SURGICAL ENDODONTICS

1. Surgical
Endodontics

2. INTRODUCTION

3. 10.3 %
Extn
Retreatment
Surgical
Endodontics
10.3 %

4. Over 1,500 years ago - Greek physician performed first
recorded endodontic surgical procedure - incision and drainage
of an acute endodontic abscess
1871 – Smith - First root end resection
1880 – Brophy - Root end filling
1881 - Claude Martin - Father of root end resection
1884 – Farrar - Root amputation
Surgical operating microscopes - 1980’s - Endodontic
microsurgery
1990s – Dr. Gary Carr surgical ultrasonic tips first designed –
Carr tips
1999 – Spartan/Obtura - Kim Surgical tips – Kis tips
HISTORY

5. Removal of tissues other than the contents of the
root canal space to retain a tooth with pulpal
and/or periapical involvement.
(Franklin Weine)
DEFINITION

6. OBJECTIVES
Toensure the placement of a proper seal between the
periodontium and the rootcanal foramina.

7. Indications
Glick and Ingle
1. Need for surgical drainage
⚫ Incisionand drainage
⚫ Trephination
2. Failed nonsurgical endodontic treatment
⚫ Irretrievableroot canal filling,material
⚫ Irretrievableintraradicular post
3. Calcific metamorphosisof the pulp space
4. Procedural errors
⚫ Instrument fragmentation
⚫ Non-negotiable ledging
⚫ Root perforation
⚫ Symptomaticoverfilling
5. Anatomic variations
⚫ Rootdilaceration
⚫ Apical root fenestration
BREAD
CFC

8. 6. Biopsy
7. Correctivesurgery
⚫ Root resorptive defects
⚫ Rootcaries
⚫ Root resection
⚫ Hemi section
⚫ Bicuspidization
8. Replacement surgery
⚫ Replacement surgery
 Intentional replantation (extraction/replantation)
 Post-traumatic
⚫ Implantsurgery
 Endodontic

9. 1. Patient’s medical status
2. Anatomical considerations
3. Practitioner’s skill and experience
Contra Indications

10. Surgical instruments
Bard Parker
Blades:
NO .10 No. 15c No. 15 No. 12 No. 11

11. ELEVATION INSTRUMENTS
09

12. TISSUE RETRACTION INSTRUMENTS
⚫ Arens tissue retractor
⚫ Selden retractor
⚫ Cats paw retractor
S
AC

13. CURETTAGE INSTRUMENTS
•Minicurettes
•Mini jacquette 34/35
•Columbia 13- 14
•Miniendodontic curettes
•Minimolten curettes

14. Osteotomy Instruments
⚫ No. 4 round bur
⚫ No. 6 round bur
⚫ No. 8 round bur
⚫ No. 57 fissure bur
⚫ Multipurpose bur
⚫ Endo-Z bur

15. RETRO FILL CARRIERS
MAP
RETRO
AMALGAM
CARRIER

16. RETRO FILL PLUGGERS

17. DENTAL OPERATING MICROSCOPE

18. CLASSIFICATION OF ENDODONTIC SURGERY
 Fisulative surgery
 Incision and drainage
 Cortical trephination
 Decompression procedures
 Periradicular surgery
 Curettage
 Root-end resection
 Root-end preparation
 Root-end filling
 Corrective surgery
 Perforation repair
 Mechanical(iatrogenic)
 Resorptive
 Periodontal management
 Root resection
 Tooth resection
 Intentional replantation
DCI
RC3

19. INCISION AND DRAINAGE

20. Materialsused
⦿ Iodoformgauze
⦿ Rubberdam material -“H” or “Christmas tree” shape.
⦿ Penrosedrain
Penrose drain Serrated drain

22. TREPHINATION

23. PERIRADICULAR SURGERY
CR3
Curettage
Root-end resection
Root-end preparation
Root-end filling

24. TREATMENT PLANNING FOR PERIRADICULAR SURGERY
1. Presurgical patient management
2. Need forprofound local anesthesiaand hemostasis
3. Managementof soft tissue
4. Managementof hard tissues
5. Surgical access, both visual and operative
6. Access toroot structure
7. Periradicularcurettage
8. Root-end resection
9. Rootend preparation
10. Root-end restoration
11. Soft-tissuerepositioning and suturing
12. Postsurgical care

25. PRESURGICAL PATIENT MANAGEMENT
A
K

26. LOCAL ANESTHESIA
TYPES OF LOCAL ANALGESIA
⚫Topical analgesia (surfaceanalgesia)
⚫Sub mucosal infiltration
⚫Subperiosteal infiltration
⚫Nerve blockanalgesia
⚫Intra ligamentaryanalgesia.
⚫Intraosseousanalgesia.

29. Failure to obtain analgesia
Pain during injection
Haematoma formation
Intravascular injection
Trismus
Paralysis
Lip Trauma
LOCAL COMPLICATIONS

30. Drug interactions
Allergy
SYSTEMIC COMPLICATIONS

31. PRINCIPLES OF FLAP DESIGN
MANAGEMENT OF SOFT TISSUE
1. Avoiding the incision overa bonydefect
2. Including the full extentof the lesion.
3. Avoiding sharpcorners
4. Avoiding incision acrossa bonyeminence
5. Making sure base of the flap should be wider than the free end.

32. 6. Avoiding incision in the mucogingival junction.
7. Taking careduring retraction.
8. Incision should be made with firm, continuous firm strokeperpendiculartothecortical
boneplate.
9. The sutured flap margin should reston solid cortical boneplate.

33. CLASSIFICATION
⚫ Full thickness (Mucoperiosteal) –
Epithelium + Connectivetissue
+Periosteum
⚫ Partial thickness (Split) -
Epithelium + Connective tissue

34. ⚫ Full mucoperiosteal flap
⚫ Triangular
⚫ Rectangular
⚫ Trapezoidal
⚫ Horizontal/Envelope
⚫ Papilla base
⚫ Limited mucoperiosteal
⚫ Sub marginal curved/Semilunar
⚫ Sub marginal scalloped rectangular/Luebke Ochsenbein

35. ⚫Full mucoperiosteal flap
⚫ Triangular
⚫ Rectangular
⚫ Trapezoidal
⚫ Horizontal/Envelope
⚫ Papilla base
⚫Limited mucoperiosteal
⚫ Sub marginal curved/Semilunar
⚫ Sub marginal scalloped rectangular/Luebke Ochsenbein

36. TRIANGULAR FLAP

37. RECTANGULAR FLAP

38. TRAPEZOIDAL FLAP

39. HORIZONTAL FLAP

40. SUBMARGIN CURVED / SEMILUNAR FLAP

41. SUB MARGINAL SCALLOPED RECTANGULAR FLAP

42. OPTIMAL OSTEOTOMY SIZE
OSTEOTOMY

43. A surgical procedure to remove diseased or reactive tissue from alveolar bone in the
periradicular area or lateral region surrounding a pulp less tooth (AAE 1994)
PERIRADICULAR CURETTAGE

44. ROOT END RESECTION

45. ◦LASER – ErYag,CO2
LOW SPEED
STRAIGHT
HANDPIECE
No.702 tapered
fissure bur
No.6 or No.8
round bur

46. BEVEL ANGLE
Advantages:
•Exposes fewer dentinal tubules, thus
preventing excess leakage and
contamination.
30-45o: 10o degree

47. ROOT END PREPARATION
⦿ Miniaturecontra-angle orstraight hand piece /ULTRASONIC
⦿ Small round or inverted cone bur.
⦿ Class I cavity preparation along the long axis of the rootwithin
the confinesof the rootcanal.
⦿ Recommended depth - 2 to 3 mm being the most
commonly advocated. (Gutmannand Harrison)
⦿ Disadvantage: Apical perforationdue todifficulty in aligning the
bur

48. RETROGRADE RESTORATIVE MATERIALS AND TECHNIQUES
Propertiesof ideal retrograderestorative
materials :
⚫ Well tolerated by periapical tissues
⚫ Bactericidal or bacteriostatic
⚫ Adhereto the tooth
⚫ Dimensionallystable
⚫ Readilyavailableand easy to handle
⦿ Notstain teeth orperiradiculartissue
⦿ Noncorrosive
⦿ Resistanttodissolution
⦿ Electrochemically inactive
⦿ Promote Cementogenesis
⦿ Radiopaque
Purpose:
To seal the apex so that no bacteria or bacterial by products can enter or leave from
the canal

49. ⚫ Guttapercha
⚫ Amalgam
⚫ Cavit
⚫ IRM
⚫ Super EBA
⚫ Glass Ionomer
⚫ Compositeresins
⚫ Carboxylatecements
⚫ Zinc phosphatecements
⚫ Zincoxideeugenol cements
⚫ Mineral trioxideaggregation (MTA)
Root End filing materials

50. SOFT TISSUE REPOSITIONING AND COMPRESSION
 Theelevated muco periosteum gentlyreplaced to
itsoriginal position with the incision lines
approximated as closelyas possible.
 Tissuecompression: Using a surgical gauze
moistened with sterile saline, gently apply firm
pressure to the flapped tissue for 2 to 3
minutes (5 minutes forpalatal tissue) before
suturing.
 Enhances intravascularclotting in thesevered
blood vessels

51. SUTURING
Purpose: Toapproximatethe incised tissueand stabilize the flapped muco
periosteum until reattachmentoccurs.
CLASSIFICATION OF SUTURE MATERIALS
⦿ Based on material:
Natural
Collagen
Gut
Silk
Synthetic fibers
Nylon
Polyester
Polyglactin
Polyglycolic acid
⦿ Absorbency:
Non absorbable
Silk
Nylon
Absorbable
Polyester
Polyglactin
Polyglycolic acid
Collagen
Gut

52. POST OPERATIVE INSTRUCTIONS AND CARE
 Do not lift up lipor pull back thecheek to look at where the surgery was
done.
 A little bleeding from surgical is normal. This should only last fora few
hours.
 A little swelling and bruising face may be evidentwhich may last fora few
days.
 Do not drink alcohol oruse tobacco (smoke orchew) for the next 3 days.
 Havea good, soft dietand drink lots of liquids for the first few days after
surgery.

53. ⚫ Place an ice bag (cold) on face where the surgery was done. Leave it
on for 20 minutes and take it off for 20 minutes. Continue this for 6
to 8 hours.
⚫ Take the prescribed medicinesas recommended.
⚫ Rinse the mouth with 1 tablespoon of the chlorhexidine mouthwash
twicedaily for 5 days.
⚫ Sutureremoval after 5-7 days by thedental personnel only.
⚫ Maintain postoperative follow up recall visits
⚫ If any problemsexists informand visityourdentist immediately.

54. Corrective surgery may involve
⚫ Root resection.
⚫ Hemi section.
⚫ Intentional replantation.
CORRECTIVE SURGERY

55. ROOT AMPUTATION

56. HEMISECTION

57. BICUSPIDIZATION

58. COMPARISON OF TRADITIONAL V/S MICROSURGERY Kim and Rubenstein, 2001
PROCEDURE TRADITIONAL MICRO-SURGERY
Identification of
apex
Difficult Precise
Osteotomy Large (=>10 mm) Small (<5mm)
Root surface
inspection
None Always
Bevel angle Large (45o) Small (<10o)
Isthmus
identification
Nearly impossible Easy
Retro
preparation
Approximate Precise
Root end filling Imprecise Precise