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Introduction

The scope of endodontic surgery has expanded beyond apicocectomy to


include periapical curettage, redisectomy, replantation transplantation,
implantation, trephination, incision for drainage and root submergence.
The term apicoectomy meant the resection of the root apex, surgical
procedures performed around the root is termed as periradicular surgery.
Failure may occur in small percentage of cases with non-surgical
endodontics therapy that eliminates periapical inflammation or infection and
allows teeth to be retained in a free healthy state, when confronted with such
cases the clinician should be prepared to initiate alternative procedure including
surgery to enhance the rate of success.
History according to Ingle
Endodontic surgery has first recorded 15 years ago when !eticus, a
"ree# physician dentist excised an acute apical abscess with a small
scalpel.
$ater the procedure was refined and populari%ed by &ullihen in 1'().
Fawas *1''+,, -hein *1')+, and "... /lac# *1''0, described root
amputation techni1ues and in 1)1) "arvin demonstrated retrofillings
radiographically.
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Classification
Endodontic surgery encompasses surgical procedures performed to
remove the causative agents to radicular and periradicular disease and to
restore these tissue to functional health. 2t can be classified as follows3
1. Surgical drainage
a. 2ncision.
b. Trephination
2. Radicular surgery
a. !pical surgery
i. 4urrettage and biopsy.
ii. !picoectomy.
iii. -etrofilling.
b. 4orrective surgery
i. 5erforative repair 6echanical
-esorptive
ii. 5eriodontal repair "T-
-esection
3. Replacement surgery
a. -eplant surgery 2ntentional
5ost traumatic
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b. Endosteal implant surgery Endodontic
8sseointegrated
(
According to Grossman periapical surgery can be classified as:
1. -oot resection or apical curettage following an orthograde filling.
Either in one stage that is, immediate root resection, or in tow stages,
in which multiple appointments separate non surgical and surgical
procedures.
7. 8rthograde filling during root resection or periapical curettage.
(. -oot resection and retrograde filling.
+. -oot resection and retrograde filling following an orthograde filling
*in one stage or two procedures,.
Indications and Contra Indications
4lean well obturated canals are the biological basis of endodontic
success mar#ed improvements in the non surgical techni1ues have improved
the success rate, however if cleaning of the canal terminus root canal access is
impossible, *a surgical approach should be considered, whenever a root canal
cant be filled properly with an orthograde filling endodontic surgery should be
considered.
! classical characteri%ation of specific indication and contraindication
has developed by $eub#e, "lic#, and 2ngle. /ased on the classifications.
Indications of endodontic surgery (Grossman)
1. !ny condition or obstruction that prevents direct access to the apical
third of the canal such as3
+
a. !natomic 9 calcifications, curvatures, bifurcations dens in dente
and pulpstones.
b. 2atrogenic 9 ledging bloc#age from debris, bro#en instruments
old root canal fillings and cemented posts.
7. 5eriradicular disease associated with a foreign body, overfilled canals,
bro#en instruments protruding into apical tissue and loose retrograde
fillings.
(. !pical perforations3 any perforation that can:t be sealed properly by a
filling within the canal.
+. 2ncomplete apexogenesis with blunderbus or other apices that do not
respond to apical closure procedure.
5. &ori%ontally fractured root tip with periradicular disease.
0. Failure to heal following non surgical endodontic treatment.
;. 5ersistant and recurring exaggeration during non-surgical treatment or
persistant, unexplainable pain after completion of non surgical
treatment.
'. Treatment of any tooth with a suspicious lesion that re1uires a
diagnostic biopsy.
). Excessively large and intruding periapical lesion.
1. <estruction of apical constricture of root canal due to uncontrolled
instrumentation.
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Contra Indications for endodontic surgery
1. 2ndiscriminate surgery.
7. 5oor systemic health.
(. 5sychological impact.
+. $ocal anatomical considerations.
Indiscriminate surgery : Endodontic surgeries should not be a cover up for
every endodontic case or a cover up for the s#ill in non surgical endo
techni1ue.
=urgeries are not simply indicated because a periadicular lesion is
present at the time of treatment, is because a large lesion is present or because
the clinician believes a lesion may become cystic.
Poor systemic health : ! complete medical history is mandatory. 2f a 1uestion
exists about the patients health, medical consultation must be sought with the
patients physician. 4ontraindications include blood dyscrasias is neurological
problems, terminal illeness, diabetes, heart diseases, pregnancy in first and
third trimestor.
5sychological emotionally distressed patient, a patient unable
psychologically to withstand or cope with any surgical procedure.
Limitations in the surgical skill and experience of the operators
Local Considerations
1. $ocali%ed acute inflammation, whereas emergency procedure such as
incision and drainage or trephination may be indicated, elective
periapical surgery should be avoided.
0
7. !natomical considerations, procedures that penetrate the mandibular
canal, maxillary sinus, mental foramen, floor of the noses or that sever
the greater palatine blood vessels should be avoided whenever possible.
(. 2naccessible surgical sites, inaccessible position and location of root
apices especially in posterior teeth and the need to gain access to the
surgical sites third dense layers of bone, such as the lingual surface of
molars or the external obli1ue ridge of the mandible may preclude a
successful result.
+. Teeth with a poor prognosis short rooted teeth, with a advanced
periodontal disease, vertically fractured teeth, non strategic and
understorable teeth should not be considered for periapical surgery.
5. Finally, peripical surgery should not be considered as a cureall to
compensate for inade1uate techni1ue that resulted in failure to heal,
surgical treatment of teeth should not be done for experience alone.
Anatomical considerations
Maxilla
- The maxillary incisors and the alveolar process are
closely related to the floor of the nose.
- ! combination of short alveolar process and long roots
allows the incisor apices to contact either bony plane of the nasal
floor.
- The lateral incisors however are seldom or close to the
nasal floor as are the central incisors.
;
- The canine occupies a >neutral position? between the
maxillary sinus and the nasal cavity and has no intimate relationship
to either cavity.
- The maxillary incisors and canines are often covered
with little or no labial cortical plate.
- =econd premolar are closer to the maxillary sinus wall
wherever molars sometimes reach the floor and at times protrude
into the sinus.
- !lthough the maxillary sinus membrane perforation
usually doesn:t cause postoperative problems, care must be ta#en to
prevent root tips, bone or other foreign bodies being inadvertently
pushed into the sinus.
- ! prominent %ygomatic process may impede surgical
access to the root of a maxillary molar tooth.
- ! palatal root of the first or second molar that is closely
aligned with the greater palatine foramen. The position and course of
the palatine bundle must be carefully determined when placing a
palatal approach to the palatal root. To avoid vessels, palatal access
is gained by reflecting a flap created by ma#ing a vertical incision
between the premolars and a short distal releasing incision of the
tuberosity.
Mandile
- 2n gaining surgical access and isolating the apex of the
lower incisors, one must ta#e care that the lingual alveolar plate is
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not also perforated anterior alveolar process is 1uite narrow in
labiolingual dimension.
- 5roximity of the mental foramen to the apices of
mandibular premolars and on occasion to the first molar.
- Thic# external obli1ue ridge in the second and third
mandibular molar region.
- The mandibular canal doesn:t interface with surgical
access except when a shallow mandibular process is associated with
long roots.
@nowledge of the most common location of a maAor nerve, such as the
inferior alveolar nerve in the mandibular canal, is of critical importance it
allows better control of the surgery and less li#elihood of postoperative
parasthesia.
- $itter and associates found the average vertical distance
from the upper border of the mandibular canal of the apices of the
second molar and the first molar to be (.5 and 5.+ mm respectively.
- !ccess for mandibular endodontic surgery from the
lingual aspect is extremely clumsy and unnecessary. <amage to the
lingual nerve or artery may occur, as well as the possibility of
confronting a wide mylohyoid ridge.
The buccolingual position of the canal can be determined by comparing
a 285! exposed at right exposed at right angle to the long axis of the tooth
with a second radiograph exposed at a vertical angulation of 75B and the central
beam directed superiorly, if in the second film the mandibular canal waves
)
inferiorly in relation to the roots apices, the canal is lingual in the apices, if it
moves upwards on the roots it is buccal, is the apices minimal movement of
canal indicates that it is in close proximity to the apices.
re!operati"e consultation #ith the patient
! proper preoperative consultation is an essential part of the total
surgical experience for both the patient and the clinician. The procedure should
be described in detail as should are potential postoperative problems such as
discomfort, swelling, bleeding, brushing, maxillary anterior penetration and
rare possibility of parasthesia.
5atient should be as#ed to sign that attest to them understanding and
treatment procedure, ris# and fees.
re!operati"e preparation and medication
5remedication becomes necessary when a patient remains overly
anxious and unaffected by the pre-operative consultation. The premedication
drugs selected should reduce anxiety, enhance the anesthetic to be
administered, and favourably reduce salivation *antisialagues,, bleeding
*epinephrine, or secondary infection *antibiotics,.
Antiseptic mouth#ash
4hlorhexidine gluconate reduces the levels of fracture in the oral cavity
and plays a important role in healing following endodontic surgery, for this
patient is instructed to rinse with the solution for 1 min twice daily for 5 days.
This regimen should begin the day before surgery.
$on steroidal anti!inflammatory drugs
1
!dministration of non-steroidal anti-inflammatory drugs before the
surgical procedure helps to reduce postoperative pain and swelling.
2buprofen enacts its effects by inhibiting the en%yme cycle-oxygenase
and preventing the formation of inflammatory mediators. 2ts analgesic and anti-
inflammatory properties result from inhibition of peripheral prostaglandin
synthesis. ! loading dose of 0mg 7 hours before surgery, and +mg every +
hours postoperatively is advised short acting barbiturates, such as pentobarbital
and secobarbital are fre1uently used for sedation. 4ommonly administered
orally, 5, 15mg C ( min prior to the surgical treatment.
Tran1uili%ers are effective drugs for surgical premedication because
they reduce apherhension, are sedatives and act as miracle relaxants. Either
meprobamite, +mg 9 + times daily for several days prior to treatment or
dia%epam *valium, 5mg ta#en orally (0 min prior to treatment is an effective
tran1uili%er and relaxant.
Impro"ing "isibility
Endodontic surgical procedures are delicate and precise. The 1uality of
endodontic surgery improves dramatically when the surgical fields in well
illuminated, magnified and bleeding is controlled.
Illumination
Dsing specially designed clips fibre-optic cable can attached directly to
surgical retraction and aspiration, head lamps are also available with 1uart%
bulbs clipped to surgical telescopes and operating from either direct current or
battery pac#.
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=urgical microscopes with a light source aimed directly at the site
provide by far the best method of illumination.
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%agnification
6agnification of the operative site ma#es it easier to differentiate root
from bone to locate the entire root surface during root end resection to locate
unfilled root canal systems and to better visuali%e root and preparations and
fillings.
&isors and loupes
6any inexpensive visors and loupes are available and provide
magnification from 1.; upto 1+.
!elescopes : are available with magnification capabilities between f7 and f',
some models are attached to a headband, but in the most popular models the
optics are affixed to specially designed spectacles.
Telescopes can be obtained with varied fields of vision *standard,
widefield, expanded field and extended range,. Eide field magnification is
becoming the most popular choice among endodontic surgeons.
%icroscopes
=urgical microscopes provide magnification levels of between f+ and
f+ after features such as through the lens fibre-optic illumination, (m
magnification foot pedal focusing and accessory optics for dental assistants.
!lthough these scopes provide crisp undistorted images proficiency in their use
demands time and patience.
'urgical instruments and materials
! surgical setup should consists of all sterile instruments and materials
needed to complete the contemplated procedure, too few instruments cause
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consternation for the surgeon who cannot efficiently and effectively complete
the tas#. Too many instruments lead to confusion and hesitation, the operator
can supplement or replace any instrument listed to accommodate personal
preference.
'urgical setup for periapical procedures
1. !naesthesia, aspirating syinge, disposable needle and several capsules
of desired local anaesthesia such as lidocaine hydrochloride, 7F
epinephrine 135,.
7. 2solation of the operative site. =terile 1x7 cotton gauge s1uares, and
cotton pellets *alcohol sponges or topical antiseptic solution should be
available to swap the operative site,.
(. 2ncision 3 /and par#er handle, Go. 15 blade and periodontal probe *to
help determine flap design,.
+. Flap Elevation and retraction, periosteal elevator.
5. 5enetration and removal of cortical bone plate, root resection and
preparation for retrograde filling is the root apex. !ssorbed straight hand
piece burs had chisel, sterile saline or anaesthetic solutions for use as a
coolant and for debridement.
0. 4urettage "oldman for H( curett, surgical excavator &u-Fiendly Go.-)
or Go.-11.
;. -etrograde filling apical amalgam carrier, plastic instrument, apical
amalgam plugger.
1+
'. =uturing, needle holder or hemostat, (- or +- sil# suture on an a
traumatic needle and scissors.
). =urgical tray, cotton pliers, explorer, mirror and cotton or racellets.
&aemostasis can be achieved by use of alugauage, gel form, bone wax
or other physical barriers, cotton, cotton roll or gauge saturated with adrenaline
are least desirable materials as the residual cotton fibres left in the crypt
provo#e a latent foreign body resection.
!stringents such as 15.5F ferric sulphate burnished into a area of
fleeding promotes haemostasis rapidly.
Anesthesia
! solution of lignocaine containing adrenaline 131, is used for a
bloc#, and lignocaine containing adrenaline 135, is used for infiltration.
2nfiltration anesthesia, using a aspirating syringe is ade1uate for most
maxillary periapical surgery.
The anesthetic is inAected subperiosteally over the operative site, attempt
to inAect deeper tissue may prove counter productive because of li#elihood of
inAecting into s#eletal muscle for additional anesthesia during the surgical
procedure, the anesthetic can be inAected directly into the bony madullary
spaces inside the open wound.
4onduction anesthesia, in which the anesthetic solution is deposited near
the mandibular foramen is used for mandibular periapical surgery.
The infraorbital inAection, posterior superior alveolar bloc# is rarely
needed for elective periapical surgery used only in emergency situations to
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avoid inspiriting needles and depositing anesthetic solution into acutely
inflamed and swollen tissue.
(lap design
4ertain cardinal principles that apply to all flap design are3
1. The base of the flap should wider than the free end, to ensure ade1uate
circulation into the flap.
7. The sutured flap margins should rests on solid cortical bone plate.
(. 2ncisions should be made with a finer, continuous stro#e, perpendicular
to the cortical bone plate the periosteum retracted with the flap, that is a
full thic#ness flap of mucoperiosteum.
+. The flap should be designed with continuous curvatures between the
hori%ontal and vertical incisions to avoid sharp angles that tear.
5. ! sinus tract when present should be included in the flap.
0. -eleasing incisions should be made between the bony eminences
because tissue even such structures is thin and stretches and tears when
sutured.
;. 5roperly designed, a retracted flap can be held in position with passive
pressure by means of a periosteal elevator pressed against underlying
solid bone.
'. Flap should generally extend one or two teeth laterally to allow for
relaxed retraction and prevent stretching and tearing.
). !void incision over a bony defect.
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)he basic flap designs used in endodontic surgery
1. Gingi"al flap : indicated in cervical area perforations, advantage is no
vertical incision, ease of repositioning disadvantage of limited access
and visibility difficult to reflect.
7. 'emilunar flap : when no underlying periodontal problems are present
esthetic crowns present, trephination. The hori%ontal component of this
flap rests on alveolar bone structure at least (mm apical to the gingival
crest and ends in the attached gingiva. -educes incision and reflection
time, maintains integrity of gingival attachment, eliminates potential
crestal bone loss disadvantage of limited access and visibility crosses
root eminences may not include active lesion healing is associated with
scarring.
(. )riangular flap : 2ndicated in midroot perforation repair, periapical
surgery involving posterior areas and short roots has advantage of easily
modifying with small retracting incisions, additional vertical incision
and extension of hori%ontal component.
<isadvantages of limited access and visibility to longer roots, tension is
created on retraction, gingival attachment severed.
+. *ectangular flap : Dseful in periapical surgery involving multiple
teeth, large lesion, longer roots. 4an get maximum access and visibility,
reduces retraction tension, facilities repositioning. <isadvantage reduces
blood supply to the flap increased incision and reflection time, interface
with gingival attachment causing gingival recession, crestal bone loss
may uncover dehiscene and suturing is more difficult.
1;
5. alatal flaps : the rich vascular supply of the palatal area provides for
excellent healing in most instances, palatal flap is prepared with a
scalloped incision around the gingival margins. -elaxing incisions are
generally placed between the cuspid and bicuspid to prevent severing of
the anastomosis of incisive and palatine vessels.
<istal 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 to the teeth on the opposite side of
the arch with a suture material.
0. +chesenbein!luke flap : 2ndicated in periapical surgery involving the
anterior regimen, longer roots, prosthetic crown present with wide band
of attached gingiva advantage is in placing incision and reflection with
enhanced visibility and access case of prepositioning, maintains
intergrity of gingival attachment. 5revents gingival recession, avoid
dehiscence prevents crestal bone loss.
<ifficult to alter if si%e of the lesion misAudged, hori%ontal component
disrupts blood supply, vertical component crosses microgingival Aunction and
enter muscle tissues.
;. *ectangular, )rape-oidal flap : 2ndicated where maximum access and
visibility is re1uired li#e in case of multiple teeth, large tension etc.
'urgical )echni.ues
.ertical incision may be relieving or relaxing incision, should be
continuous, linear and well defined. !void repeated incisions, do not ma#e an
1'
incision on bony prominence. 2ntrasulcular invasion follows the contour of the
labial surface of the teeth.
*eflection
2s initiated with a sharp curves end of a Go. + molt curette or the &u
friedly curette. The elevators are used to reflect both the mucous and
periosteum. The elevator always on the bone and never on the flap.
Hard tissue management
The average thic#ness of the bone overlying the mesial root of the
mandibular first molar is +.7mm.
To penetrate the thic# cortical bone a rotating Go. 0 extra length surgical
bur mounted in a high speed impact hand piece should be introduced slowly.
This hand piece has an angled head that facilities easy entry and visibility and
doesn:t blow air or oil into the surgical site. 4opious irrigation with a sterile
saline accompany all attempts to remove bone, Iaccording to Fisher and "ross,
4uelle and EedgehoodJ, irreversible bone necrosis is reali%ed when
temperature exceeds 50B4.
! window is cut which is created by preparing an openings in the bone
with a long, round bur, =.&. Go. + or 0. Two of the opening penetrate the
cortical plate adAacent to the mesial and distal sides of the root near its apical
third. The (
rd
openings are connected with a superficial cut by means and tissue
burs, that is =.&. Go. ;1 or ;7. ! hand chisel &u-Fried% Go. 1 is used to
elevate and to remove the cut bone of preparation of >the window? and
exposure of the periapical tissue.
1)
Fre1uently, especially in the maxillary anterior region, the cortical bone
can be penetrated with hand chisels or hand trephines alone. 5enetrating the
periapical tissue with hand instruments is more efficient than with burs, is less
li#ely to gauge the root and is less frightening for the patient. The window can
be extended by hand chisels.
To determine the locale of the window use the radiograph as a >road
mp?. The radiographic tooth length and root anatomy can be measured and
transferred to the mouth for orientation. The osseous topographic features
overlying the root, that is through in the mesial and distal aspects of the root
itself, are useful.
! radiographic mar#er, such as a small piece of gutta-percha, can be
placed on the cortical bone over the proAected site of the root apex, and a
radiograph can be exposed in the usual mar#er. This method is accurate for
determining which str is immediately beneath the mar#er, and it is accessibility
is limited and orientation is uncertains.
eriapical curettage and root resection
8nce apex has been located curette and remove all the pathologic soft
tissue surrounding the root down to the hard surrouding bone with a "oldman-
-d Go.( curette or a surgical excavator. 2f complete curettage is obstructed by
the presence of the root, the tip should be reduced carefully by shaving if about
1-( mm with a tapered fissure no. ;4, until the granulation tissue can be
removed for biopsy.
2t is suggested that the soft tissue of the lesion surrounding the root
should be curetted in total. &owever this is not always possible or practical,
7
especially if the lesion involves the maxillary antrum viability of the adAacent
teeth is Aeopardy, or the mandibular vessels.
8ccassionally, the root and apex are difficult to locali%e even after
removing the cortical bone. The root can be distinguished from its surrounding
by its color, morphologic features, and hardness. -oot structure is harder that
the soft cancellous bone with a defined anatomic outline and a different color
when viewed in a washed and debrided operative field, 4ambru%%i and
associate described use of methylene blue to identify and isolate root apex.
The decision to resect the apical tip depends on the 1uality of the seal
between the root canal and the surrounding periodontium. 2f the seal is
satisfactory, periapical curettage and removal of the pathologic tissue and the
extruded filling material will suffice.
The old concept of always resecting a root tip is no longer valid. ! root
is resected when canals cant be properly obturated, such as an obturation inside
the canal, other indication for root resection are3
1. -oot perforation.
7. !pical root fracture.
(. 5athologic root defects.
- !ny anatomic factors that prevent the proper preparation
and sealing of the canal such as calcified, bifurcated, or lateral and
accessory canals.
&igh-speed fissure burs are used to resect the root end. ! lingual-to-
labial bevel angled at (-+5B4 to the coronal aspect of the tooth and in line of
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sight. The advent of small microscopic surgical mirrors and ultrasonic root end
preparation techni1ues are enabled the cut in some cases to be reduced to B.
*oot end preparation
The basic preparation for a root end filling is best done with a small
round bur micro contra angle handpiece. The canal can be located with a sharp
explorer or horse scaler.
The depth preparation should be 7 to ( mm and in center of the root.
$ateral over preparation may result in a wea#ening of the apical root structure
and development of crac#s upon condensation or dimensional change of silver
amalgam.
! slot preparation is suggested where access is limited. The canal is
located and prepared to a vertical length of ( to 5 mm with a no. ; bur and
straight handpiece. -etention is placed with a inverted bur.
The most commonly used retrofilling material are 2-6 super E/!
cement, amalgam, #etac silver glass ionomer cement.
(lap 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 particle of filling material, bone or root structure. /efore
suture a radiograph should be ta#en to verify the removal of filling particles.
-einAection of local anesthetic could help to control bleeding and extend
comfort to the patient.
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*epositioning of flap
The flap is closed by gently placing the most apical position of the flap
first. The flap is smoothened to place with a 7 x 7 gauge sponge so that the
natural and incisional reference points are matched.
&amision has recommended 7 to ( minutes of compression to develop a
thin fabrin clot under flap.
'uturing
The function of the suture is to secure the flap in its original or desired
position.
=utures that are tightly placed compromise circulation, increase changes
of sutures to tear open once the tissues swell.
=uturing needles traumatic *eyeless @uaged,, needles which are
advantageous because of their reverse cutting edge.
- The needle should penetrate 7 to ( mm from wound
margin.
- =uture materials are divided as3
1. !bsorbable *disposed by body en%ymes,.
7. Gonabsorbable *walled off,
E.g. 3 !bsorbable 9 surgical gut *traps food,
Gonabsorbable 9 =il# *ethicon,
The flap is gently replaced and smoothened into position with a 7x7
gauge sponge until the incisional reference points match. The first suture
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should pass through the most dependent unattached tissue and the incision can
result in teasing of the tissue. ! surgeons #not that is most effective and less
li#ely to slip.
=ling suspensory or circumferential suturing is an effective techni1ue
for maximum tissue adaptation. 2nterrupted sutures may also be placed.
ost!operati"e se.uelae
The following post-operative se1uelae can occur after endodontic
surgery.
/0 '#elling
!lthough swelling doesn:t occur in all the cases, it is sufficiently
common to warrant every effect to prevent it, such as by #eeping trauma to a
minimum during operation.
Effective method for reducing swelling is the application of control
compress over the surgical area for 7 min. every hour post operatively.
En%yme preparations and corticosteroids are used but are not
recommended for routine use.
10 ain
5ain is usually minor complaint and can generally be controlled with
mild analgesics.
20 3chymosis
<iscoloration of the s#in from extravasation and brea#down of blood in
that area, and can travel along facial tissue planes and may appear near the
7+
angle of the Aaw, under the eye, these >blac#-and blue? mar#s usually disappear
within 7 wee#s.
40 arasthesia
! transient parasthesia sometimes lasts from a few days to a few wee#s
after root resection in any part of the Aaw more li#ely to occur resection of teeth
in the mandible patient should be advised of this possibility before the
operation.
50 'titch abscess
8ccasionally a stitch abscess develops. 5ossible causes areK local
laceration of tissue during suturing, accumulations of food debris at the site of
suturing, typing the #not in the line of incisions or irritation by the suture
material itself.
60 Hemorrhage
=econdly hemorrhage is seldom observed when occur, a brea#down of
the blood clot should be suspected. 2f cold compresses do not stop the bleeding
an inAection should be made into the area, wound should be reopened, irrigated
with local anesthetic solution, and sutured.
70 erforation
5erforation of the antrum may occur postoperatively in any of the
maxillary teeth from cuspid to molar, it is not serious, provided no foreign
bodies are introduced, a blood clot forms and a suitable flap has been coated
and sutured properly, a prophyactic antibiotic should be considered.
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80 Iatrogenic
Ehen the area of rarefaction is extensive and intrusive it is always
possible to disrupt the blood and nerve supply to adAacent teeth during
curettage. To prevent this complication root canal treatment and filling may be
done first.
ost surgical instructions
1. The patient should be instructed to apply an ice pac# for 7-( min.
each has the first day.
7. The patient should be raise the lip or engage in extended conversion
because such activity can tear out the sutures.
(. =hould avoid brushing the teeth near the surgical siteK the sutures can
ripped out inadvertently by the toothbrush.
+. ! softer or semisolid diet, should be prescribed for the first few days,
after eating the patient should debride the wound by flushing it with a
saline or bicarbonate soda mouthwash.
5. 5ost-operative pain can be controlled with mild analgesics.
0. Go unwanted, antibiotics should be prescribed, antibiotic of choice is
penicillin ., orally administered 1mg to start, followed by 5mg +
times daily for ( to + days.
For penicillin allergic patient is erythomycin 5mg initially, then
75mg every 0 hr for ( to + days.
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Additional instructions
1. 2n case of bleeding apply constant steady pressure, using an ice pac# on
the face over the surgical site for 7-( min.
7. 2n the event of an emergency, call the dentist.
(. -ecall approximately 1 day later for suture removal.
*epair
The initial repairs occur across the margins of the line of incision.
&ealing by first intension usually occurs within 5 days, healing ta#es place
across the incisional margin, the length of the incisions is not a factor, if the
suture fails or tear, then healing will occur with the fixation of granulation
tissue *second intention, lasting + to 0 wee#s.
-epairs of periapical tissue is usually complete within a year, and
progressive repair should be noticeable on a radiographs 0 months after the
operation.
Additional surgical procedures
!t times, the endodontist is called on to perform other related surgical
procedures by modifying and applying the previously described techni1ues
using the surgical s#ills and #nowledge needed for periapical surgery.
Incision and drainage
Ehen the build up of exudates penetrates the cortical plate, swelling
occur and pain diminishes, if the swelling persists, that is it locali%e into a soft,
fluctuant, palpable mass it should be drained by the 1uic#, sharp thrust of the
7;
scalpel that the center of the soft, fluctuant mass down to the solid cortical bone
plate after attaining anesthesia *&ilton method,.
)rephination
! procedure used to relieve pain, the cortical bone is perforated by
engine-driven or hand operated terpine, to release the build up of pressure and
exudates around the root apex of a tooth.
Trephination will afford emergency relief because, in effect an artificial
sinus that is prepared through which trapped exudates in the bone is released.
The site must be anestheti%ed, an incision made to expose and penetrate
the bone through the cortical plate with a large, round bur Go. +-', and with a
sterile coolant. The path of penetration must be a direct line to the periapical
tissue surrouding the root apex, any deviation can cause repairable damage to
the root itself, such as from penetration into the mandibular canal or mental
foramen. Trephination is therefore used infre1uently as a means of pain
control.
Hemisection and *adisectomy
-adisectomy denotes the removal of one or more roots of a molar.
&emisection refers to sectioning of the crown of a molar tooth, with
either the removal of half the crown and its supporting root structure or
the retention of both halves to be used after reshaping and splinting as
two premolars.
7'
Indications for radisectomy
1. Ehen periodontal involvement of one root is severe.
a. Dntreatable furcation involvement.
b. Extensive loss of bone has occurred.
7. Ehen endodontic treatment of one root is technically impossible or
when such treatment has failed.
(. Ehen root has been destroyed by extensive caries.
+. Fractured root of an upper molar.
Contraindications
1. Ehen loss of bone involves more than one root and the remaining would
have inade1uate support.
7. Ehen bridge span is long and the abutment tooth would read inade1uate
support.
(. Ehen roots are fused.
Armamentarium
- =urgical length of long shan# fissure bur si%es ;, ;1, 55;, 5''.
- $ong tapered fissure diamond stro#es to smoothen retained tooth
segment.
- Elevator 9 straight, apical elevator.
- Forceps 9 upperClower forceps, universal forceps.
7)
- Endodontic treatment should proceed root treatment.
- ! flap need not be raised if root amputation performed on
periodontally not involved teeth.
- ! flap has to be reflected if the teeth is periodontally involved.
)here are t#o methods by root amputations can be performed:
1. .ertical cut method 3 utili%e a long shan#, tapered fissure carbide bur in
airotor to section through the entire crown and root to the furcea in
gaining separation.
Ad"antages of "ertical cut method
1. <irect visuali%ation of bur penetrates to ensure that preparation will be
in the correct position.
7. -emoval of that portion of the crown that is over the root to prevent
undesirable postoperative occlusal forces.
(. 5osition of each cut, based on the anatomy of the furcea, to allow the
root to cleave along desirable angles.
+. Excellent visuali%ation of furcea after amputation.
10 Hori-ontal cut preparation
&ori%ontal cut made through the tooth without the crown being altered
in the preparation.
4utting the tooth in this manner leaves a deep trough between the crown
and the alveolar mucosa which is obvious trap for food and debris.
(
!ny occlusal forces over the amputed root will be tend to put severe
stress from a undersirable direction on the remaining roots.
*!mputation procedures on mandibular molars also #nown as
bucispidation,.
rocedure
! gentle curve is made in a + silver cone and inserted it through furca
from the buccal to lingual.
The rest of the procedure is as in vertical procedure for maxillary molar.
Indications for hemisecton
1. Ehen periodontal involvement of one root is severe.
7. Ehen loss of bone is extensive in furcation area.
(. Ehen caries involves much of the root.
Contraindications are similar to that for radisectomy
rocedure
- The roots to be retained undergo endodontic therapy and
the pulp chamber is filled with amalgam.
- Go filling material is placed into the root to be removed
for that entire half of the tooth will be extracted.
- ! sharp contour explorer or periodontal probe is used to
identify the buccal and lingual furcations.
(1
- /y first placing the tip of a high speed tapered fissure
bur in the furcation, the operator can effectively section the molar
with usually.
- !n elevator should be wedged between the two halves
and slightly rotated to differentiate if the separation is complete.
- The pathologic half is extracted with forceps or eased
out with an elevator.
- The soc#et area, is lightly curetted and pac#ed with bone
waxCgelform.
- This is followed by copious irrigation.
'ummary and Conclusion
!ll endodontic procedures should ensure the placement of a proper seal
between the periodontium and the root canal foramina. Ehen this seal can:t be
achieved satisfactorily by wor#ing through the canal system, a surgical
procedure presents visual and manipulative control of the area and placement
of the seal through the surgical site.
Ehen failure occurs in non-surgical endodontic therapy the clinician
should be prepared to initiate alternative procedure including surgery to
enhance the rate of success.
(7
'9*GICAL 3$:+:+$)IC'
C+$)3$)'Contents
2ntroduction
&istory
4lassification
2ndication and 4ontraindication
!natomic 4onsiderations
5reoperative 4onsultation with the patient
5reoperative preparation and 5remedication of the patient
!rmamentarium
Flap <esign
=urgical techni1ue
=uturing
5ostoperative se1uelae
5ostoperative management of the patient
=ummary L 4onclusion
((