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Periapical surgery
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- 2. Endodontic Surgical ProceduresEndodonticSurgical Procedures Incision and drainageIncision and drainage Periapical curettagePeriapical curettage ApicoectomyApicoectomy Retrograde endodontic treatmentRetrograde endodontic treatment Perforation repairPerforation repair Root resectionRoot resection Hemisection (± root removal)Hemisection (± root removal) Exploratory surgeryExploratory surgery Intentional replantationIntentional replantation
- 3. Endodontic Surgical ProceduresEndodonticSurgical Procedures Incision and drainageIncision and drainage Periapical curettagePeriapical curettage ApicoectomyApicoectomy Retrograde endodontic treatmentRetrograde endodontic treatment Perforation repairPerforation repair Root resectionRoot resection Hemisection (± root removal)Hemisection (± root removal) Exploratory surgeryExploratory surgery Intentional replantationIntentional replantation
- 4. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
- 5. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required Foreign body reaction with extruded materialForeign body reaction with extruded material
- 6. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required Foreign body reaction with extruded materialForeign body reaction with extruded material Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively)
- 7. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required Foreign body reaction with extruded materialForeign body reaction with extruded material Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively) If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canalVery long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration
- 8. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required Foreign body reaction with extruded materialForeign body reaction with extruded material Perforation repairPerforation repair (that can not be done conservatively)(that can not be done conservatively) If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canalVery long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration Patient factorsPatient factors Medical / dental condition, time, costs, recent crown, etc.Medical / dental condition, time, costs, recent crown, etc.
- 9. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Psychological aspectsPsychological aspects Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery
- 10. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Psychological aspectsPsychological aspects Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate GrungGrung et alet al - 28% higher success if non-surgical- 28% higher success if non-surgical re-treatment was done prior to surgeryre-treatment was done prior to surgery
- 11. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Psychological aspectsPsychological aspects Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate GrungGrung et alet al - 28% higher success if non-surgical- 28% higher success if non-surgical re-treatment was done prior to surgeryre-treatment was done prior to surgery Surgery is a “one visit” techniqueSurgery is a “one visit” technique Can not disinfect the canal with irrigants and/or medicamentsCan not disinfect the canal with irrigants and/or medicaments
- 12. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well
- 13. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well Surgery “entombs” bacteria rather than killing orSurgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal
- 14. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well Surgery “entombs” bacteria rather than killing orSurgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal Surgery does not remove the pathway of entry alongSurgery does not remove the pathway of entry along which the bacteria have entered & infected the toothwhich the bacteria have entered & infected the tooth This is usually caries, a defective restoration, or a crackThis is usually caries, a defective restoration, or a crack
- 15. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Over-extended root filling materialsOver-extended root filling materials Will not always cause a foreign body reactionWill not always cause a foreign body reaction Hence, always watch and reassess over timeHence, always watch and reassess over time
- 16. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Over-extended root filling materialsOver-extended root filling materials Will not always cause a foreign body reactionWill not always cause a foreign body reaction Hence, always watch and reassess over timeHence, always watch and reassess over time Large, well-defined radiolucenciesLarge, well-defined radiolucencies Are not always cysts as often thought by many dentistsAre not always cysts as often thought by many dentists Can be any form of periapical pathosisCan be any form of periapical pathosis Size and borders indicate time & speed of developmentSize and borders indicate time & speed of development
- 17. Periapical SurgeryPeriapical Surgery ConsiderationsConsiderations Potential post-operative sequelaePotential post-operative sequelae Swelling and bruisingSwelling and bruising InfectionInfection Pain / discomfortPain / discomfort Anaesthesia / ParaesthesiaAnaesthesia / Paraesthesia Tissue discolourationTissue discolouration ScarringScarring Gingival recessionGingival recession Loss of interdental papillaLoss of interdental papilla Altered aestheticsAltered aesthetics
- 18. Possible Indications forPossibleIndications for Periapical SurgeryPeriapical Surgery ““It must be recognised that few trueIt must be recognised that few true indications exist for the endodonticindications exist for the endodontic surgical approach”surgical approach” Gutman JL.Gutman JL. Surgical EndodonticsSurgical Endodontics 1991: 501991: 50
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- 20. Endodontic Surgery -StagesEndodontic Surgery - Stages a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan b)b) Local AnaesthesiaLocal Anaesthesia c)c) Periosteal FlapPeriosteal Flap d)d) CurettageCurettage e)e) ApicoectomyApicoectomy f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling a)a) Wound Closure - suturesWound Closure - sutures b)b) Post-operative InstructionsPost-operative Instructions c)c) Follow-up & ReviewFollow-up & Review
- 21. Endodontic SurgeryEndodontic Surgery Butfirst – some general principlesBut first – some general principles
- 22. Flap DesignsFlap Designs Semi-LunarSemi-Lunar Gingival crestGingival crest TriangularTriangular TrapezoidalTrapezoidal GingivalGingival Luebke-OschenbeinLuebke-Oschenbein
- 23. Semi-Lunar FlapSemi-Lunar Flap In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva
- 24. Semi-Lunar FlapSemi-Lunar Flap In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva Poor accessPoor access Incision often over the lesionIncision often over the lesion Difficult moisture controlDifficult moisture control (haemorrhage)(haemorrhage) Difficult to repositionDifficult to reposition Uncomfortable during healingUncomfortable during healing Leaves scarsLeaves scars
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- 26. Gingival FlapGingival Flap Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision
- 27. No accessto apexNo access to apex May be useful for coronalMay be useful for coronal third perforationsthird perforations Used for palatal flapsUsed for palatal flaps But difficult !But difficult ! Gingival FlapGingival Flap Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision
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- 29. Horizontal incisionin the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision Triangular FlapTriangular Flap
- 30. Horizontal incisionin the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision ““First choice” flap for endodontic surgeryFirst choice” flap for endodontic surgery Good accessGood access Good visionGood vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition Triangular FlapTriangular Flap
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- 33. Recall - 6Months Triangular FlapTriangular Flap
- 34. Recall - 3Months Triangular FlapTriangular Flap Recall - 6 Months
- 35. Horizontal incisionin the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions Trapezoidal FlapTrapezoidal Flap
- 36. Horizontal incisionin the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions ““Second choice” for endodontic surgerySecond choice” for endodontic surgery Trapezoidal FlapTrapezoidal Flap
- 37. Horizontal incisionin the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions ““Second choice” for endodontic surgerySecond choice” for endodontic surgery Begin as a triangular flap and then do 2Begin as a triangular flap and then do 2ndnd vertical incision if extra access requiredvertical incision if extra access required Good access & visionGood access & vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition Trapezoidal FlapTrapezoidal Flap
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- 39. Trapezoidal FlapTrapezoidal Flap Recall- 6 Months
- 40. Luebke-Oschenbein FlapLuebke-Oschenbein Flap Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin
- 41. Luebke-Oschenbein FlapLuebke-Oschenbein Flap Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin Vertical incisionsVertical incisions 1 or 21 or 2 Depends on howDepends on how much accessmuch access is requiredis required
- 42. Luebke-Oschenbein FlapLuebke-Oschenbein Flap Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin Vertical incisionsVertical incisions 1 or 21 or 2 Depends on howDepends on how much accessmuch access is requiredis required Little, if any, scarringLittle, if any, scarring
- 43. Luebke-Oschenbein FlapLuebke-Oschenbein Flap Use for anterior teeth with crownsUse for anterior teeth with crowns To avoid gingival recessionTo avoid gingival recession
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- 47. No. 15- for periosteal flapsNo. 15 - for periosteal flaps No. 11 - for incision and drainageNo. 11 - for incision and drainage Stabbing actionStabbing action Scalpel BladesScalpel Blades
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- 49. General Principles forGeneralPrinciples for Periosteal FlapsPeriosteal Flaps
- 50. General Principles forGeneralPrinciples for Periosteal FlapsPeriosteal Flaps
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- 69. Materials– Past andPresentMaterials– Past and Present AmalgamAmalgam CavitCavit IRMIRM Super-EBASuper-EBA Composite resinsComposite resins Gutta perchaGutta percha Glass ionomersGlass ionomers MTA (ProRoot)MTA (ProRoot)
- 70. CorrosionCorrosion Galvanism(with posts)Galvanism (with posts) Tattoo on mucosaTattoo on mucosa ExpansionExpansion Dimensional changesDimensional changes Marginal breakdownMarginal breakdown Excess not absorbableExcess not absorbable Mercury releaseMercury release Difficult to condenseDifficult to condense Condensation scatterCondensation scatter Cavity largeCavity large Undercuts neededUndercuts needed Poor adaptation to wallsPoor adaptation to walls No anti-bacterial actionNo anti-bacterial action Difficult to remove forDifficult to remove for re-treatmentre-treatment Amalgam Disadvantages & Problems
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- 75. Poor tissuecompatibilityPoor tissue compatibility Due to continuous release of eugenolDue to continuous release of eugenol Fibrosis of adjacent tissueFibrosis of adjacent tissue SolubleSoluble Large cavity requiredLarge cavity required Difficult to handle materialDifficult to handle material Esp. Super-EBAEsp. Super-EBA IRM + Super-EBA Disadvantages & Problems
- 76. Low tissuetoxicityLow tissue toxicity Bone appositionBone apposition Good sealing abilityGood sealing ability Chemical bond to dentineChemical bond to dentine RadiopaqueRadiopaque Easy to mix & placeEasy to mix & place Colour contrast to toothColour contrast to tooth Short setting timeShort setting time Moisture controlMoisture control HaemorrhageHaemorrhage Relatively largeRelatively large cavity requiredcavity required Glass Ionomer Advantages Disadvantages
- 77. Gutta Percha +Sealer Low tissue toxicityLow tissue toxicity Good sealing abilityGood sealing ability RadiopaqueRadiopaque Colour contrast to toothColour contrast to tooth Conservative cavity onlyConservative cavity only Anti-bacterial (sealer)Anti-bacterial (sealer) Advantages Easy to mix & placeEasy to mix & place Good physical propertiesGood physical properties Satisfies requirements ofSatisfies requirements of root filling materialsroot filling materials Proven and acceptableProven and acceptable material for RCF’s formaterial for RCF’s for over 120 yearsover 120 years
- 78. ReferenceReference FavourableFavourable UncertainUnfavourableUncertain Unfavourable NordenramNordenram et alet al 19701970 56 %56 % 36 %36 % 8 %8 % HartyHarty et alet al 19701970 9090 -- 1010 RudRud et alet al 19721972 8383 1414 33 MalmströmMalmström et alet al 19821982 7474 1717 99 ForsellForsell et alet al 19881988 6868 2121 1111 AmagasaAmagasa et alet al 19891989 9595 -- 55 GrungGrung et alet al 19901990 8585 1414 11 FriedmanFriedman et alet al 19911991 7070 3030 -- RappRapp et alet al 19911991 5656 3333 1111 Abbott 1999Abbott 1999 92.392.3 4.24.2 3.53.5 Treatment Outcome StudiesTreatment Outcome Studies All re-treats after retro. amalgam
- 79. Endodontic SurgeryEndodontic Surgery --with GP + AH26with GP + AH26
- 80. Endodontic Surgery -StagesEndodontic Surgery - Stages a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan b)b) Local AnaesthesiaLocal Anaesthesia c)c) Periosteal FlapPeriosteal Flap d)d) CurettageCurettage e)e) ApicoectomyApicoectomy f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling a)a) Wound Closure - suturesWound Closure - sutures b)b) Post-operative InstructionsPost-operative Instructions c)c) Follow-up & ReviewFollow-up & Review
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- 84. Incision + PeriostealFlapIncision + Periosteal Flap
- 85. Bone Removal &CurettageBone Removal & Curettage
- 86. Retrograde Canal PreparationRetrogradeCanal Preparation
- 87. Retrograde Canal PreparationRetrogradeCanal Preparation
- 88. Retrograde Canal PreparationRetrogradeCanal Preparation
- 89. Retrograde Canal PreparationRetrogradeCanal Preparation
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- 92. Sealer - AH26Sealer - AH 26
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- 94. Sealer - PlacementSealer- Placement
- 95. Retrograde Root FillingRetrogradeRoot Filling
- 96. Retrograde Root FillingRetrogradeRoot Filling
- 97. Retrograde Root FillingRetrogradeRoot Filling
- 98. Retrograde Root FillingRetrogradeRoot Filling
- 99. Retrograde Root FillingRetrogradeRoot Filling
- 100. Retrograde Root FillingRetrogradeRoot Filling
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- 102. Post-Operative InstructionsPost-Operative Instructions ALSO:ALSO: 1.1.Post-op RadiographPost-op Radiograph 2.2. Suture RemovalSuture Removal 4-5 days4-5 days 3.3. ReviewsReviews 3-4 months3-4 months 12 months12 months 3 years3 years
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- 105. Review - 3months
- 106. Review - 12months
- 107. Review - 3years
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- 110. Review - 8years