Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

Introduction Definition History Indication Contraindication Classification of Endo. surgeries

1.Trephination

2.Periradicular curretage

3. Periradicular surgery

(i) Root end resection (Apicectomy)

(ii) Root end preparation & filling

Conclusion

Introduction

Surgical intervention is required where endodontic

treatment has failed and tooth is to be retained rather than

extracted.

The percentage of success of endodontic treatment

has been consistently high but failures may arise due to

infection, poor access cavity preparation, inadequate

instrumentation, obturation, missed canals and coronal

leakage.

So if this happens, Surgical endodontics is

needed to save the tooth.

Definition-Surgical endodontics is defined as,” Removal of tissues

other than the contents of root canal to retain a tooth with

pulpal or periapical involvement”

History

Surgical endodontics is not a recent innovation.

Trephination and incision and drainage are being done

since ancient times.

In 11th century, first case of endodontic surgery was

performed by Abulcasis.

Root end resection (Apicectomy ) was first

documented in 1871 and apicectomy with retrograde

cavity preparation and filling with amalgum was

documented in 1890.

Root amputation was first introduced by Black and

Inlitch in 1886 , then was dealt by Younger (1894)

and Guerini (1909)

In 1930, indications for endodontic surgery were

proposed.

In 1940, Triangular flap was first described by

Fischer.

Neumann and Eikan descibed Trapezoidal flap in

1940.

Semilunar incision was first described by Partsch

hence it is also known as Partsch incision.

INDICATIONS

1. Need for surgical drainage

2. Failed endodontic treatment1. Irretrievable root canal filling material2. Irretrievable intraradicular post

3. Calcification of the pulp space

4. Procedural errors1. Instrument fragmentation2. Non-negotiable ledging3. Root perforation

5. Symptomatic overfilling.

6. Anatomic variations.

A. Root dilaceration.

B. Apical root fenestration.

7. Biopsy.

8. Corrective surgery.

1. Root resorptive defects

2. Root caries

3. Root resection

4. Hemi-section

5. Bi-cuspidization

CONTRAINDICATIONS

Poor systemic health.

Local anatomical considerations

Poor periodontal status.

Short root length.

Acute infection.

Non restorable teeth

Success of surgical treatment over non-surgical treatment.

Medical history

Periodontal evaluation

Patient’s motivation

Informed consent

CLASSIFICATION OF ENDODONTIC SURGICAL PROCEDURES

I. Surgical drainage1. Incision and drainage2. Cortical trephination (fistulative surgery)

II. Periradicular surgery1. Curettage2. Biopsy3. Root-end resection4. Root-end preparation and filling

5. Corrective surgeryi. Perforation repair

a. Mechanical (iatrogenic)b. Resorptive (internal and external)

ii. Root resectioniii. Hemisection & Bi-cuspidization

III. Replacement surgery i. Replantation

IV. Implant surgery1. Endodontic implants2. Root-form osseointegrated

implants

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

Incisions and flaps PRINCIPLES OF DESIGN-

Principles and guidelines are applied to the location and

extent of incision.

Why should one follow the principles ???

“The adherence to these principles will ensure that the

flapped soft tissues will fit snugly in their original

position and will properly cover the osseous wound site

and provide an adequate vascular bed for healing”

PRINCIPLES:

1. Avoid severing vessels and nerves

2. Make incisions far away from the surgical area to ensure that the wound margins are over sound bone and there is room for adjustments when unexpected extensions are necessary.

3. Design the flap so that there is adequate visibility without overexposure of bone.

4. The base of the flap should be the widest

portion to maintain proper circulation.

5. There should be no sharp angles on the flap

6. Vertical or oblique incision should not be

over root eminence. It is best to incise in the

trough.

7. Maintain the integrity of the interdental

papillae.

8. Use sharp instruments to avoid tearing the

mucoperiosteum.

9. Be gentle with the flap.

10. Do not incise close to the gingival sulcus

while using a horizontal or semilunar

incison

11. Incise in the attached gingiva for

semilunar flaps.

NOTE:

“More trauma results from short incision rather

than long incision”.

Vertical incision

Sulcular incision

Semilunar incision

Modified semilunar incision

Ochsenbein-Leubke incision

Classification of Flaps:

1. Full mucoperiosteal flaps:

(a) Triangular (one vertical releasing incision)

(b) Rectangular (two vertical releasing incisions)

(c) Trapezoidal (broad-based rectangular)

2. Limited mucoperiosteal flaps

(a) Submarginal curved (semilunar)

(b) Submarginal scalloped rectangular (Ochsenbein-

Luebke)

Full Mucoperiosteal Flaps.

TRIANGULAR FLAP.

The triangular flap is formed by a intrasulcular

incision and one vertical releasing incision.

ADVANTAGES:

Good wound healing as there is minimal disruption of the vascular supply to the flapped tissue,

Ease of flap reapproximation, with a minimal number of sutures required.

DISADVANTAGE:

It provides Limited surgical access because of the single vertical releasing incision.

Difficult to expose the root apices of long teeth (eg, maxillary cuspids and mandibular incisors.)

Additional access can be easily obtained by placement of a distal releasing incision.

It is recommended for maxillary incisors and posterior teeth.

“It is the only recommended flap design for mandibular posterior teeth”.

RECTANGULAR FLAP: The rectangular flap is formed by an intrasulcular and

two vertical releasing incisions.

ADVANTAGES:

Increased surgical access to the root apex.

This flap design is especially useful for mandibularanterior teeth, multiple teeth, and teeth with long roots, such as maxillary canines.

DISADVANTAGES:

Difficulty in reapproximation of the flap margins and wound closure.

Postsurgical stabilization is also more difficult as the flapped tissues are held in position solely by the sutures. This results in a greater potential for postsurgical flap dislodgment.

This flap design is not recommended for posterior teeth.

TRAPEZOIDAL FLAP: Similar to the rectangular flap with the exception that

the two vertical releasing incisions meet intrasulcularincision at an obtuse angle.

Trapezoidal Flap ctnd…..

The angled vertical releasing incisions are designed to create a broad-based flap with the vestibular portion being wider than the sulcular portion.

Flap design is made on the assumption that it will provide a better blood supply to the flapped tissues.

Trapezoidal Flap ctnd…..

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

Trapezoidal Flap ctnd…..

This will result in more bleeding, a disruption of the vascular supply to the unflapped tissues, and shrinkage of the flapped tissues.

Limited Mucoperiosteal Flaps: Submarginal Curved (Semilunar) Flap:

The submarginal or semilunar flap is formed by a curved incision in the alveolar mucosa and the attached gingiva.

The incision begins in the alveolar mucosa extending into the attached gingiva and then curves back into the alveolar mucosa.

Advantages – No advantages

Disadvantages-

1. Poor surgical access

2. Poor wound healing

“This flap design is not recommended for periradicularsurgery”.

Submarginal scalloped rectangular (Luebke-ochsenbein) flap:

The submarginal scalloped rectangular flap is a modification of the rectangular flap in which the horizontal incision is not placed in the gingival sulcusbut in the buccal or labial attached gingiva.

ADVANTAGES: It does not involve the marginal or interdental gingiva

and the crestal bone is not exposed.

DISADVANTAGES: Vertically oriented blood vessels and collagen fibers

are severed, resulting in more bleeding and a greater potential for flap shrinkage, delayed healing, and scar formation.

FLAP REFLECTION:

Flap reflection is the process of separating the soft tissues (mucosa and periosteum) from the surface of the bone.

The periosteal elevator is used gently to elevate the periosteum and its superficial tissues from the cortical plate.

After reflection of the attached gingival tissues, elevation is continued more apically lifting the alveolar mucosa along with periosteum until adequate surgical access is obtained.

A thin gauze may be used for reflection to prevent tearing of the flap.

Hard tissue management in endodontic surgery involves 3 stages:

1.Trephination

2.Periradicular curretage

3. Periradicular surgery

(i) Root end resection (Apicectomy)

(ii) Root end preparation & filling

OSTEOTOMY:

Osteotomy is the removal of some portion of the cortical plate to expose the root end.

Clinician should precisely locate the root end.

A number of factors should be considered to determine the location of the bony window.

The angle of the crown to the root should be assessed.

When a root prominence or eminence in the cortical plate is present, the root angulation and position are more easily determined.

Measurement of the entire tooth length on well-angled radiograph and transferred to the surgical site by the use of a sterile millimeter ruler.

When the cortical plate is intact, locate the body of the root coronal to the apex where the bone covering the root is thinner.

Once the root has been located and identified, the bone covering the root is slowly and carefully removed with light brush strokes, working in an

apical direction until the root apex is identified.

Barnes identified four ways by which the root surface can be distinguished from the surrounding osseous tissue:

(1) Root structure generally has a yellowish color,

(2) Roots do not bleed when probed,

(3) Root texture is smooth and hard as

compared to the granular and porous

nature of bone, and

(4) The root is surrounded by the periodontal

ligament.

Definition- It is the perforation made through the cortical plate or apical foramen to accomplish the release of pressure in the periapical area from the accumulation of exudate within the alveolar bone.

Indications-

This technique is employed in cases of periapicalabcess in which there is no swelling or drainage but much pain.

Small incision is made over the periapicalregion .flap is reflected and bone is examined.

Radiograph is taken with radiopaque marker for confirmation. So that there is no chance of penetration in the wrong area.

CORTICAL TREPHENATION:

Perforation of the cortical plate to accomplish the release of pressure from the accumulation of exudatewithin the alveolar bone.

The treatment of choice for these patients is drainage through the root canal system (apical trephination) whenever possible.

Apical trephination involves penetration of the apical foramen with a small endodontic file and enlarging the apical opening to a size No. 20 or No. 25 file to allow drainage from theperiradicular lesion into the canal space.

The decision about whether to perform apical or cortical trephination is based primarily on clinical judgment regarding the urgency of obtaining drainage.

PERIRADICULAR CURETTAGE:

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

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

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

Periradicular Surgery

ROOT-END RESECTION (APICOECTOMY)

Historically, many authors have advocated periradicular curettage as the definitive treatment in endodontic surgery without

root-end resection.

Their rationale was to maintain a cementalcovering on the root surface and to maintain as much root length as possible for tooth stability.

INDICATIONS:

These indications may be classified as,

1) Biological

2) Technical.

Biologic factors:

Persistent symptoms,

Persistent periradicular lesion.

Technical factors:

Periapical infection in teeth with…

Radicular posts,

Crowned teeth without posts,

Irretrievable root canal filling materials,

Procedural accidents.

There are three important factors for the surgeon to consider before performing a root-end resection:

(1) Instrumentation,

(2) Extent of the root end resection,

(3) Angle of the resection.

1.Instrumentation:

Ingle et al. recommended that root-end resection is best accomplished by the use of tapered fissure bur or round bur in a low-speed straight handpiece.

Gutmann and Harrison, have suggested the use of a high-speed handpiece and a surgical length plain fissure bur.

NOTE:

“Plain fissure burs, at high and low speed,

produce the smoothest resected root

surface”.

2.Extent of the Root-End Resection:

Earlier, it was believed that it is necessary to resect the root at the level of healthy bone.

Average length of root resection is 3mm whichis considered enough to eliminate the sourceof infection.

however surgeon must evaluate the patient on an individual basis.

1. Visual and operative access to the surgical site

2. Anatomy of the root (shape, length, curvature).

3. Number of canals and their position in the root

4. Need to place a root-end filling surrounded

by solid dentin.

5. Presence and location of procedural error

6. Presence and extent of periodontal defects.

NOTE:

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

3.Angle of Root-End Resection.

It should be 30 ° -45 ° from the line perpendicular to the long axis of the tooth facing toward the buccalor facial aspect of the root.

The purpose is to provide enhanced visibility to the root end and operative access to accomplish a root end preparation.

NOTE:

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

Root-End Preparation:

The purpose of a root-end preparationin periradicular surgery is to create a

cavity to receive a root-end filling.

It is performed by the use of small round orinverted cone burs and straight low-speedhandpiece.

It should be done parallel to the long axis ofthe root.

Root-End Filling:

The purpose of a root-end filling is to establish a seal between the root canal space and the periapicaltissues.

Suitable root-end filling material should be,

(1) Able to prevent leakage of bacteria and their

biproducts into the periradicular tissues,

(2) Nontoxic & Noncarcinogenic,

(3) Biocompatible with the host tissues,

(4) Insoluble in tissue fluids,

(5) Dimensionally stable,

(6) Unaffected by moisture during setting,

(7) Easy to use

Root-End Filling Materials:

Numerous materials have been suggested for use as root-end fillings, including:

Amalgam, Gutta-percha, Glass ionomers, Composite resins, Carboxylate cements, Zinc phosphate cements, Zinc oxide–eugenol cements,

Mineral tri-oxide aggregate (MTA).

REPOSITIONING AND SUTURING:

Several authors have compared the effects of continuous and interrupted suture techniques.

Their findings indicate that the interrupted suturing technique provides better flap adaptation than does the continuous technique and, therefore, is the recommended technique, and the most commonly used, for endodontic surgery.

1. Ask not to drink alcohol or use any form of tobacco.

2.. Ask not to lift up the lip or pull back the cheek to

look at where surgery was done. This may pull the

sutures and cause bleeding.

3. A little bleeding from the surgical site is normal.

This should only last for a few hours. There may be

little swelling of the face. This should only last for a

few days.

4. Place an ice bag (cold) on face where surgery was

done. Leave it on for 20 minutes and take it off for 20 minutes. Do this for 6 to 8 hours.

5. After 8 hours, the ice bag should not be used. The day after surgery, warm saline gargle. Do this as often as possible for the next 2 to 3 days. Advice for warm saline gargle.

7. Rinse the mouth with 1 tablespoon of chlorhexidinemouthwash two times a day, once in the morning and once at night for 5 days.

8. Recall for removal of sutures after 7 days,

CONCLUSION :

During the last 20 years, endodontics has encountered dramatic shift in the use of periradicular surgery.

Previously, periradicular surgery was commonly considered as the treatment of choice when nonsurgical treatment had failed but nowadays periradicular surgery has become very selective in contemporary dental practice.

Text book of endodontics, Ingle 5th edition.

Textbook of oral & maxillofacial surgery ByDaniel M. Laskin. Vol.2

Text book of endodontics, Nisha Garg.

Text book of endodontics By Grossman.

Text book of Surgical endodontics, Guttman

Thank you