ENDODONTIC SURGERY

Presented by Reham Hassan

Associate Professor, Endodontic Department Minia University

• Endodontic surgery involve all surgical

procedures performed to remove

causative agents of periradicular pathosis

and to restore the periodontium to a state

of biologic and functional health.

Definition:

The aim of surgical endodontics is to

restore the integrity of the supporting tissues of

a tooth or teeth, when non-surgical endodontics

has failed and re-treatment cannot be

undertaken or is contraindicated.

I.R. Matthew. 2007.

Changing Concept!!!

The term CONSERVATIVE TREATMENT has been used as an equivalent for non-surgical endodontic treatment but it applied also to surgical endodontics as the surgical procedure becomes the conservative effort to avoid radical sequela-the extraction of the tooth.

• The current concept is treat a tooth non-surgically and to follow the progress of therapy by periodic clinical and radiographic examinations.

Many of the previously accepted indications are no longer valid in light of current concept of the biological basis for endodontic treatment.

Therefore, it must be recognized that periradicular surgery has become very selective in modern endodontics.

Also, the retreatment possibilities offered by modern endodontics has reduced the number of cases requiring surgery.

False Indications

1.Extreme Apical Curvature .

The introduction of Ni Ti instruments allows a better ability to axially prepare curved canals that were otherwise candidates for root end resection.

2. Internal resorption.

Heavy irrigation with hypochlorite and subsequent canal enlargement followed by thermoplasticized obturation technique.

Conventional Endodontics Surgical Endodontics

3.Presence of immature apex:

Hermetic sealing of the apex impossible.

The final result produced a tooth with extremely thin dentin walls

Complicated by a decreased

crown-root ratio if an apicectomy was done.

35 monthes after intial treatment

4. Persistent pain

Missed canal The presence of an additional unexpected canal such as mesiobuccal root of maxillary molars and first bicuspids.

Cause

4. Persistent pain.

Incomplete cleaning and shaping

Periapical tissue inflammation due to

retained irritants within the root canal foramina that

could not be removed with instrumentation.

4. Persistent pain .

• Operator's inability to locate the elusive apical constriction.

Indications for endodontic surgery:

1) Need for surgical drainage.

2) Failed non-surgical endodontic treatment.

a. Irretrievable root canal filling material.

b. Irretrievable intraradicular post.

3) Calcific metamorphosis of pulp space “Solid

tooth”.

4) Procedural errors:

a. Instrument separation.

b. Non-negotiable ledging.

c. Root perforation.

d. Symptomatic overfilling.

5) Anatomic variations:

a. Root dilacerations.

b. Apical root fenestration.

6) Biopsy.

7) Corrective surgery:

a. Root resorptive defects.

b. Root caries.

c. Root resection (Amputation).

d. Hemisection.

e. Bisection (Bicuspidization).

8. Replacement surgery. (Intentional replantation).

9. Implant surgery:

a. Endodontic implant.

b. Osseointegrated.

1-Faliure of root canal therapy.

a-Irretrievable root canal filling material.

b-Irretrievable intraradicular post.

2-Calcific metamorphosis of the pulp space.

3-Procedural errors.

1- Instrument fragmentation.

2- Symptomatic overfilling.

3- Nonnegotiable ledging.

4-Iatrogenic Root perforation

Root dilacerations or Bayonet shape canal.

4-Anatomic variations.

(5) Surgery to gain information from a biopsy.

6-Corrective surgery.

• a-Root resorptive defects.

• b-Root caries.

• c-Root resection.

• d-Hemisection.

• e-Bicuspidization.

A-Root Resorptive Defects.

B-Root Caries.

C-Root Resection.

Removal of one or more roots of multi-rooted teeth , which separated at the junction of roots & into the crowns.

D-Hemisection.

Surgical division of multi-rooted teeth & the removal of the defective half

E-Bicuspidization.

Surgical division of a tooth

with the root that leaves the two halves of the crown and their respective roots retained in its place .

7- A Horizontal fracture of root apex with pulpal necrosis.

10-Replacement surgery

1-Replant surgery

1- Intentional

2- Posttraumatic

2- Implant surgery

• 1- Endodontic

2- Endosseous

CONTRA-INDICATIONS FOR

ENDODONTIC SURGERY

A-THE PATIENT MEDICAL STATUS.

Patient must be physically, mentally,

and systemically healthy enough to

permit uneventful healing.

1-Clotting Deficiencies.

2-Diabetes.

3-Dialysis Patients.

4-Immunocompromised patients.

B-ANATOMIC CONSIDERATIONS.

The major anatomic considerations of important

to endodontic surgery involve:

1-the nasal floor.

2-the maxillary sinus.

3-the mandibular canal and its neurovascular

bundle.

4-the mental foramen and its neurovascular bundle.

5-anatomic limitations to adequate visual and

mechanical access to surgical site,too thick

cortical plate of bone.

C- PERIODONTAL CONDITION.

D-VERTICAL ROOT FRACTURE.

E-UNSKILLED SURGEON.

A skilled surgeon with the

needed armamentarium is

usually able to circumvent these

anatomic limitations and

accomplish successful

endodontic surgery.

The majority of endodontic

surgical procedures should be

done by trained endodontic

specialists.

CLASSIFICATION OF

ENDODONTIC SURGICAL

PROCEDURES

1-Surgical drainage

a-Incision & drainage . (I&D)‏

b-Cortical trephination (fistulative surgery) & Marsupulization

2-Periradicular surgery:

a-Curretage. b-Biopsy c-Root-end resection.

d-Root-end preparation and filling.

c- Corrective surgery:

i-Perforation repair:

-Mechanical. -Resorptive (internal& external)‏

ii-Root resection. iii-Hemisection.

3-Replacement surgery (extraction/ replantation).‏

4-Implant surgery:‏

a-Endodontic implant.‏

b-Root –form osseo integrated implants.‏

1-SURGICAL DRAINAGE

A-Incision & Drainage (I&D). ‏

B-Cortical Trephination.

a-Incision & drainage . (I&D)‏

Definition:

Release of purulent or hemorrhagic exudates from a tissue swelling.

Aim:

• Decrease of pain.

• Elimination of toxins to:-

- Accelerate healing.

- Allows rapid penetration of antibiotic to the affected area.

Indications of (I&D)

Treatment of acute apical abscess.

Treatment of fluctuant , localized soft tissue swelling.

Generalized ,defuse, & indurated swelling Systemic antibiotic. Hot saline mouth wash.

The problems accompanying of ( I & D)

1) Optimal time to drain.

2) Obtaining adequate local anesthesia.

3) Maintain the drainage site.

Ideal time for drainage

When:- The immediate area to be incised, should

feel soft under the finger tip.

If pressure is exerted on one side & transmitted through the fluid & felt as a wave on the opposite side of the swelling.

The apex of the swelling may appear whitish or yellowish .

Problem???

I. Anesthesia

The presence of inflammation & swelling.

Injection into the region is painful due to pressure.

Fear of spreading of the infection.

Block anesthesia with topical anesthesia in the region.

1) topical disinfectant.

2) Administration of L.A

3) Perform a horizontal incision with a No. 11 scalpel which placed at base of

fluctuant area.

4) probing with hemostat into incisional wound to facilitate a more effective results.

5) Placement of drainage &giving antibiotic and patient must have another appointment

in 4-7 days

6) Removing the rubber drain after 4-7 days.

Complete healing

2-TREPHINATION.

1-Apical Trephination

2-Cortical Trephination

1) APICAL TREPHINATION

It is drainage through the root canal system.

Penetration of the apical foramen with small endodontic file and enlarging the apical opening to #20 or #25 to allow drainage from the Periradicular lesion into canal space.

2) CORTICAL TREPHINATION.

Definition: It is a procedure involving the perforation of the cortical plate

to release the pressure from the accumulation of exudates within alveolar bone

INDICATION OF TREPHINATION.

1) If the Apical fistulation fails to give sufficient drainage & pressure remains within the periapical bone.

2) Patients who present with sever pain but with no intra oral or extra oral swelling.

3) When pain cannot be controlled by Intracanal procedures.

1)Giving local anesthesia.

2) The site of trephination should be as close as possible to the

apex of then offending tooth.

3) Semilunar flap is made through mucoperiosteal tissue opposite

to the apex of then offending tooth.

4) Reflect the flap & expose the area opposite to the root apex.

7) The trephination is initiated from buccal approach never from

lingual or palatal.

8) No.6 or No.8 a rose head surgical bur or fissure bur in high- speed

hand piece to penetrate or perforate the cortical plate as holes on

the periphery of the circle of 1 cm in diameter.

9) Use a fissure bur to connect between these holes & remove disc of

bone of 1 cm in diameter.

10) H or T is placed & sutured.

11) Giving antibiotic and patient return in 4-7days.

12) At the subsequent appointment the drain is removed and

apicoectomy with retrograde filling is performed.

Thank You