surgical endodontics

1. Endodontic Surgery
Dr. Junaid Shakeel

2. Categories of endodontic surgery
1. Abscess drainage.
2. Periapical surgery.
3. Hemisection or root amputation.
4. Intentional replantation.
5. Corrective surgery.

3. Abscess drainage

4. Periapical surgery

5. Hemisection or root amputation

6. Intentional replantation

7. Corrective surgery

8. Drainage of abscess
• Removal of pus .
• Relieves pain.
• Reduces the bacterial load.
• Improves the blood supply.
• Prevents the development of life threatening
complications.
• Cause of abscess development is to be
determined.

9. How to drain an abscess ?
• Emergency chamber opening of tooth.
• Extraction of tooth.
• A surgical stab incision with 11# blade. A drain
is placed to keep the incision open.

10. Surgical drains in place.

11. Periapical surgery
• Also called periradicular surgery.
• Involves :
-surgical exposure of root apex (RCT treated)
-apicectomy and currettage
-retrograde filling
-closure of defect

12. surgical exposure of root apex
(RCT treated)

13. apicectomy and currettage

14. retrograde filling

15. closure of defect

16. Indications of periapical surgery
• Anatomic problems preventing complete
debridement or obturation.
• Restorative considerations that compromise
treatment.
• Horizontal root fracture with apical necrosis.

17. • Irretrievable material preventing canal
treatment or retreatment.
• Procedural errors during treatment.
• Large periapical lesions that do not resolve
with root canal treatment.

18. • Anatomic problems.
• Restorations.
• Horizontal root fracture.
• Irretrievable material.
• Procedural errors.
• Large periapical lasions.

19. Contraindications for periapical
surgery (or cautions)
• Unidentified cause of RCT failure.
• When conventional root canal treatment is
possible.
• Combined coronal treatment & apical surgery.
• When retreatment of a failed rct is possible.

20. • Vital structures in jeopardy.
• Structures interfering with access & visibility.
• Compromise of crown root ratio.
• Systemic complications (bleeding disorders).

21. Surgical steps
of
periapical surgery

22. 1. antibiotics
• Prophylactic administration.
Panicillin v (2.0gm)
clindamycin (600mg)
1 hour before

23. 2.Flap design
• A properly designed flap results in good
healing.
• Features of a properly designed flap ?

24. properly designed flap
• Wider at the base.
• Incision lies on healthy bone, not on the
resorbed bone over the pathology.
• The vertical incision lines should not be at 90
degrees to the base of the flap.
• Incision should be over the line angles of
tooth.
• Interdental papilla should be saved.

25. properly designed flap

26. Types of flaps
• According to incision :
Semilunar incision.
Submarginal incision.
Full mucoperiosteal incision.
• According to shape :
2 cornered
3 cornered

27. Semilunar incision
• Submarginal curved.
• Slightly curved half moon horizontal incision in
alveolar mucosa.
• Easy reflection & quick access to peri radicular
structures.
• Limits providing full evaluation of root surfaces.

28. • If a root is fractured, performing a root ressection
is not possible , through this incision.
• Incision is primarily based on unattached mucosa,
heal more slowly and greater chances of
dehiscence.
• Excessive bleeding and scarring. Contraindicated
in endodontic surgery.

29. Semilunar incision

30. Submarginal incision
• Horizontal component of submarginal incision is in
attached gingiva with 1 or 2 vertical releasing incision.
• Generally the incision is scalloped in horizontal line,
with obtuse angles at the corners.
• Incision is used most successfully in maxillary anterior
region.
• Pre requisite is 4mm of attached gingiva and good
periodontal health.

31. • Major advantage is esthetics.
• Leaving the gingiva intact around margins of
the tooth is less likely to result in crown
resorption and tissue recession with crown
margin exposure.
• Lesser risk of incising over the defect and
better access & visibility.

32. Submarginal incision

33. Full mucoperiosteal incision
• Is made into the gingival sulcus, extending to
the gingival crest.
• Includes elevation of interdental papilla, free
gingival margin, attached gingiva & alveolar
mucosa.
• Preferred over the other 2 designs.

34. • Provides;
maximum access & visibility.
Not incising over the lesion or bony defect.
Fewer tendencies for hemorrhage.
Complete visibility of root.
Lesser scarring.
• Disadvantages :
flap is difficult to replace and suture.
More chances of gingival recession.

35. Full mucoperiosteal incision

36. 3. anesthesia
• Nerve blocks.
• Infiltration.
• Intra-ligamentary.

37. 4. Incision & reflection
• Full thickness incision is made through the
periosteum.
• Reflection of the flap, vertically then
horizontally.
• Elevator must rest on bone.

38. 5. Periapical exposure
• Frequently the bone overlying the apex is
resorbed.
• If the opening is small, it is enlarged with a
surgical bur.
• Bony window should be adquate.
• Root apex can be approximated with the help of
probe and radiograph.

39. Periapical exposure

40. Root end ressection
• It removes the region which most likely had
poorest obturation. Lateral canals and distal
curvatures are usually present in this region.

41. Root end ressection
• Before sectioning, a trough is created around
apex, to expose & isolate the root end.
• Bevelling in faciolingual direction.
• By minimizing the length of bevel, fewer
dentinal tubules are exposed, redcuing the
apical leakage.

42. Root end ressection
• 2 – 3 mm ressection.

43. 7. Root end preparation
• After root end ressection, it should be
prepared to facilitate retrograde obturation.
This prevents leakage.
• The depth of preparation must be atleast
1mm.
• Ultrasonic instruments offer better control &
ease of use. Better cleaning.

44. Root end preparation
• Constant irrigation is required to prevent
overheating.

45. 8. Root end filling material
• Amalgum
• M.T.A
• Resin
• Zinc oxide

46. • Radiographic confirmation
• Replacing the flap
• Suturing
• Post operative instructions
• Medications
• Suture removal

47. Corrective procedures

48. • Bicuspidization
• Hemisection
• Reimplantation

49. • Indications :
procedural errors
resorptive defects
• Contraindications :
– Anatomic impediments
– Inaccesible defects
– Repair wound creates periodontal defects