.
8.Root end preperation
9.Root end filling
10.Soft tissue repositioning and suturing.
11.Post surgical care.


 LOCAL ANESTHESIA & HEMOSTASIS:
 OBJECTIVES.

1. To obtain profound and prolonged anesthesia.
2. To provide good hemostasis both during and after surgical
procedure.
 SELECTION OF THE ANESTHEIC AGENT:Lidocaine

Hydrochloride is the commonly used agent.

 SELECTION OF VASOCONSTRICTORS: Epinephrine is the
commonly used.

 SITE OF INJECTION.


 SOFT TISSUE MANAGEMENT:
-Surgeons goal must be to minimize the trauma to both the soft and hard
tissues involved in the surgical procedure
-Most of the periradicular procedure requires the raising of the
mucoperiosteal flap.
 CLASSIFICATION OF SURGICAL FLAPS .

1.Full mucoperiosteal flap
a.Triangular (one vertical relasing incision).
b.Rectangular
c.Trapezoidal
d.Horizontal
2.Limited Mucoperiosteal flap.
a.Submarginal curved
b.Submarginal scalloped rectangular.


 INCISIONS:Accomplished by using 1 or 4 scalpel blades No11,12 ,15
and 15c.
-Horizontal incision should be made first followed by vertical releasing
incisions,by holding the scalpel handle in a pen grasp,initial incision stroke
must penetrate the mucosa & gingiva followed by a second that penetrates
the periosteum to the surface of the cortical bone .
 FLAP REFLECTION: The process of separating the soft tissues from
the surface of the alveolar bone.This process should begin in the vertical
incision.
-A periosteal elevator is used to elevate the periosteum &its superficial
tissues from the cortical plate.
-The periosteal elevator is inserted between the periosteum & bone,it is
directed coronally.
-This technique allows for all directive reflective forces to be applied to the
periosteum & bone.It is referred to as undermining elevation.


 FLAP RETRACTION: Process of holding in position the reflected soft
tissues.
-Accomplished by a tissue retractor .
-After retraction the periosteal surface of flap should be frequently irrigated
with saline.


 HARD TISSUE MANAGEMENT
-Following the reflection & retraction of the mucoperiosteal flap,surgical access must be
made through the cortical bone to the roots of the teeth.

- Cutting of osseous tissue with a No 6 or No 8 round bur produces less inflammation
and results in smoother cut surface and a shorter healing time

 PERIRADICULAR CURETTAGE.
-Removal of periradicular inflammatory tissue is accomplised by sharp surgical bone
curettes & angled periodontal curettes.

-A local anesthetic with a vasoconstrictor is injected into the soft tissue mass.

-Largest bone curette is placed between the soft tissue mass and the lateral wall of the
bony crypt with the concave surface of the curette facing the bone.

-Pressure should be applied around the lateral margins of the lesion.


-Once the soft tissue has been freed along the periphery of the lesion, the
bone curette should be turned with the concave portion toward the soft
tissue and used in a scrapping fashion,to free the soft tissue from the deep
walls of the bony crypt.
 ROOT END RESECTION :
 INDICATIONS
1. Biologic –Persistent symptoms
-Presence of a periradicular lesion
2. Technical-Interradicular posts
-Crowned teeth without posts.
-Irretrievable root canal filling materials.
-Procedural accidents.
 INSTRUMENTATION: Ingle et al recommended the use of No 702
tapered fissure bur or No 6 or No 8 round bur in the low speed straight
handpiece.
 EXTENT OF ROOT END RESECTION :Root should be resected to the
level of healthy bone since the portion of the root that extended into the
diseased tissue was infected and the cementum was necrotic.


 Angle of root end resection: In periradicular surgery should be 30-45
degrees from the long axis of the root facing toward the buccal or facial
aspect of the root ,to provide enhanced visibility to the resected root end &
operative access to enable the surgeon to accomplish a root end preparation
with a bur in low speed handpiece.
 Once the desired extent & bevel of the root end resection have been
achieved the face of the resected root surface should be carefully examined
to verify that complete circumferential resection resection has been
accomplished.
 This can be accomplished by a fine,sharp explorer around the periphery of
the resected root surface.
 If incomplete resection is in doubt,some amount of Methylene blue is
applied to the root surface for 5-10 sec.
 After this area has been irrigated with sterile saline,the periodontal
ligament will appear dark blue thereby highlighting the root outline.


 ROOT END PREPERATION-
 OBJECTIVES:To create a cavity to receive a root canal filling.
 PROCEDURE:-Surgical Hemostasis is achieved bt the use of hemostatic
agents like Bone wax,Epinephrine,Ferric sulfate,Thrombin,Calcium
Sulfate,Gelatin,Absorbable collagen.
-Preparation of Class1 cavity down the long axis of the root within the
confines of the root canal using either a small round or inverted cone bur in
a contra-angle or straight handpiece.
-Recommended depth of the preparation ranged from 1-5mm .
 ULTRASONIC ROOT END PREPERATION:Use of
ultrasonics in root end preperation has become very popular and has many
advantages over the traditional bur type preparation.
 ADVANTAGES: 1.Smaller preparation
2. Less need for a root end bevelling
3. Deeper preperation .
4. More parallel walls for better retention


 ROOT END FILLING: The purpose of the root end filling is to
.
establish a seal between the root canal space and the periapical tissue
 IDEAL REQUISITES FOR ROOT END FILLING MATERIALS :
1. Prevent the leakage of Bacteria and their byproducts into periradicular
tissues.
2. Non toxic
3. Non cariogenic.
4. Bio compatible.
5. Insoluble in tissue fluids.
6. Dimensionally stable.
7. Easy to use.
8. Radio opaque.

:
MATERIALS USED Gutta percha,Amalgam,Cavit,Intermediate
restorative material(IRM),Super EBA,Glass ionomer,Composite resins,
Carboxylate cements,Zinc Phosphate cement,Zinc oxide eugenol&Mineral
trioxide aggregate(MTA).


 MTA-MINERAL TRIOXIDE AGGREGATE:
Presently used root end filling material
Composed of Calcium and phosphorus ions derived primarily from tri-
calcium silicate,tri-calcium aluminate,tri-calcium oxide & silicate oxide.
Its pH when set is 12.5 & setting time is 2 hrs and 45 min.
Compressive strength of MTA is reported to be 40 MPa ,immediately after
setting & increases to 70 MPa after 21 days.
It has superior sealing ability to that of Super EBA & is less cytotoxic than
Amalgam, IRM and Super EBA


 SMEAR LAYER REMOVAL:
-Irrigation with tetracyclin removes the smear layer.
-Doxycyclin can also be used because of its long lasting effect on root
surface.
-Currently available materials are intermediate restorative material,Super
EBA & MTAD.
 PLACEMENT & FINISHING OF ROOT END FILLINGS.
-Depends on the type of filling material used.
-Amalgam may be carried to the root end preparation with a small K-G
carrier.
-Zinc oxide Eugenol cements are attached to the back side of a spoon
excavator or the tip of a plastic instrument or Hollenbeck carver & placed
into the root end preparation.
- MTA is placed by using the back side of a small spoon excavator or by
using a amalgam carrier.


 SOFT TISSUE REPOSITIONING & SUTURING
-Final step in periradicular surgical procedure are wound closure & soft
tissue stabilization.
 REPOSITIONING & COMPRESSION.
-The elevated mucoperiosteal tissue should be gently replaced to the
original position with the incision lines approximated as closely as
possible.
-Using a surgical gauze,slightly moistened with sterile saline,gentle but firm
pressure should be applied to the flapped tissue for 2-3 min before
suturing.
-Tissue compression both before & after suturing not only enhances
intravascular clotting in the severed blood vessels but also approximate the
wound edges.


 SUTURING:
-OBJECTIVE: Approximate the incised tissues and stabilize the flapped
mucoperiosteum until reattachment occurs.
-SUTURE MATERIALS:
Synthetic fibers like nylon,polyester,polygalactin and polyglycolic acid.
Collagen ,Gut and silk.
-NEEDLE SELECTION.:Needle with a reverse cutting edge.
-SUTURING TECHNIQUES:
Various suturing techniques can be used like
1.Single Interrupted suture
2.Interrupted loop suture –most prefered for better flap adaptation.
3.Vertical Mattress suture
4.Single sling suture


POST SURGICAL CARE AFTER ENDO
SURGERY
Two important components of post surgical care are
1.Genuine expression of concern and reassurance to the patient regarding both their
physical and emotional experience.
2.Good patient communication.
 INSTRUCTIONS OF POST OPERATIVE CARE:
1.Do not do any difficult activity for the rest of the day.
2.Do not consume alcohol or use of tobacco for the next 3 days.
3.Have a good diet and drink lots of liquids for first few days after surgery.
4.Do not lift up the lip or pull back the cheeks to look at where the surgery is done,this
may pull the stitches and cause bleeding.
5.An ice bag can be placed on the face where surgery was done for 20 min for every 6-
8 hrs.
6.Pain relievers should be used
7.Mouth should be rinsed with one tablespoon of chlorhexidine mouthwash 2 times a
day for 5 days.


COMPLICATIONS & MANAGEMENT
 BLEEDING AND SWELLING: Slight oozing of blood from several
microvessels may be evident for several hours following surgery.
- Proper compression of surgical flap,application of the ice pack with firm
pressure to the facial area over the surgical site.
-Ice pack should be applied in 20 min in an on and off cycle,should be
repeated for 6-8 hrs.
-If minor bleeding persists for more than 12 hrs following surgery it can be
managed by the patient with proper home care.
-Patient should be instructed to slightly moisten a gauze pad and place it
over the bleeding site while applying firm pressure.
-If the home treatment fails then the dentist should be consulted.
-A local anesthetic agent containing 1: 50,000 epinephrine must be injected
and tissue compression is applied to the bleeding area.
-Application of moist heat over the surgical site is recommended and
should begin until 24 hrs following surgery.


 DISCOLORATION: Seen in the mucoperiosteal or facial tissues,is a result
of the breakdown of the blood that has leaked into the surrounding tissues
-Requires no treatment.
-In patients with echymosis,application of moist heat may be beneficial for
upto 2 weeks following surgery.
-Heat promotes fluid exchange and speeds resorption of discoloring agents
from the tissue.
 PAIN: Long acting local anesthetic agents such as Bupivacine or
Etidocaine provide 6-8 hrs of local anesthesia and upto 10hrs of local
analgesia.
-They can either be used in surgery or in conjunction with Lidocaine
1:50,000 epinephrine or at the conclusion of a surgical procedure.
 INFECTION: The clinical signs and symptoms of post surgical infection
are evident within 36-48 hrs after the surgery.
-Most common indications are increased pain and swelling.
-Systemic antibiotics like Penicillin V dosage is 1.0g as an initial
dose,followed by a maintenence dose of 500mg for 3-4 hrs.
-If patient is allergic to penicillin,clindamycin initial dose of 600mg
followed by a maintenance dose of 150-300mg depending on age & wt of
the pt for every 8 hrs.


 ORAL HYGINE: Tooth brush in the surgical area should not be used as it
may dislodge the mucoperiosteum flap.
-A cotton swab soaked with Chlorhexidine oral rinse or 3% Hydrogen
Peroxide remove debris should be used twice daily for 4-6 days.
 SUTURE REMOVAL:

-Suture and the surrounding mucosa should be cleaned with a cotton swab
containing a mild disinfectant followed by H2O2.
-A topical anesthetic should also be applied with a swab at the surgical site.
-Sharp pointed scissors are used to cut the suture material,followed by
grasping the knotted portion with cotton plies.


CORRECTIVE SURGERY.
 Corrective surgery is categorized as surgery involving the correction of
defects in the body of the root other than the apex.
 INDICATIONS:1.Resorption (internal & external).
2.Procedural accidents.
3.Root Caries.
4.Root Fracture
5.Periodontal Disease.
Reparative defects of the root and associated procedure are classified as
follows:
1.Perforation repair a.)Mechanical b.)Resorptive /Caries.
2.Periodontal repair a.) Guided tissue regeneration
b.)Root Resection/Hemisection.
c.)Surgical correction of the radicular lingual groove.



PERFORATION REPAIR:
Perforation occuring on the mesial roots of the maxillary and mandibular
molars are usually managed by the intentional replantation,root resection or
hemisection.
Midroot Perforations should be sealed internally if possible or calcium
hydroxide should be placed as an intracanal dressing & sealed at a
subsequent appointment.
If the perforation is located in the apical third of a root,a root end
resection,extending to the point of the perforation and a root end filling
should be considered.
 RESORPTION:If a resorptive defect opens into the gingival sulcus &
if the approach can be made from the buccal or facial side,a full
mucoperiosteal flap should be raised and the extent of the defect
established.
If the resorption defect has not extended into the pulp space,it should be
restored with a suitable material such as amalgam,composite resin or glass
inonomer cements.


 PERIODONTAL REPAIR:
 GUIDED TISSUE REGENERATION: is a procedure used to regenerate
lost periodontal structures through different tissue response.
-It consists of placing barriers of different types to cover the bone and
periodontal ligament thus separating them from the gingival epithelium
-The memberane is removed after 5 weeks.
 MATERIALS USED FOR GTR:

 NON RESORBABLE :Millipore filler paper,Polytetrafluoroethylene

membrane,Rubber dam,Teflon membranes.
 RESORBABLE: Natural Collagen,Synthetic-Polylactic acid & Glycolic

acid,Acetyl tributylcitrate resorbable Membrane.
 ROOT RESECTION/HEMISECTION:
 Root resection:Removal of a entire root forms a multirooted tooth leaving
the clinical crown intact.
 Hemisection:Seperation of a multirooted tooth & the removal of a root &
the associated portion of the clinical crown.


 ROOT BISECTION /
BICUSPIDIZATION :Refers to a
division of the crown that leaves the
two halves and their respective roots
-Should be considered in
mandibular molars in which
periodontal disease has invaded
the bifurcation and when repair of
internal furcation perforatins have
been unsucessful


 SURGICAL CORRECTION OF THE RADICULAR LINGUAL GROOVE:
Radicular lingual groove commonly seen in the maxillary lateral & central
incisors,this developemental defect in the root formation precludes the deposition
of cementum in the groove,hence it prevents periodontal ligament attachment.
-The groove then causes a narrow perodontal pocket that can lead to retroinfection of
the pulp.
 PROCEDURE:Following palatal surgical exposure of the defect,the groove is
eliminated by grinding it away with the round burs or diamond points.
 REPLACEMENT SURGERY:
 INTENTIONAL REPLANTATION: Extration and replacement of the tooth into
its alveolus after the corrective procedure has been done.
 INDICATIONS: 1.) Inadequate interocclusal space to perform non surgical
endodontic treatment
2.) Non surgical treatment is not feasible because of canal obstruction i.e.
Calcifications of the pulp space,posts,seperated instruments.
3.) Surgical approach for periradicular surgery is not practical because of limiting
anatomic factors i.e risk of parasthesia because of proximity of root apices to the
mandibular canal; or mental foramen.


4.)Non Surgical & surgical treatment have failed & symptoms / pathosis persists.
5.)Visual access inadequate to perform root end resection & root end filling.
6.)Root defects (Resorption,Perforation.)
 STEPS IN EXTRATION / REPLANTATION:
1.)Following incision of the periodontal fibres with a No.15 scalpel blade,tooth to be
extracted.
2.)Appropriate forceps are chosen and beaks are wrapped with a sterile gauze sponge
that is saturated with normal saline or Hanks Balanced Salt Solution.
3.)Following extraction tooth should be held with a forceps,protected by saturated
gauze.
4.)Roots of the tooth should be thoroughly examined for the presence of root
fractures,perforations or resorptions.
5.)Root surfaces should be constantly bathed with either normal saline or Hanks
Balanced salt sol during the time the tooth is out of its socket.
6.)If no root fractures are evident & the prognosis for replantation appear positive,root
defects should be repaired with an appropriate material.
7.)If root end resection is indicated it should be done with a plain fissure bur in a high
speed handpiece under constant irrigation


8.)Extraction socket should be irrigated with normal saline and gently
suctioned to remove any blood clot that may have formed.
9.)Tooth is then carefully returned to its socket.
10.)A rolled gauze sponge should be placed on the occlusal aspect of the tooth
and the patient instructed to bite down foe 5 min so that the interocclusal
force will seat the tooth into the socket.
11.)If excessive mobility is evident then splinting is suggested.
12.)In case of a posterior tooth stabilization may be achieved by placing a
figure -8 suture over the occlusal surface of the tooth.
13.)Patient should be seen 7-14 days following replantation to evaluate tooth
mobility and removal of stabilizers.
14.)Post surgical evaluation is recommended at 2,6 & 12 months following
surgery.


IMPLANT SURGERY.
 There are 2 types of endosteal implants:-
1. Endodontic Implants.
2. Osseointegrated implants/Endosseous implants.
 ENDODONTIC IMPLANTS: A metallic implant extending through
the root canal of a tooth into periapical bone structure,thereby lengthening
the root of a pulpless tooth.
 INDICATIONS:

1. For stabilizing periodontally weakened bridge abutment.
2. When adjacent teeth are poor abutments.
3. Incisor which is hard to restore.
 OSSEOINTEGRATED IMPLANTS: A direct anchorage of an
implant by the formation of bony tissue around it without growth of fibrous
tissue at the bone implant interface.


OSSEO INTEGRATED IMPLANTS.


 PROCEDURE:
 EXTRATION & CURETTMENT PROCEDURE : Tooth should be extracted

with as little trauma as possible.
- It is important to retain the cortical bone buccal & lingual to the extraction
socket.
-All soft tissue should be removed from the bony crypt with curettes.
 IMPLANT PLACEMENT: Implant apex should be stabilized in at least 3-4

mm of bone & the implant head should be positioned to confirm to either
the central fossa,in posterior teeth or the cingulum in anterior teeth or
screw retained prosthesis.
- For cement retained anterior prosthesis the implant head should be placed
in line with the incisal edge of the adjacent teeth.
 BONE GRAFT & MEMBRANE PLACEMENT :Demineralised freezed

dried bone allograft is commonly used.
- Bone graft material is hydrated with sterile saline and packed into the void.
 SOFT TISSUE CLOSURE :Primary closure is the closure of choice ,when

it is not possible a non resorbable membrane is used.


 SUPPORTIVE THERAPY: Following immediate implant placement a
broad spectrum antibiotic such as Amoxyillin,Cephalexin or Clindamycin
is prescribed for a period of 7-14 days.
- Suture remain in place for 2 weeks and those cases that contain a
membrane be monitored every 2 weeks until the membrane is removed.


CONCLUSION

 A surgical approach to a failed root canal treatment should only be
considered when an orthograde approach is not possible.
 The reason for failure should be carefully diagnosed before surgery is
prescribed .


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