This document provides information on endodontic surgery procedures. It describes indications for endodontic surgery such as failure of nonsurgical root canal treatment or need for biopsy of periradicular tissue. Steps of the surgery are outlined including case diagnosis, surgical access, root-end resection and preparation, root-end filling, and closure. Instruments, flap design, osteotomy, curettage, and postoperative care are also summarized. Reasons for related procedures like hemisection, radisection, and intentional replantation are provided. The document aims to inform about endodontic surgical techniques and considerations.

1. Endodontic Surgery
BDS IV
Makerere University

2.  It is possible that a non surgical root canal procedure
wont be able enough to save your tooth and your
endodontist will recommend surgery.
 There is no need for a patient to get worried about
surgery because advanced technologies like digital
imaging and operating microscopes allow the procedure to
be performed quickly comfortable and successfully.

3. Objectives and rationale
 Curettage- for of the pathologically affected
periradicular tissue which cannot be accessed in
an orthograde approach e.g. granuloma, true
cysts, and foreign body reactions.
 Resection – of root apices that cant be removed
non surgically.
 Inspection- mostly in failing clinical cases to find
out the cause

4. Indications
 Failure of non surgical endodontic treatment
 In periradicular disease affecting root filled tooth in the
following cases
1. obliterated root canals
2. Teeth with full crown restorations
3. Presence of a post whose removal may cause root
fracture
 Biopsy of the periradicular tissue is needed.
 Failure of previous surgery
 Anatomical problems like severe root curvature

5.  Horizontal apical root fracture
 Periodontal considerations leading to hemisection or radisection
Contraindications
1. Patient factors, including the presence of severe systemic disease and psychological considerations.
2. Dental factors including:
• unusual bony or root configurations
• lack of surgical access
• possible involvement of neurovascular structures
• poor supporting tissue such as in severe uncontrolled periodontal disease
3. The skill, training, facilities available, and experience of the operator, should also be considered.

6. Steps of endodontic surgery
 Case diagnosis
 Preoperative surgical notes- CHX mouth rinses and NSAIDS to reduce postope pain
 Anaesthesia/hemostasis
 Management of soft and hard tissues
 Surgical access or osteotomy
 Access to root structure
 Root-end preparation
 Periradicular curettage
 Root-end filling
 Soft-tissue repositioning and suturing
 Postsurgical care

7. Instruments used
 Examination and inspection- micromirrors, perio probe
 Incision elevation curettage- handle and blade, molts curette, periosteal elevators
 Retraction
 Osteotomy and root resection-impact air 45 degree hand piece, lindemann burs
 Preparing root end-microsurgical ultrasonic instruments and MTA root end filling
instrument
 Irrigation-stropko irrigator and micro suction
 Hemostasis
 Suturing- suture handle and sutures

10. Soft tissue management
Surgical flap design is variable and depends on a
number of factors, including:
• access to and size of the periradicular lesion
• aesthetics
• adjacent anatomical structures.
The raised flap must be protected from damage and
desiccation during surgery and retractors should rest
on sound bone.

11. Rules for placing incisions
 Performed meticulously in such a manner that facilitates healing by primary intention.
 A complete and sharp incision deep into the bone at one stroke. Many incision lines make suturing
difficult.
 The vertical releasing incisions are placed on interdental bone.
 Care should be taken of the incised flap under moist and retracted conditions with tissue retractor.
 Interdental papilla has to be protected and preserved in both anterior esthetic zones and posterior
regions.

12. Hard tissue management
 Osteotomy
 Involves the removal of cortical plate to expose the root.
 An assessment of the length of the root and its axis should be made to ensure
that bone is removed accurately.
 Further bone removal should be carried out with a bur in a reverse-air
handpiece, cooled by copious sterile saline or sterile water.

13. Periradicular curettage
 Removal of soft tissue from the periradicular region
 This is to allow adequate visualization of the root apex.
 Curettes are used
 Pathological material should, if possible, be sent for histopathological
examination

14. The size of the osteotomy should be minimal enough to hasten
healing while being large enough to microscopically access,
examine, explore, and instrument the root apex.
An ideal and adequate osteotomy (4 mm in diameter).

15. Root-end resection
 Carried out as close to 90 degrees to the long axis of the tooth as possible to
1. reduce the number of exposed dentinal tubules
2. to ensure access to all the apical anatomy.
 The apical 3 mm of the root tip is resected perpendicular to the long axis of the root.
 Carried out with great care with the help of a bur in an Impact air 45° handpiece.

16.  It is believed that about 93% of the lateral canals and 98% of apical ramifications are removed
when 3 mm of root apex is resected

17. Root-end preparation
 The preparation should be
1. 3mm deep, in the long axis of the tooth,
2. incorporate the whole pulp space morphology
 best carried out with an ultrasonically powered tip
 The tips should be used at low power and with a light touch to reduce the risk of root
cracking.
 should be carried out with sterile saline or water as a coolant.
 The root walls should be examined to ensure that they are free of debris and previous root
canal fillings

18. Root-end filling
 The root-end preparation should be isolated from fluids, including blood.
 A suitable haemostatic agent should be placed in the bony crypt and the root end cavity dried
 The root-end filling material should be compacted into the cavity with a small plugger to ensure a
dense fill.
 MTA
 Radiographic verification of the quality of the root end filling is appropriate before wound closure.

19. Closure of the surgical site
 The soft tissue flap is re-apposed with sutures.
 Optimum healing being achieved with primary closure.
 After suturing, the tissues should be compressed with damp gauze for 3–5 minutes.
 Sutures are removed 48–96 hours post-operatively providing the wound is stable.
 Synthetic monofilament sutures are therefore the preferred.

20. Post operative care
 Clean the oral cavity
 Place gauge over the surgical area
 Allow patient to rest for some time
 Ice bags should be placed ant interval of 5 minutes, they help reduce
post operative swelling and inflammation
 Anti septic rinsing should be done for there days after surgery every
after a meal
 Warm mouth rinse a day after surgery to improve circulation in the
surgical area thus healing
 Antibiotics are not mandatory Grossman et al
 But anti-inflammatory drugs and analgesics are prescribed

21. Post operative complications
 Post op pain
 Haemorrhage
 Post operative swelling
 Infection

22. Radisection and Hemisection
 Radisectomy denotes the removal of one or more roots of
a molar.
 Hemisection refers to sectioning of the crown of a molar
tooth, with either the removal of half the crown and its
supporting root structure or the retention of both halves,
to be used after reshaping and splinting as two
premolars.

23. Why hemisection or radisection
 At times, a multirooted tooth has an untreatable periodontal lesion on one or
more of its roots, but the remaining root or roots are well supported and
treatable
 To retain a portion of this strategic tooth and avoid extraction of the entire
tooth, hemisection or radisectomy can be performed

24. Indications of radisection
 Extensive bone loss around one root of an upper molar
 Fractured root of a molar
 Root has been perforated and cannot be treated endodontically
Contraindications.
 When loss of bone involves more than one root, and the remaining roots would have inadequate
support
 When the involved tooth is an abutment tooth for a long span bridge
 When the roots are fused

27. hemisection
The indications:
 When periodontal involvement of one root is severe
 When loss of bone is extensive in the furcation area
 When caries involves much of one of the roots
Note
 Endodontic treatment should precede root removal.
 The coronal seal placed in the pulp chamber over the root to be removed should have set before
hemisection or radisectomy to avoid “core material scatter” in the adjacent tissues

29. Intentional Replantation
 Intentional replantation is the purposeful removal of a tooth and its almost
immediate replacement, with the objective of obturating the canals apically
while the tooth is out of the socket.

30. Indications
 Difficulty of access for surgical endodontics especially in lower second and third molars
 When the apex of the involved tooth is in close proximity to key anatomical structures such as
the mental nerve

31.  The procedure involves careful extraction of the tooth under adequate asepsis and anaesthesia.
 Care should be exercised in ensuring that the periodontal ligament is not injured and is
frequently washed with HBSS solution during the extraoral procedural time.
 The root resection and retro filling is done with ultrasonic tips and MTA.
 The tooth is then reinserted into the socket and the buccal and lingual cortical plates are
manually compressed.
 A semirigid temporary splint is then placed to stabilize the tooth.
 Regular follow-up of such cases is important to ascertain the status of such teeth