surgery lecture 5

8/14/2019 surgery lecture 5

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Principles of endodontic surgeryFirst of all am so sorry for being late, but that's becoz I want to put the slide in the lec. Tomake it easier and helpful, and unfortunately I dont have the soft copy of them, so I typedthem for you. You dont have to go back to the handout unless f u want:p

There is a misconception that surgery can resolve or treat any problem,this is not always right becoz of that, many endodontic surgeries were

performed for the wrong reason, where other modalities such as rootcanal treatment or retreatment, may be prefared and may solve the

problem and result in a satisfactory treatment.

For ex. If we have a tooth that has RCT and still has complaint, weshouldnt go directly to and do surgerywe just simply re- treat the tooth

by RCT and this might solve the problem.satisfactory results.And f we use surgery for everything this will lead to failure .

SURGERY is NOT ALWAYS INDICATED

Definition:-

Endodontic surgery: is prevention or management of peri-radicularpathology by asyrgical approach.In general, this includes abcess drainage, periapical surgery, correctivesurgery, intentional implantation.and root removal.

Whats the meaning of Peri radicular pathology?Its a pathological entities that develop around the root.SO we want to prevent or manage them

PIC FIG 1 page 2This is a tooth has pathology at its apical part ---- abscess drain throughbone into soft tissue either Intra-orally or extra-orally.

Peri-apical surgery has different schools, it includes a variety ofprocedures or variety of treatment options like management ofabcesses but but baisically we mean by peri-apical surgery:

1- apecectomy

2- curettage.

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Drainage of an Abscess:-

An abscess is a collection of pus which is related to the oral cavity andrelated to teeth, so it is either presented intra orally or extra orally, why isthat??

What are the factors which determine that its either located intra or extra orally?Its muscle attachment for ex. Lateral incisor has an apex which islocated more palatally another one has an apex which is located morelabially.. upper 1st molar has 3 roots: MB, DB, and P.. f the the infectionis related to the palatal root then u might find the w]swelling palatally.Immunity can also affect, but its another factor, not our topic today.Drainage of an abcess will release purulent or hemorrhagic transudatesand exudates from focus of liquefaction necrosis.

When u drain an abcess what would u achieve?1- relief pain becoz weve pressure that coz pain2- improve circulation.

What are themethods or techniques of drainage an abscess?1- through the root canal.2- using an intraoral incision.3- using an extraoral incision.4- Through the alveolus of the extraction.5- Drainage may also be performed with trephination of the

buccal bone, when the root canal is inaccessible.PICFIG 2 page 3We have a swelling which present intraorally and we use a knife to inciseit, after that pus can be present in more than one compartment, we takethe mosquito or the artery forceps and insert it through the incision whileits closed then we open it inside the lesion, why??To convert the pus that present in multiple compartmentinto singleones so the pus from different compartment will drain through ur

incison.Next step: we need to keep this incision open to allow pus and exudatesto drain, how can we do that??By insertion of a DRAINDRAIN is made from rubber we fix it to the margin of incision withsuture and leave it for 24-48 hrs.After that if there is any pus it should drain and then we release the

pressure,, we remove the drain and most of the time we dont need to doanything we just remove the drain and that's it.

Another option of incision and drainage is to extract the tooth and drainpus from the socket.

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We will try to know when it is indicated to do priapical surgery:-

1- Anatomical factors:Conditions that may compromise RCT, that prevent

instrumentation, obturation, or both. These conditions include:1. Calcifications.2. Sever root curvature.3. Constricted canals.4. Dental anomalies. ( dens in dente)

PIC " sorry I don't have it"Dens in dente: is simply tooth within tooth its not easy to do RCT.

2- Restorative considerations :1. when attempting RCT through a restoration couldcompromise the restoration's retention or perforate the root.2. failed RCT on a tooth that has been restored with a

post and core. Many posts are difficult to remove or may cozroot fracture during removal.

PIC x-ray" I don't have it also" : fractured apical part remove it,clean apical area -- it will heal nicely.PIC another fracture.

3- Horizontal root fracture :After traumatic root fracture, the apical segment undergoes pulpnecrosis.Becoz this cannot be predictably treated from coronal approach, theapical segment is removed surgically after root canal treatment of thecoronal portion.4- Irretrievable materials in canal :

Objects such as separated instruments, restorative materials,segments of posts, or other foreign objects occasionally blockcanals. those materials must be removed surgically.

5- Procedural errors:The followings may result in RCT failure:

1. Breakage of small instruments in the canal.2. foreign bodies driven into periapical tissues3. gross overfills4. Perforations of the inferior wall of pulp chamber or

perforation of the root.5. Surgical correction is necessary in these situation.

6- Large unresolved lesions after RCT:Very large periradicular lesions do not heal or may even enlargeafter adequet debridement and obturation. These are gently best

resolved with decompression and not curettage, which may damageadjacent structures.

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Contraindications of periapical surgery:These are cautions not pure contraindications, i.e. f we they may

become an indications for periapical surgery.

1- unidentified cause lead to treatment failure:doing surgery to correct a treatment failure for which the coz cannotbe identified is often unsuccessful. i.e. f we dont know the coz of surgerythis will lead to failure surgery.

2- A when orthograde conventional RCT is possible.3- Simultaneous RCT and apical surgery.4- Anatomic consideration:

1. Teeth close to maxillary sinus.2. external oblique ridge over mandibular second and third

molars.3. zygomatic buttress may inhibit access to maxillary molarapices.4. a prominent chin creats a shallow vestibule with limitedaccess to mandibular anteriors5. the mental foramen is of concern but is easily avoided byidentifying its position radio graphically and during flap reflection.

5- Poor crown and root ratio:Teeth with very short root have compromised bony supportand are poor candidate for surgeryHowever, shorter roots may support a relatively long crownif the surrounding cervical periodontium is healthy.

6- Medical complication:There is no specific ones for endodontic surgery exist that would not

be similer to those for other types of oral surgical proceadures.

What are the surgical procedure for apicectomy and

periapical curettage??

1- Local anesthesia.2- Falp design.3- Incision and reflection.4- Acess to the apex.5- Curettage.6- Root end resection.7- Root end preparation and filling.8- Radiographic verification.9- Flap replacement and suture.10- Postoperative instructions.11- Sutural removal.

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12- Long- term evaluation.

II- Flap Design :a carefully reflected flap will result in good acess and u'll be able to see

wt are u going to do and performing the surgery with ease.

We have three types of flaps: semilunar, submarginal, and fullmucoperiosteal.

1- Semilunar: ))Slightly curved half-moon horizontal incision in alveolar mucosa.Its performed 2 mm away from the margins of the teeth foresthetic reasons, otherwise there will be recession and exposure

of the apical part of the tooth especially the anterior area.It's not advocated today for these reasons:-

1. It provides a restricted surgical access .2. It also carries the danger of postsurgical defects byincising through tissues that are not supported by bone.3. It compromises blood supply, which could lead toshrinkage, gapping, and secondary healing.4. Close proximity of the incision to the osteotomy site,which makes hemostatic control more challenge.

FIG 3 in the slide page 6.

2-Submarginal Flap:The horizontal component is in attached gingiva with one or two

accompying vertical incisions. Its scalloped in the horizontal line, withobtuse angles at the corners. It is used successfully in the maxillaryanterior region.

The major advantage is esthetic: leaving the gingiva intact around the

margins of crowns is less likely result in bone resorption with tissuerecession and crown margins exposure.Compared to semilunar flap, it provides less risk of incising over a bonydefect and provides better access and visibility.

Disadvantages:Hemorrhage along the cut margins.Occasional healing by scaring, compared with full mucoperiostealflap.

FIG 4 in the slide page 7.

2- Full mucoperiosteal flap:

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It is an incision in the gingival sulcus, extending to the gingivalcrest.This procedure includes elevation of interdental papilla, freegingival margin, attached gingiva, and alveolar mucosa.

Advantages:1.Maximum access and visibility.2.Not incising over the lesion or bony defect.3.less tendency for hemorrhage4.complete visibility of the root.5.Allowance of root planning and bone contoring6.Reduced likelihood of healing with scar formation

Disadvantages:1.More difficult to place and replace a suture

2.Gingival recession frequently develops, exposing crownmargins or cervical root surfaces.FIG 5 in the slide page 8.It has 2 types:

A.Triangular flap (three corners):

Indicated in the anterior and post. Regions of both maxillaand mandible.Requires horizontal intrasulcular incision and single verticalincision.

The horizontal one: is made with the scalpel held near vertical position,extending through the gingival sulcus and the gingival fibers down to thelevel of crestal bone.When passing through the interdental region, care should be taken toensure that:the incision is separating the buccal and lingual papillae .A clean incision is vital to prevent sloughing of the papillae due tocompromised blood supply and to prevent unaesthetic look of double

papillae.

The vertical one: is prepared between the root eminences parallel to thelong access of the root." In the anterior surgery, vertical incision is

prepared closest to the surgeon. While in posterior surgery, it alwaysconstitutes the mesial of the flap."It is important to keep the base of the flap as wide as the top so that thevertical incision is kept parallel to the vertically positionedmicrovasculature. So the least number of vessels and fibers are severed,which will lead to fast healing without scarring.

It should meet the tooth at the free gingival margin with 90 degree, and

should terminate at the mesial or distal to the tooth.

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Triangular flap has disadvantage, which is limited surgical access. So arectangular flap design should be considered f maximum access isrequired.FIG 6, 7 page 8 and FIG 8 page 9.

B.Rectangular flap ( four corner):

It is very similar to triangular design except for addition of a secondvertical releasing incision.It is indicated for:

Anterior surgery when more access is needed.Used when multiple teeth will be operated on or when roots arelong.

Disadvantages: include technique sensitive wound closure and higher

chance for flap dislodgement.FIG 9 page 10. Rectangular submarginal flap design:

Does not include the marginal and inter dental gingival.It can be used in both maxillary anterior or posterior regions but whensufficient width of attached gingival is available.

Indication:

1.In teeth with existing fixed restoration.2.Where aesthetic is the major concern.

Contra indications:

In the mandible, coz the attached gingival is narrow, andaesthetic is not the major concern.

About 2mm of the attached gingival from the depth of the gingivalsulcus must be present before this flap design is selected.This design is formed by scalloped horizontal incision and one or twovertical incisions depending on surgical access that is needed.This incision reflects the contours of the marginal gingival and providesadequate distance from the depth of the gingival sulci. It also serves as

guide for correctly re-positioning the flap for suturing.FIG 10 page 11.All flap corners should be rounded to promote smoother healing andminimize scar formation.The angle of the incision should be 45 degree in relation to the cortical

plate, to allow the widest cut surface and better adaptation for the flapwhen it is repositioned.FIG 11 page 11.This angulation will add an additional safety measure to protect the 2mm

of attached gingival.Advantages:

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Leaving the marginal and interdental gingival intact in addition to leavingcrestal bone unexposed.

Disadvantages:

The severance of supraperiostal vessels, which could leave the un-reflected tissue without blood supply.This can be prevented by preserving an adequate width of un-reflectedgingival tissue, so this will derive secondary blood supplies from PDLand interaosseous blood vessels.

The healing of this flap is quite similer to the full mucoperiosteal flap.

III- Incision and Reflection:

It is important to incise and reflect a full- thickness flap to minimizehemorrhage and to prevent tearing of the tissues. This incision should befirm and made theough the periosteum to bone.Reflection: reflect the flap from the vertical incision down to bone, thenraising the horizontal component. When reflect the periosteum theelevator must firmly contact bone while the tissue is raised.FIG 12 page 12.Once you reflect the flap u can seen area of apex of root most of the time.

IV- Periapical exposure:Coz the lesion perforates the bone so u can see the perforation area, butsometimes in the lateral incisor for ex. Is inclined palatally so bone may

be intact, how can u locate the site of the apex??Root tip may be located with a radiograph, and u can measure it by perio

probe and apply into bone, this will give u estimation of the position ofroot apex.or, u can use a file.FIG13 page 13.

Now if the lesion perforate the bone and the area is small, u can widen itby using round bur,- on vented high-speed hand-pieces or electricalsurgical hand-pieces otherwise the use of handpiece that direct the airwater and abrasive particles into the surgical site shouldn't be used -,toremove bone and increase the exposure of periapical area So u willhave better access.

V-curettage:Most of the granulomatous inflamed tissues surroundingthe apex should

be removed to:1.Gain access and visibility of the apex.

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2.Obtain a biopsy for histological examination.3. Minimize hemorrhage.

Some areas of the lesion may be inaccessible to the curettes, such as thelingual aspect of the root. Portions of inflamed tissue or epithelium may

be left, without compromising healing, so total removal is not necessary.If hemorrhage from soft or hard tissue is excessive, which compromisevisibility, homeostatic agents are useful. The best hemorrhage control isto apply and hold direct pressure over the bleeding site with gauze.FIG 15 page 14.The material that we remove can be used as biopsy.

VI- Root end resection:It is not always indicated. It is useful in two situations:

1.To gain access to the canal for examination and placement ofa root end preparation and restoration.2.To remove an undebrided or unobturated portion of the root.This is may be necessary in cases with dilacerated roots, ledgedor blocked canals, or apical canal space that is inaccessible dueto restorations, and in accessing of lingual structures. (I.e. f weremove this part of root we can see the lingual aspect of it andsee it clearly).

The apical part of root has lateral canals, and f there are more than onethey will not be filled by root canal material so the bacteria will gainaccess to the canals, mostly they are in the last 3-4 mm of most apicalarea of root.SO removal of this part will lead to removal of un cleaned canals.

Procedure:

1-A trough is created around the apex with tapered fissure bur toexpose and isolate the root end.2-The resection is with the same tapered fissure bur.

3-Bevel: a bevel of varying degrees is made in facio-lingual angledepending on the location and whether a root end preparation is to be

placed.We can make this bevel either at zero angle or at 45 degree.

Advantages of zero bevels:

1.Ensure equal resection of the root apex on both buccal and lingualaspects.2.Minimal exposure of dentinal tubules, which result in reduction inapical leakage.

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3.the root canal anatomy is no longer elongated in buccolingualdirection, thus facilitating retropreperation and retrofilling

procedures.4. Amount of root removed

Sufficient root apex should be removed to provide a larger surface and toexpose the additional canals1.2-3 mm of the total root length is usually adequate2.One-half to one third of the root may be resected for apicalaccess.

45-degree bevel:

Using this bevel will enable us to see some of the lateralcanals.Number of dentinal tubules that are exposed are more

more leakage.

FIG 16 page 15, FIG 17 page 16.Even f u want to do zero bevel, u cant do it sometimes becoz of the

angulation of the root and the angualtion of the handpiece. U'll reach 10-15 degree not zero. So the ideal is 10 degree bevel the 45 degree bevelcannot either be made for the same reason.

VII- root end preparation and restoration:

It is indicated f there is an inadequate apical seal.It is like class I preparation should extend to at least 3-4mm in to the root.

Root end preparation done:1- by slow speed.2- Specially designed hand piece.3- Ultrasonic tips.

Advantages of ultrasonic instruments:

1. control and ease of use.2. permit less apical root removed3.formation of cleaner shaped preparation

FIG 19 page 17.

VIII- root end filling materials:The root end filling material should:-

1- seal well2- be tissue tolerant

3- easily inserted4- minimally affected by moisture

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5- visible radio graphically6-must be stable and non resorbablethe material that can be used:

1. Amalgam

2.mineral trioxide aggregate(MTA)3.reinforced zinc oxide cements ( IRM and super EBA)4. Glass Inomer cement.

Q. dose amalgam do any irritation?A. placing amalgam inside the tooth is more irritant than place it at the

apex, imagine that u are placing amalgam in a huge number of dentinaltubule while here we are putting it at the apex only.

IX- Irrigation:

The surgical site is flushed with normal saline to remove soft and hardtissue debris, hemorrhage, clots and excess root end filling material.

X-Rdiografic verification:It is important to be made before suturing, to verify the surgical objects

are satisfactory. And f correction are needed to make them beforesuturing.XI-Flap replacement and suturing

XII_ Postoperative instructions

XIII recallSuture removal.Recall evaluation

Some failure after surgery are evidenced only by radiographic

finding.

A 1- year follow- up is good indicator.

Failure:

1-persistant symptoms, pain, swelling, presence ofsinus tract, deep probing defect, or other adversefindings.2-F after 1 year, radiograohic evidence shows nodecrease in lesion size or lesion size increase.

Adjuncts:

Some of the newer devices and materials have improved surgicalprocedures. These includes:

1.Light and magnification devices:1- surgical microscope.2- Fiber optics.

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Goog Luck..

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surgery lecture 5

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