18 

Principles of Endodontic Surgery

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STUART E. LIEBLICH

CHAPTER OUTLINE
Drainage of an Abscess, 365 Flap Replacement and Suturing, 380
Postoperative Instructions, 380
Periapical Surgery, 365
Suture Removal and Evaluation, 380
Indications, 367
Anatomic Problems, 367 Corrective Surgery, 380
Restorative Considerations, 368 Indications, 381
Horizontal Root Fracture, 368 Procedural Errors, 381
Irretrievable Material in the Canal, 369 Resorptive Perforations, 381
Procedural Error, 369 Contraindications, 381
Large, Unresolved Lesions After Root Canal Treatment, 369 Anatomic Considerations, 381
Contraindications (or Cautions), 369 Location of Perforation, 381
Unidentified Cause of Treatment Failure, 371 Accessibility, 382
When Conventional Endodontic Treatment Is Possible, 371 Considerations, 382
Simultaneous Root Canal Treatment and Apical Surgical Approach, 382
Surgery 371 Repair Material, 383
Anatomic Considerations, 371 Prognosis, 383
Poor Crown-Root Ratio, 372 Surgical Procedure, 383
Medical (Systemic) Complications, 372
Fractured Teeth, 384
Surgical Procedure, 372
Healing, 384

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Antibiotics, 372
Flap Design, 373 Recall, 385
Semilunar Incision, 373
To Perform a Biopsy or Not, 386
Submarginal Incision, 373
Full Mucoperiosteal Incision, 374 Adjuncts, 386
Anesthesia, 374 Light and Magnification Devices, 386
Incision and Reflection, 376 Surgical Microscope, 386
Periapical Exposure, 376 Fiberoptics, 387
Curettage, 377 Guided Tissue Regeneration, 387
Root End Resection, 377 Bone Augmentation, 387
Root End Preparation and Restoration, 378 When to Consider Referral, 388
Root End–Filling Materials, 379 Training and Experience, 388
Irrigation, 380 Determining the Cause of Root Canal Treatment Failure, 388
Radiographic Verification, 380 Surgical Difficulties, 388

E ndodontic surgery is the management of periradicular disease by

a surgical approach. In general, this includes abscess drainage,
periapical surgery, corrective surgery, intentional
replantation, and root removal (Box 18.1).
Conventional endodontic treatment, also known as orthograde
endodontics, is generally a successful procedure; however, in 10% to
15% of cases symptoms can persist or recur spontaneously. 1 Such
findings as a draining fistula, pain on mastication, or the incidental
finding of a radiolucency increasing in size indicate
problems with the initial endodontic procedure. Many endodontic
failures occur 1 year or more after the initial root canal treatment,
often complicating a situation because a definitive restoration may
have already been placed. This creates a higher “value” for the tooth
because it now may be supporting a fixed partial denture.
Surgery has traditionally been an important part of endodontic
treatment. However, until recently, little research has focused on
indications and contraindications, techniques, success and failure
(i.e., long-term prognosis), wound healing, and materials and devices
364
CHAPTER 18  Principles of Endodontic Surgery 2. E
365 xpl
orat
• BOX 18.1 Factors Associated With Success and ion
Failure in Periapical Surgery • BOX 18.2 Categories of Endodontic Surgery of
the
Success • Abscess drainage root
• Dense orthograde fill • Periapical surgery
• Hemisection or root amputation surf
• Healthy periodontal status:
• No dehiscence • Intentional replantation ace
• Adequate crown-root ratio • Corrective surgery for
• Radiolucent defect isolated to apical one-third of the tooth frac
• Tooth treated: ture
• Maxillary incisor
s or
• Mesiobuccal root of maxillary molars
• Postoperative factors: othe
• Radiographic evidence of bone fill following surgery must be able to recognize the procedures indicated in particular r
• Resolution of pain and symptoms situations. When referring a patient to a specialist for treatment, path
• Absence of sinus tract the general dentist must have sufficient knowledge to understand olo
• Decrease in tooth mobility the potential success of the procedure. Studies show that apical
gic
surgery can have outcomes of greater than 85% over a 3-year
Failure con
period. 2 Knowing the likelihood of success allows the referring
• Clinical or radiographic evidence of fracture diti
• Poor or lack of orthograde filling
dentist to provide describe the surgical procedure as well as
ons
• Marginal leakage of crown or post provide appropriate counseling to the patient. In addition, the
• Poor preoperative periodontal condition generalist should assist in the follow-up care and long- term
• Radiographic evidence of post perforation assessment of treatment outcomes. The final determination of
• Tooth treated: success (e.g., as to when a definitive final restoration should be
• Mandibular incisor placed) is often the responsibility of the referring dentist.
• Postoperative factors:
•
•
Lack of bone repair following surgery
Lack of resolution of pain
Drainage of an Abscess
• Fistula does not resolve or returns Drainage releases purulent or hemorrhagic transudates and
From Thomas P, Lieblich SE, Ward Booth P. Controversies in office-base surgery. In: Ward-Booth P, exudates from a focus of liquefaction necrosis (i.e., abscess).
Schendel S, Hausamen J-E, eds. Maxillofacial Surgery. 2nd ed. London: Churchill Livingstone; 2007. Draining an abscess relieves pain, increases circulation, and
removes a potent irritant. The abscess may be confined to bone or
may have eroded through bone and the periosteum to invade soft
tissue. Managing these intraoral or extraoral swellings by incision
for drainage is reviewed in Chapters 16 and 17. Draining the
to augment procedures. Because of this lack of information, referral infection does not eliminate the cause of the infection, so
for surgery—such as the routine correction of failed endodontic definitive treatment of the tooth is still needed.
treatment, removal of large lesions believed to be cysts, or single-visit An abscess in bone resulting from an infected tooth may be
root canal treatment—may have been inappropriate. A decision on drained by two methods: (1) opening into the offending tooth
whether to approach the case surgically or to consider orthograde coronally to obtain drainage through the pulp chamber and canal or
(through the coronal portion of the tooth) endodontic retreatment is (2) a formal incision and drainage (I&D), with or without placement
dictated by various clinical and anatomic situations. Other treatment of a drain. An I&D is indicated if the spread of the infection is rapid,
options, such as extraction of the tooth with placement of an implant, if space involvement is evident, or if opening the tooth coronally does
may be preferred and are associated with a higher long-term success not yield obvious purulence. The decision regarding a drain is based
rate. However, a consensus conference concluded that endodontic on whether the abscess cavity will remain open on its own. Infections
therapy and implant procedures are considered equally successful. that have spread to multiple contiguous spaces often dictate the need
Additional procedures on the tooth, whether orthograde retreatment or to place a drain. In addition, if dependent drainage is not established, a
periapical surgery, may reduce the long-term success rate of the tooth drain should be considered. An I&D permits the dentist to obtain a
because each treatment is associated with additional tooth structure sample of the pus for culture and sensitivity testing when indicated.
removal. When surgery is indicated, under the correct clinical Most community-acquired endodontic infections do not require
situations it can maintain the tooth and its overlying restoration. Fig. culture and sensitivity testing unless the patient is medically
18.1 is an algorithm to help guide the clinical decision regarding compromised or has failed to respond to an empirical course of
whether endodontic surgery is indicated. antibiotics or if the infection was acquired in a hospital setting, which
predisposes to antibiotic-resistant forms of bacteria.
This chapter presents the indications and contraindications for
endodontic surgery, diagnosis and treatment planning, and the basics
of endodontic surgical techniques. Most of the procedures presented Periapical Surgery
should be performed by specialists or, on occasion, specially trained
and experienced generalists. Surgical approaches are often in Periapical (i.e., periradicular) surgery includes a series of
proximity to anatomic structures such as the maxillary sinus (Box procedures performed to eliminate symptoms. Periapical
18.2) and inferior alveolar nerve, so expertise in working around these surgery includes the following:
structures is mandatory. Nonetheless, the general dentist must be 1. Appropriate exposure of the root and the apical region
skilled in diagnosis and treatment planning and
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366 Part IV Infections NO

NO

Lim
Algorithm for apical surgery: res

Symptomatic tooth (continued pain, sinus tract, gross pulpal involvement) Ul

pre
Re
Failed previous endodontics? NO Refer for RCT RCT successful YES Final restoration fill

YES NO Po
rad
Can tooth be retreated? YES Will patient accept retreatment? YES Retreatment
To
as
NO ic
mo
Evidence of crack/fracture? YES Extract Implant/prosthesis

NO
Im
the

YE
Adequate periodontal status? NO Abutment for existing prosthesis? NO

Pe
(,25% vertical bone loss,
pocket depth ,5 mm)
Ev
YES
bo

YES Abutments and prosthesis in good condition? res

NO
Adequate tooth structure YES
NO
for prosthesis? NO Extract Implant/prosthesis pe
Ev

YES
res
•F
Patient able to tolerate surgery su
tre
YES

Surgical exploration

Fracture found? YES Molar tooth YES Tooth periodontally sound YES Resect root
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 CHAPTER 18  Principles of Endodontic Surgery 367

3. Curettage of the apical tissues
4. Resection of the root apex
5. Retrograde preparation with the ultrasonic tips
6. Placement of the retrograde filling material
7. Appropriate flap closure to permit healing and minimize
gingival recession
Indications
After the completion of endodontics, symptoms associated with
It is important to tell the patient preoperatively that endodontic
surgery is exploratory. The precise surgical procedure is dictated by
the clinical findings once the site is exposed and explored. For
example, a fracture of a root may be noted, and the decision whether
to resect the root or extract the tooth will need to be made
intraoperatively. If the tooth is to be extracted, provisions for
temporization must be made in advance if removal is an esthetic
issue, or a decision must be made to close the flap and schedule a
future extraction. The patient must also give preoperative consent for
an extraction if it is deemed necessary intraoperatively.

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the tooth may lead to the recommendation for periapical surgery.
Most commonly, patients have a chronic fistula and drainage.
Other signs can include pain and the sudden onset of a vestibular
space infection. Incidental findings of an increasing radiolucent
area found on routine radiographs may also lead to the decision to
treat the periapical region surgically.
The success of apical surgery varies considerably
depending on the reason for and nature of the procedure. With
failed root canal treatment, retreatment often is not possible, or
a better result cannot be achieved by a coronal approach. If the
cause of the failure cannot be identified, surgical exploration
may be necessary (Fig. 18.2). On occasion, an unusual entity
in the periapical region requires surgical removal and biopsy
for identification (Fig. 18.3). Indications for periapical surgery
are discussed in the following sections (Box 18.3).
Anatomic Problems
Calcifications or other blockages, severe root curvatures, or con-
stricted canals (e.g., calcific metamorphosis) may compromise root
• BOX 18.3 Indications for Periapical Surgery
• Anatomic problems preventing complete debridement or obturation
• Restorative considerations that compromise treatment
• Horizontal root fracture with apical necrosis
• Irretrievable material preventing canal treatment or retreatment
• Procedural errors during treatment
• Large periapical lesions that do not resolve with root canal treatment

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A B

C
• Fig. 18.2 Surgical exploration. (A) The patient had persistent pain over the midroot region following what appears to be successful
endodontic treatment. (B) Surgical exploration reveals perforation of the buccal root during the endodontic treatment with displaced gutta-percha. (C)
Postoperative periapical film of surgical removal of the extruded gutta-percha and mineral trioxide aggregate seal.
368 Part IV Infections

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A B
• Fig. 18.3 Surgical removal of pathosis. (A) The patient was referred for surgery because of an increasing radiolucent
area after conventional endodontic treatment. Note the atypical nature of the radiolucent lesion, which indicates tissue submission should be
done in conjunction with the apical surgery. (B) Treat-ment by apical surgery with amalgam retrograde seal, along with a biopsy of the
associated tissue. The final diagnosis was cystic ameloblastoma.

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A B C

• Fig. 18.4 (A) Anatomic problem of a severe root curvature, for which surgery is indicated. (B) Apical resection and root
end retrograde mineral trioxide aggregate the seal. (C) An image taken 4 months after surgery shows regeneration of bone.

canal treatment (e.g., prevent instrumentation, obturation, or
both) (Fig. 18.4). A nonobturated and cleaned canal may lead
to failure because of continued apical leakage.
Although the outcome may be questionable, it is preferable
to attempt conventional root canal treatment or retreatment
before apical surgery. If this is not possible, removing or
resecting the uninstrumented and unfilled portion of the root
and placing a root end filling may be necessary.
Restorative Considerations
Root canal retreatment may be risky because of problems that may
occur from attempting access through a restoration such as a crown
on a mandibular incisor. An opening could compromise retention of
the restoration or perforate the root. Rather than attempt the
root canal retreatment, root resection and root end filling may
successfully eliminate the symptoms associated with the tooth.
A common indication for surgery is failed treatment on a
tooth that has been restored with a post and core (Fig. 18.5).
Many posts are difficult to remove or may cause root fracture
if an attempt at removal is made to retreat the tooth.
Horizontal Root Fracture
Occasionally, after a traumatic root fracture, the apical
segment undergoes pulpal necrosis. Because pulpal necrosis
cannot be predictably treated from a coronal approach, the
apical segment is removed surgically after root canal treatment
of the coronal portion (Fig. 18.6).
Irretrievable Material in the Canal
Canals are occasionally blocked by objects such as broken
instru-ments (Fig. 18.7), restorative materials, segments of
posts, or other foreign objects. If evidence of apical pathosis is
found, those materials can be removed surgically, usually with
a portion of the root (Fig. 18.8). A broken file can be left in the
root canal system if the tooth remains asymptomatic and is not
itself an indication for apical surgery.
• Fig. 18.5 Irretrievable posts and apical pathosis. Root end resection
and filling with amalgam to seal in irritants, likely from coronal leakage.
CHAPTER 18  Principles of Endodontic Surgery
369
Procedural Error
Broken instruments, ledging, gross overfills, and perforations may
result in failure (Figs. 18.9 and 18.10). Although overfilling is not
itself an indication for removal of the material, surgical correction
is beneficial in these situations if the tooth becomes symptomatic.
Because the obturation of the canal is often dense in these
situations, surgical treatment has an excellent prognosis.
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Large, Unresolved Lesions After Root Canal Treatment
Occasionally, very large periradicular lesions may enlarge after
adequate debridement and obturation. These lesions are
generally best resolved with decompression and limited
curettage to avoid damaging adjacent structures such as the
mandibular nerve (Fig. 18.11). The continued apical leakage is
the nidus for this expanding lesion, and root resection with the
placement of an apical seal often resolves the lesion.
Contraindications (or Cautions)
If other options are available, periapical surgery may not be the
preferred choice (Box 18.4).
• BOX 18.4 Contraindications (or Cautions) for
Periapical Surgery
• Unidentified cause of root canal treatment failure
• When conventional root canal treatment is possible
• Combined coronal treatment and apical surgery
• When retreatment of a treatment failure is possible
• Anatomic structures (e.g., adjacent nerves and vessels) are in jeopardy
• Structures interfere with access and visibility
• Compromise of crown-root ratio
• Systemic complications (e.g., bleeding disorders)
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A B C

• Fig. 18.6 (A) Horizontal root fracture (arrow), with failed attempt to treat both segments. (B) The apical segment is removed surgically, and
retrograde amalgam is placed. (C) Healing is complete after 1 year.
370 Part IV Infections

D
A B
•
• Fig. 18.7 (A) Irretrievable separated instruments in mesial-buccal canal. A separated instrument requires surgical .
intervention only if the tooth becomes symptomatic. (B) Following resection of root with fractured instrument and placement of amalgam seal. 18.8
(A)
Irretr
ieva
ble
mat
erial
(arr
ow)
in
mesi
al
and
pala
tal
can
als
and
apic
al
path
osis.
(B)
Can
als
are
A B re-
treat
ed,
but this has failed. (C) Treatment is root end resection to level of gutta-percha in the mesial and palatal aspects. (D) After 2 years, healing is
complete.

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A B
• Fig. 18.9 (A) Overfill of injected obturating material has resulted in pain and paresthesia as a result of damage to
inferior alveolar nerve. (B) Corrected by retreatment, apicectomy, curettage, and a root end amalgam fill.
Unidentified Cause of Treatment Failure
Relying on surgery to correct all root canal treatment failures could
be labeled indiscriminate. An important consideration is to (1)
identify the cause of failure and (2) design an appropriate corrective
treatment plan. Orthograde retreatment is often indicated and offers
the best chance of success. Surgery to correct a treatment failure for
which the cause cannot be identified is often unsuccessful. Surgical
management of all periapical pathosis, large periapical lesions, or
both is often not necessary because they will resolve after appropriate
root canal treatment. This includes lesions that may be cystic; these
also usually heal after root canal treatment.
When Conventional Endodontic Treatment Is Possible
In most situations, orthograde conventional endodontic
treatment is preferred (Fig. 18.12). Surgery is not indicated
simply because debridement and obturation are in the same
visit, although there has been a long-held, incorrect notion that
single-visit treatment should be accompanied by surgery,
particularly if a periradicular lesion is present.
Simultaneous Root Canal Treatment and Apical Surgery
Few situations occur in which simultaneous root canal therapy
and apical surgery are indicated. An approach that includes both
of these as a single procedure typically has no advantages. It is
preferable to perform only the conventional treatment without the
adjunctive apical surgery because the surgery will not necessarily
improve the outcome. In some patients the conventional root
canal procedure is ineffective at eliminating symptoms. In this
scenario, in spite of adequate instrumentation and antibiotics,
purulent exudate from the tooth or a vestibular swelling is still
present. A combined orthograde obturation with a simultaneous
periapical surgery to curette the apical region and seal the tooth
can be successfully coordinated and the symptoms resolved. The
dentist can instrument and seal the tooth with the plan to see the
surgeon that day for definitive periapical surgery. The endodontic
CHAPTER 18  Principles of Endodontic Surgery 371
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filling material is densely condensed and can even be out the
apex (to a reasonable degree, not impinging on local anatomic
structures) if the surgeon will resect a small portion of the
apical region and place a retrograde seal (Fig. 18.13A–C).
Anatomic Considerations
Although most oral structures do not interfere with a surgical
approach, they must be considered. Expertise in operating around
a structure such as the maxillary sinus or the mental nerve region
is imperative before undertaking surgery in these regions.
Exposure of the maxillary sinus, which occurs in most molar
apical surgeries, is itself not a complication but a known
consequence of the surgery (Fig. 18.14). Creating a sinus opening
is neither unusual nor dangerous. However, caution is necessary
not to introduce foreign objects into the opening and to remind
the patient not to exert pressure by forcibly blowing the nose until
the surgical wound has healed (for 2 weeks). Correct flap design
is also crucial to prevent the development of an oral-antral
communication. The sulcular flap keeps the incision line far from
the sinus opening, thus allowing spontaneous healing.
Surgical procedures around the mental foramen require
caution to avoid stretch injury or direct damage to the nerve. In
my opinion, exposure of the mental nerve is safer than attempting
to estimate its position. Careful subperiosteal reflection of the flap
with adequate release allows the surgeon to identify the nerve
where it exits from bone. Once identified, staying a safe distance
above, anteriorly, or both is crucial to preventing an injury.
Important to note is that the nerve may have an anterior loop of 2
to 4 mm, so that distance should be accounted for anteriorly.
When molar apical surgery is performed, the midroot of the molar
should be identified by slow removal of bone, which should be
carried inferiorly (Fig. 18.15A–C). Once reaching the apical region,
cautious curettage of the soft tissue lesion is carried out to avoid
mechanical injury of the inferior alveolar nerve as it passes under the
molar roots (see Fig. 18.15D–G). As mentioned earlier, it is not
necessary to remove the entire area of periapical granulation
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372 Part IV Infections
A B
• Fig. 18.10 Repair of perforation. (A) Furcation perforation results in extrusion of material (arrow) and pathosis. (B) After flap
reflection and exposure, the defect is repaired with mineral trioxide aggregate. (C) Evaluation at 2 years shows successful healing. (Courtesy Dr. L.
Baldassari-Cruz, University of Iowa.)
tissue or cyst, if present, because treating the apical lesion and
sealing of the root canal with the retrograde filling cause the
apical lesion to heal.
Poor Crown-Root Ratio
Teeth with very short roots have compromised bony support
and are poor candidates for surgery; root end resection in such
cases may compromise stability. However, shorter roots may
support a relatively long crown if the surrounding cervical
periodontium is healthy (see Fig. 18.6).
Medical (Systemic) Complications
The general health and condition of the patient are always
essential considerations. Contraindications for endodontic
surgery are similar to those for other types of oral surgery.
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Surgical Procedure
Antibiotics
Almost without exception, periapical surgery is performed in an area
with mixed acute and chronic infection. Because of the nature of the
surgery and the potential for the spread of infection into adjacent
spaces, preoperative prophylactic administration of antibiot-ics
should be considered. Risk for infection of the hematoma exists
because of the amount of edema expected after the procedure. In
addition, inadvertent opening of adjacent structures such as the
maxillary sinus is expected to occur with molar surgeries. As
discussed elsewhere in the text, the basics of antibiotic prophylaxis
are that antibiotics are to be administered before surgery to have any
protective benefit. The surgeon should consider a preoperative dose
of penicillin V potassium (2 g) or clindamycin (600 mg) 1

A
B be followed (see Chapter 3). Although several pos-sibilities exist, the
C tooth is impractical. The incision is based primarily in the unattached
• Fig. 18.11 Decompression of large lesion. (A) Extensive periradicular
lesion that has failed to resolve. Coronal leakage in either treated tooth is
possible. (B) A surgical opening to defect is created; a polyethylene tube
extends into the lesion to promote drainage. (C) After partial resolution, root
end resection and filling with amalgam are performed.
hour before surgery. The need for postoperative dosing has not
been clearly defined and may not be of benefit to the patient.
Other adjuncts, such as the perioperative administration of
corticosteroids, may reduce edema and speed recovery.
However, the use of corticosteroids may increase the risk of
infection, so prophylactic antibiotics may be necessary.
CHAPTER 18  Principles of Endodontic Surgery 373
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A B
• Fig.18.12 (A) Inadequate root end resection and root end filling
have failed to seal the apex. (B) Root canal treatment is readily
accomplished, with good chance of success.
Flap Design
Surgical access is a compromise between the need for visibility of the
surgical site and the potential damage to adjacent structures. A
properly designed and carefully reflected flap results in good access
and uncomplicated healing. The basic principles of flap design should
three most common incisions are (1) semilunar,
(2) submarginal, and (3) full mucoperiosteal (i.e., sulcular).
The submarginal and full mucoperiosteal incisions have either
a three-corner (i.e., triangular) design or a four-corner (i.e.,
rectangular) design.
Semilunar Incision
Although the semilunar incision is a popular incision among
practitioners, this type of incision should be avoided because of the
limitations and potential complications. This is a slightly curved half-
moon horizontal incision in the alveolar mucosa (Fig. 18.16).
Although the location allows straightforward reflection and quick
access to the periradicular structures, it limits the clinician in
providing full evaluation of the root surface. If a fracture is noted,
performing a root resection through this incision or extracting the
or alveolar mucosa, which heals more slowly with a greater chance of
dehiscence than a flap based primarily in attached or keratinized
tissue. In addition, the flap design carries the flap over the inflamed
surgical site, and this inflamed mucosa is at a high risk of breakdown.
Other disadvantages to this incision include excessive hemorrhage,
delayed healing, and scarring; therefore this design is contraindicated
for most endodontic surgery.
Submarginal Incision
The horizontal component of the submarginal incision is in attached
gingiva with one or two accompanying vertical incisions (Fig. 18.17).
In general, the incision is scalloped in the horizontal line, with obtuse
angles at the corners. The incision is used most suc-cessfully in the
maxillary anterior region or, occasionally, with
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374 Part IV Infections

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A B C

• Fig. 18.13 (A) Lower incisors with persistent symptoms despite reinstrumentation. The canals are densely filled and a
slight overfill is inconsequential as the patient will see the surgeon the same day for apical surgery. (B) At the completion of the apical surgery
with placement of a mineral trioxide aggregate retrograde seal. (C) Six months later the bony defect is nearly completely healed without the use
of any graft.

Disadvantages include hemorrhage along the cut margins into T

the surgical site and occasional healing by scarring compared he
with the full mucoperiosteal sulcular incision. The incision also full
provides limited access should a fracture be noted or other muc
situation in which extraction or root resection is indicated. ope
rios
Full Mucoperiosteal Incision teal
The full mucoperiosteal incision is made into the gingival sulcus, desi
extending to the gingival crest (Fig. 18.18). This procedure includes gn
elevation of interdental papilla, free gingival margin, attached is
gingiva, and alveolar mucosa. One or two vertical relaxing incisions pref
may be used, creating a triangular or rectangular design. erre
d
ove
• Fig. 18.14 Sinus communication during root apical surgery of an r
upper molar. The closure with the sulcular incision is far away and
unlikely to lead to an oral-antral communication.
the
othe
r
maxillary premolars with crowns. Because of the design, prerequisites two
are at least 4 mm of attached gingiva and good periodontal health. tech
The major advantage of this type of incision is esthetics. niq
Leaving the gingiva intact around the margins of crowns is less ues.
likely to result in bone resorption with tissue recession and The
crown margin exposure. Compared with the semilunar incision, adv
the submarginal incision provides less risk of incising over a anta
bony defect and provides better access and visibility. ges
incl
ude maximum access and visibility, not incising over the lesion
or bony defect, lower risk for hemor-rhage, complete visibility of
the root, allowance of root planing and bone contouring, and
reduced likelihood of healing with scar formation. The
disadvantages are that the flap is more difficult to replace and to
suture; in addition, gingival recession can develop if the flap is
not reapproximated well, exposing crown margins or cervical
root surfaces (or both).
As a general rule, flaps should be designed that are
trapezoidal, having a broader base than edge (see Fig. 18.18A).
A trapezoidal flap design creates a longer component in the
nonkeratinized tissue. However, in cases when the vertical
release crosses bony prominences over the roots of teeth and
across the muscle frenum, the dental papilla just adjacent to the
released flap may have a compromised blood supply and the
potential for recession. In such cases, making the vertical release
more perpendicular to the sulcus may permit the same amount of
flap release (see Fig. 18.18B). The vertical incision should
parallel the long axis of teeth and should be made between two
teeth where the tissue is the thickest and has the best blood
supply. The direct vertical incision makes sense because the
blood supply to the gingiva follows the long axis and is oriented
longitudinally.
Anesthesia
For most surgical procedures, anesthetic approaches are
conventional. In most mandibular regions, a block is administered;
then local infiltration of an anesthetic with epinephrine is given to
enhance hemostasis. Frequently, the patient is sensitive to curettage
of the inflammatory tissue, particularly toward the lingual aspect.
Some of the sensitivity may be decreased by a preemptive
periodontal ligament or intraosseous injection, using a device
specifically designed for this purpose. Placing a cotton pellet soaked
with local anesthetic solution can also reduce this discomfort.
A long-acting anesthetic agent such as bupivacaine is recom-
mended for the inferior alveolar nerve block. Bupivacaine 0.5%
with epinephrine 1 : 200,000 has been shown to give long-lasting
anesthesia and, later, provide a lingering analgesia. Long-acting
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A

B C

D E

F G
• Fig. 18.15 (A) A preoperative radiograph showing the periapical pathologic condition amenable to apical surgery. (B) Full-
thickness mucoperiosteal flap to expose lateral border of mandible. As is typical, no obvious bony perforation exists. (C) Careful removal of the
thick buccal bone to expose the apical portion.
(D) Apical one-third exposed before resection of root. (E) Both roots resected and mineral trioxide
aggre-gate seal placed following ultrasonic preparation. (F) Immediate postoperative radiograph with
mineral trioxide aggregate seal visible. (G) Five months after surgery, bone fill is evident.
https://t.me/LibraryEDent
376 Part IV Infections
• Fig. 18.16 Semilunar flap incision, primarily horizontal and in
alveolar mucosa. Because of limitations of access and poorer healing,
this design is contraindicated.
• Fig. 18.17 Submarginal incision is a scalloped horizontal line in
attached gingiva, with one or two vertical components. This incision is
usually confined to the anterior maxillary region.
local anesthetic agents such as bupivacaine do not diffuse well
through tissue because they are highly protein bound, which
limits their effectiveness for an infiltration-type injection.
Some patients request sedation because of their concern
about having a surgical procedure. If active infection is
present in the region, profound local anesthesia may not be
possible to achieve, and these patients may be candidates for
intravenous sedation or general anesthesia.
Incision and Reflection
A firm incision should be made through the periosteum to bone.
Incision and reflection of a full-thickness flap is important to
minimize hemorrhage and to prevent tearing of the tissue. Reflection
is with a sharp periosteal elevator beginning in the vertical incisions
and then raising the horizontal component. To reflect the perios-
teum, the elevator must firmly contact bone while the tissue is raised
(Fig. 18.19). Reflection is to an apical level adequate for access to the
surgical site, although still allowing a retractor to have contact with
bone. Enough width and vertical release of the flap must be included
to prevent the flap from being stretched, which can lead to tearing
and slower healing.
Postsurgical recession, especially around teeth in the esthetic
zone, is a concern. Recession may be exacerbated in cases where
preexisting full coverage crowns are present. In 2007, von Arx et al. 3
reviewed different types of incisions and the outcomes on periodontal
health. They found that a sulcular incision without reflection of the
interdental papilla and with direct, vertical-releasing (i.e.,
nontrapezoidal) incisions provides the best outcome.
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A
B
• Fig. 18.18 (A) Full mucoperiosteal (i.e., sulcular) incision. The horizontal
incision is into the sulcus, accompanied by one (i.e., three-corner) or two
(i.e., four-corner) vertical components. This represents the classic trape-
zoidal flap with the base broader rather than the peripheral edge. (B) In
comparison, by making the vertical-releasing incision(s) along the long axis
of adjacent teeth, the length of the flap in nonkeratinized tissue is
decreased, which reduces pain and accelerates the healing.
Periapical Exposure
Frequently, cortical bone overlying the apex has been resorbed,
exposing a soft tissue lesion. If the opening is small, it is enlarged
using a large surgical round burr until approximately half the root
and the lesion are visible (Fig. 18.20). With a limited bony
opening, radiographs are used in conjunction with root and bone
topography to locate the apex. A measurement may be made with
a periodontal probe on the radiograph and then transferred to the
surgical site to determine the apex location.
To avoid air emphysema, handpieces that direct pressurized
air, water, and abrasive particles (or combinations) into the
surgical site must not be used. Vented high-speed handpieces or
electrical surgical handpieces are preferred during osseous entry
and root end resection. Sealed-end air-pressurized handpieces
direct air away from the surgical site, and handpieces that use
nitrogen gas also prevent air emphysema. Regardless of the
handpiece used, copious irrigation should be performed with a
syringe or through the handpiece with sterile saline solution.
Enough overlying bone should be removed to expose the area
around the apex and at least half the length of the root. Good
access and visibility are important; the bony window must be
adequate. The clinician should not be concerned about the bone
removal because once the infection resolves, bone will reform.
The exposure of the root is done before resecting the root to avoid
the risk of blending the root in with bone and losing surgical
orientation. This is especially critical in the mandible, where the bone
is dense. Lower incisor roots are carefully exposed because proximity
with adjacent teeth could lead to treatment of the wrong
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A
• Fig. 18.19 Full-thickness flap is raised with sharp elevator in firm contact with bone. Enough tissue is raised to allow access
and visibility to apical area. (A) Frontal view. (B) Cross-section.
A
• Fig. 18.20 Apical exposure. A large round burr is used to “paint” the bony window. Enough bone is removed to give good
visibility and access to lesion and apex. (A) Frontal view. (B) Cross-section.
apex. The curvature of the root, particularly the maxillary lateral
incisor, demands close attention to avoid surgical misadventures.
Curettage
Most of the granulomatous, inflamed tissue surrounding the
apex should be removed (Fig. 18.21) to gain access and
visibility of the apex, to obtain a biopsy for histologic
examination (when indicated), and to minimize hemorrhage.
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B
If possible, tissue should be enucleated with a suitably sized sharp leav
curette, although total lesion removal usually does not occur. A
cleaner bony cavity has the least hemorrhage and the best visibility.
Often, extensive debris may have been forced out the apex of the tooth
during the initial endodontic therapy. Cleaning out this debris removes
what may have been the nidus for the acute or chronic infection.
Tissue removal should not jeopardize the blood supply to an adjacent
tooth. In addition, some areas of the lesion, such as on the lingual
aspect of the root, may be inaccessible to curettes. Portions of
inflamed tissue or epithelium may be left, without compromising
healing; total removal is not necessary. As noted before, it is better to
e a small portion of this tissue than to damage the inferior alveolar
nerve.
If hemorrhage from soft or hard tissue is excessive to the
extent that visibility is compromised, homeostatic agents or
other control techniques are useful, but the homeostatic agents
should be removed after use. Hemorrhage control can be
achieved by holding direct pressure over a bleeding site with
gauze soaked in local anesthetic solution with epinephrine and
by minimizing suction at the site of a bleeder.
Root End Resection
Root end resection is indicated because it removes the region
that most likely had the poorest obturation because of the
distance from the coronal portion of the tooth. The presence of
accessory canals increases at the apex as well, which may have
not been initially cleaned and debrided, thus leaving a source
of continued infection.
Before sectioning, a trough is created around the apex with a
tapered fissure burr to expose and isolate the root end. The resection is
done with the same tapered fissure burr. Depending on the location, a
bevel of varying degrees is made in a faciolingual direction (Fig.
18.22). With the use of ultrasonic instruments to prepare the apex, a
minimal bevel is needed, especially in anterior
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378 Part IV Infections
A
• Fig. 18.21 Curettage. Much of lesion that is accessible is removed with large curettes. Usually, remnants of tissue
remain, which is not a problem. (A) Frontal view. (B) Cross-section.
A
• Fig. 18.22 Root end resection. Approximately one third of apex is removed with tapered burr. Amount removed and degree of bevel varies
according to situation. (A) Frontal view. (B) Cross-section.
maxillary teeth. By minimizing the length of the bevel, fewer
dentinal tubules are exposed, thus reducing leakage into the
apical region.
The amount of root removed depends on the reason for
perform-ing the resection. Sufficient root apex must be removed
to provide a larger surface and to expose additional canals. In
general, approximately 2 to 3 mm of the root is resected—more,
if necessary, for apical access or if an instrument is lodged in the
apical region; less if too much removal would further
compromise stability of an already short root.
Root End Preparation and Restoration
A retrograde filling should be placed unless technical aspects prohibit
it. The filling seals the canal system, preventing further leakage. The
depth of the preparation must be at least 1 mm deeper than the length
of the bevel to seal the apex adequately. In the past, root end
preparation was done by slow-speed, specially designed
microhandpieces (Fig. 18.23). The rotary instruments are too
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B
complicated to follow the root canal system, occasionally
leading to misaligned preparations. Contemporary apical
preparation uses ultrasonic tips (Fig. 18.24).
Ultrasonic instruments offer the advantages of control and ease of
use; they also permit less apical root removal in certain situations
(Fig. 18.25). Another advantage of the ultrasonic tips, particularly
when diamond coated, is the formation of cleaner, better-shaped
preparation. Evidence suggests that success rates are significantly
improved with ultrasonic preparation. The ultrasonic tip can prepare
the isthmus between the two canals of the mesiobuccal roots of upper
first molars, which is a significant cause of conventional endodontic
failure on these teeth. While preparing the apex with the ultrasonic
instruments, constant saline irrigation is needed to avoid overheating,
which causes fracture of these fine instruments. Various designs and
shapes of tips are available to access different apices of each tooth in
the oral cavity. The ease of use and special angulations require less of
a bony opening and less beveling of the apical region and permit a
deeper, denser fill.
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B
A
• Fig. 18.23 Root end preparation and retrograde filling material (mineral trioxide aggregate) placement.
(A) Piezoelectric unit with 3-mm long tip to prepare the apical end. (B) Special carriers for delivering
the mineral trioxide aggregate retrograde filling material.

A B
• Fig. 18.24 (A) Ultrasonic tips are good alternative for root end preparation. (B) These tips permit prepa-ration with
better control and less root removal and the need for less bevel, which exposes fewer dentinal tubules.

intermediate restorative material, Cavit, and different luting cements

• Fig. 18.25 Ultrasonic preparation tips are available in different
shapes for accessing different teeth in the oral cavity compared with
the diameter of the conventionally used rotary burrs.
Root End–Filling Materials
The root end–filling material is placed into the cavity preparation
(Fig. 18.26). These materials should seal well and should be
tissue tolerant, easily inserted, minimally affected by moisture,
and visible radiographically. Importantly, the root end–filling
material must be stable and nonresorbable indefinitely.
Amalgam (preferably zinc free), intermediate restorative material,
and super ethoxybenzoic acid cement have been commonly used
materials. Gutta-percha, composite resin, glass ionomer cement,
have also been recommended; these materials have less clinical
documentation of success. Mineral trioxide aggregate (MTA) has
shown favorable biologic and physical properties and ease of
handling; it has become a widely used material. MTA has been
shown to be conducive to bone growth over the apical region. MTA
is a hydrophilic material, similar to Portland cement. MTA has a
working time of approximately 10 minutes, although it takes 2 to 3
hours to reach final set, which is not an issue because the root apex is
not a load-bearing region, at least not until bone fills in the defect.
The surgeon must be careful not to irrigate MTA out after placement,
so irrigation is done before placing the filling, and any excess is
wiped with a just-dampened cotton pellet.
MTA, with its properties, may be placed in a field in which
some hemorrhage has occurred; the final set is not adversely
affected by blood contamination. Von Arx published a meta-
analysis in 2010 that showed a higher success rate with the use of
MTA as a filling material (91.4%) compared with other materials.
Each of these root end–filling materials has different, unique
mixing and placement characteristics. The clinician should practice
with each before placement in a patient. Special carriers for MTA
have been designed and work well to deliver the material. A metal
carrier with a disposable plastic sleeve contains the material and
keeps it from contacting additional moisture as it is carried to the
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380 Part IV Infections
A
• Fig. 18.26 Special small carriers are used to place material, which is then packed with small condens-ers. Other cement
types of materials are carried and compacted with paddles and burnishers. (A) Frontal view. (B) Cross-section.
surgical site. MTA can be condensed and added to so that the
fill is complete.
Irrigation
The surgical site is flushed with copious amounts of sterile saline
to remove soft and hard tissue debris, hemorrhage, blood clots,
and excess root end–filling material. As mentioned with regard to
MTA, the irrigation is done before the MTA is placed to avoid
washing the filler out of the apical preparation.
Radiographic Verification
Before suturing, a radiograph is obtained to verify that the
surgical objectives are satisfactory. If corrections are needed,
these are made before suturing.
Flap Replacement and Suturing
Just before closure, the cervical region of the exposed teeth is gently
scaled to remove any debris, preexisting calculus, and granulation
tissue. This brief intervention speeds the reattachment and reduces
greatly the chance for recession. The flap is returned to its original
position and is held with moderate digital pressure and moistened
gauze. This expresses hemorrhage from under the flap and gives
initial adaptation and more accurate suturing. Absorbable monofila-
ment sutures are typically used to permit ease of removal, if needed,
and are associated with less wicking and retention of surface bacteria.
A sling suture is ideal in the esthetic zone to avoid gingival recession
(Fig. 18.27). After suturing, the flap should again be compressed
digitally with moistened gauze for several minutes to express more
hemorrhage. This limits postoperative swelling and promotes more
rapid healing.
Postoperative Instructions
Oral and written information should be supplied in simple,
straightforward language. The wording should minimize anxiety
arising from normal postoperative sequelae by describing the ways in
which the patient can promote healing and comfort. Instructions
inform the patient of what to expect (e.g., swelling, discomfort,
possible discoloration, and some oozing of blood) and the ways in
which these sequelae can be prevented, managed, or both. The
surgical site should not be disturbed, and pressure should be
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B
maintained (cold packs over the surgical area until bedtime
might help). Oral hygiene procedures are indicated
everywhere except the surgical site; careful brushing and
flossing may begin after 24 hours. Proper nutrition and fluid
intake are important but should not traumatize the area.
A chlorhexidine rinse, twice daily, reduces bacterial count
at the surgical site. This may minimize inflammation and
enhances soft tissue healing.
Analgesics are recommended, although pain is frequently
minimal; strong analgesics are usually not required. No
category of pain medication is preferred; selection depends on
the clinician and the patient. Analgesics for moderate pain
usually suffice and are most effective if administered before
the surgery or at least before the anesthetic wears off. A
protocol that works well is 400 mg of ibuprofen every 4 hours
for 48 hours starting as soon as the patient returns home.
The patient is instructed to call if excessive swelling or pain is
experienced. Postoperative complications are a response to injury
from the procedure; infection after this type of surgical procedure
is rare. However, the patient should be evaluated in person if
difficulties arise. Occasionally, sutures have torn loose, a foreign
body (e.g., a cotton pellet) is under the flap, or an overreaction of
soft tissues occurs. Again, antibiotics are not indicated; palliative
or corrective treatment usually suffices.
Suture Removal and Evaluation
Sutures ordinarily are removed in 5 to 7 days, if still present and
not resorbed, with shorter periods being preferred to enhance
healing. After 3 days, swelling and discomfort should be
decreasing. In addition, evidence of primary wound closure must
be present; tissues that were reflected should be in apposition.
Occasionally, a loose or torn suture may result in nonadapted
tissue. In these cases the margins are only readapted and
resutured if in the maxillary anterior esthetic zone.
Corrective Surgery
Corrective surgery is the management of defects that have occurred
by a biologic response (i.e., resorption) or iatrogenic (i.e., procedural)
error. These defects may be anywhere on the root, from cervical
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A B
D E
• Fig. 18.27 (A–F) Schematic of sling suture for reapproximating a gingival flap. This type of suture is helpful to prevent
recession around teeth and existing crowns. (Modified from Cohen ES. Sutures and suturing. In: Atlas of Cosmetic Reconstructive Periodontal
Surgery. 2nd ed. Philadelphia: Lea & Febiger; 1994.)
• BOX 18.5 Corrective Surgery
Indications
• Procedural errors (e.g., perforations)
• Resorptive defects
Contraindications
• Anatomic impediments
• Inaccessible defect
• Repair would create periodontal defect
margin to apex. Many defects are accessible; others are
difficult to reach or are in virtually inaccessible areas. Usually,
an injury or defect has occurred on the root. In response to the
injury, an inflammatory lesion may be present, or one may
develop in the future. A corrective procedure is necessary. In
general, the procedure involves exposing, preparing, and then
sealing the defect. Usually included are removal of irritants
and rebuilding of the root surface (Box 18.5).
Indications
Procedural Errors
Procedural errors are openings through the lateral root surface created
by the operator, typically during access, canal instrumenta-tion, or
after space preparation (Fig. 18.28). The result is perforation, which
presents a difficult surgical challenge, more so than repairing damage
to a root end. Perforations often require restorative manage-ment and
completion of the endodontic treatment, usually in conjunction with
the surgical phase. The location of the perforation influences success;
some are virtually inaccessible. If the defect is
CHAPTER 18  Principles of Endodontic Surgery 381
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C
F
on the interproximal aspect, in the furcation, or close to adjacent
teeth or to the lingual aspect, adequate repair may not be possible
or is compromised. Defects that are too far posterior (particularly
on the distal or lingual aspects) may be difficult to reach. The
nature and location of the perforation should be determined with
angled radiographs before the decision is made whether to repair
surgically, to remove the involved root, or to extract.
Resorptive Perforations
Resorptive perforations may originate internally or externally (
Fig. 18.29), resulting in a communication between the pulp
and the periodontium. A more serious defect is one that
extends to include cervical exposure to the oral cavity.
Resorption occurs for several reasons, but most cases include
sequelae to trauma, internal bleaching procedures, orthodontic
tooth movement, restorative procedures, or other factors causing
pulp or periradicular inflammation. Occasionally, resorptions are
idiopathic, with no demonstrable cause.
As with procedural errors, the considerations as to
treatability and surgical approach are similar.
Contraindications
Anatomic Considerations
Consideration must be given to structural impediments to a
surgical approach. Few impediments exist, and most can be
managed or avoided. Included are various nerve and vessel
bundles and bony structures such as the external oblique ridge.
Location of Perforation
As mentioned previously, the defect must be accessible
surgically. This means the clinician must be able to locate and,
ideally, readily visualize the surgical area.
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382 Part IV Infections

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A B

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C D
• Fig. 18.28 Postperforation repair. (A) A lesion developing lateral to the off-centered post suggests per-foration. (B) The
perforation is identified (arrow) on flap reflection. (C) The post is reduced to within the root. (D) The cavity is filled with amalgam.

hemostasis and material placement. A general guideline is that

Accessibility
A handpiece or an ultrasonic instrument generally is necessary
to prepare the defect. Therefore the defect must be reachable,
without impedance by structures or by lack of visibility.
Considerations
Surgical Approach
Repair presents a unique set of problems. The defect may wrap from
the facial to the proximal to the lingual aspect, creating not only
difficulties in visualization but also problems with access and
the defect is larger and more complex than it appears on a
radiograph.
In general, the defect must be enlarged to provide a sound
cavosurface margin and to avoid knife-edge margins. Occasionally,
the repair is internal (from inside the canal), with material being
extruded through the defect. The excess is removed and contoured
with burrs or sharp instruments. The objective is to seal and stabilize
the defect with a restorative material. If a post or other material is
perforating the root, it must be reduced with burrs to within root
structure and a cavity prepared. The defect is then restored with one
of the materials mentioned previously.
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A B

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• Fig. 18.29 External resorption repair. (A) The mesially angled radiograph shows the defect (arrow) to be lingual. (B)
After flap reflection, crestal bone reduction, and rubber dam isolation, the defect is prepared (arrow). Margins must be in sound tooth structure.
(C) The cavity is filled with amalgam, and the flap is apically positioned. (D) Long-term radiographic and clinical evaluations are necessary;
occasionally, resorption recurs.

A defect in the middle or apical third that is properly

Repair Material
External repair is often done with suitable materials such as
MTA or super ethoxybenzoic acid. MTA, in particular, shows
favorable biologic properties, and its white color blends in if
there is thin tissue over the defect.
Prognosis
Repairs in the cervical third or furcation, in particular, have the
poorest prognosis. Communication often is eventually established
with the junctional epithelium, which results in periodontal
breakdown, loss of attachment, and pocket formation. This means
that a periodontal procedure (e.g., crown lengthening) would be
required in conjunction with the defect repair.
384 Part IV Infections
prepared and sealed has a very good long-term prognosis.
Surgical Procedure
After the basic approaches with periapical surgery, the next step is to
perform corrective surgery. Flap designs are similar but are more
limited. A sulcular incision is usually required, with at least one
vertical incision to form a three-cornered flap. A full-thickness flap is
reflected, and bone is removed to expose the defect (Fig. 18.30).
Bone removal must be adequate to allow maximal visualiza-tion and
access. If possible, a rim of cervical bone should be retained to
support the flap and possibly to enhance reattachment; this is
frequently not possible with cervical defects.
 A
B
• Fig. 18.30 (A) The misdirected post is perforating distally. (B) The full mucoperiosteal (i.e., sulcular inci-sion) three-
corner flap is raised, and bone is removed to expose the defect.
A
• Fig. 18.31 (A) The post is reduced to well within the root, and the cavity is prepared. (B) In this cross-section through
the defect, a lingual wall to the preparation is evident.
The preparation of a facial or lingual defect is similar to
that of a class 1 cavity preparation (Fig. 18.31). An
interproximal defect resembles a class 2 preparation, with an
opening from the facial (or lingual) aspect and including the
interproximal wall but leaving a lingual wall (if possible).
The facial or lingual cavity is then filled by direct placement of the
material. The material is carved flush with the cavity margins. Flap
replacement, suturing, and digital pressure have already been described
earlier. Suture removal should be within 3 to 6 days. Postoperative
instructions are similar to those after periapical surgery.
Fractured Teeth
Preoperative radiographs and a careful clinical examination should
be done with a high index of suspicion of a vertical root fracture
before undertaking surgery. Mandibular molars and maxillary
premolars are the teeth that most frequently have occult vertical root
fractures. Although surgical exploration may be needed to show the
presence of a fracture definitively (Fig. 18.32), subtle radiographic
signs may alert the surgeon that a fracture is present and that surgery
is unlikely to be successful. Tamse et al. looked at radiographs of
maxillary premolars for comparison with the
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clinical findings at the time of surgery. 4 Very few (1 out of
15) teeth with an isolated, well-corticated periapical lesion
had a vertical root fracture. In contrast, halo-type
radiolucency was almost always associated with a vertical
root fracture (Fig. 18.33). This type of radiolucency is also
known as a J type in which a widened periodontal ligament
space connects with the periapical lesion creating the J
pattern.
In patient discussions, it is critical to review the exploratory
nature of the surgery, and the author of this chapter routinely uses
that as a descriptor of the planned surgery. In cases of root fracture,
a decision during surgery may need to be made either to resect a root
or extract a tooth if a fractured root is found. Obtaining the
appropriate preoperative consent and determining how the extracted
tooth site will be managed (with or without a temporary removable
partial denture) must be established before surgery commences.
Healing
Healing after endodontic surgery is rapid because most tissues being
manipulated are healthy with a good blood supply, and tissue
replacement enables repair by primary intention. Soft tissues (e.g.,
periosteum, gingiva, alveolar mucosa, and periodontal
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A B

C
• Fig. 18.32 (A) A fistula on midbuccal portion of the mesiobuccal root of a molar. (B) A full-thickness sulcular incision
reveals an unsuspected vertical root fracture. (C) Resection of the mesiobuccal root can be accomplished because a sulcular incision was
used, as opposed to a semilunar type.

ligament) and hard tissues (e.g., dentin, cementum, and bone)

are involved. Time and mode of healing vary with each but
involve similar processes. The specifics of short-term healing
of soft and hard tissues are discussed in Chapter 4.

• Fig. 18.33 The halo radiolucency involving the entire length of the
root is often pathognomonic for a vertical root fracture.
Recall
Recall evaluations to assess long-term healing are important.
Some failures after surgery are evidenced only by radiographic
findings. A 1-year follow-up is generally a good indicator. If,
after 1 year, radiographic evidence shows no decrease in lesion
size or the lesion size increases, it generally indicates a failure
and persistent inflam-mation. A decrease in lesion size (indicating
hard tissue formation) may lead to complete healing and requires
evaluation at 6 to 12 months. Of course, persistent symptoms—
such as pain or swelling (or both), presence of sinus tract, deep
probing defects, or other adverse findings—also indicate failure.
Healing by scar tissue forma-tion after surgery occurs primarily
in the maxillary incisors (Fig. 18.34). This is unusual and has a
unique radiographic appearance with an irregular distinct outline,
often separated from the root end. Healing by scar tissue
formation is considered a successful outcome.
Frequently, structures over the apex do not regenerate to a normal
appearance. At times, connective tissue or bony arrangements
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386 Part IV Infections
A B
• Fig. 18.34 Healing by scar tissue formation. (A) Failed treatment because of transportation and perfora-tion, leaving area
of canal (arrow) undebrided and unobturated. (B) Root end resection, curettage, and root end filling. (C) After 2 years, an area of radiolucency is
seen. Sharp border, separation from apex, and distinct radiolucency show this to be a scar.
leave a slightly “widened” periodontal ligament space. This
should have relatively distinct, corticated margins and not be
diffuse (which indicates inflammation and a failure).
To Perform a Biopsy or Not
A clinical controversy has ensued over the consideration as to
whether all periapical lesions treated surgically should have
soft tissue removed and submitted for histologic evaluation.
An editorial by Walton questioned the rationale of submitting
all soft tissue recovered for histologic examination, which then
ignited a series of letters to the editor. 5 Some organizations,
such as the American Association of Endodontists, have stated
in their standards that if soft tissue can be recovered from the
apical surgery, it must be submitted for pathologic evaluation.
On cursory review, it seems that it is easier to make this
recom-mendation than to have the surgeon determine whether
there is anything unusual about the case that warrants histologic
examina-tion. Walton makes a convincing argument against the
submission of all tissues because similar-appearing radiolucencies
that are not treated surgically do not have tissue retrieved for
pathologic identification.5 It also is accepted that the
differentiation between a periapical granuloma or periapical cyst
has no direct bearing on clinical outcomes and therefore cannot
be used as a rationalization for the submission of tissue.
The dilemma falls back to the surgeon that if a rare lesion
should present itself in the context of a periapical lesion and a
biopsy is not performed in a timely manner, the surgeon may
have exposure in a potential malpractice suit. Many surgeons
have a case or two in their careers that have “surprised” them
on the basis of the final pathologic diagnosis. However,
careful review of these cases usually depicts a clinical
situation inconsistent with a typical periapical infection.
An approach more logical than purely defensive is to set up
guidelines on which to determine that submission of tissue is not
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C
• BOX 18.6 Rationale in Decision for Biopsy of
Periapical Lesions
• Was there evidence of preendodontic pulpal necrosis?
•
•
Is the characteristic of the radiolucency “classic”?
Will the patient return for follow-up radiographs?
If all of these criteria are met, the surgeon may decide to
not submit routinely collected periapical tissue.
indicated. These guidelines are listed in Box 18.6. It is
recommended that the surgeon have documented in the record
the rationale for electing not to submit tissue in each specific
case. At a recent meeting of the American Association of Oral
and Maxillofacial Surgeons, only 8% of those attending a
symposium on endodontic surgery reported that they “always”
submit tissue for histologic examination.
Adjuncts
Some of the newer devices and materials have enhanced and,
in some cases, improved surgical procedures. These include
the light and magnification devices and techniques of guided
tissue regeneration.
Light and Magnification Devices
Surgical Microscope
The microscope has been adapted and used for surgery, as well as for
other diagnostic and treatment procedures in endodontics (Fig.
18.35). Advantages of the microscope include magnification and in-
line illumination. Microscopes also can be adapted for videotaping
and to transmit the image to a television monitor for direct viewing
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of the source of infection permits regeneration of the junctional CH

epithelium and healing without the use of membranes. PT
R
18
Bone Augmentation Pr
ci
Various substances have been placed in the periradicular surgical s
cavities in the attempt to enhance bony healing. Because of the En
location of the cavity and because most of the periphery is encased od
in bone or the periosteum, spontaneous bone regeneration is nt
predictable. Such augmentation materials are of minimal to no Su
benefit and need not be placed. Because the materials are being er

38

• Fig. 18.35 Surgical microscope has been adapted for endodontic pro-
cedures, including surgery. Magnification and in-line illumination
enhance visualization for diagnosis and treatment. Add-on binoculars
for dental assistant are useful adjunct. (From Johnson WT. Color Atlas
of Endodon-tics. Philadelphia: WB Saunders; 2002.)

or recording. These adaptations enhance the view of the

surgical field, help identify previously undetected structures,
and facilitate surgical procedures. Although some clinicians
advocate and are excited about the use of these microscopes, as
yet, substantial clinical benefits have not been demonstrated
through long-term controlled studies. However, some evidence A
suggests that the microscope use improves surgical techniques
and short-term outcomes.6
Fiberoptics
A new system, known as endoscopy, is available that uses a
very small, flexible fiber bundle that contains a light and an
optic system. The optics are connected to a monitor that
permits visualiza-tion of precise details of the surgical site.
This system also gives the clinician the option of videotaping
and recording the procedures.

Guided Tissue Regeneration

Originally intended for periodontal surgery, guided tissue
regenera-tion also has been applied to endodontic surgery. The
membranes used in this procedure are applied where defects have B
extended to cervical margins or as a covering of large defects
surrounded by bone. These membranes, particularly those that are
resorbable, may prove useful in selected situations. However,
evidence indicating their long-term effectiveness in endodontic
surgery is incomplete, and studies have not shown an increase in
bone density when a membrane is used. Whether use of
membranes results in long-term, substantial benefits has not been
demonstrated. This chapter author’s opinion is that the elimination
 C
• Fig. 18.36 (A) Large periapical lesion associated with teeth #27 and
#28 in proximity with an implant. Apical surgery was performed (B) with
a mineral trioxide aggregate seal; no graft or membrane was placed
into the defect. (C) Bone fill after 3 months.

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placed in a site with active infection, these adjuncts may then act
as a nidus for infection. Reviewing the literature provides some
studies that show increased radiographic success with concomitant
grafting, particularly with large lesions (>10 mm).7 Other studies
fail to show a benefit with grafting. 8 It is my experience that, as
noted previously, elimination of the chronic infection by apical
surgery will allow bone fill in even substantial defects (Fig. 18.36)
without the need for bone grafting.
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388 Part IV Infections References

1. Ng YI, Mann V, Rhabaran S, et al. Outcome of primary root canal
treatment: systematic review of the literature. Int Endod J.
When to Consider Referral 2007;41(1):6–31.
4. T
ams
2. Raedel M, Hartmann A, Bohm S, et al. Three-year outcomes of e A,
Although many of the procedures presented in this chapter apicetomy: mining an insurance data base. J Dent. 2015;43(10): Fuss
appear relatively straightforward, endodontic surgery is often 1218–1222. Z,
complex and difficult to perform. Clinicians should carefully 3. Von Arx T, Vinzens-Majaniemi T, Burgin W, et al. Changes of peri- Lust
consider the problems before undertaking such surgeries. odontal parameters following apical surgery: a prospective clinical study ig J,
of three incision techniques. Int Endod J. 2007;40(12):959–969. et al.
Training and Experience Radi
ogra
Most generalists do not have the advanced training, including phic
didactic and clinical experience, necessary to perform surgical feat
procedures. These procedures are a unique discipline and require ures
of
special skills in diagnosis, treatment planning, and management;
verti
they also require a special armamentarium. Skill in long-term cally
evaluation and resolution of failures or other complications is also fract
important. With increased emphasis on standards of care and ured
litiga-tion problems, coupled with the availability of experienced ,
special-ists, general dentists should consider their own expertise endo
as it relates to case difficulty. These procedures are often the last dont
hope of tooth retention. Lack of training may result in inadequate icall
y
or inappropriate surgery, loss of a particular tooth, and possible
treat
damage to other structures. One study has shown an improvement ed
in success rates with a more experienced surgeon.9 max
illar
Determining the Cause of Root y
pre
Canal Treatment Failure mol
Two steps are critical to success, particularly if surgery is being ars.
considered: (1) identification of the cause of failure and (2) Oral
design of the treatment plan. Frequently, surgery is not the best Surg
Oral
choice, but when necessary, it must be done appropriately. A
Med
specialist is better able to identify these causes and approach their Oral
resolution. If the cause of the failure cannot be identified, these Path
cases must be considered for referral. ol
Oral
Surgical Difficulties Radi
ol
In many situations, surgical accessibility is limited and even hazard- End
ous. For example, the neurovascular bundle near mandibular od.
posterior teeth and maxillary palatal root apices presents the potential 199
for creating paresthesia, excessive hemorrhage, or both. Complicating 9;88
:348
structures include overlying bone throughout the mandible and in the
–
palate, the frena and other muscle attachments, fenestrations of 352.
cortical bone, and sinus cavities. These structures require care, the 5. W
proper use of instruments, and surgical skill. alto
In summary, most of the procedures discussed in this n
chapter require greater training and experience than are RE.
provided in an undergraduate dental education program. If the Rou
clinician has not had additional postgraduate training and tine
hist
experience, referral should be considered. opat
hologic examination of endodontic periradicular surgical specimens:
is it warranted? Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
1998;86(5):505.
6. Pecora G, Kim S, Celleti R. The guided tissue regeneration
principle in endodontic surgery: one year postoperative results of
large periapical lesions. Int Endod J. 1995;28:41–46.
7. Tascheri S, Del Fabbro M, Testori T. Efficacy of xenogenic grafting with
guided tissue regeneration in the management of bone defects after endodontic
surgery. J Oral Maxillofac Surg. 2007;65:1121–1127.
8. Slaton CC, Loushine RJ, Weller RN, et al. Identification of
resected root-end dentinal cracks: a comparative study of visual
magnification. J Endod. 2003;29:519–522.
9. Lustmann J, Friedman S, Shaharabany V. Relation of pre- and
intraoperative factors to prognosis of posterior apical surgery. J

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Endod. 1991;17:239–241.

Bibliography
Andreassen J, Rud J. Correlation between histology and radiography
in the assessment of healing after endodontic surgery in 70 cases.
Int J Oral Surg. 1972;1:161.
Danin J, Linder LE, Lundqvist G, et al. Outcomes of periradicular
surgery in cases with apical pathosis and untreated canals. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87:227.
El Deeb ME, Tabibi A, Jensen MR Jr. An evaluation of the use of
amalgam, Cavit and calcium hydroxide in the repair of furcation
perforations. J Endod. 1982;8:459.
El-Swiah JM, Walker RT. Reasons for apicectomies: a retrospective study.
Endod Dent Traumatol. 1996;12:185.
Forbes G. Apical microsurgery for failed endodontics. Atlas Oral
Maxillofac Surg Clin North Am. 2000;8:1.
Garrett KK, Kerr MM, Hartwell G. The effect of a bioresorbable
matrix barrier in endodontic surgery on the rate of periapical
healing: an in vivo study. J Endod. 2002;28:503–506.
Gray G, Hatton JF, Holtzmann DJ, et al. Quality of root-end
preparations using ultrasonic and rotary instrumentation in
cadavers. J Endod. 2000;26:281.
Gutmann JL, Dumsha TC, Lovdahl PE. Problem Solving in
Endodontics: Prevention, Identification, and Management. 4th ed.
St Louis, MO: Mosby; 2006.
Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical
consideration and clinical techniques. Int Endod J. 1985;18:8.
Gutmann JL, Harrison JW. Surgical Endodontics. Boston, MA:
Blackwell Scientific; 1994.
Harrison JW, Jurosky KA. Wound healing in the periodontium
following endodontic surgery. 1. The incisional wound. J Endod.
1991;17: 425.
Harrison JW, Jurosky KA. Wound healing in the periodontium
following endodontic surgery. 2. The dissectional wound. J
Endod. 1991;17: 544.
Harrison JW, Jurosky KA. Wound healing in the periodontium
following endodontic surgery. 3. The osseous excisional wound. J
Endod. 1992;18:76.
Iqblal M, Kim S. For teeth requiring endodontic treatment, what are
the differences in outcomes of restored endodontically treated
teeth compared to implant supported restorations? Int J Oral
Maxillofac Implants. 2007;22(suppl):96–116.
Lieblich SE. Periapical surgery: clinical decision making. Oral
Maxillofac Surg Clin North Am. 2002;14:179–186.
Lieblich SE, McGivenin WE. Ultrasonic retrograde preparation. Oral
Maxillofac Surg Clin North Am. 2002;14:167–172.
Lubow RM, Wayman BE, Cooley RL. Endodontic flap design:
analysis and recommendation for current usage. Oral Surg Oral
Med Oral Pathol. 1984;58:207.
 https://t.me/LibraryEDent
McDonald N, Torabinejad M. Surgical endodontics. In: Walton R,
Torabinejad M, eds. Principles and Practice of Endodontics. 3rd ed.
Philadelphia, PA: WB Saunders; 2002.
Morgan LA, Marshall JG. A scanning electron microscopic study of in
vivo ultrasonic root-end preparations. J Endod. 1999;25: 567.
Pantschev A, Carlsson AP, Andersson L. Retrograde root filling with
EBA cement or amalgam: a comparative clinical study. Oral Surg
Oral Med Oral Pathol. 1994;78:101.
Sauveur G, Roth F, Sobel M, et al. The control of haemorrhage at the
operative site during periradicular surgery. Int Endod J. 1999;32:
225.
Shabahang S. State of the art and science of endodontics. J Am Dent
Assoc. 2005;136:41.
Skoner JR, Wallace JA, Fochtman F, et al. Blood mercury levels with
amalgam retroseals: a longitudinal study. J Endod. 1996;22:140.
Stromberg T, Hasselgren G, Bergstedt H. Endodontic treatment of
traumatic root perforations in man: a clinical and roentgenological
follow-up study. Sven Tandlak Tidskr. 1972;65:457.
CHAPTER 18  Principles of Endodontic Surgery
389
Tamse A, Fuss Z, Lustig J, et al. Radiographic features of vertically
fractured, endodontically treated maxillary premolars. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 1999;88:348–352.
Torabinejad M, Chivian N. Clinical applications of mineral trioxide
aggregate. J Endod. 1999;25:197.
von Arx T. Failed root canals: the case for apicoectomy (periradicular
surgery). J Oral Maxillofac Surg. 2005;63:832.
von Arx T, Penaroccha M, Jensen S. Prognostic factors in apical surgery
with root end filling: a meta-analysis. J Endod. 2010;36:957–973.
von Arx T, Walker WA III. Microsurgical instruments for root-end
@LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬
cavity preparation following apicoectomy: a literature review.
Endod Dent Traumatol. 2000;16:47.
Walton RE. Routine histopathologic examination of endodontic perira-
dicular surgical specimens: is it warranted? Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1998;86(5):505.
Witherspoon D, Gutmann J. Haemostasis in periradicular surgery. Int
Endod J. 1996;29:135.
Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular surgery:
a clinical prospective study. Int Endod J. 2000;33:91.
https://t.me/LibraryED
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