The document provides a comprehensive overview of surgical endodontics, detailing its history, definitions, indications, contraindications, and classifications of procedures. It specifically addresses surgical interventions required when traditional endodontic treatments fail, emphasizing techniques like root-end resections and periradicular surgeries. Additionally, it discusses principles for flap design and management, along with various suturing techniques to optimize healing after surgery.

1. Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2.  Introduction
 Definition
 History
 Indication
 Contraindication
 Classification of Endo. surgeries
1.Trephination
2.Periradicular curretage
3. Periradicular surgery
(i) Root end resection (Apicectomy)
(ii) Root end preparation & filling
Conclusion

3. Introduction
Surgical intervention is required where endodontic
treatment has failed and tooth is to be retained rather than
extracted.
The percentage of success of endodontic treatment
has been consistently high but failures may arise due to
infection, poor access cavity preparation, inadequate
instrumentation, obturation, missed canals and coronal
leakage.
So if this happens, Surgical endodontics is
needed to save the tooth.

4. Definition-
Surgical endodontics is defined as,” Removal of tissues
other than the contents of root canal to retain a tooth with
pulpal or periapical involvement”

5. History
Surgical endodontics is not a recent innovation.
Trephination and incision and drainage are being done
since ancient times.
In 11th century, first case of endodontic surgery was
performed by Abulcasis.
Root end resection (Apicectomy ) was first
documented in 1871 and apicectomy with retrograde
cavity preparation and filling with amalgum was
documented in 1890.

6. Root amputation was first introduced by Black and
Inlitch in 1886 , then was dealt by Younger (1894)
and Guerini (1909)
In 1930, indications for endodontic surgery were
proposed.
In 1940, Triangular flap was first described by
Fischer.
Neumann and Eikan descibed Trapezoidal flap in
1940.
Semilunar incision was first described by Partsch
hence it is also known as Partsch incision.

7. INDICATIONS
1. Need for surgical drainage
2. Failed endodontic treatment
1. Irretrievable root canal filling material
2. Irretrievable intraradicular post
3. Calcification of the pulp space
4. Procedural errors
1. Instrument fragmentation
2. Non-negotiable ledging
3. Root perforation

8. 5. Symptomatic overfilling.
6. Anatomic variations.
A. Root dilaceration.
B. Apical root fenestration.
7. Biopsy.
8. Corrective surgery.
1. Root resorptive defects
2. Root caries
3. Root resection
4. Hemi-section
5. Bi-cuspidization

9. CONTRAINDICATIONS
 Poor systemic health.
 Local anatomical considerations
 Poor periodontal status.
 Short root length.
 Acute infection.
 Non restorable teeth

10.  Success of surgical treatment over non-surgical
treatment.
 Medical history
 Periodontal evaluation
 Patient’s motivation
 Informed consent

12. CLASSIFICATION OF ENDODONTIC SURGICAL
PROCEDURES
I. Surgical drainage
1. Incision and drainage
2. Cortical trephination (fistulative surgery)
II. Periradicular surgery
1. Curettage
2. Biopsy
3. Root-end resection
4. Root-end preparation and filling

13. 5. Corrective surgery
i. Perforation repair
a. Mechanical (iatrogenic)
b. Resorptive (internal and external)
ii. Root resection
iii. Hemisection & Bi-cuspidization
III. Replacement surgery
i. Replantation
IV. Implant surgery
1. Endodontic implants
2. Root-form osseointegrated
implants

14.  In most cases drainage through the canal is all
that is needed to treat the periradicular abcess
of pulpal origin but there are times, when
invasion of anatomic spaces has extended to a
point that does not allow drainage through the
tooth, and effectively remove the pus then It
becomes mandatory to incise and drain the
abcess.

15. Incisions and flaps
PRINCIPLES OF DESIGN-Principles
and guidelines are applied to the location and
extent of incision.
Why should one follow the principles ???
“The adherence to these principles will ensure that the
flapped soft tissues will fit snugly in their original
position and will properly cover the osseous wound site
and provide an adequate vascular bed for healing”

16. PRINCIPLES:
 1. Avoid severing vessels and nerves
 2. Make incisions far away from the surgical
area to ensure that the wound margins are
over sound bone and there is room for
adjustments when unexpected extensions
are necessary.
3. Design the flap so that there is adequate
visibility without overexposure of bone.

17. 4. The base of the flap should be the widest
portion to maintain proper circulation.
5. There should be no sharp angles on the flap
6. Vertical or oblique incision should not be
over root eminence. It is best to incise in the
trough.

18. 7. Maintain the integrity of the interdental
papillae.
8. Use sharp instruments to avoid tearing the
mucoperiosteum.
9. Be gentle with the flap.
10. Do not incise close to the gingival sulcus
while using a horizontal or semilunar
incison

19. 11. Incise in the attached gingiva for
semilunar flaps.

20. NOTE:
“More trauma results from short incision rather
than long incision”.

21.  Vertical incision
 Sulcular incision
 Semilunar incision
 Modified semilunar incision
 Ochsenbein-Leubke incision

22. Classification of Flaps:
1. Full mucoperiosteal flaps:
(a) Triangular (one vertical releasing incision)
(b) Rectangular (two vertical releasing incisions)
(c) Trapezoidal (broad-based rectangular)
2. Limited mucoperiosteal flaps
(a) Submarginal curved (semilunar)
(b) Submarginal scalloped rectangular (Ochsenbein-
Luebke)

24. Full Mucoperiosteal Flaps.
TRIANGULAR FLAP.
 The triangular flap is formed by a intrasulcular
incision and one vertical releasing incision.

25.  ADVANTAGES:
 Good wound healing as there is minimal disruption
of the vascular supply to the flapped tissue,

 Ease of flap reapproximation, with a minimal number
of sutures required.
 DISADVANTAGE:
 It provides Limited surgical access because of the
single vertical releasing incision.
 Difficult to expose the root apices of long teeth (eg,
maxillary cuspids and mandibular incisors.)

26.  Additional access can be easily obtained by placement
of a distal releasing incision.
 It is recommended for maxillary incisors and
posterior teeth.
 “It is the only recommended flap design for
mandibular posterior teeth”.

27. RECTANGULAR FLAP:
 The rectangular flap is formed by an intrasulcular and
two vertical releasing incisions.

28.  ADVANTAGES:
 Increased surgical access to the root apex.
 This flap design is especially useful for mandibular
anterior teeth, multiple teeth, and teeth with long
roots, such as maxillary canines.
 DISADVANTAGES:
 Difficulty in reapproximation of the flap margins and
wound closure.
 Postsurgical stabilization is also more difficult as the
flapped tissues are held in position solely by the
sutures. This results in a greater potential for
postsurgical flap dislodgment.
 This flap design is not recommended for posterior
teeth.

29.  TRAPEZOIDAL FLAP:
 Similar to the rectangular flap with the exception that
the two vertical releasing incisions meet intrasulcular
incision at an obtuse angle.

30.  Trapezoidal Flap ctnd…..
 The angled vertical releasing incisions are designed
to create a broad-based flap with the vestibular
portion being wider than the sulcular portion.
 Flap design is made on the assumption that it will
provide a better blood supply to the flapped
tissues.

31.  Trapezoidal Flap ctnd…..
 Since the blood vessels and collagen fibers in the
mucoperiosteal tissues are oriented in a vertical
direction, the angled vertical releasing incisions will
severe more of these structures.

32.  Trapezoidal Flap ctnd…..
 This will result in more bleeding, a disruption of
the vascular supply to the unflapped tissues, and
shrinkage of the flapped tissues.

33. Limited Mucoperiosteal Flaps:
 Submarginal Curved (Semilunar) Flap:
 The submarginal or semilunar flap is formed by a
curved incision in the alveolar mucosa and the
attached gingiva.

34.  The incision begins in the alveolar mucosa extending
into the attached gingiva and then curves back into
the alveolar mucosa.
 Advantages – No advantages
 Disadvantages-
1. Poor surgical access
2. Poor wound healing
 “This flap design is not recommended for periradicular
surgery”.

35. Submarginal scalloped rectangular (Luebke-ochsenbein)
flap:
 The submarginal scalloped rectangular flap is a
modification of the rectangular flap in which the
horizontal incision is not placed in the gingival sulcus
but in the buccal or labial attached gingiva.

36.  ADVANTAGES:
 It does not involve the marginal or interdental gingiva
and the crestal bone is not exposed.
 DISADVANTAGES:
 Vertically oriented blood vessels and collagen fibers
are severed, resulting in more bleeding and a greater
potential for flap shrinkage, delayed healing, and scar
formation.

37.  FLAP REFLECTION:
 Flap reflection is the process of separating the soft
tissues (mucosa and periosteum) from the surface of
the bone.
 The periosteal elevator is used gently to elevate the
periosteum and its superficial tissues from the cortical
plate.

38.  After reflection of the attached gingival tissues,
elevation is continued more apically lifting the
alveolar mucosa along with periosteum until
adequate surgical access is obtained.
 A thin gauze may be used for reflection to prevent
tearing of the flap.

39.  Hard tissue management in endodontic surgery
involves 3 stages:
1.Trephination
2.Periradicular curretage
3. Periradicular surgery
(i) Root end resection (Apicectomy)
(ii) Root end preparation & filling

40.  OSTEOTOMY:
 Osteotomy is the removal of some portion of the
cortical plate to expose the root end.
 Clinician should precisely locate the root end.
 A number of factors should be considered to
determine the location of the bony window.
 The angle of the crown to the root should be
assessed.

41.  When a root prominence or eminence in the
cortical plate is present, the root angulation and
position are more easily determined.
 Measurement of the entire tooth length on well-angled
radiograph and transferred to the
surgical site by the use of a sterile millimeter
ruler.

42.  When the cortical plate is intact, locate the body of
the root coronal to the apex where the bone covering
the root is thinner.
 Once the root has been located and identified, the
bone covering the root is slowly and carefully
removed with light brush strokes, working in an
apical direction until the root apex is identified.

43.  Barnes identified four ways by which the root
surface can be distinguished from the
surrounding osseous tissue:

 (1) Root structure generally has a yellowish color,
 (2) Roots do not bleed when probed,
 (3) Root texture is smooth and hard as
 compared to the granular and porous
 nature of bone, and
 (4) The root is surrounded by the periodontal
 ligament.

44.  Definition- It is the perforation made through the
cortical plate or apical foramen to accomplish the
release of pressure in the periapical area from
the accumulation of exudate within the alveolar
bone.
 Indications-
 This technique is employed in cases of periapical
abcess in which there is no swelling or drainage
but much pain.

45.  Small incision is made over the periapical
region .flap is reflected and bone is
examined.
 Radiograph is taken with radiopaque marker
for confirmation. So that there is no chance of
penetration in the wrong area.

46.  CORTICAL TREPHENATION:
 Perforation of the cortical plate to accomplish the
release of pressure from the accumulation of exudate
within the alveolar bone.

47.  The treatment of choice for these patients is
drainage through the root canal system (apical
trephination) whenever possible.
 Apical trephination involves penetration of the
apical foramen with a small endodontic file and
enlarging the apical opening to a size No. 20 or
No. 25 file to allow drainage from the
periradicular lesion into the canal space.
 The decision about whether to perform apical or
cortical trephination is based primarily on clinical
judgment regarding the urgency of obtaining
drainage.

48.  PERIRADICULAR CURETTAGE:
 Involves removal of the periradicular inflammatory
tissue and is best accomplished by using various sizes
and shapes of sharp surgical bone curettes and angled
periodontal curettes.

49.  Entire tissue mass is removed by inserting the
bone curette, between the soft tissue mass
and the lateral wall of the bony crypt with the
concave surface of the curette facing the
bone.

50. Once the soft tissue lesion has been freed
along with the periphery, the bone curette
should be turned with the concave portion
toward the soft tissue and used in a scraping
manner to free the tissue from the deep walls
of the bony crypt.

51.  Periradicular Surgery
 ROOT-END RESECTION (APICOECTOMY)
 Historically, many authors have advocated
periradicular curettage as the definitive
treatment in endodontic surgery without
root-end resection.
 Their rationale was to maintain a cemental
covering on the root surface and to maintain as
much root length as possible for tooth stability.

52.  INDICATIONS:
 These indications may be classified as,
1) Biological
2) Technical.
Biologic factors:
 Persistent symptoms,
 Persistent periradicular lesion.

53. Technical factors:
Periapical infection in teeth with…
 Radicular posts,
 Crowned teeth without posts,
 Irretrievable root canal filling materials,
 Procedural accidents.

54.  There are three important factors for the
surgeon to consider before performing a
root-end resection:
(1) Instrumentation,
(2) Extent of the root end resection,
(3) Angle of the resection.

55.  1.Instrumentation:
 Ingle et al. recommended that root-end resection
is best accomplished by the use of tapered
fissure bur or round bur in a low-speed straight
handpiece.
 Gutmann and Harrison, have suggested the use
of a high-speed handpiece and a surgical length
plain fissure bur.

56.  NOTE:
 “Plain fissure burs, at high and low speed,
produce the smoothest resected root
surface”.

57.  2.Extent of the Root-End Resection:
 Earlier, it was believed that it is necessary to
resect the root at the level of healthy bone.

58. Average length of root resection is 3mm which
is considered enough to eliminate the source
of infection.
 however surgeon must evaluate the patient on
an individual basis.
1. Visual and operative access to the surgical site
2. Anatomy of the root (shape, length,
curvature).
3. Number of canals and their position in the
root

59. 4. Need to place a root-end filling surrounded
by solid dentin.
5. Presence and location of procedural error
6. Presence and extent of periodontal defects.

60.  NOTE:
“Conservation of tooth structure during
root-end resection is desirable; however,
conservation should not compromise the
goals of the surgical procedure”.

61.  3.Angle of Root-End Resection.
 It should be 30 ° -45 ° from the line
perpendicular to the long axis of
the tooth facing toward the buccal
or facial aspect of the root.
 The purpose is to provide enhanced
visibility to the root end and
operative access to accomplish a
root end preparation.

62.  NOTE:
 Recent literature states that beveling of root end
results in opening of dentinal tubules on the
resected root surface that may communicate with
the root canal space and result in apical leakage,
even when a root end filling has been placed.

63. Root-End Preparation:
The purpose of a root-end preparation
in periradicular surgery is to create a
cavity to receive a root-end filling.
It is performed by the use of small round or
inverted cone burs and straight low-speed
handpiece.
It should be done parallel to the long axis of
the root.

65. Root-End Filling:
 The purpose of a root-end filling is to establish a
seal between the root canal space and the periapical
tissues.
 Suitable root-end filling material should be,
(1) Able to prevent leakage of bacteria and their
biproducts into the periradicular tissues,
(2) Nontoxic & Noncarcinogenic,
(3) Biocompatible with the host tissues,
(4) Insoluble in tissue fluids,
(5) Dimensionally stable,
(6) Unaffected by moisture during setting,
(7) Easy to use

66.  Root-End Filling Materials:
Numerous materials have been suggested
for use as root-end fillings, including:
Amalgam,
 Gutta-percha,
 Glass ionomers,
 Composite resins,
 Carboxylate cements,
 Zinc phosphate cements,
 Zinc oxide–eugenol cements,
 Mineral tri-oxide aggregate (MTA).

67.  REPOSITIONING AND SUTURING:
 Several authors have compared the effects of
continuous and interrupted suture techniques.
 Their findings indicate that the interrupted suturing
technique provides better flap adaptation than does
the continuous technique and, therefore, is the
recommended technique, and the most commonly
used, for endodontic surgery.

69. 1. Ask not to drink alcohol or use any form of tobacco.
2.. Ask not to lift up the lip or pull back the cheek to
look at where surgery was done. This may pull the
sutures and cause bleeding.
3. A little bleeding from the surgical site is normal.
This should only last for a few hours. There may be
little swelling of the face. This should only last for a
few days.

70. 4. Place an ice bag (cold) on face where surgery was
done. Leave it on for 20 minutes and take it off for
20 minutes. Do this for 6 to 8 hours.
5. After 8 hours, the ice bag should not be used. The
day after surgery, warm saline gargle. Do this as
often as possible for the next 2 to 3 days. Advice for
warm saline gargle.
7. Rinse the mouth with 1 tablespoon of chlorhexidine
mouthwash two times a day, once in the morning and
once at night for 5 days.
8. Recall for removal of sutures after 7 days,

71.  CONCLUSION :
 During the last 20 years, endodontics has
encountered dramatic shift in the use of
periradicular surgery.
 Previously, periradicular surgery was commonly
considered as the treatment of choice when
nonsurgical treatment had failed but nowadays
periradicular surgery has become very selective
in contemporary dental practice.

72.  Text book of endodontics, Ingle 5th edition.
 Textbook of oral & maxillofacial surgery By
Daniel M. Laskin. Vol.2
 Text book of endodontics, Nisha Garg.
 Text book of endodontics By Grossman.
 Text book of Surgical endodontics, Guttman

73. Thank you