Dr. Özkan ADIGÜZEL

1. Surgical Endodontics
9/15/2009 Endo 15 1

2. Modern concept of Endodontics has modified the approach to
treatment
Attempting to determine the cause of persistent periradicular
disease. Treatment is directed to eliminate the etiology.
Which is the presence offbbacteria and microbial irritants
in the root canal space.
Microorganism can be survive in the well treated root canals,
in dentinal tubules, canal irregularities, deltas and
isthmus areas. If these completely entombed periradicular
healing should be occur.
Over extended RCT is not indicated for apical surgery but it
will contributed to failure due to toxic material like
formaldehyde
Vertical root fracture
9/15/2009 Endo 15 2

3. Radiolucencey
In
Radiograph
Orthograde -Clean
Root filling -Shape
Treatment of choice -Fill
9/15/2009 Endo 15 3

4. When reading x-ray’s following should be considered
*Natural foramina over the apex
*Other pathological lesions
*maxillary sinus
Treatment of choice
Stress
Orthograde Root filling
Surgery
failure discomfort
Reroot filling
failure
9/15/2009 Endo 15 4

5. General indications for Endodontic surgery
1. Access to the root canal
2. To establish drainage
3. Need to seal the system
4. To repair any defect in the root
5. Surgical resection of multi-rooted teeth
9/15/2009 Endo 15 5

6. Surgical procedures in Endodontics
1. Incision to establish drainage
2. Periapical (Peri radicular) curettage
3. Apicectomy
4. Surgical repair of roots ( Corrective surgery )
5. Root amputation (Resection)
6. Hemi section
7. Intentional replantation
9/15/2009 Endo 15 6

7. Medical history
Well documented medical history is essential
Rheumatic fever (Not contraindicated)
Heart diseases
Diabetes
Blood dyscrasias
Steroid therapy
Impaired renal/hepatic function
CVA
9/15/2009 Endo 15 7

8. Contraindications ( Or Cautions )
Poor Psychological health / poor health
Post radiation therapy
Difficult accessibility
-Palatal roots
-Disto buccal root of upper 7 7
-Distal 7 ( External oblique ridge )
Limited mouth opening
Poor periodontal support
No cortical plate
Very short roots
Beyond capabilities and experience
Anatomical structures in jeopardy ( nerve)
9/15/2009 Endo 15 8

9. (1) Incision and Drainage
The only surgical procedure in acute inflammation
Antibiotics
Drainage through root canal
Anaesthesia
Local
Spray
Gel
Sub mucosal injection
*Incise with bard parker No 11 blade or
*Aspirate with wide bore needle ABST
Extra oral drainage could be referred to a specialized unit
9/15/2009 Endo 15 9

10. (2) Apicectomy & Retrograde apical seal
The term “Apicectomy” refers to only a stage of an operation
Objectives is to seal the canal system at the apical foramen from
the peri radicular tissue. Actually, Apicectomy by it self can’t
resolve root canal failure .It should accompanied the retro seal.
It is an adjunct for Orthograde root filling
Success rate is less than implant
a. Cannot seal all lateral canals
b. Exposed areas of root canal material is greater there for long
term success is also affected
WASHINGTON STUDY
9/15/2009 Endo 15 10

11. Indications for Apicectomy
Retreatment of a failed root filling
*Retreatment of Orthograde is also failed
- Difficulty in removing filling
- Unfilled apical delta
- Original canal cannot be negotiated
- Filling Material has been extruded-with symptoms causing
. deficient apical seal,
9/15/2009 Endo 15 11

12. Procedural difficulty
-Aberrant Anatomy
E.g.,Maxillary molars, Lower incisors, lower premolars
- Unusual root canal configuration
E.g., severe dilacerations
-extensive Secondary dentine formation
E.g.,Ageing process,Calcification
- FractureddIInstrument with symptoms
- Open apex
Vital Ca(oH)2 …………….Apexogenasis
Nonvital Ca(oH)2…………Apexification
Failure Surgery
Conventionally blocked apices
E.g., Existing post in the root canal
---Redo- it/Surgery
9/15/2009 Endo 15 12

13. Surgical repair
latrogenic E.g., Perforated Apex
Pathological---Internal Resorption
---External
Treat with Ca(OH)2 in both occasions, it fails
Surgery
Fracture apical 1/3 of root
When biopsy is required
Cost
Cracked root / tooth
persistent Cyst
Treatment alternatives ?
Diagnostic E.g., biopsy
9/15/2009 Endo 15 13

14. Surgical Technique
Analgesia
Reflection of flap
Location of apex
Curettage of area
Resection of root
Retrograde cavity Preparation
Retrograde filling
Flap replacement
Post op instruction
Suture removal
Follow up
9/15/2009 Endo 15 14

15. Analgesia
1. Anaesthesia
2. Haemostasis – Improved vision
- Less time
- Less blood loss
- Less post op discomfort
Failure to produce good anesthesia is a problem in apical surgery
A. Local
B. General
C. Sedation
9/15/2009 Endo 15 15

16. Local Anesthesia
2% Lignocaine with 1:80,000 adrenaline
1:50,000 adrenaline
[Analgesic & Haemostatic effect]
Maxilla -Superior dental nerves
Palate - Greater Palatine nerve
- Long spheno palatine nerves
Mandible -Inferior Dental Nerve
lN
- Lingual Nerve
Slow infiltration, 1-2ml per minute
9/15/2009 Endo 15 16

17. Flap Designing
Adequate exposure
*Good surgical access
*Visualization
*Lightning
Adequate Blood supply – Avoid tissue necrosis
*Broad base - Adequate blood for margins
Edges of flap should rest on the bone
Clean incisions, it Should not cross -bony eminence e.g.;canine
-neurovascular bundle, ex:
- mental
Healthy Periodontal tissue - lingual, palate
9/15/2009 Endo 15 17

18. Types of flaps
1. Semilunar flap (Partsch incision)
2. Sub marginal (Leubke-orchsenbain)
3. Full mucoperioseteal
----triangular
----rectangular
----trapezoid
----envelope (Horizontal)
9/15/2009 Endo 15 18

19. Semilunar Flap
Simple
Easy to suture
Incision is drawn a semicircle from near the apex of the adjacent
tooth in Apical alveolar mucosa towards the gingival margins
around the area operated on, finishes at the apex of the tooth on the
other side. Margin of the flap should extent up to attach gingivael.
Disadvantages;
Scarring
May lie on unsupported bone if the lesion is larger than
expected
9/15/2009 Endo 15 19

20. Full mucoperioseteal flap
Excellent view
Excellent access
No scaring
Can be extended
Maintain intact vertical blood supply
Problems
-Time consuming
-flap reflection is difficult
-meticulous suturing is necessary
-Possible loss of interdental papilla
9/15/2009 Endo 15 20

21. Reflection of flap
Vertical relieving incisions are placed firmly down the line angle
of the teeth on the either side of the operating teeth in to the
gingival Crevices taking in the gingival papilla.
Horizontal incision made along the gingival crevice
to join the vertical incision
Blade is held in near vertical position
Raised a good mucoperioseteal flap.
9/15/2009 Endo 15 21

22. Location of the apex
-easy when perforated
-use radiographs
- rose head no 1 or tapered fissure bur/ISO 18-24
- priced off the cortical plate
- just exposed the apical area
- Copious irrigation
Curettage
-soft tissues around the apex
to be curetted
-more local at this stage
-uncover the apex
9/15/2009 Endo 15 22

23. Resection of root
Minimum amount of apex is shaved at 300- 450 to provide access to
. the canal ?
Root beveled
Retrograde cavity preparation
-use small ½ or ¼ rose head round bur, ISO 008
- create a simple surface cavity
9/15/2009 Endo 15 23

24. Corrosion
Retrograde root filling
Long term success
-apical area is cleaned with saline. Apical inflammation
-packed the cavity with wet gauze. Mercury ?
-dry with cotton wool.
-Zinc free Amalgam is packed to the cavity.
Hill amalgam carrier.
KG retrograde carrier.
Materials
super EBA Composite resin
IRM Diaket
Glass Ionomer cement MTA
9/15/2009 Endo 15 24

25. 9/15/2009 Endo 15 25

26. Replacement of flap
-4/0 black silk
-vertical mattress
-Suture removalliin 5 days
Post operative period
Pain……………………………Analgesics
Antibiotics
Swelling……………………….ice bags, externally
Discomfort ……………………warm salt water mouth baths
chlorhexidine
Oozing ………………………..24h normal
Activities ………………………Avoid Alchohol / smoking
9/15/2009 Endo 15 26

27. X-rays
Think twice before undertaking
difficult surgical procedure.
Consider carefully risk and benefits of
the surgical procedure.
If you do not have personal skills
always refer to someone with required
skills
Success 25%-90%
9/15/2009 Endo 15 27

28. Tooth which is able to be removed one piece
atruamatically
Curve root teeth not indicated
Perio endo lesions
Root fracture can be cement using dentine
bonding
9/15/2009 Endo 15 28