This document provides an overview of the history and techniques of endodontic surgery. It discusses how endodontic surgery was first recorded over 1500 years ago and has evolved since. The document then covers classifications of endodontic surgical techniques, anatomical considerations, preoperative preparation, armamentarium, surgical procedures like flap design and osteotomy, and advances in materials. It emphasizes that endodontic surgery should only be considered when conventional root canal treatment is not possible and outlines factors for a successful outcome.

1. HISTORY
 Endodontic surgery was first recorded 1500 years ago when
AETIUS, excised an acute apical absess with small scalpel.
 HULLIHEN in 1839 stated:
 “Make an incision through the gum, along the
entire length of the fang”.
 Then apply a reasted fig / bruised raisins to the
gums”.
This was a refinement over AEITUS.
 The other contributors were Farror (1884); Rhein (1897); G.V.
Black (1886) and Garvin (1919).
 CURRENTLY, endodontic surgery is predictable, and often
necessary procedure which is generally accepted.
 Surgical procedures play an extremely important role in the
management of endodontic problems.
 As failure does occur in a small percent of cases which are non-
surgically treatment with conventional endodontic therapy,
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2. clinicians should be prepared to initiate alternative procedures,
including surgery to enhance the rate of success.
 Nevertheless, GROSSMAN stated that, it is indicated in fewer
than 5% of all endodontic patients.
 The success rate of endodontic surgery, however is high, from
73% to 99%.
 PERSSON reported a successful result following root resection
in 73% of 26 teeth.
SOMMER reported 95% of success rate in more than 100 root
resected eases.
PHILLIPS & MAXMAN claimed 99% success rate in more than
600 cases.
GROSSMAN AND OLEIT reported 90 to 99% of success rate.
Confusion in Terminology / Misnomers !
 “Apicectomy” was the term used injudicrously for
years to describe many types of endodontic surgical procedures.
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3.  The terminology has been modified to more accurately
describe the specific procedures encompassed under the heading
“Surgical Endodontics”.
At Present – “Periradicular Surgery” is more acceptable term
when referring to surgical procedures performed around the root.
Root End Resection; “Apicetomy” Old Term - is used to describe the
removal of the apical portion of the root.
Root End Filling – describes the procedure of placing a filling into a
prepared apex.
“Placement of retro-filling / reverse filling” – Micromer and
grammatically incorrect.
Endodontic Surgery:
Is defined as a surgical procedure related to problems of the
pulpless / periodontally – involved tooth requiring root amputation and
endodontic therapy.
I. Endodontic Surgical Techniques can be Classified as follows:
(Classification by Ingle).
i) Surgical Drainage
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4. (a) Incision
(b) Trephination
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5. ii) Radicular Surgery
(A) Apical Surgery (B) Corrective Surgery
1. Curettage & Biopsy 1. Miscellaneous corrective
(Periapical surgery)
2.Apicoectomy 2. Root resection
3. Intentional Replantation 3. Hemisection
4. Bisection
II. Another Classification:
1) Surgical Drianage Trephination
Incision
2) Radicular surgery
Apical surgery Corrective surgery
- Curettage and biopsy - Perforative repair
Mechanical
Resorptive
- Periodontal repair GTR
Resection
- Apicoectomy
- Retrofilling
3) Replacement surgery
Replant surgery Endosteal implant surgery
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6. Intentional Post traumatic Endodontic Osseointegrated
Most endodontic problems can be treated / retreated by
conventional therapy and peri-radicular surgery should not be
considered a panacea when endodontic problems arise.
Clean, well obturated canals are the biological basis of
endodontic success. If the canal terminus can be reached through a
coronal access, then these are the pathways to be considered.
Endodontically Treated Tooth
Failure Success
No Access Yes Poor Evaluate fill Good
Yes Restorative No
Need
Considerations
Surgery RC treatment Recall No treatment
 If the canal terminus through the coronal access cavity is
impossible, a surgical approach should be considered.
 Even then, the pulp chamber and as much of the root canal(s) as
possible, should be instrumented and obturated before surgery to
reduce the critical concentration of the irritant within the root
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7. canal system and conventionally close off portals of exit that
exist coronal to the apex.
 These are very few contraindications to Pa surgery.
- Psychological / systemic problems of the patients.
- The practitioners experience / expertise in the procedures.
- Inaccessibility.
- Anatomical problems i.e. unusual bone / root
configurations.
Anatomical Considerations:
 Surgical procedures to anterior teeth are generally uncomplicated and
uninhibited.
 With the exception of the nasal spine and the rare nasal fistula.
 In the posterior region the following critical structures make access
to root apices difficult.
 Proximity of the mental foramen to the apices of mandibular
premolar at times to the first molar.
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8.  A thick external oblique ridge – in the 2nd
and 3rd
mandibular
molar region (traumatic and difficult).
(In such cases the apex of a tooth is located in the center / lingual
aspect of the mandibule, the thick cortical plate and the shallowness of
the vestibule make access to the apex difficult and trauma).
 The location of the mandibular canal:
(If the radiograph shows canal moving inferiorly in relation to the
root apices, the canal is lingual to the apices.
If it moves upwards on the roots, it is buccal to the apices.
Minimal movement of the canal indicates that it is in close
proximity to the apices).
(I Madi M) Mesial root apex – to the superior border of the
neurovascular bundle is about 5.3mm.
 The maxillary sinus in close proximity to the root apices.
Premolar, molar – maxillary
(May penetrate the sinus floor and establish a communication
between the periodontal and the mucoperiosteal lining of the sinus).
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9.  A prominent zygomatic process that impedes surgical
access to the rest of the maxillary molar teeth.
 A palatal root of the first and 2nd
molar that is closely
aligned with the greater palatine foramina.
Good-quality radiographs are essential if a critical assessment of
the position, location and angulation for root apices and of local
anatomical structures is to be of value before surgery.
COMMUNICATION WITH PATIENT:
- The surgical procedure should be described in details, as
should all potential postoperative problems such as discomfort,
swelling, bleeding, brushing, maxillary antrum penetration and rare
possibility of paraesthesia.
- A hand drawn illustration is often useful.
- Alternative to surgery such as no treatment, tooth
extraction and referral should also put forward.
- Patient should be asked to sign that at tests to their
understanding and acceptance of procedure, risks and fees.
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10. PREOPERATIVE PREPARATION AND PREMEDICATION OF
THE PATIENT:
Antiseptic mouthwash: According to Leo JPS 1970,
chlorehexidine gluconate 0.2% reduces the levels of bacteria in the oral
cavity and play an important role in healing following endodontic
surgery.
- Patient is instructed to rinse the solution for 1 minute
twice daily for one week prior to the surgery.
ADMINISTRATION OF non-steroidal anti-inflammatory drugs
before the surgical procedures helps to reduce post-operative pain and
swelling.
Ibuprofen exerts its effect by initiating the enzyme cyclo-
oxygenase and prevents the formation of inflammatory mediators. A
dose of 600mg  to 2 hours Before surgery. And 400mg – 4 hours
postoperatively.
However the maximum daily dose should not exceed – 3200mg.
Ibuprofen – causes:
- Mild gastrointestinal irritation (so should be taken with
food).
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11. Contraindicated:
- In patients with peptic ulcer.
PARACETAMOL: is an acceptable alternative for patients who need
to avoid ibuprofen, but it exhibits an anti-inflammatory dynamics.
SHORT ACTING BARBITURATES: such as pentobarbital and
secobarbital are frequently used for sedation, oral administration is most
common, 50-150mg, 30 minutes prior to the surgical treatment.
Transquilizers effectively reduce apprehension and act as muscle
relaxants.
Diazepam – 5mg – orally – 30 minutes prior to the treatment
narcotics can be effective premedication.
ARMAMENTARIUM
The suggested surgical setup for periapical surgery:
1) Anaesthesia – lidocaine, epinephrine.
2) Sterile cotton gauge – 2x2.
3) Periosteal elevator.
4) Straight handpiece burs – 2, 4, 6, 8, 33 ½ hand chisel, sterile
saline, handpiece (st and CA) and microhead contra-angle.
5) Surgical curette.
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12. 6) Apical amalgam carrier, plastic instrumentation, amalgam
plugger and condenser.
7) Needle holder / hemostat, silk suture and scissors.
8) Surgical tray cotton pliers, explores, mirror etc.
IMPROVED VISIBILITY:
- Fiberoptic light source could be used, which is attached to
surgical aspirators / retractors.
- Magnification of operative site using visors and loupes.
- Surgical telescropes and microscopes also provide cresp
and undistorted images of operating site.
- High tongue surgical drills are preferred – as they prevent
subcutaneous air emphysema.
HAEMOSTASIS:
- The injection of a local anesthesia into the oral tissues
before Pa surgery has 2 important purposes:
- Anaesthesia.
- Haemostasis.
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13. ANAESTHESIA IN UPPER JAW:
- Lignocaine (between 2 and 4ml) containing 1:50,000
adrenaline (2% lignocaine – 1:80,000 adrenaline is effective local
anaesthetic in minor oral surgery).
INFILTRATION:
- The approximated levels of the root apices (buccally).
- Attempts to inject deeper tissues may prove counter
productive, because of the likelihood of injecting into skeletal
muscle (because β receptors are presents and causes vasodilatation)
increased bleeding rather than haemostasis.
PALATAL INFILTRATION:
- An increment of 0.3ml is sufficient. Along with nerve
blocks.
MANDIBLE:
Lignocaine with 1:80,000 adrenaline for:
- Infiltration alveolar block.
- Buccal n block.
- Lingual infiltration-?
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14. Lignocaine with 1:50,000 adrenaline not used for palatal
injections – ISCHAEMIA.
PACKING:
- Packing foreign agents into the bony cavity is a
controversial method of producing haemostasis.
- Cotton, cotton wool/ gauge saturated with adrenaline are
least desirable materials (the fibres left in the crypt cause –
latent foreign body reaction, if trapped along the margins
of the root end filling – impair the apical seal).
- Agents like GELFOAM
SURGICEL are advocated as local
(Inflammatory treatment COLLAPLUG haemostatic agents
if left in the surgical site) BONE WAX
- Collaplug (Biocompatible and excessive cost).
- 15.5% ferric sulphate (astringent).
WHATEVER, haemostatic technique is chosen, bleeding must be
re-established before – reapproximating and suturing flap.
SURGICAL PROCEDURE
- Flap design.
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15. - Exposure of the site.
Incision
Flap reflection
Flap retraction
Osteotomy
- Curettage and biopsy.
- Apicoectomy.
- Retropreparation.
- Retro-filling.
- Flap closure.
Flap repositioning.
Suturing.
GENERAL PRINCIPLES FOR FLAP DESIGN:
1. Incision should be placed in a single firm stroke
lying on bone.
2. Extend the flap so as to allow design to be wider
at base for better vascularity.
3. Include adjacent ½ normal teeth in flap for
adequate mechanical accessibility and visibility.
4. Always place flap over sound bone. Avoid bony
defects as flap in these areas will undergo necrosis.
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16. 5. Avoid placing incision lines over areas of bony
prominences as mucosa here is very thin and can undergo fine
strations.
6. Do not extend incision beyond attached gingiva to
alveolar mucosa – As healing takes longer at the alveolar mucosa
junction.
7. Avoid sharp margins.
8. While raising flap care should be taken to include
full thickness flap including periosteum.
THE BASIC FLAP DESIGNS USED IN ENDODONTIC
SURGERY CURRENTLY ARE:
- Gingival flap.
- Semilunar flap (curved flap).
- Triangular flap (single vertical flap).
- Ochesenbein cuebke flap.
- Rectangular flap.
- Minivertical flap.
- Trapezoidal flap.
- Modified flap.
- Palatal flap.
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17. Triangular flap / single vertical:
Indications:
- Midroot perforation repair.
- Periapical surgery.
Post areas.
Short roots.
Advantages:
- Easily modified.
Small relaxing incision
Additional vertical incision.
Extension of horizontal components.
- Easily repositioned.
- Maintains integrity of blood supply.
Disadvantages:
- Limited access and visibility to long roots.
- Tension created on retraction.
- Vertical incision penetrate alveolar mucosa.
- Gingival attachment served.
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18. OCHEENBEIN-LUEBKE FLAP / SCALLOPED
Indications:
- Prosthetic crowns present.
- Periapical surgery.
Anterior region.
Longer roots
- Wide band of attached gingiva.
Advantages:
- Ease in incision and reflection.
- Enhanced visibility and access.
- Ease in repositioning.
- Maintains gingival attachment.
Prevents recession.
Avoids dehiscences.
Prevents crestal bone loss.
Disadvantages:
- Horizontal component disrupts blood supply.
- Vertical components crosses MGT and may enter muscle
tissue.
- Difficult to alter if size of lesion misjudged.
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19. Rectangular flap / Double vertical
Indications:
- Periapical surgery.
Multiple teeth.
Large lesions.
Long / short roots.
- Lateral root repairs.
- Full length root visualized.
Advantages:
- Provides maximum access and visibility.
- Reduce retraction tension.
- Facilitates repositioning.
Disadvantages:
- Decreases because to the flap.
- Increases incision and reflection TIMC
- Gingival attachment violates.
- Suturing is difficult.
Trapeziodal flap / Double vertical:
Indications, Advantages and disadvantages:
- Similar to rectangular flap.
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20. Gingival flap:
Indications:
- Cervical resorptive defects.
- Cervical area perforations.
- Periodontal procedures.
Advantages:
- No vertical incision.
- Ease of repositioning.
Disadvantages:
- Limited access and visibility.
- Difficult to reflect and retract.
- Stretching and tearing.
- Gingival attachment violated.
SEMILUNAR FLAP / CURVED
Indications:
- Esthetic crowns present.
- Trephination.
Advantages:
- Reduces incision and reflection time.
- Maintaining integrity of gingival attachment.
- Eliminates crestal bone loss.
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21. Disadvantages:
- Limited access and visibility.
- Increases hemorrhage.
- Crosses root eminences.
- May not include entire lesion.
- Stretching and tearing.
- Repositioning is difficult.
- Healing is associated with scarring.
Mini vertical
Indications:
- Trephination.
Advantages:
- Decreased tissue damage.
- Good healing.
- Less vessels and nerves are rest.
Disadvantages:
- Decreased visibility and accessibility.
PALATAL FLAP:
Indicated:
- Overextended palatal obturation / perforation.
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22. Review for:
- Maxillary sinus.
- Root length.
Advantages:
- Of sling suture.
- It holds the palatal flap in operating position and increase
access and visibility.
Disadvantages:
- Crimping of the tough palatal tissue.
- Decreased BS.
- Leads to necrosis.
- Sloughing of the flap.
After the surgical site is exposed by:
Incision, flap reflection, retraction, the clinicians can consider the
many advances in endodontic surgical techniques and materials into
their practice in order to ensure more predictable results.
The following aspects are:
- Hard tissue management / osteotomy.
- Root end resection and preparation / apicecotomy.
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23. - Root end filling materials.
- Postoperative care of the patient.
FLAP DESIGN
Requirements of an ideal flap:
1) Should allow good visual and mechanical accessibility.
2) Good vascularity wide base.
3) Should be placed on sound bone on no bony defects.
4) Should be so placed such that adjacent 1-2 teeth be included in
flap design.
5) Incisions should not be placed over bony prominences.
6) Avoid sharp corners.
7) Avoid placing extending over MCJ at it takes longer limits heal.
8) Base is the widest point of the flap: The need for the width at the
base is to afford sufficient circulation to the raise portion of the
flap so that the edges do not become ischemic and later slough.
9) Avoiding incision over a bony defect.
10)Include the full extent of the lesion.
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24. 11)Avoid sharp corners: Tips of sharp corners have a tendency to
become ischemic before collateral circulation across the sutured
tissues becomes established.
12)Avoid incisions across a bony prominence: Usually found in the
maxillary cuspid lesion, since the mucosa covering the eminence
is thinner than that covering the eminence is thinner than that
covering the interdental bone, less circulation is available to
provide nutrition to the edges of a flap placed on eminence. Also,
unesthetic scar formation develops.
13)Guarding against possible dehiscence: Maxillary molars and
bicuspids.
14)Avoid the mucogingival junction: The junction of the attached
gingiva and the alveolar mucosa has extremely friable tissues.
Incisions placed here take much longer time to heal.
15)Flap should generally extend one or two teeth laterally to allow
for relaxed retraction and prevent stretching and tearing of tissue.
16)Care during retraction should be taken after the flap is opened the
tissue retracted from the underlying bone must be held away from
the surgical site.
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25. 17)A full thickness mucoperiosteal flap should be raised to maintain
the integrity of the periosteum.
The basic flap designs used in endodontic surgery currently are:
1. Gingival flap
Indications:
- Cervical resorptive defects.
- Cervical area perforations.
- Periodontal procedures.
Advantages:
- No vertical incision.
- Ease of repositioning.
Disadvantages:
- Limited access and visibility.
- Difficult to reflect and retract.
- Predisposed to stretching and tearing.
- Gingival attachment violated.
2. Semilunar flap (curved flap):
Indications:
- Esthetic crowns present.
- Trephination.
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26. Advantages:
- Reduces incision and reflection time.
- Maintains integrity of gingival attachment.
- Eliminates potential crestal bone loss.
Disadvantages:
- Limited access and visibility.
- Predisposed to stretching and tearing.
- Tendency to increase hemorrhage.
- Crosses root eminences.
- Repositioning is difficult.
- May not include entire lesion.
- Healing is associated with scarring.
3. Triangular flap (single cervical flap):
Consists of a single vertical incision and a horizontal crevicular
incision. Vertical incision is placed 2 teeth away from affected tooth.
Extends from mucobuccal junction obliquely to a point to interest
the gingival interproximally at 90°. The horizontal incision is placed
crevicularly to form the base of the flap for adequate visibility and
accessibility.
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27. In case of greater accessibility another vertical relining incision is
placed distally.
Indications:
1. In case of mid root perforations (resorption /caries).
2. Short roots.
3. Posterior teeth.
- Can be easily modified by
i. Including relaxing vertical incisor.
ii. Extending horizontal incisors.
iii. Can be easily repositioned.
iv. Good vascularity maintain.
- Can not be utilized for in case of longer roots
i. Tension on retractor.
ii. Involves alveolar mucosa – healing decay.
iii. Gingingival attachment altered.
Advantages:
- Easily modified.
 Small relaxing incisions.
 Additional vertical incision.
 Extension of horizontal component.
- Easily repositioned.
- Maintains integrity of blood vessels.
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28. Disadvantages:
- Limited access and visibility to longer roots.
- Tension is created on retraction.
- Vertical incision penetrates alveolar mucosa.
- Gingival attachment severed.
4. Ochsenbein luebke flap – scalloped.
The horizontal scalloped incision is placed on premolar attached
gingiva. Vertical incisions are then extended back into alveolar mucosa.
Indicated in cases of:
1. Esthetic crowns.
2. Wide band of attached gingiva present.
3. Long roots, wide lesions.
Indications:
- Prosthetic crown present.
- Periapical surgery.
 Anterior region (maxillary).
 Longer roots.
- Wide band of attached gingiva.
Advantages:
- Good visibility and accessibility.
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29. - Preserves attached gingival health.
- Prevents recession.
- Prevents crestal bone loss.
- No scar tissue formation.
- Longer time for reflection and retraction.
- Involves alveolar mucosa hence relaxation is delayed.
- Blood supply may be compromised.
Disadvantages:
- Horizontal component disrupts blood supply.
- Vertical component crosses mucogingival junction and
enter muscle tissue.
- Difficult to alter if size of lesion misjudged.
5. Rectangular flap:
This flap is usually carried out when:
1. Multiple teeth are involved.
2. Large periapical lesions.
3. teeth with long roots.
- Good accessibility and visibility.
- Violation of gingival attachment.
- Crevicular bone loss.
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30. Advantages:
- Increased reflection and retraction time.
- Vascularity compromised.
- Flap undergoes recession.
- Difficult to reposition.
Disadvantages:
- Suturing is difficult.
6. Mini vertical flap:
This flap involves a single vertical incision proximal to the
involved apex.
Indicated in cases of trephination:
- Less tissue damage.
- Visibility and accessibility reduced.
- Good healing as less vessels and served one cut.
7. Palatal flaps:
The need to reflect the palatal tissues of the maxilla may be
needed in certain cases. As in any flap all rules for flap design are
applicable however, the rich vascular supply of the palatal area
provides for excellent healing in most instances.
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31. - Palatal flap is prepared with a scalloped incision around
the gingival margins.
- Relaxing incisions are generally placed between the first
cuspid and bicuspid to prevent severing of the anatomose
of incisive and palatine vessels.
Distal incision is placed distal to second molar on the maxillary
tuberosity to prevent severing the greater palatine vessels.
- The free end of the flap could be tied the teeth on the
opposite side of the arch with a suture material.
8. Trapezoidal flap:
To there rectangular flap but with added obliqueness of the
vertical incision.
Indicated in cases of:
1. Multiple teeth involvement.
2. Large periapical lesions.
3. Long / short roots.
Advantages:
1. Better visibility and accessibility.
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32. 2. Blood supply is compromised as a large number of
mucoperiosteal vessels are intererupted – increased haemoma.
3. Flap undergoes extraction, shrinkage.
4. Gingival attachment is compromised.
5. Crestal bone compromised.
6. Recession seen.
7. Difficult to approximate.
8. Increased reflection and retraction time.
Modified trapezoidal flap by Vneeland 1-2mm of crest of
gingiva a scalloped incision (horizontal is given to maintain the
crevicular gingiva intact foramen healing. The horizontal incision given
is a reverse bevel incision from here a full thickness mucoperiosteal flap
is reflected.
1. Incision allows primary healing to take placed as incision is
attached gingiva i.e. rich in collagen fibres.
2. Can be easily repositioned.
3. Suturing done only on vertical incision lines.
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33. Surgical Technique:
i) Incision
Vertical incision (relieving, relaxing)
- Incision should be continuous, linear and well defined.
- Avoid treated incisions.
- Do not make an incision on bony prominence.
Intrasulcular incision
- Incision follows the contours of the labial surface of the
teeth.
ii) Reflection – UBECO No. 2 double ended periosteal
elevator, periosteal elevator  molt curette, Hu friedy.
- Reflection is initiated with a sharp convex end of a no. 4
molt curette or the Hu friedy curette.
- The elevators are used to reflect both the mucosa and
periosteum.
- The elevator always on the bone and never on the flap.
- A thin gauze may be used for reflection to prevent tearing
on the flap.
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34. iii) Retraction:
Retraction is placed on the bony firmly above the bony defect.
The reflected tissue should lie freely against the retractor and not be
pushed or pulled against lip or cheek. The size of the retractor should
secret the size of the flap. Too small retractions will allow the tissue to
flap over whereas too large retractors will traumatize the surrounding
tissues.
Small retractors – periosteal elevator.
Large – anistin, Minnesota Hanchan.
Hard tissue management:
The average thickness of bone overlying the mesial root of the
mandibular first molar is 4.2mm.
To penetrate this thick cortical bone a rotating No. 4 extra length
surgical bur mounted in a high speed Impact hand piece (Palisades
Dental) should be introduced slowly. This handpiece has an angled head
that facilitates surgical entry and visibility and does not blow air or oil
into surgical site. Copious irrigation with a sterile physiological saline
should accompany all attempts to remove bone. (according to Fister and
Gross, Cavelle and Wedgewood) irreversible bone necroses is realized
when temperature exceeds 56°C. (A small window is cut and a sterile
34

35. broken off head of a bar is placed in the depression, (sterile ruler)
(window preparation).
iv) Curettage and biopsy:
Once apex has been located curettage is performed with a sharp
(Molt 4) / Goldman Fox-3 curette. First the back side of a curette is used
to loosen the fibrous capsule from the wall. Then the loosened
inflammatory tissue is scooped out of the cavity with a curette or using
Allis tissue holding forceps.
It is suggested that the soft tissue of the lesions surrounding the
root should be curetted in toto. However, this is not always possible or
practical, especially if the lesions involves the maxillary antrum, vitality
of adjacent teeth is in jeopardy, or the mandibular vessels.
The old concept that cementum must be curetted away is not
based on scientific fact. A biopsy of soft tissue curettements is
recommended as a safeguard.
Use of instruments that crush tissue, such as hemostats or needle
holders is discouraged. Instruments that puncture and grasp such as the
allis forceps are more favourable for the removal of sizeable specimens.
The tissue is placed in a specimen bottle of 10% formalin and sent to the
laboratory for diagnosis.
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36. In case of excess gutta-percha overfilling exists. It can be
removed with a fast rotating No. 6 or 8 bur. The GP should be then
burnished and compressed back in the canal space with a ball burnisher.
v) Apicoectomy:
Root end resection refers to the removal of the apical portion of
the root best accomplished by obliquely resecting the most apical
portion of the involved root with a large round bur size 702 or # 6 or # 8.
Reasons for RER:
a) This segment is known for anatomical variations such as
accessory canals, deltas and severe curve it is also the area in
which operator errors such as zips, ledges and perforation are
likely to occur.
b) Some apices close to the maxillary sinus, nasal cavity and
mental neurovascular bundle may require RER to provide
working room for apical curettment or place retrofilling. By
resecting the apex a buffer area of bone can fill in so the apex is
not in immediate proximity to the anatomic entity.
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37. Selden has described the endoantral syndrome caused by
irritation of an apex to the sinus even though the tooth was
endodontically treated and needed RER.
Matsura, Cummings has suggested that an apical resection of 2 to
3mm to expose the canal and eliminate accessory canals 90° resection
care must be ensure that the resection is carried completely through the
root from buccal to lingual.
Preparation with microscopic ultrasonic tips – Preparation has a
5-3mm depth in 2-3 minutes with continuous irrigation to cool the
surface and maximize cutting.
High speed burs are used to resect the root end.
A lingual-to-labial bevel angled at 30 to 45° to the coronal aspect
of the tooth – (enhances surgical visibility and accessibility).
vi) Root end preparation:
Retropreparation is best done with a small round bur micro contra
angle handpiece. The canal can be located with a sharp explorer or
morse scaler.
The depth of penetration should be 2 to 3mm and in center of the
root. Lateral over preparation may result in a weakening of the apical
37

38. root structure and development of cracks upon condensation or
dimensional change of Ag amalgam
A slot preparation is suggested by Matsura where access is
limited. The canal is located and prepared to a vertical length of 3 to
5mm with a # 700 bur and straight handpiece. Retention is placed with a
inverted cone bur.
Ultrasonic Retropreparation: Sonically/ ultrasonically drives
microsurgical retrotrips because commonly available in the early
1990’s.
The pioneers in the field of ultrasonic cavity preparation under
enhanced visibility using a surgical operating microscope are Buchanan,
Carr, Rubinstein, Reuben and others.
Preparation is done with ultrasonic unit and special tips that are
only ¼mm in diameter and 3mm in length (about 1/10th
the size of
conventional HP).
The REP time is 1 to 2 minutes. CaPO4 cement is a mixture of 2
Ca PO4 compounds – overextend, one basic – when combined sets to
form hydroxyapatite.
vii) Retrofilling materials:
38

39. viii) The most commonly used retrofilling materials are
IRM, Super EBA cement, Amalgam, Ketac silver glass ionomer
cement. Amalgam is carried to the apex with a small K-G
retrofilling carrier sized for retropreparations.
Small K-G retrofilling caries.
Messings gun
Messings gun to place amalgam in deeper hand to reach areas.
Dr. Raymonds carrier and condensor caries and condensor retrofilling
instrument developed by Dr. Raymond.
Microscopic endodontic surgeries carried out using operating
microscopes first proposed by:
- Buchanan
- Carr
- Rubinstein.
- Reuben.
Advantages:
- Surgical microscope – it reveals:
- Tiny #
- Exists of accessory canals.
- Isthmuses.
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40. - Fins preparation done with piezoelecitric ultrasonic units
and special.
The advent of small microscopic surgical mirrors and ultrasonic
root end preparation techniques has enabled the cut in some cases to be
reduced to 0°.
If the obturation coronal to the defect has been performed
satisfactorily, it may be appropriate to resect only the unacceptable
segment of the root and not place a root end filling.
(If the apical gutta-percha is seen, it can be well burnished to the
resected root tip).
But if there is ever any doubt about the quality of the apical seal a
root end filling should be used.
ix) Flap closure
Following retrofilling procedure, the bone wax or ferric sulfate is
removed and the surgical site is thoroughly debrided with irrigating
solution to remove any loose particles of filling materials bone or root
structure. Before suture a radiograph should be taken to verify the
removal of filling particles. Reinjection of local anesthesia could help to
control bleeding and extend comfort to the patient.
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41. Repositioning of the flap:
The flap is closed by gently placing the most apical portion of the
flap first. The flap is smoothed to place with a 2 x 2 gauge sponge so
that th natural and incisional reference points are matched.
Harrison has recommended 2 to 3 minutes of compression to
develop a thin fibrin clot under the flap.
x) Suturing
The function of the suture is to secure the flap in its original or
desired position.
Sutures that are tightly placed compromise circulation, increase
changes of sutures to tear open once the tissues swell.
Suturing needles  traumatic (eyeless / swaged) needles which
are advantageous because of their reverse cutting edge.
The needle should penetrate 2 to 3mm from wound margin.
Suture materials are divided as:
1. Absorbable (digested by body enzymes).
2. Non-absorbable – (Walled off).
E.g. Absorbable  Surgical gut (traps food); Non-absorbable 
Silk (Ethicon).
41

42. The flap is gently replaced and smoothened into position with a
2x2 gauge sponge until the incisional reference points match. The first
suture should pass through the most dependent unattached tissue and the
proceed through the attached tissue and be tied. A puncture too close to
the incision can result in teasing of the tissue. A surgeons knot is most
effective and least likely to slip.
Sling suspensory or circumferential suturing is an effective
technique for maximum tissue adaptation. Because the lingual anchor is
lingual surface of the tooth. There is no tearing of the weaker lingual
tissue as the suture thread settle obstrusively against linguo-gingival
surface of the crown.
Postoperative Sequelae
The following postoperative sequelae can occur after endodontic
surgery.
1) Swelling:
Although swelling does not occur in all the cases, it is sufficiently
common to warrant every effort to prevent it, such as by keeping trauma
to a minimum during operation.
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43. - Effective method of reducing swelling is the application of
cold compress over the surgical area for 20 minutes every hour
postoperative.
- Enzyme preparations and corticosteroids are used.
2) Pain.
3) Ecchymosis
The discoloration of skin due to extravasation and brakdown of
blood in that area can travel along fascial planes and may appear near
angle of the jaw, under the eye, neck and even chest. These back and
blue marks usually disappear within 2 weeks.
4) Parasthesia:
Transparent parasthesia sometimes lasts for a few days after root
resection in any part of the jaw. It is very rare in the maxilla.
5) Stitch abscess
Possible causes are local laceration of tissue during suturing
accumulation of food debris or irritation of suture material itself.
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44. 6) Hemorrhage
Secondary hemorrhage is quite usual following root resection. If
hemorrhage occurs time to time a cold compress is placed over the site.
7) Perforation
Perforation of the antrum may occur postoperative in a maxillary
teeth from cusp to molar. It is not a serious sequale unless foreign bodies
are introduced. A suitable flap is coated and sutured properly followed
by an antibiotic coverage.
8) Iatrogenic
When rarefaction of area is extensive and intrusive it is always
possible to disrupt blood and nerve supply to the adjacent tooth. To
prevent this complication endodontic therapy should be initiated prior to
surgical and
Advances in Endodontic Surgeries
1. Use of microscopy and ultrasonic technology for retro
preparations.
2. Use of carr surgical micromirror (Microns 3mm diagram in
different shapes and angulations). This mirror allows to check for
44

45. completeness of canal wall preparation and removal of old
fillings.
3. Use of specialized carriers and pluggers to carry and condense
the retrofilling material.
4. Super EBA is material of choice caused with No. 12 poor –
excavator condensed with minute pluggers 025mm diagram,
burnished and trimmed and finished.
5. Surgical microscope allows is deotaping for post surgery patient
education videoprints can be made by a micro computer video
printer.
Causes for inadequate apical seal according to Carr:
1. Inadequate extent of apical preparation in a buccal-lingual
direction.
2. Apical preparation not in the long axis of the cnal.
3. Inadequate retention.
4. Failures to remove isthmus in between canals.
These failures can be overcomed by microscopic endodontic
surgeries.
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46. POSTOPERATIVE MANAGEMENT OF THE PATIENT
Preferably the instructions should written and explained to the
patient.
Ice pack and pressure:
- Patient should be instructed to apply an ice pack over the
surgical site and firmly, but gently press the pack on the facial
tissues.
- The pressures and reduction in temperature slows the flow
of blood promotes coagulation in severed vessels and ultimately
decreases post-operative bleeding and swelling.
- Cold reduces sensitivity of peripheral nerves endings and
acts as an analgesic.
Application of moist heat:
Application of moist heat on the surgical site is acceptable after
18 to 24 hours. Heat promotes the flood flows and enhances an
inflammatory response that is essential for wound healing during the
first and second postoperative days.
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47. Avoidance of activity:
It should be instructed to restrain from strenuous activity for the
remainder of the day on which the surgery was performed. To prevent
tearing of the sutures patient is instructed.
1. No a raise the lip and look at the operated area.
2. Do not brush in the operated area use mouthwashes.
Diet:
An adequate balanced diet, preferable soft foods such as eggs,
mashed potatoes fruit juices, soap, malted milk.
Oral hygiene:
Chlorhexidine mouthwash thrice daily for a week after the
surgery.
Pain management – At 3 levels:
An analgesic maintenance dose of 400mg every 8 hourly for first
3 operative days.
Narcotic though controversial can be prescribed hydrocodone
(7.5mg) with 750mg paracetamol every 4 to 6 hours.
47

48. Incision and Drainage:
It is a standard procedure to drain an abscess. There are two
problems that accompany this procedure firstly, optimal time to
intervene and secondly obtaining adequate local analgesic.
Ideally, the immediate area to be incised, the pointed area should
feel soft and fluctuant under the examiner’s fingertips. There should be a
fluid thrill that is when pressure is applied the feeling should be
transmitted through the fluid. The apex of the swelling may appear
whitish or yellowish. This is the ideal time to incise and drain.
Learning the correct moment of surgical intervention is gained by
experience.
Sometime a lesion may be in the indurated stage. In such cases
the patient is prescribed antibiotics and hot saline rinses half hourly to
bring the abscess to a head. But there is not thumb rule in the matter of
incising and draining while the lesions is still in indurated stage.
The second problem, that is obtaining local analgesia exists
because:
1. It is difficult to establish profound analgesia for an inflamed and
abscessed area.
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49. 2. Reluctance to inject into the area is because initially it is very
painful due to increase in fluid pressure by injecting into the
region, but it also unwise to risk the spread of infection by the
pressure of injection.
LA can be of 3 types:
- Short acting – procaing 2-3 hours.
- Intermediate acting – Prilocaine, Lignocaine 3-5 hours.
- Long acting – Eliodocaine, bupivocaine 8-10 hours.
3. Acting on CNS by prevents modulating pain at CNS. By use of
opoids like morphine, iodine 60-120mg, pestidine,
Treatment of pain
- Preoperative AIDS or conclusteroids.
- Long acting LA
- Centrally acting opoids.
The following guidelines for administering anesthesia should be
followed:
- Topical anesthesia should be applied liberally followed by
conduction analgesia peripheral to the site of infection.
- Block anesthesia followed by conduction anesthesia is
best.
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50. - A intramucosal wheal infiltration around the perimeter of
the lesion is given.
Armamentarium:
2" x 2" gauge sponges.
Three cotton swabs.
One scalpel with No.11 blade.
One small curved haemostat.
One needle holder.
One half curved cutting needle with 000 silk thread.
One suture scissors.
One aspirator tip.
Selection rubber dam ‘T’ drain.
- Gauge is placed to catch the flow.
- Swab the area with disinfectant.
- Test the depth of anesthesia and perform a sweeping
vertical incision with a No.11 scalpel through the most pointed area
to the bone and irrigate copiously with anaesthetic solution.
- Aspirate immediately.
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51. - Open the incised area widely by following out the tract
with a haemostat. Spread the handles of haemostat to separate the
beaks.
- Place a T drain with the bar of the drain inside the
incision.
- Suture the drain in place if necessary.
HEMISECTION
Hemisection refers to sectioning of the crown a molar tooth, with
either the removal of half of the crown and its supporting root structure
or the retention of both halves, to be used after reshaping and splinting
as two premolars.
Indications for hemisection:
1. When periodontal involvement of one root is severe.
2. When loss of bone is extensive in furcation area.
3. When caries involves much of the root.
Contraindication for hemisection:
1. When loss of bone involves more than one root, and the
remaining root would have inadequate support.
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52. 2. When bridge span is long, and the abutment tooth would rend
inadequate support.
3. When roots are fused.
Procedure:
- The roots to be retained undergo endodontic therapy and
the pulp chamber is filled with amalgam.
- No filling material is placed into the root to be removed,
for that entire half of the tooth will be extracted.
- A sharp cowhorn explorer or periodontal probe is used to
identify the buccal and lingual furcations.
- By first placing the tip of a high speed tapered fissure bur
in the furcation, the operator can effectively section the molar with
accuracy.
- An elevator should be wedged between the two halves and
slightly rotated to determine if the separation is complete.
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53. - The pathologic half is then extracted with forceps or eased
out with an elevator. The socket area is lightly curetted and packed
with bone wax /gel foam.
This is followed by copious irrigation.
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54. TREPHINATION
This surgical form is used to secure drainage and alleviate pain
when exudates in the cancellous bone is dammed up behind the cortical
plate.
The tremendous pressure leads to excruciating pain of an
intraosseous acute apical periodontitis or apical abscess. This
intraosseous pressure can be released and the area decompressed
through trephination, which provides a pathway to empty pus and other
acid exudates.
After a good local anesthesia is obtained, a mini vertical incision
provides adequate access and landmark visualization.
- The focal area of lesions is pinpointed by examination,
and working through the soft tissue cortical plate of bone
is grossly removed with a No. 8 bur to identify the root
apex.
- The bone is then penetrated at the apex with a no. 4 bur.
Trephination speeds relief and healing, but may not be
accompanied by a great flow of exudates or pus.
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55. Bicuspidation: carried out when only furcation area is involved and
remaining tooth structure is normal. In such cases the tooth usually
cover mandibular molars are split in half buccolingually at furcation
area to give 2 premolars which are recontoured and capped to allow
proper cleaning at interdental area.
RADISECTOMY
Synonymous : Root Amputation
Radisectomy denotes the removal of one or more roots of molar.
This procedure is often done for periodontal reasons.
Indications for Radisectomy:
1. When endodontic treatment of one root is technically impossible
or when such treatment has failed.
2. When untreatable furcation involvement is present and removal
of root will facilitate oral hygiene in that area.
3. When extensive loss of bone has occurred around one root of an
upper molar.
4. When a fractured root of an upper molar is present.
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56. 5. When a root has been perforated and root be treated
endodontically.
6. When a root has been destroyed by extensive decay.
Contraindications:
1. When loss of bone involves more than one root and the remaining
root would have inadequate support.
2. When roots are fused.
Armamentarium:
- Surgical length or long shank fissure bur sizes 700, 701,
557 and 558.
- Long tapered fissure diamond stones – to smoothen
retained tooth segment.
- Elevators  straight, apical elevators.
- Forceps  upper / lower forceps.
Endodontic therapy is completed prior to the surgical procedure:
- A flap need not be raised if root amputation performed on
periodontally involved teeth.
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57. - A flap has to reflected if the teeth is periodontally
involved.
There are two methods by root amputations can be performed:
1. Vertical cut method:
Utilizes a long shank, tapered fissure carbide bur in airrotor to
section through the entire crown and root to the furca in gaining
separation.
Advantages of vertical cut method:
1. Direct visualization of bur penetration to ensure that preparation
will be in the correct position.
2. Removal of that portion of the crown that is over the root to
prevent undesirable postoperative occlusal forces.
3. Position of each cut, based on the anatomy of the furca, to allow
the root to cleave along desirable angles.
4. Excellent visualization of furca after amputation.
2. Horizontal cut preparation.
Horizontal cut is made through the tooth without the crown being
altered in the preparation.
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58. Cutting the tooth in this manner leaves a deep trough between the
crown and the alveolar mucosa which is obvious trap for food and
debris.
Any occlusal forces over the amputated root will tend to put
severe stress from a undesirable direction on the remaining roots.
Amputation procedures on mandibular molars:
- Also known as bicuspidization.
Procedure:
A gently curve is made in a size 40 silver cone and inserted it
through furca from the buccal to lingual.
The rest of the procedure is as in vertical procedure is an in
vertical cut method for maxillary molars.
Storage media:
1. HBSS
2. Vtaspan – decreased incidence of root resorption after re
implantation.
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59. Corrective surgeries:
1. Perforative repairif in coronal 3rd
of root can be sealed using
Super EBA.
- If in middle 3rd
and communicating with periodontium
then RCT followed by packing canal with Ca(OH)2 to promote
cementogenesis.
- If the resorptive defective is communicating to oral cavity
then a connective radicular surgery has to be performed.
- Raised flap – perform RCT fil up resorptive site using
amalgam / Super EBA (Then obdurate canal completely in next
setting).
2. Periodontal repair: Guided tissue regeneration: This is based on
the principle of placement of a banus membrane that prevent
epithelial migration and down growth of junctional epithelium
into healing periodontium. Thus allows blood clot to undergo
regeneration in a stable environment with the proliferation of
indifferent mesenchymal cells to form fibroblasts, cemento and
osteoblasts. Thus allowing plug films to get reattached onto the
surface of a new cementum. These barrier membranes may be
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60. resorbable or non-resorbable (has to be removed after 6 weeks) of
banner membrane cortex.
Endodontic Implants:
 It is a metallic extension of the root with the object of increasing.
1. The root to crown ratio.
2. To give the tooth stability in the arch.
 Endo implants are useful for the treatment of:
1. Periodontally involved teeth requiring stabilization.
2. Transverse root # involving loss of the apical fragment / the
presence of 2 fragment that cannot be aligned.
3. Pathologic resorption of the root apex incident to chronic abscess.
4. A pulpless tooth with an unusually short root.
5. Internal resorption affecting the integrity and strength of the root.
6. A tooth in which additional root length is desired for improving
its alveolar support.
The success of an Endodontic implant depends on:
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61.  Proper case selection and close adherence to the following
criteria.
 Normal root anatomy without curvature / defelctions.
 Alveolar bone is sufficient for retention and stability of both the
tooth and the implant.
Contraindicated:
1. When multiple incisors are periodontally involved and the
adjacent teeth would serve as satisfactory abutment.
2. When anatomic structures are close to the apex.
3. The inclination of the tooth.
4. h/o bleeding problems.
5. h/o bone infection (month/any extremities).
6. h/o rheumatic heart disease, diabetes and other systemic illness.
The disadvantages of Endo implants, which can result in failure:
 Poor apical seal resulting in Pa rarefaction around the root apex.
 Extrusion of excessive sealer.
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62.  Perforation of the lateral root surface / perforation of a curved
root near the root apex.
 A structurally weakened tooth.
 Limitations : Because of the local anatomic factors.
Instruments:
Special instruments and filling materials are required for the
successful outcome:
1) Extra long (40mm) reamers in standardized size 70 to 140.
2) Special intraosseous drill.
3) Standard chrome-cobalt endodontic implant sizes 70 to
140.
Technique:
 Anaesthetic the tooth and involved area with a local anaesthetic.
 Rubber dam is applied.
 Access preparation, enlargement and irrigation of the root canal
is carried out.
62

63.  Larger and wider access preparation in the clinical crown-to-
accommodate the placement of the rigid implant “straight line”.
 In addition, the root canal should be enlarged to at least the size
of a No. 60 instrument.
 A marker is then set on the 40mm reamer at a level equivalent to
the length of the tooth plus the number of ---- the implant will
extend beyond the root apex.
 Thus the bone is reamed to the desired length.
 Irrigate with anaesthetic solution / saline as NaOCl may irritate
the Pa tissue).
 Irrigation – debrides the canal, controls haemorrhage.
 Dry the canal with sterile absorbent points.
 Select the implant to the least equivalent instrument used, score it
lightly to the desired WL (occlusal tip to cancellous bone).
 Implant must fit tightly and must penetrate the bone to the
prepared length.
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64. Implant – must fit at the apical foramen. If not adjustments
should be made by cutting of the implant 1mm of the tip and then
tried out.
 With the help of a plugger seat the implant during cementation.
 Then the coronal portion is replaced by crown / post-type crown
(seat the implant to the level corresponding to the midroot, so as
to provide sufficient space to cement post-core crown later.
 Replantation / reimplantation is the insertion of a tooth in its
socket after its complete avulsion resulting from traumatic injury.
 Intentional replant: is the intentional removal of a tooth and its
reinsertion into the socket after orthograde obturation and
resection of the root tips, resection of the root tips followed by
retrograde obturation teeth.
 Transplantation is removal of a tooth / tooth bud from one socket
and transplanting it into another socket.
Autotransplantation Allotransplantation
From one socket to another From one person to another
Socket of the same person
3 types of materials are used:
64

65. - Metals.
- Ceramics.
- Polymers and composites.
65

66. Metals:
- Stainless steel.
- Co-Cr-Mo.
- Ti & Ti-Al vanadium.
- Metal with surface coating.
Hydroxyapatite Bioglass
Non reactive Aluminium O2
Conclusion
Keeping in mind, the degree of difficulty and complexity of
endodontic cases we are currently challenged to treat demand all our
resources to include surgical endodontics.
66