Recent Advances In Endodontic Surgery

Presented byHena Rahman (JR-III)

INTRODUCTION

According to the strictest definition of the word surgery, most endodontic treatment falls into the category of a surgical procedure, since removal of tissues, such as vital pulp, necrotic debris, or dentin, is involved. However, as commonly used, the term endodontic surgery refers to the removal of tissues other than the contents of the root canal space to retain a tooth with pulpal and/or peri-apical involvement. Endodontic surgery encompasses surgical procedures performed to remove the causative agents of radicular and peri-radicular disease and restore these tissues to functional health. With the recent advent of magnification and illumination, coupled with ultra-sonic root end canal preparations and sealing with new retro-grade filling materials, the success of surgical endodontic treatment will provide the answer to solving myriad problems that were once considered hopeless. The expanded scope of surgical endodontics includes apical curettage, apicoectomy, root end filling, root resections, hemisections, replantation, transplantation, and guided tissue regeneration, with more advances on the horizon. This gives the clinician a wide range of choices in this conservative approach. Microsurgery is defined as a surgical procedure on exceptionally small and complex structures with an operating microscope. The microscope enables the surgeon to assess pathological changes more precisely and to remove pathological lesions with far greater precision, thus minimizing tissue damage during the surgery. One of the most significant developments in the past decade in endodontics has been the use of the operating microscope for surgical endodontics . The medical disciplines (e.g. neurosurgery, ENT, and ophthalmology) incorporated the microscope into practice 20 to 30 yr ahead of us. It is now inconceivable that certain procedures in medicine would be performed without the aid of the microscope. The operating microscope provides important benefits for endodontic microsurgery in the following ways: Advantages and uses of operating microscope

i. Visualization of surgical field ii. Evaluation of surgical technique iii. Use of fewer radiographs iv. Patient education through video v. Reports to referring dentists vi. Reports to insurance companies vii.Documentation for dental legal purposes viii. Video libraries for teaching purposes ix. Marketing the dental practice x. Less occupational stress INDICATIONS FOR ENDODONTIC SURGERY 1. Surgical Drainage A. Necessity for drainage 1. Elimination of toxins 2. Alleviation of pain 2. Apical surgery A. Irretrievable root canal fillings 1. Obviously inadequate filling 2. Apparently adequate filling B. Calcified canals C. Procedural errors 1. Instrument fragmentation. 2. Nonnegotiable ledging. 3. Over instrumentation and apical fracture. 4. Symptomatic overfilling. D. Presence of dowels E. Anatomic variations F. Apical cyst G. Biopsy H. False indications. 1. Presence of an incompletely formed apex, making hermetic sealing of the apex impossible.

Replacement surgery A. 10. 7. .  Post-traumatic. Perforating carious and resorptive defects C. Replant surgery  Intentional. indicating destruction of apical cementum and dentin. CLASSIFICATION OF ENDODONTIC SURGERY It can be classified as follows: 1. Implant surgery  Endodontic. 6. 3. Persistent pain. Periodontal-endodontal defects  Guided tissue regeneration.  Correction. 3. 2. Extreme apical curvature.  Site of surgery. 9. B. CONTRA-INDICATIONS TO ENDODONTIC SURGERY 1.  Root resection. Internal resorption. 3. 5. bisection. Failure of previous treatment. 4. Fracture of root apex with pulpal death. Indiscriminate surgery. Extensive destruction of peri-apical tissue and bone involving one third or more of the root apex.  Poor bony support. radicular gingival groove. Root anomalies B. Local anatomic factors  Short root length. Psychological impact. Corrective surgery A. Inability to gain negative culture.  Endosseous. hemi section. Surgical drainage  Incision 2. 11. Poor systemic health. 8.Marked overfilling. Presence of crater shaped erosion of the root apex. Root apex that appears to be involved in a cystic condition. 4. 4.

Replant surgery  Intentional  Post traumatic. 1. Replacement surgery.  Guided tissue regeneration. Trephination (fistulative surgery) 2. 3. multiple foramina. Apical surgery. The surgical operating microscope was used for the first time in Precision is a key element in neurosurgery and ophthalmology in 1960. resected root surface under high magnification reveals anatomic details such .  Mechanical. provides the necessary illumination with a bright.shaped canals and apical root fractures.  Resection. shallow level.  Retro filling. A. The surgical operating microscope. endodontic microsurgery because of the restricted access to the surgical field. B. 2. which has long been a standard instrument in medical surgery. Periodontal repair. This enhanced visibility allows the surgeons to locate and treat anatomic variations such as partial or complete isthmus. Radicular surgery A. C.  Endodontic  Osseo-integrated (endosseous) Implication of microsurgery in Endodontics In medicine. focused light and magnification upto 32x. Main advantages of microsurgical approach are small osteotomies.  Curettage and biopsy (peri-radicular surgery). Corrective surgery.  Apicoectomy. incorporation of the concept of microsurgery began in the late 1950’s. B.  Resorptive. Perforative repair. Endosteal implants surgery. These variations often cannot be treated by nonsurgical means.

Examination of failed clinical cases and extracted teeth by surgical operating microscopes reveal that the surgeon cannot predictably locate.as isthumi. then the reasons for surgical failure by the traditional approach become clear. If we accept the premise that the success of endodontic surgery depends on the removal of all necrotic tissue and complete sealing of the entire root canal system. and the maxillary sinus. Although the chances of damage to these structures are minimal. traditional endodontic surgery does not have a positive image in the dental profession because of its invasive nature and questionable outcome. the mental foramen. Comparing Traditional and Modern Endodontic Microsurgery Procedure Traditional Surgery Microsurgery Precise Small (= < 5mm) Precise Small (< 10 degrees) Customary Precise Identification of the apex Sometimes difficult Osteotomy Root surface inspection Bevel angle Isthumus identification Retro preparation Large (= > 10 mm) Imprecise Large (45 degrees) Nearly impossible Approximate . The Differences between Traditional and Microsurgical Techniques in Endodontic Surgery Endodontic surgery is perceived as difficult because the surgeon must often approximate the location of anatomical structures such as large blood vessels. ultrasonic instrument permit conservative coaxial root end preparations and precise retrofills. lateral canals. especially ultrasonic instruments. These limitations can only be overcome with the use of the microscope with magnification and illumination and the specificity of microsurgical instruments. canal fins. Together with microscope. and fill all the complex apical ramifications with traditional surgical techniques. clean.

Cases in the D. The symptoms are the only reason for the surgery.8% Healing Success (over 1 40 – 90% yr) Classification of Endodontic Microsurgical cases Endodontic surgery can be classified as follows:1 Class A represents the absence of a periapical lesion. 4 Class D represents a clinical picture similar to class C with a periodontal pocket 5 Class E classifies a periapical lesion with an endodontic and periodontal communication but no root fracture 6 Class F represents a tooth with an apical lesion and complete denudement of the buccal plate. 6 _ 0 monofilament 2–3 days post-op 85 – 96. proper and successful treatment requires not only endodontic microsurgical techniques but also current periodontal surgical techniques. E. 3 Class C represents the presence of a large periapical lesion progressing coronally but without periodontal pockets. B and C present no significant treatment problems and do not adversely affect the successful treatment outcomes.Root end filling Sutures Suture removal Imprecise 4 _ 0 silk 7 days post-op Precise 5_ 0. the membrane barrier techniques) PRESURGICAL PRECAUTIONS . but unresolved symptoms after nonsurgical approaches have been exhausted. Classes A. (eg. Although these cases are in the endodontic domain. 2 Class B represents the presence of a small periapical lesion & no periodontal pockets. F categories present serious difficulties.

An earache is usually indicative of radiating pain from an infected ipsilateral mandibular molar tooth. swelling. Endodontic surgical procedures produce transient bacteremia. endocarditis. It is important that the patient be treated in consultation with the patient’s physician. The patient’s complaint or complaints and chronologic history of the problem should guide the line of inquiry to identify the etiology and source of the problem. therefore having it come within a few inches of the face can be intimidating. organ transplants. This is extremely important because most surgeries are done under local anesthesia so the patient’s confidence in the surgeon allays anxiety. The tooth should be evaluated for its periodontal integrity and for fractures. The interview give the surgeon the opportunity to develop thrust within the patient. or placement of an implant prosthesis.Patient interview The patient interview is an important part of the diagnostic work-up. such as a hip or knee replacement. to assess the patient’s state of mind and physical conditions. The surgeon should also explain the microscope and microsurgical methods. Medical Evaluation A systematic approach to determine the patient’s medical condition is essential. (e. the success of surgical endodontics becomes questionable. hence antibiotics must be given prophylactically for patients with a history of rheumatic fever. most importantly to establish a rapport with the patient. it should be traced with a gutta-percha point. For most patients this is the first experience with a microscope. reinforced pain such as earache and heaviness or tightness of the jaws or muscles). In cases designated class E or F. If a sinus tract has developed. . the most recent guidelines of the AHA should be observed. Oral examination The oral examination should be conducted in a systematic manner and in a specific sequence. Extraoral swelling indicates that surgery should be postponed until the swelling is reduced with oral antibiotics.g. Pain. abnormal or damaged heart valves.

inferior alveolar nerve bundle. PREMEDICATION The drugs used in endodontic practices before and after endodontic surgery are:1 Anti-inflammatory analgesics:. long axis. Radiographic evaluation Anatomic deviations.Reduces microflora with a 0.peridex. the morning of surgery & 1 hr before surgery. periradicular pathosis. root resorption.A vertical fracture can be detected clinically or radiographically or upon elevation of the flap. perioguard) given the night before surgery. With this regimen most patients will not require narcotic pain medication.12% chlorhexidine gluconate mouth rinse (eg:. It is very important to view the radiograph systematically. 2 Tranquilizers – sublingual triazolam taken 15-30 minutes before the surgery relieves anxiety. Atleast two periapical radiographs taken from different angles ie one straight on and the other 250 to 300 mesially or distally are needed to ascertain root length.It is recommended that the patient (average weight of 150lbs) take ibuprofen (400 mg) just before surgery to minimize the postsurgical inflammatory response. fractures. changes in bone patterns and the success or failure of prior endodontic therapy can be obtained from radiographs. morphology and proximity to the mental foramen. 4 Antibacterial rinses . 3 Antibiotics – patients in poor health must be premedicated in accordance with the most recent AHA recommendations. or the antrum which allows the clinician to visualize the three-dimensional space. evidence of traumatic injuries. To minimize bleeding problems during surgery the dose should not be taken sooner. periodontal disease. Rinsing continued after the surgery for 1 week reduces microorganisms in the oral cavity & .

and the number of collocated β . High concentration of 1:50. The predominant receptor in the oral tissues is an α .000 epinephrine is preferred for surgery. The current recommended maximum doses of For endodontic microsurgery. An aspirating syringe ensures that epinephrine is not accidentally injected into the blood stream. Hemostasis in a surgical procedure can be considered in three phases (1) presurgical (2) surgical and (3) post surgical. LOCAL ANESTHESIA AND HEMOSTASIS Adequate hemostasis is a prerequisite for microsurgery. Epinephrine Connection – ideally for the purposes of endodontic surgery.receptor. local anesthesia has two prime purposes (1) anesthesia and hemostatis. A good topical anesthetic ointment or transoral lidocaine patch (eg: .promotes better healing.000 epinephrine.2 receptors is very small. effective hemostasis is essential because the bone crypt & resected . Thus the drugs predominant effect in the oral mucosa.Dentipatch) is left in place for a minimum of 2 minutes to take effect. Virtually the effects associated with epinephrine in dentistry are dose – route dependent. root surfaces have to be examined at high magnification. submucosa and periodontium is that of vasoconstriction. because it produces effective and lasting vasoconstriction via the α-adrenergic receptors in the smooth muscle of the arterioles. The anesthetic solution of choice for endodontic surgery is lidocaine 2% Hcl with 1:50. Presurgical phase Local Anesthesia – In surgical endodontics. an adrenergic vasoconstrictor would be a pure & agonist. This prevents the anesthetic from being dissipate prematurily by the microcirculation.

epinephrine in local anesthetics are: Epinephrine Mg/ml 0.01 0.000 epinephrine. increasing the potential for substantial bleeding during surgery. not only is hemostasis inadequate. infiltration into the surgical site is essential for hemostasis. Pulse rates returned to normal within 4 minutes Local anesthetic injection techniques Inferior alveolar nerve block using the epinephrine – containing lidocaine has been shown to reduce blood flow to the jaw by 90% along with buccal and lingual infiltration to enhance the vasoconstrictive effect at the surgical site. minimal surface contact with microvascular and neural channels and less than optimal . If the anesthetic is injected in to the muscle. statistically insignificant increases in pulse rate 2 minutes after the injection.000 1:200. As skeletal muscle has a predominance of β -2 receptors. resulting in delayed and limited diffusion into adjacent tissues. the injection of epinephrine into muscle will produce vasodilation rather than vasoconstriction and therefore must be avoided.000 epinephrine There was no correlation between the administration of epinephrine. but a more rapid uptake of the anesthetic and vasoconstrictor occurs.20 0. The infiltration sites for the anesthesia are in the loose connective tissue of the alveolar mucosa near the root apices. Rapid injection produces localized pooling of solution in the injected tissues. What ever the injection technique used for anesthesia.20 0.5 11 22 Clinical reasons for using 1:50.000 Mg 0. blood pressure and pulse rate during periapical surgery using 1:50. The majority of patients had transitory.005 Maximum parts/thousand 1:50.20 ml 10 20 40 # cartridges 5.02 0.000 1:100.

For surgery on anterior teeth. 11-inch needle in an aspirating syringe. mesial and distal to the tooth. another infiltration injection of one-half carpule is made into the lingual aspect of the tooth. an infraorbital block injection can be very effective to attain profound anesthesia in this area.hemostasis. After the mandibular block. a supplemental nerve block should be injected near the incisive foramen to block the nasopalatine nerve. One carpule of 2% lidocaine HCl (ie. For surgery in the posterior quadrant. The choice for the supplemental anesthetic is also a 2% lidocaine Hydrochloride (eg: xylocaine) solution with 1:50. the anesthetic is injected near the greater palatine foramen to block the greater palatine nerve.000 epinephrine is also preferred with a 27 gauge. xylocaine) solution with 1:50. If the bleeding persists. If a patient has a large swelling in the cuspid and premolar region. The initial incision should be delayed for atleast 15 minutes after the injection until the soft tissues through out surgical site have blanched. Maxillary Anesthesia 1 Infiltration anesthesia in the mucobuccal fold over the apex of the root and in the adjacent mesial and distal areas is the most effective anesthesia for maxillary teeth. another carpule is injected in to the mucobuccal fold.000 epinephrine Mandibular Anesthesia – For surgery in the mandible a mandibular and long buccal nerve block with a supplemental infiltration injection in the mucobuccal fold and lingual mucosa in the apical area is the most effective method. topical hemostats should be considered. Hemostatic Control during Surgery Local hemostasis can be achieved by the pressure technique of pressing cotton pellets or gauze into the bone crypt for a few minutes. Topical Hemostats The topical Hemostatic agents are:- . After 10 minutes.

2 pellets contain 0. . thus there is minimal absorption into the systemic circulation. Ferric sulfate solution Etiologic agents Thrombin VSP (Throbostat.55 mg racemic epinephrine and Racellet no. Kalamazoo.2 mg.Mechanical Agents Bone wax (Ethicon. Thrombogen) Absorbable Hemostatic agents Intrinsic action 1) Gelfoam (The Up john Co.. The following procedure is most effective to achieve local hemostasis quickly during apical surgery:1 A small epinephrine – saturated cotton pellet is first placed in th bony crypt and packed solidly against the lingual wall of the bony crypt. The amount of epinephrine in each pellet varies according to the number on the label.3 pellets contain an average of 0. NJ) Chemical agents Epinephrine – saturated cotton pellets and other vasoconstrictors. For example Racellet no.2 pellets do not seem to change the pulse rate of patients when pressed into the bone cavity for 4 minutes. MI) 2) Absorbable collagen 3) Microfibrillar Collagen hemostats Extrinsic action 1) Surgicel Mechanical 1) Calcium Sulphate Epinephrine pellets – Racellets are cotton pellets containing racemic epinephrine HCl. Somerville. Suggested by Grossman. This is plausible because topically applied epinephrine causes immediate local vasoconstriction. Racellet no.

It’s a bone-inductive agent and is absorbed The commercially available FS solutions are control – 50% FS. Ferric sulfate solution – Ferric sulfate (FS) is a hemostatic agent causing hemostasis by agglutination of blood proteins from blood with both ferric and sulfate ions and the acidic pH (0. tamponade effect). At this time even the most persistent bleeding should have stopped. Calcium sulfate paste It is not designed as topical hemostat. FS is known to be cytotoxic and to cause tissue necrosis.e. filling until the entire bone crypt. FS solution is applied to the bone crypt. Monsel sol – 70% FS . small sterile cotton pellets are packed in over the first pellet. The color differences are useful for identification of the sources of any persistent bleeders.21) of the solution occlude the capillary orifices. Brushing FS solution on to the buccal surface around the bone crypt just before retrofilling ensures hemostasis during this important procedure. FS is an excellent hemostatic agent on the buccal plate for small bleeders and is readily applied and easily removed by the yellowish FS fluid turn into a dark brown or brown coagulum immediately upon contact with epinephrine.2 In quick succession. but systemic absorption of FS solution is unlikely because the coagulum isolates it from the vascular bed. CS paste acts by mechanically blocking blood vessels (i. 3 Pressure is applied on these pellets and all but the last pellet is removed after 2-4 minutes. FS has also been found to damage bone and to delay healing when used in maximum amounts and when left in-situ. FS affects hemostasis through a chemical reaction with blood. When there is a persistent bleeding despite of the epinephrine and cotton pellet technique. & Stasis – 21% FS. When the FS coagulum is completely removed and the surgical site is thoroughly irrigated with saliva immediately after hemostasis and before closure. there is no adverse reaction.

Calcium sulfate paste. After the surgery. it is tamped down with a moist cotton pellet. Thrombin. MCH is prepared from bovine corium. which then release coagulation factors. Gelfoam. CS comes as a powder and a mixing solution. sterilized gauze placed over the suture helps stabilize the flap and control oozing of the blood from the surgical sites. Post surgical Hemostasis To avoid post surgical bleeding. These and plasma factors help form fibrin and subsequently a clot. boen wax and surgical achieve hemostasis through a tamponade effect by mechanically blocking open vessels. the Cs is left in the bone cavity. combining with fibrinogen to form blood clots. wet. After placing the pellet into the bone. 5 minutes off. whereas epinephrine causes vasoconstriction by activating α adrenergic receptors. . Collagen.by the body after 2 to 3 weeks. where it acts as a barrier to the faster –growing soft tissue and potentially a matrix for the osteoblasts. exposing the root apex for further surgery. CS is an excellent agent for a large bone crypt that does not respond to the other methods of hemostasis. Gelfoam made of animal skin gelatin acts intrinsically by promoting the disintegration of platelets causing release of thromboplastin. Collagen is known to aggregate platelets. pasty pellet the size of the osteotomy. for 1 to 2 days. An ice cold. Other commercially available hemostats – Many other commercially available topical hemostats are costlier effective and include bone wax. CS paste hardens quickly and the excess is removed. which promotes rapid hemostasis by attracting platelets. it is important that hemostasis be maintained after the flap is sutured. and surgical. The gauze should be placed into the mucobuccal fold for about 1hr and an ice pack should be applied to the cheek 10 minutes on. Hemostat (MCH). Thrombin is a protein that acts rapidly in an intrinsic fashion. Microfibrillar collagen. which can be mixed to make a thick.

The two reasons for proper management of soft tissue when performing endodontic surgery include:. especially when the root is long. retraction. The rectangular design have the base of the flap as wide as the top which follows the direction of the tissue fibers of blood vessels because less severity to . The horizontal incision extends from the gingival sulcus. This design reflects the entire soft tissues. The vertical incision should be firmly against cortical bone between the root eminences. Design for sulcular full thickness flap The flap design involves horizontal and vertical incisions. FLAP DESIGNS The two major categories of flap designs are (1) Sulcular full thickness flap (or full mucoperiosteal flap) and (2) mucogingival flap design (or limited mucopperiosteal flap). elevating and retracting the flap with minimum trauma to the tissue and repositioning. because the mucoperiosteum is thin over the root eminence and tears easily. incision. The rectangular design may be better for anterior teeth than the triangular design because it provides better access to the root apex. suturing the flap precisely into its original position. attached gingival. through the fibers of the periodontal ligament to the crestal bone. This can be achieved by proper flap designing making precise incision.SOFT TISSUE MANAGEMENT The soft tissue management consists of flap design. repositioning & suturing. elevation.to gain adequate access to the surgical site and to ensure good post surgery healing. The incision should pass through the mid-col area separating the buccal and lingual papillae. midcol and mucosa overlying the cortical plate with the horizontal incision being an intrasulcular incision. Thus provides the best access to all surgical sites in the oral cavity and can be a triangular flap with one vertical releasing incision or a rectangular flap with two vertical releasing incisions.

For surgery on a mandibular first molar. In general whether it is the triangular or rectangular design. The purpose of the scalloped horizontal incision is to provide a guide for the correct repositioning of the elevated flap for suturing which leaves a faint unnoticeable scar in the attached gingiva. the sulcular full thickness flap is preferred for most endodontic surgical cases. hard. Design for mucogingival flap: The mucogingival flap design or limited mucoperiosteal flap design is most suitable for crowned teeth. The vertical incision of the mucogingival flap should be parallel. The junction where the horizontal scalloped incision in the attached gingival meets the vertical incision should be rounded to promote smoother and faster healing. knobby scar. the flap should be broader at the base to facilitate better microvascular perfusion (ie Trapezoidal flap). the vertical releasing incisions should be made distal or mesial of the first premolar . There is a significant difference in healing and potential scar formation. they are wider at the base in the L – O design. The angle of the incision in relation to the cortical plate is 45 degrees. In fact. the wider-based flap causes delayed healing and unsightly scars because the incision cuts the fiber lines and blood vessels obliquely rather than tracing them. Earlier it was taught. . For posterior teeth the triangular design with one mesial vertical releasing incision is recommended. The mucogingival flap differs from Leubke – Ochsenbein design in that the two vertical releasing incisions are parallel. The design calls for a scalloped incision in the middle of the attached gingiva reflecting one half of he attached gingiva close to the mucobuccal fold. leaving the remaining one half of the attached gingival intact around the root and the sulcus. where there is an esthetic concern for open – crown margins as a result of the surgery. because this angle provides the widest cut surface allowing for better adaptation once the flap is repositioned. Sharp 900 angled intersection makes healing slower and leaves a small.the fibers & allowing the sutured incisions to heal quickly with no scarring.

The elevators P14S or P9 HM are placed underneath the gingiva at the line angle. The mucoperiosteum is lifted away from the alveolar bone by gently lifting the elevator toward the apex while it is under the flap. The serrated tips provide better anchorage on the bone and . Retractors have narrow tips which are convex possessing problems.Semilunar flap Widely used in the past. The sharp wide end of the elevator is placed at a 45 degree angle to the cortical bone surface. a traumatized flap will also swell. Retractors in Endodontic Microsurgery KP retractors have wider (15mm) and thinner (0. FLAP RETRACTION The retractor should be chosen for the specific purpose and to fit the anatomy of the cortical plate. because the only point of contact with the bone is the small area at the top of the curve. FLAP ELEVATION After giving horizontal and releasing incisions.5 mm) serrated working ends. The irregular surfaces of buccal cortical plates can easily contribute to tearing or perforating the flap during the reflection. Moist gauze underneath the initially reflected flap helps by gently pushing the gauze with an elevator to produce a smooth flap elevation which have minimal bleeding. the microperisteum is elevated and reflected with a sharp elevator. making it difficult to place it back to its original position without additional trauma. the mucoperiosteum peeling motion closely tracing the cortical bone contours. In addition to shrinking. Where the cortical bone protrudes the convex retractor is an unstable anchor. A perforated or torn flap will be difficult to suture. Now rarely used because it does not allow for adequate access to the surgical site and often leaves a noticeable scar. Some are concave & some are convex to accommodate the irregular contours of the buccal plate.

KP – 1 retractor has a V shaped working end to fit the bone eminences in the maxillary molar and mandibular incisor regions. the remaining sutures can be placed. After the flap has reassumed its original size. The KP – 2 retractor has a slight concavity in the center and is curved gently inward to accommodate the slight bone eminences found in the maxillary canine region. a chilled (with ice water). damp gauze pad is placed firmly on the flap with finger pressure to remove accumulated blood and fruits from underneath the flap. Repositioning of the Flap After surgical procedures the retracted tissue is carefully repositioned with tissue forceps. more predictable postoperative outcome. SUTURE MATERIALS AND SUTURE TECHNIQUES Silk sutures are braided and exhibit a wicking effect that accumulates bacterial plaques. Resorbable gut sutures are/not recommended. Synthetic monofilament sutures. Flap shrinks during lengthy surgery. except when patient can’t return. the Groove technique overcomes the danger of being close to the mental foramen during . such as supra mid and monovicryl. so that the light from the microscope is not reflected. The surfaces of the retractors are matted. Removal of sutures is recommended within 48 hrs.prevent accidental slipping. Another suture is placed just above the free ends to reduce the tension on the free ends. mandibular surgery. Regardless of the suture materials. The KP – 3 retractor tip has a slight convexity that is well suited for the mandibular premolar and molar bone anatomy. The preferred suture size is 5 – 0 or 6 – 0. hence the flap may have to be stretched for proper adaptation and first strategic suture is placed into the free ends of the triangular or rectangular flap. After repositioning the flap. resulting in a better. Also causes severe inflammation to the incision site. have no wicking effect. flexibility as compared to 4-0 silk sutures without the risk of causing inflammation. The third strategic suture is a sling suture around the tooth centre to the flap. Monofilament sutures have smoothness. A clean. bloodless surgical site will aid in the accurate repositioning of the flap.

the clinician should superimpose the visualized mental image gained from the radiographs and clinical examination onto the cortical plate. except when a 6-0 or smaller sutures are used. and the antrum can be ascertained. the inferior alveolar nerve. the position of the apices in relation to the crown. The vertical releasing incision is sutured with interrupted sutures. Two simple suturing techniques are there:. Suturing under the microscope provides negligible added advantage. In addition.patient must keep the surgical site as clean as possible by frequent rinsing with warm salt water and chlorhexidine to prevent any plaque accumulation after the surgery. The first step is to expose periapical radiographic images perpendicular to the roots from two different horizontal angles. The suture is then led around the lingual and interproximal aspects of the tooth to go through the adjacent buccal papilla. the proximity of each apex to the apices of adjacent teeth. concern.5 x to 4. OSTEOTOMY Osteotomy is the removal of the facial cortical plate to expose the root end. the interproximal In the sling-suturing technique. This is done to ascertain the length and curvature of the roots.interrupted and sling. and the number of roots. It must be approached with a visualized 3-D image to ensure it is made exactly over the root apices. where a knot is made to secure the suture. the mental foramen. the buccal gingival papilla is pierced with a 3/8 inch circle or straight 5-0 suture needle that is then brought through the interproximal space of the tooth. and sulcular incisions are sutured with sling sutures. because the site for suturing is readily seen by with 3.5 x telescopes. The value of using a microscope with this procedure is marginal. Once the flap has been raised. The path is now reversed to arrive at the first buccal papilla. To locate the apex:The 6-0 sutures are generally used for crowned maxillary anterior teeth where gingival esthetics and crown margins are always a .

soft and bleeds when scraped with probe.13 and no. leaving just enough space to manipulate the ultrasonic tip and microinstruments within its confines.1 round. whereas the bone is white. The absence of a distinct periodontal ligament stain at mid magnification (10 x to 12X) indicates that the root tip has not yet been exposed.1) Mark the probable apex position on to the buccal plate using the radiograph as a guide 2) Make a 1 mm deep indentation with a no. The large osteotomy causes slower and incomplete healing period. yellowish color and is hard. Large size of the osteotomy causes destruction of the buccal plate resulting in periodontic endodontic communication. A larger than 10 mm osteotomy was the norm with the previous method. The root has a darker. high speed bur and fill it with a small amount of radioopaque material such as gutta-percha. even a small osteotomy looks huge. Root tip when cannot be distinguished. Under 10 x to 20 x magnification of the microscope. A radio graph exposed with this marker in place will show the marker in relation to the root apex. Periradicular Curettage Periradicular curettage does not eliminate the origin of the lesion it only relieves the symptoms temporarily. methylene blue is used at the osteotomy site which stains the periodontal ligament. This is one of the true advantages of using the microscope in endodontic surgery. Optimal Osteotomy size Osteotomy should be as small as possible but just large enough to manipulate ultrasonic tips freely within the bone crypt.14 curettes . The microscope clearly distinguishes the root tip from the surrounding bone. This magnified field forces the clinician to work in a small space with small but precise movements resulting in a small osteotomy. Because the length of an ultrasonic tip is about 4 to 5 mm. The granualomatous soft tissue must be removed completely before the apex is resected done by Columbia no.

Canal system appears elongated with more acute bevels. under 12 x to 25 x microscope magnification. Another advantage of examining the resected root surface under the microscope is the identification of the causes of endodontic failure. Two important elements to consider with this procedure are 1) Extent of apical resection (apicoectomy) 2) Bevel Angle Microleakage is the common denomine underlying the failures in endodontics and endodontic surgery. Once the bone crypt is free of granulation tissue and the root tip is clearly identified. The most frequent causes are missed canals. APICAL RESECTION Apical resection is a root end resection or apicoectomy. premolar and molar teeth demonstrate an hourglass shape. This is done at low magnification of 4 x to 8 x with the Lindemann bur in an Impact Air 45 handpiece using copious water spray. the resection must be extended deeper lingually. . the resected root surface is stained with methylene blue and is examined carefully using a CX – 1 microexplorer. This is done to verify that the entire root tip has been removed. If the stained PDL is visible only around the buccal aspect. The outline of the anterior teeth demonstrate usually around outline. 3 mm of the root tip is resected perpendicular to the long axis of the root. apical microfractures with amalgam retrofillings and lingual perforations of lingually positioned apices. especially with lingually inclined roots. Try to resect perpendicular to the long axis of the root. The resected root surface is examined at midmagnification (10 x to 12 x) for the presence of the periodontal ligament.or molt or Jaquette 34/35 curettes under medium magnification (10 x to 16 x) Inspection of Resected Root Surface under the microscope Once hemostasis is established in the bony crypt. The most common failures of premicroscope endodontic surgery can be attributed to misplaced amalgam retrofilling. poor canal obturation and microfractures.

mesiolingual root of mandibular molars. No biologic basis for this practice existed.Extent of Apicoectomy The amount root tip to resect depends on the incidence of lateral canals and apical ramifications at the root end.2. Bevel Angle Bevel helps the surgeon to view the apex so that it can be identified and retroprepared. No bevels angle thus would be best. counting the incidence of lateral canals and apical ramifications at each level. Together with a small osteotomy and bevels between 0 and 10 degrees. . Additional resection reduced the percentage insignificantly. Any remaining lateral canals are sealed during retrograde filling of the canal. In this manner. surgical complications. Only when 3 mm of the apex is resected are lateral canals reduced by 3 %. A root resection of 3mm at a 0-degree level angle removes the majority of anatomic entities that are potential causes of failure. thus preserving tooth and bone structure promoting better healing. Bevel angle is used to 1) gain visual and operating access for root tip /resection 2) place retrofilling materials and 3) Inspect. which are offset by 90 degrees from the handle. These reasons were especially true for operating on lingually inclined roots eg:. ultrasonic retropreparation tips and micromirrors allows the apex to be prepared with virtually no bevel. Early the bevel angle is 45 degrees. Therefore removing the apex beyond 3mm is of marginal value and compromises a sound crown / root ratio.3and 4 mm from the apex. such as the unnecessary reduction of the crown to root ratio and creation of a periodontic endodontic communication can be eliminated or minimized. Gilheany and colleagues found a positive correlation between increasing bevel angles and increasing apical leakage. The combination of the microscope. Using a computer system the roots of the Hess models were resected. the minimal removal of both cortical plate and the root apex are ensured. 1. This is made possible by small. only 3 mm long ultrasonic tips.

The root end preparations did not often follow the long axis of the root.The root resection must be done perpendicular to the long axis of the root. rather it went off to the side. Retropreparation not placed down the long axis of the pulp canal 2. Resections not made at 90 degrees to the long axis result in an uneven or incomplete resection of the apex. ROOT END PREPARATION It’s the fulfillment of biologic imperative with the hermetic sealing of any actual or potentially noxious agent within the physical confines of the root. Retropreparation lacks sufficient retention form 3. Often retrofillings were too large. resulting in a dislodged apical seal. Retropreparation lack proper (bucco – lingual) extension to assure adequate seals 4. occasionally perforating the lingual aspect of the root end. Retropreparation weakens delicate apical dentin by unnecessary over enlargement ULTRASONIC APICAL PREPARATION One of the advancements in endodontic surgery that allowed greater efficiency . leaving leaky lateral canals. The clinician should use a 10-degree bevel and tilt the patients head to the side. The buccal aspect is resected but the lingual part is partially or not resected at all. surgeons must approach the resection with this lingual inclination in mind. covering most of the resected root surface and too shallow. Retropreparation fails to include isthmus areas 5. Ideal retropreparation It is a class I preparation alteast 3 mm into root dentin with walls parallel to and coincident with the anatomic outline of the pulpal space. Major errors of retropreparation 1. for optimal viewing of the apex. away from the microscope. Because the apices of many teeth (especially maxillary anterior teeth) are tilted slightly lingually.

Kis tips are different from CT tips in terms of shaft angle. It is important at this stage that the tip is positioned parallel with the long axis of the root. more convenient angles. including the crown and root eminence and compare this with the position of the ultrasonic tip. and Spartan / obtura co. The advantages of ultrasonic tips over microhead burs are 1 Better access. Thirdly. 4 Precise isthmus preparations with parallel canal walls for better retention of filling materials. and relocation of irrigation port.was the adaptation of piezoelectric ultrasonics for root end preparations. 2 More thorough debridement of tissue debris. tip angle and length. depending upon the location of each apex. especially in difficult to reach areas as the lingual apex. Satelect/ Amadent Co. These microtips are very narrow in diameter ie about one tenth the size of a conventional microhead handpiece.) to accommodate virtually all access situations. Ultrasonic Root End Preparation This procedure is accomplished under the miscroscope at low-to-mid magnifications (14 x 16x). 3 Conservative preparations tracing the long axis at a precise depth of 3 mm. the surgeon must examine the position of entire tooth at low magnification (4 x). at low magnification (4 x to 6 x). To accomplish this. The first ultrasonic tips for endodontics and endodontic surgery were the CT tips made of stainless steel (SS) and designed by Dr. Gary Carrin 1990. the selected ultrasonic tip is positioned at the apex. Ultrasonic tips are available in various configurations (Analytic Endo. The location of the ultrasonic irrigation shaft. Failure to make this comparison will risk an . a number of appropriate tips are preselected. which must be critically examined at high magnification (16 x to 25 x) to see the microanatomy. In 1999 Kis tips were introduced which have cutting efficiency by coating the tip with zirconium nitride. delivers maximum irrigation volume directly into the cutting site. The resected root surface then is stained with methylene blue.

the preparation must be inspected at high magnification (16 x to 25 x).off-angle root end preparation or perforation. A typical 3 mm retropreparation should take less than 1 minute with kis tips. The incidence of lateral canals and apical examination in the natural apex have been studied. The completed preparation should be inspected for clean. Fourth. sharply defined walls. Depth of the root end preparation The optimal depth of the root end preparation should be 3 mm. Although a retropreparation deeper than 3 mm does not provide any greater benefits. & over 95% of these anatomic entities are found within the apical 3 mm. For effective cutting action. anatomic structures like accessory canals and microfracture. INSPECTION OF THE ROOT END PREPARATION The root end is best prepared at low to-mid magnification (8 x to 12 x). The mirrors are small enough to fit into an osteotomy measuring no larger than 4 to 5 mm in diameter. Inspection of root ends cannot be performed thoroughly without the aid of micromirrors. The reflective surface is made of either highly polished stainless steel or sapphire. a retropreparation shorter than 3 mm may jeopardize the long-term success of the apical seal. a light sweeping motion using short forward and backward and up and down strokes can be done. Micromirrors One of the key instruments in microsurgery is the micromirror. COMPACTION OF GUTTA-PERCHA IN THE RETROPREPARED . especially on the difficult –to-reach facial wall and confirmation that the parallel walls are sharply defined and smooth. Preparation is inspected with a micromirror at high magnification of 16 x to 25 x. A thorough inspection should include the interior canal walls for remnants of gutta-percha. the ultrasonic tip is activated and the apical canal is retroprepared with copious water coolant to a depth of 3 mm.

Retrogate filling materials are:ISTHUMUS In general sense it is a narrow strip of land connecting two larger lands . The retroprepared canals must be void of any gutta-percha or debris for the final filling. At 3 mm from the apex. a “lateral connection” by Pineda and an “anastomosis” by Vertucci. which can be either complete or incomplete. Isthmus is a narrow connection between two root canals which usually contains pulp tissue. The isthmus has been called a “corridor” by Green.2 mm diameter and a length.CAVIY The remnants of gutta-percha have to be compacted well to a 3 mm depth with microcondensers. isthmuses are often found to Amalgam Guttapercha Gold foil Titanium screws Glass ionomers Ketac silver Zinc oxide – eugenol Cavit Composite resins Polycarboxylate cement Poly HEMA Bone cements IRM Super EBA Mineral Trioxide Aggregate (MTA) . with a 0. Many different type of micro condensers with different handles are there. but their working tips are basically the same. In many teeth with a fused root there is a weblike connection between two canals called an isthmus.

infection maxillary sinus perforation and transient paresthesia. it must be cleaned. patients sometimes misunderstand or simply do not remember the verbal instructions for this reason written instructions allay confusion or further anxiety. and over 80% of the mesial roots of the mandibular first molars have one. POSTOPERATIVE SEQUELAE Surgical sequelae include pain. 30% of the maxillary and mandibular premolars. especially in molar teeth. Thus isthmus is a part of a canal system and not a separate entity. Isthmus frequency The isthmus is most frequently observed between two root canals within one root. Because of anxiety and nervousness. premature separation of sutures. Thus. without rootend preparation and/or root-end filling. Importance of Finding and Treating the Isthmus When an isthumus was present. accordingly. Isthumuses should be identified. The untreated isthumi are one of the main causes of treatment failure of apical surgery. these cases would eventually fail. Long-acting anesthetic agents such as bupivacaine (ie mercaine) or etidocainel (ie. usually fails. This high incidence of isthmuses in premolars and molars is an important consideration when performing apical surgery. shaped and retrosealed. swelling. At the 3-mm level from the original apex. especially in the posterior teeth. To minimize postsurgical sequelae. Duranest) can be injected . oral and written postoperative instructions must be given to the patient and the person accompanying the patient. ecchymosis laceration. the majority of posterior teeth contain an isthmus. prepared and properly sealed' The high incidence of isthumi found during microsurgery was surprising and prompted an anatomic investigation. 90% of the mesiobuccal roots of maxillary first molars have an isthmus.merge two canals in one root. This is one of the reasons why apicoectomy alone. Pain Pain is usually not a serious problem.

The patient is provided an ice pack to press lightly against the cheek or jaw for at least 30 minutes to constrict the cut microvasculature. This is basically an esthetic problem. The ecchymosis for the maxillary premolar surgical site is found in the neck area. it is when the mental nerve presents near the second premolar and first molar. ecchymosis occurs below the surgical site because of gravity. Paresthesia When Paresthesia occurs. Intermittent application of ice packs. Swelling Swelling is a common surgical sequelae & is a major concern for the patient. Also. Patients must be informed that the surgical site and face may swell regardless of the home care. sterile water. Hemorrhage Postoperative haemorrhage is rare. To prevent it from occurring two 2 x 2 sterile gauze pads are folded in half and moistened with chilled. Rarely are narcotic analgesics required. for the first 2 days almost minimizes swelling. The patient should be assured that the ecchymosis has no bearing on the success or severity of the case. It is more prevalent in elderly patients with capillary fragility and patients with fair skin. Ecchymosis Ecchymosis is the discoloration of facial and oral soft tissues because of the extravasation and subsequent breakdown of blood in the intestinal subcutaneous tissues. Ibuprofen or acetaminophen regimen always ensures that any pain will be minimal and transient. 10 minutes on an 5 minutes off. Inflammatory swelling of the surgical site may cause .postoperatively in to the surgical site to control pain for a period of upto 8 hours. Transient paresthesia may occur even if the surgical site is far from the nerve. Frequently. patients must be assured that the degree of swelling is not an indication of the success or failure of the surgery or the severity of the case. minimizes swelling and promotes initial coagulation. This pack is placed over the sutured flap in the buccal fold and pressed by the surgeon with moderate pressure for several minutes.

The patient should return for a postsurgical checkup in 1 week. Paresthesia some times can be permanent. normal sensation generally returns within a few weeks.temporary impingement on the mandibular nerve causing transient paresthesia. Maxillary sinus perforation Perforation of the schneiderian membrane covering the sinuses may occur. The patient should be instructed to elevate the head during the night. utmost care should be taken to prevent any material from entering the sinus. If perforation of the sinus occurs. . Prophylactic antibiotic therapy with augmentin 500 mg every 6 hours along with Sudafed for 1 week should be prescribed. If the nerve has not been severed. The patient should be assured of the probable return of sensation in the affected side. it may take a few months to regain normal sensation. Rarely.

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