3. 1. Need for surgical drainage.
2. Failed non-surgical treatment:
a) Irretrievable root canal filling.
b) Irretrievable intraradicular post.
c) Continuous post- operative
discomfort.
a) Recurrent exacerbation of
non-surgical endodontic treatment.
4. 3. Calcific metamorphosis of pulp space.
4. Horizontal fracture with associated periapical
or periodontal lesion.
5. 5. Procedural errors:
a) Instrument separation.
b) Non-negotiable ledging.
c) Root perforation.
d) Severe apical
transportation.
a) Symptomatic overfilling.
6. 6. Anatomic variations:
a) Root dilacerations.
b) Apical root fenestration.
c) Non-negotiable root curvatures.
7. 7. Corrective surgery:
a) Root resorption defects.
b) Root caries.
c) Root resection.
d) Hemisection.
e) Bi-cuspidization.
8. 8. Replacement surgery:
a) Intentional replantation.
b) Post-traumatic replantation.
9. Implant surgery:
a) Endodontic implants.
b) Osseo-integrated implants.
10. Biopsy and exploratory surgery.
9. 1. Poor periodontal condition.
2. Medically compromised patients:
a) Active leukaemia or neutropenia.
b) Uncontrolled diabetes mellitus.
c) Recent serious cardiac or cancer surgery.
d) Liver or kidney damage.
e) Very old age.
10. f) Uncontrolled hypertension.
g) Uncontrolled bleeding tendency.
h) Immuno-compromised patients.
i) Recent myocardial infarction or taking
anticoagulants.
j) Recent radiation therapy of the head and neck.
k) First trimester of pregnancy.
11. 3. Mental or psychological status:
a) Patient does not desire surgery.
b) Very apprehensive patient.
c) Inability to stand stresses of long
complicated operations.
4. Surgical skills and ability.
5. Short roots in which removal of the apex
compromises prognosis.
12. 6. Anatomic considerations:
a) Severely lingually or palatally inclined
roots.
b) Root apices very close to the mandibular
canal or the mental foramen.
c) Too thick buccal bone plate.
d) Restricted access to the root tip.
7. Proximity to the maxillary sinus or nasal floor.
13. 8. Miscellaneous:
a) Non restorable tooth.
b) Vertically fractured teeth.
c) Non-strategic teeth.
14.
15. I. Fistulative surgery (surgical drainage):
a) Incision and drainage (I &D).
b) Cortical trephination.
II. Periradicular surgery:
a) Curettage.
b) Biopsy.
c) Root end resection.
d) Root end preparation.
16. III. Corrective surgery:
1. Perforation repair.
a) Mechanical (iatrogenic).
b) Resorptive (internal and
external).
2. Root resection.
3. Hemisection.
IV. Replacement surgery.
18. a) Incision and drainage (I & D):
Surgical drainage is indicated when pus and or
exudate form within the soft tissue or alveolar
bone as a result of periradicular lesion.
19.
20. Philosophy of treatment:
Localized swelling I & D only
Diffuse swelling spread to tissues
and spaces I & D and systemic antibiotic.
Hard indurated, diffuse swelling allow
to become soft fluctuant and localized by
giving antibiotics before I & D.
21. Nerve block &/or ring block anesthesia are
preferred.
Nitrous oxide analgesia and antianxiety drugs are
recommended.
Horizontal incision should be placed at the most
dependant part of the swelling.
22.
23. b) Trephination:
This technique is done to drain the pus and
toxins accumulated behind the cortical plate.
A suitable incision is established after detection
of the position of root apex.
A surgical round bur or fissure bur may be used
to penetrate the cortex and cancellous bone
about 2mm beneath the suspected apical tip.
A full circle of cortical bone is removed until the
root tip and the lesion are uncovered.
24.
25. Factors affecting prognosis of periradicular
surgery:
Recording complete dental and medical
history.
Evaluation of the accessibility to the surgical
site.
Vitality tests and radiographic evaluation.
Patient’s compliance and cooperation.
28. Local anesthesia and haemostasis:
Lidocaine with vasoconstrictor (xylocaine) is the
anesthetic of choice due to its high success rate,
prolonged effect and low allergic potential.
The two major groups are the esters and amides.
The important difference of these groups is not
their effect but the manner in which they
metabolized and their allergic reactions.
29. Esters (e.g. Ravocaine) have a much higher allergic
potential.
Amides; e.g. lidocaine (xylocaine), mepivacaine
(carbocaine), prilocaine (citanest), articaine
(ultracaine), are metabolized in the liver.
Patients with liver dysfunction should administer
amides with caution.
Patients with renal impairment may be unable to
remove the anesthetic solution from blood,
therefore asking for medical consultation is
important.
30. If the use of amide anesthetic is absolutely
contraindicated, the esters agents will be the only
choice; e.g. procaine – propoxycaine with
levonordefrin (Ravocaine with Neo-Cobefrin).
Epinephrine (adrenaline) is the most effective and
widely used vasoconstrictor.
Vasoconstrictors increase effect and
duration of anesthesia and control bleeding.
Vasoconstrictors sympathomimetics act
on α & β adrenergic receptors.
Vasoconstrictor agents epinephrine
(adrenaline) & Levonordephrine (Neo-cobefrin).
31. For nerve block 1:100000 to 1:200000
adrenaline concentration is used.
For better haemostasis 1:50000
concentration.
Rate of injection 1 to 2 ml / min. using
30- gauge needle.
Infiltration anesthesia needle bevel
towards & touching bone.
Rapid injection produces pooling of
solution reducing effect & hemostasis.
32.
33.
34. Mechanism of hemostasis and the rebound
phenomenon:
α receptors predominant in oral mucosa
and ginigva vasoconstriction.
β receptors predominant in skeletal
muscles vasodilatation.
Rebound phenomenon due to rebound
from α to β response.
35. Rebound phenomenon (active hyperaemia) happens
after the effect of α receptors decreases.
The restricted blood flow slowly returns to normal.
Then the reactive hyperaemia occurs due to local
hypoxia and acidosis caused by prolonged
vasoconstriction.
Injecting more anesthesia will never reestablish
hemostasis.
In long surgical operations complicated
hemostasis – dependent procedures are done first.
36. Classification:
I. Full mucoperiosteal flaps:
a) Triangular (single vertical releasing incision)
b) Rectangular (double vertical releasing incisions)
c) Trapezoidal (broad base rectangular)
d) Horizontal (no vertical releasing incision)
e) Papilla-base.
II. Limited mucoperiosteal flaps:
a) Submarginal curved (semi- lunar)
b) Submarginal scalloped rectangular (luebke – ochsenbein)
37. Principles and guidelines for flaps:
1. Incision should be placed over solid bone. A
minimum of 5mm of bone should exist between the
incision line and surgical bony defect.
2. Avoid incision lines over radicular eminences such
as canines and maxillary first bicuspids.
3. Avoid incisions across major muscle attachment.
4. Extent of horizontal incisions should be adequate to
provide access with minimal soft tissues trauma.
5. Extent of vertical incisions should be sufficient to
allow the tissue retractor to seat on solid bone
leaving the apex well exposed.
38.
39. 6) Avoid incision in the mucogingival junction.
7) Junction between horizontal and vertical incision lines
should either include or exclude the involved interdental
papilla.
8) Flaps should include the full thickness of the
mucoperiosteum.
40. 9. Avoid horizontal and severly angled vertical incisions.
The supraperiosteal vessels assume a vertical course
parallel to long axis of teeth. Collagen fibers of the
gingival mucosa (gingival ligament)are vertically
oriented as well. These severely angled incisions shrink
excessively during surgery as a result of contraction of
cut collagen fibers and severance of gingival blood
vessels. It often results in placing excessive tension
during suturing , tearing out of the nutrition and
subsequent scar formation as a result of healing by
secondary intention.
41. 10. In case of submarginal incisions a minimum of
2mm attached gingiva should be kept around
each tooth.
11. Avoid improper treatment of periosteum.
42. The entire soft tissue overlying the cortical bone
plate is reflected.
The advantage of these flaps is keeping intact
supraperiosteal vessels.
43. a) Triangular flap:
Two incisions; horizontal and vertical.
Vertical releasing incision.
Horizontal incision intrasulcular
gingival incision.
44. Rapid, good wound healing.
Advantages:
Ease of closure.
45. Disadvantages Limited surgical access.
Indications:
Maxillary incisor region.
Maxillary and mandibular posterior teeth.
The most recommended flap for posterior
mandibular region
46. Not recommended for:
Teeth with long roots (maxillary canines)
Mandibular anterior teeth due to the lingual
inclination of their roots.
47. b) Rectangular flap:
Two vertical and a horizontal intrasulcular incision.
Advantages Good surgical access.
- Difficult reapproximation of margins.
Disadvantage: - Difficult post surgical stabilization.
- Great potential for post surgical flap
dislodgement.
49. c) Trapezoidal flap:
Two vertical releasing incisions which join a
horizontal intrasulcular incision at obtuse
angles. It creates a broad-based flap.
It was assumed that this provide a better blood
supply.
50. Disadvantages:
More bleeding due to disruption of more of the
vertically oriented blood vessels.
Shrinkage, pocketing or clefting of soft tissue due to
severing of more collagen fibers.
Wound healing by secondary intention.
Contraindication periradicular
surgery.
51. d) Horizontal (envelope) flap:
A horizontal, intrasulcular incision with no vertical
releasing incision.
It has a very limited application due to the limited
surgical access.
53. Indications:
Repair of cervical defects; such as perforations,
resorption, cervical caries.
Hemisection.
Root amputation.
Contraindication Periradicular
surgery.
54. e) Papilla-base Flap:
A horizontal incision at the papillary base
extending intrasulcular toward the crestal bone.
At least one vertical incision is established.
Advantage:
No recession of the papillae following surgery.
Indications:
Mandibular and maxillary anterior and posterior
teeth
55. They have a submarginal (subsulcular) horizontal,
or horizontally oriented, incision, and does not
include marginal or interdental tissues. Therefore
in this type of flaps more vertically oriented
blood vessels and collagen fibres are severed.
56. a) Submarginal curved (Semilunar) Flap:
A curved incision in the alveolar mucosa and
attached gingival.
Incision begins at the alveolar mucosa extending
into attached gingival and then curves back
into the alveolar mucosa, resembling a half
moon.
57. Advantage Does not disturb the
gingival margin and interdental papillae.
Disadvantages:
Poor surgical access.
Poor wound healing due to disruption of blood
supply to un-flapped tissues.
Difficult wound closure.
Postsurgical scarring.
58. b) Submarginal scalloped rectangular (luebke –
ochsenbein) Flap:
A modification of the rectangular flap.
It provides the advantages of the rectangular and
semilunar flaps.
The horizontal incision is placed in the attached
gingival.
The horizontal incision is scalloped following the
contour of marginal ginigva above the free gingival
groove.
59. :Advantages
Does not involve marginal or interdental gingivae.
Crestal bone is not exposed.
Adequate surgical access.
Disadvantages:
Disruption of vertically oriented blood vessels
producing more bleeding.
Severing vertically oriented collagen fibres producing
flap shrinkage.
Difficult reapproximation.
Delayed healing.
Scar formation.
60. Indications:
In presence of gingivitis or marginal periodontitis.
In presence of fixed prosthesis.
When bony dehiscence is suspected.
61. Considerations in palatal surgery:
Palatal approach is difficult limited
visibility and accessibility.
Indicated flap designs:
1. Horizontal (envelope).
2. Triangular.
62. The horizontal intrasulcular incision extends
mesially to :
Envelope flap palatal midline.
Triangular flap mesial to the first premolar.
Extends distally as far as needed to give accessibility.
63. Triangular flap:
Vertical releasing incision extends from a point
near midline and join the anterior extent of
the horizontal incision mesially.
Vertical palatal incisions are safe in premolar
area, or mesial to it.
Greater palatine artery branches rapidly as it
courses anteriorly.
64. Indications of palatal flaps:
Surgical procedures in palatal roots of molars and
premolars such as apicectomy, amputation, or
perforation repair.
Repair of perforations or resorption defects of palatal
surfaces of anterior teeth.
65. Flap reflection and retraction:
Marginal gingiva is very delicate do not
begin reflection in the horizontal incision.
Attached supracrestal tissues are clinically very
important.
Damaging these tissues apical epithelial
downgrowth causing:
Increased sulcular depth and loss of soft tissue
attachment level.
Submarginal flaps:
Reflection should not begin also in the horizontal
incision.
Reflecting forces may damage wound edges,
delay healing, and causes scar formation.
66. Flap Reflection:
The process of separating the soft tissues from surface of
alveolar bone.
It should begin in the vertical incision few millimeters
apical to its junction with the horizontal incision.
Once this part is lifted from cortical plate a periosteal
elevator is inserted between it and the bone with its sharp side
toward bone.
The elevator is then moved coronally so that;
The marginal and interdental gingivae as well as the wound
edge are separated without direct application of dissectional
forces.
By doing so all direct reflective forces are applied to
periosteum and bone only.
The horizontal sulcular incision may be made with a scalpel.
67.
68. Flap Retraction:
Retractor should rest on sound cortical bone.
If retractor rests on the base of reflected tissues
damage of microcirculation and delayed healing occur.
Time of retraction:
General rule: the longer the flap is retracted the greater the
post surgical complications
Because of:
Reduced vascular flow.
Tissue hypoxia.
69. Frequent flap irrigation with sterile saline to
prevent dehydration.
Limited mucoperiosteal flaps more
susceptible to dehydration.
Therefore, they require more frequent irrigation.
70. Hard tissue management :
To gain access to the root apex removal of
covering osseous tissue.
Osseous tissue response to heat:
1. Above 400c increase in blood flow causing
hyperaemia.
2. 47 – 500c for a 1min. osseous resorption.
3. 50 – 530c for 1 min. stasis of blood and death of
blood vessels.
4. At 560c inactivation of alkaline phosphatase
enzyme.
5. At 600c or more complete termination of blood
flow and tissue necrosis.
71. Tissue response to bone removal:
Decrease in blood supply during surgery
less bone resistance to heat and injury.
No. 6 or 8 round bur with efficient coolant
less inflammation and smoother cut surface.
72. Light “brush strokes” with short, multiple periods of
cutting will:
Maximize cutting efficiency.
Minimize frictional heat.
Cutting bone with diamond stone bony
defects heal at a very slow rate.
Impact Air 45* high speed hand piece:
Increase visibility.
Increase accessibility.
Air exhausted to the rear of the turbine rather than toward
the bur.
73. Hazards of using high speed hand piece in
surgery:
1. Surgical emphysema of the face.
2. Fatal descending necrotizing mediastinitis.
3. Pressurized non-sterile air blown into open surgical
spaces.
74. To accurately determine and locate the position of the root apex to
gain access through the cortical bone plate, the following guidelines should
be followed:
1 Radiographs are taken in straight, mesial and distal angulations.
2 Assess the angulations of the crown to the root accurately.
3 Measure the entire tooth length with a smooth broach or a file.
4 Locate the beginning of the root, the bone covering the root is thinner
cervically.
5 Probing the bone forcibly may show the presence of small defect.
When a small defect is noticed, then a piece of lead sheet or gutta-percha
can be placed in it and radiographed.
75. Characteristic points to differentiate root surface
from bone:
1. Root is yellowish in color.
2. Root texture is smooth and hard, while that of
bone is porous and granular.
76.
77. 3. Root does not bleed when probed.
4. Root is surrounded by periodontal ligament.
Methylene blue dye is used to identify the
periodontal ligament.
78. Indications:
1. To establish access to the root.
2. To remove infected or pathologic tissues from
the bone surrounding the root.
3. To remove over extended filling.
4. To remove necrotic cementum.
5. To assist rapid healing and repair of
periradicular tissues.
79. Surgical technique:
Local anesthesia.
Design the suitable flap.
Expose the surgical site.
Insert bone curette between soft tissue and bone and
apply pressure against the bone to remove the
pathologic tissues.
Grasp the pathologic tissues with tissue forceps and
send them for examination.
80.
81.
82. Definition: the ablation of apical portion of the
root end.
Indications:
Could either be due to biological factors (60%)
or technical factors (40%).
83. Biological factors:
1. Persistent symptoms, such as pain, infection or
swelling.
2. Periradicular and radicular lesions; such as
cysts or resorptive defects.
3. Anatomical variations; such as dilacerated
apex, multiple accessory canals, immature and
blunderbuss canals.
4. Blocked and calcified canals.
84. Technical factors:
1. Iatrogenic errors; such as perforations, ledges and
separated instruments.
2. Presence of irretrievable obturating material.
3. Presence of post and core restorations.
4. Presence of overfilling or poor apical seal.
Factors to be considered prior to root-end resection:
1. Instrumentation.
2. Extent of root-end resection.
3. Angle of root-end resection.
85. 1. Instrumentation:
Round burs (hi and slow speeds) ditching of
the resected root surface
Cross cut fissures (both speeds) rough and
irregular surface with gutta percha smeared all over
Plain fissure (both speeds) smoothest surface
and least distortion of gutta percha
Ultra fine diamond (both speeds) rough surface.
ER: YAG laser clean smooth root surface
CO2 laser after fissure bur good sealing of
open dentinal tubules.
86. Advantages of using laser in periradicular
surgery:
1. Reduction of postoperative pain.
2. Hemostasis.
3. Reduction of permeability of root surface.
4. Sterilization of root surface.
5. Absence of discomfort and vibrations.
6. Reduction of trauma.
87. 2. Extent of root-end resection:
There is no agreement on how much of the root
end should be resected
Historically: it was thought that resection
should be done up to the level of healthy bone
Recent studies showed that there is no
correlation between them.
88. Factors dictate the extent of root
resection:
1. Access and visibility of surgical site.
2. Anatomy of the root ie. Shape, length, acute apical
curvatures.
3. Anatomy of resected root surface ie. Accessory
canals, ramifications
4. Presence and location of iatrogenic errors.
5. Presence of periodontal defects.
6. Presence of root fractures.
7. Need to place root-end filling into sound structure.
3mm resection reduction of 93% lateral
canals and 98% ramifications
89.
90. 3. Angle of root-end resection:
Historically: angle of root-end resection
should be 30 to 45 from long axis facially.
This was suggested to improve visibility and
accessibility
91. Recently it was found that:
Beveling opening more dentinal tubules risk of
leakage
Beveling changes the opening of root canal from
circular to ovoid increases the surface area
Beveling sharp angled root-end concentrates
stresses irritation.
Beveling apical lesions are obscured on radiographs
by the sharp angled root tip
Beveling may not include the palatally or lingually
placed foramina in the resected portion of the root.
92.
93. A bevel of 0-10 is recommended with resection at the
level of 3mm.
Advantages of zero degree bevel:
1. Exposure of fewer dentinal tubules.
2. Maintains maximum root length.
3. Reduced size of osteotomy.
4. Less apical leakage.
Resection should be complete with no segment of the
root left unresected.
94. Objective: To create a cavity into which a root-
end filling can be placed.
Ideal root-end preparation:
“A CLass I preparation drilled at least 3mm into
root dentin with walls parallel to or coincident
with the anatomic outline of the pulp space.”
95. Requirements of an ideal root-end
preparation:
1. The apical 3mm of root canal must be cleaned and
shaped.
2. Preparation parallel to the anatomic outline of the
pulp cavity.
3. Adequate retention form.
4. Removal of isthmus tissues if present.
5. Dentin walls are not weakened.
96. Traditional root-end cavity preparation:
Miniature contra angle.
small round or
inverted cone bur.
Pediatric size contra angle.
Inverted cone bur undermines root structure
due to sharp edges.
If the bur was deviated from the long axis
undermining or perforation.
Main disadvantage creation of large steotomy
for accessibility.
97.
98. Ultrasonic root-end cavity preparation:
Developed to solve the problems of bur preparation
Advantages:
1. Smaller size osteotomy and better access.
2. Less or no need for bevelling.
3. The deepest preparation possible coincedent with
pulp space anatomy.
4. More parallel walls for better retention.
5. Less debris and smear layer.
99.
100. Designs of root-end cavities:
Class I cavity (box shape): Approximately 2 to 3mm
deep and parallel with the long axis of the root,
created in the centre of the cut root surface. The
preparation is made with a small round bur and
undercut with the round or inverted cone bur
101. Slot preparation: If root location or its angle
prevent a parallel entrance, a modified
preparation (called a slot or Matzuri) is
recommended to avoid the risk of root
perforation.
102. After apicectomy a tapered fissure bur is placed
in the apical canal opening perpendicular to the
long axis of the root. A 3 to 5mm groove or slot
is prepared apically – gingivally in the facial
root surface and undercut with a round bur.
The final shape of the cavity resembles the
keyhole.
This preparation is suitable for the mandibular
incisors and molars.
103. The filling material is carried into the
cavity with a suitable
carrier, compacted
with a burnisher and
excess is removed
with a carver or
periodontal curette.
104. Requirements of an ideal retrograde filling
material:
1. Well tolerated by surrounding tissues.
2. Adhesive or cohesive to tooth structure.
3. Dimensionally stable.
4. Resistant to dissolution.
5. Promote comentogenesis.
105. 6. Bactericidal or at least bacteriostatic.
7. Non corrosive.
8. Electrochemically inactive.
9. Does not stain tooth or periradicular tissues.
10. Allow adequate working time, and then set
quickly.
11. Readily available and easy to handle.
12. Radiopaque.
107. The most popular and widely used since the last
century.
Advantages:
1. Easy to manipulate.
2. Readily available.
3. Well tolerated by surrounding tissues.
4. Radiopaque.
5. Tight apical seal initially.
Disadvantages:
1. Slow setting.
2. Dimensionally unstable.
3. Shows signs of leakage with time.
4. Stains resulting in formation of tattoo.
5. More cytotoxic than IRM, super EBA and MTA.
108. 1. Unmodified ZO-E cements are weak and have a long
setting time.
2. High water solubility.
3. Release free eugenol when comes in contact with
moisture.
Effects of free eugenol:
1. Inhibit synthesis of prostaglandin by preventing
synthesis of cyclo-oxygenase.
2. Inhibit sensory nerve activity.
3. Inhibit mitochondrial respiration.
4. Kills microorganisms.
5. Allergic.
109. 1. ZO-E reinforced by adding 20% polymethacrylate.
2. Less resorbable.
3. Milder tissue reaction than unmodified ZO-E.
4. Mild to zero inflammatory effect after 30 days.
5. Higher success rate compared to amalgam.
110. Advantages:
1. Neutral pH.
2. Low solubility.
3. Radiopaque.
4. Strongest and least soluble of all ZO-E formulations.
5. High compressive and tensile strengths.
6. Less leakage than amalgam.
7. Non resorbable.
8. Good adaptation to the walls.
111. Disadvantages:
1. Difficult to manipulate due to short setting time.
2. Sensitive to humidity before setting.
3. Tends to adhere to surfaces.
112. Composed of tri-calcium silicate, tri-calcium
aluminate, tri-calcuim oxide and silicate oxide.
Bisthmus oxide is added for radiopacity.
pH 12.5 when set.
Setting time 2 hrs 45 minutes.
High compressive strength (40MPa 70MPa
after 3 weeks).
A little weight loss after setting.
113. MTA placement technique:
1. Pack the surrounding bone with a sterile gauze.
2. Mix powder and liquid (distilled water) to a
putty consistency.
3. Carry the mix into the cavity with amalgam
carrier or messing gun.
4. Compact with micropluggers.
5. Clean the surrounding surface with a damp
gauze.
114. Advantages of MTA:
1. Least toxic of all materials.
2. Excellent biocompatibility.
3. Hydrophilic (not affected by moisture or blood).
4. Superior sealing ability.
5. Radiopaque.
Disadvantages:
1. Difficult to manipulate.
2. Longer setting time.
3. Expensive.
115. Post Surgical Care
Following surgery final inspection, cleaning
and radiographic examination.
Flap is repositioned, edges are approximated
and sutured.
116. 1. No violent activity or work for 24 hours.
2. Stop alcohol and tobacco for the next 3 days.
3. Good nutrition. A lot of liquid diet for the next few days.
4. Do not lift up the lips or cheeks.
5. A little bleeding and swelling are normal for the next few
days.
6. Application of ice bags on the face – 20 min. on and 20
min. off – for the next 6 to 8 hours.
7. Next day after surgery hot fomentations for 3 to 5 days.
8. Prescribed antibiotics and analgesics should be taken
regularly.
9. Mouth rinsing with chlorhexidine mouth wash 3
times/day for one week.
10. Removal of sutures after 5 to 7 days.
117. Definition: the surgical procedure required to
repair defects occur as a result of therapeutic
misadventures or pathologic process.
118. a) Perforation Repair:
Perforation initial attempt is internal, non-surgical
repair.
The best approach for perforation repair:
Surgical repair of perforation defect + filling of surrounding
bony defect with decalcified freeze – dried bone.
Strip perforation:
Occurs frequently in;
Thin distal aspect of mesial roots of lower molars and
mesiobuccal roots of upper molars.
Non surgical repair 1st option
Surgical repair is very difficult therefore root
amputation or hemisection.
119.
120. Cervical defects:
Caused by caries or external resorption.
1. Does not penetrate into pulp space:
Envelope flap curettage and preparation
repair with MTA, glass ionomer, amalgam etc.
Crown lengthening or vertical extrusion may be
done for crowning.
2. Penetrates into pulp space:
RCT. The canal should be packed with Ca(oH)2 for
a few days followed by obturation.
121. Mid-root perforations:
Immediately sealed via internal approach.
If surgical approach is needed as mentioned
above.
Apical perforations:
Surgical removal of the apical third with
retrofilling if needed.
122. Indications:
1. Severe bone loss around one root of a multirooted tooth.
2. Severe periodontal lesion around one root of a multirooted
tooth.
3. Vertical fracture of one root of a multirooted tooth.
4. A perforating external or internal resorption of one root.
5. The need to retain the rest of the tooth for a fixed restoration.
Contraindications:
1. The remaining roots have inadequate periodontal – osseous
support.
2. Fused roots.
3. Remaining roots can not be endo-treated.
4. Poor oral hygiene.
123. Procedure:
Rubber dam application
RCT of the roots to be retained.
Half of the canal of the root to be amputated is filled
with MTA or amalgam.
Amputation of the root and recontouring of the
crown.
Resection is done with a fissure bur or a surgical
length bur.
124. Removal of the resected root.
Resection and recontouring should be done
before flap retraction.
A full mucoperiosteal flap is reflected.
Removal of resected root after reducing its
length cervically to facilitate its removal.
Smoothening of crestal bone and suturing.
125. o The recontoured crown should resemble a
sanitary pontic.
o Crown recontouring reduces stresses of
occlusion.
o Crown recontouring provides access for
cleaning and good home care.
o Palatal root amputation is contraindicated
because it means loss of tooth retention.
126.
127.
128. Indications:
1. Difficult root amputation.
2. The same indication for root amputation.
3. Retaining half of a molar to occlude with the opposing
molar.
Contraindications:
1. Inadequate bony support for the retained half.
2. Fused roots.
3. Inability to restore the remaining half.
129.
130. 1. Rubber dam application.
2. RCT. of the retained part of the molar and permanent coronal
restoration.
3. Occlusal reduction and identification of the furcation area.
4. Initial resection begins on the buccal surface and moves in a
lingual and apical direction until the furcation area is reached
by means of a surgical length fissure bur.
5. Once resection reached the furcation area, the rubber dam is
removed and the final separation is completed.
6. A limited envelope flap is reflected.
7. The portion of the tooth to be removed is elevated and
extracted.
8. Smoothening of marginal bone and suturing of the flap.
By this technique the lower molar will be turned into a premolar.
131.
132.
133.
134. Hemisectioning of mandibular molar and
retaining both halves in place.
The two halves are then crowned turning this
molar into two premolars.
Purpose:
Opening molar furcation area in a favorable
situation for cleaning and maintenance in case of
periodontally involved furcation areas.
135.
136. Retaining a tooth in place by inserting a rigid
metal post from the access cavity through the
root canal and extending into the periapical
bone for a distance of about 1 cm to stabilize
the tooth.
This procedure may either be done non-
surgically or surgically
