Endodontic Surgical ProceduresEndodontic Surgical Procedures
Incision and drainageIncision and drainage Periapical curettagePeriapical curettage ApicoectomyApicoectomy Retrograde endodontic treatmentRetrograde endodontic treatment Perforation repairPerforation repair Root resectionRoot resection Hemisection (± root removal)Hemisection (± root removal) Exploratory surgeryExploratory surgery Intentional replantationIntentional replantation
Endodontic Surgical ProceduresEndodontic Surgical Procedures
Incision and drainageIncision and drainage Periapical curettagePeriapical curettage ApicoectomyApicoectomy Retrograde endodontic treatmentRetrograde endodontic treatment Perforation repairPerforation repair Root resectionRoot resection Hemisection (± root removal)Hemisection (± root removal) Exploratory surgeryExploratory surgery Intentional replantationIntentional replantation
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
Foreign body reaction with extruded materialForeign body reaction with extruded material
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
Foreign body reaction with extruded materialForeign body reaction with extruded material
Perforation repair Perforation repair (that can not be done conservatively)(that can not be done conservatively)
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
Foreign body reaction with extruded materialForeign body reaction with extruded material
Perforation repair Perforation repair (that can not be done conservatively)(that can not be done conservatively)
If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canal Very long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required
Foreign body reaction with extruded materialForeign body reaction with extruded material
Perforation repair Perforation repair (that can not be done conservatively)(that can not be done conservatively)
If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canal Very long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration
Patient factorsPatient factors Medical / dental condition, time, costs, recent crown, etc.Medical / dental condition, time, costs, recent crown, etc.
Periapical Surgery Periapical Surgery
Considerations Considerations Psychological aspectsPsychological aspects
Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery
Periapical Surgery Periapical Surgery
Considerations Considerations Psychological aspectsPsychological aspects
Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery
Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate Grung Grung et alet al - 28% higher success if non-surgical - 28% higher success if non-surgical
re-treatment was done prior to surgery re-treatment was done prior to surgery
Periapical Surgery Periapical Surgery
Considerations Considerations Psychological aspectsPsychological aspects
Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery
Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate Grung Grung et alet al - 28% higher success if non-surgical - 28% higher success if non-surgical
re-treatment was done prior to surgery re-treatment was done prior to surgery
Surgery is a “one visit” techniqueSurgery is a “one visit” technique Can not disinfect the canal with irrigants and/or medicamentsCan not disinfect the canal with irrigants and/or medicaments
Periapical Surgery Periapical Surgery
Considerations Considerations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material
Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well
Periapical Surgery Periapical Surgery
Considerations Considerations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material
Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well
Surgery “entombs” bacteria rather than killing or Surgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal
Periapical Surgery Periapical Surgery
Considerations Considerations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material
Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well
Surgery “entombs” bacteria rather than killing or Surgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal
Surgery does not remove the pathway of entry along Surgery does not remove the pathway of entry along which the bacteria have entered & infected the toothwhich the bacteria have entered & infected the tooth This is usually caries, a defective restoration, or a crackThis is usually caries, a defective restoration, or a crack
Periapical Surgery Periapical Surgery
Considerations Considerations Over-extended root filling materialsOver-extended root filling materials
Will not always cause a foreign body reactionWill not always cause a foreign body reaction
Hence, always watch and reassess over timeHence, always watch and reassess over time
Periapical Surgery Periapical Surgery
Considerations Considerations Over-extended root filling materialsOver-extended root filling materials
Will not always cause a foreign body reactionWill not always cause a foreign body reaction
Hence, always watch and reassess over timeHence, always watch and reassess over time
Large, well-defined radiolucenciesLarge, well-defined radiolucencies Are not always cysts as often thought by many dentistsAre not always cysts as often thought by many dentists
Can be any form of periapical pathosisCan be any form of periapical pathosis
Size and borders indicate time & speed of developmentSize and borders indicate time & speed of development
Periapical Surgery Periapical Surgery
Considerations Considerations Potential post-operative sequelaePotential post-operative sequelae
Swelling and bruisingSwelling and bruising
Infection Infection
Pain / discomfortPain / discomfort
Anaesthesia / ParaesthesiaAnaesthesia / Paraesthesia
Tissue discolourationTissue discolouration
ScarringScarring
Gingival recessionGingival recession
Loss of interdental papillaLoss of interdental papilla
Altered aestheticsAltered aesthetics
Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery
““It must be recognised that few true It must be recognised that few true indications exist for the endodontic indications exist for the endodontic
surgical approach” surgical approach”
Gutman JL. Gutman JL. Surgical EndodonticsSurgical Endodontics 1991: 50 1991: 50
Endodontic Surgery - StagesEndodontic Surgery - Stages
a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan
b)b) Local AnaesthesiaLocal Anaesthesia
c)c) Periosteal FlapPeriosteal Flap
d)d) CurettageCurettage
e)e) ApicoectomyApicoectomy
f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling
g)g) Wound Closure - suturesWound Closure - sutures
h)h) Post-operative InstructionsPost-operative Instructions
i)i) Follow-up & ReviewFollow-up & Review
Endodontic SurgeryEndodontic Surgery
But first – some general principlesBut first – some general principles
Flap DesignsFlap Designs
Semi-LunarSemi-Lunar
Gingival crestGingival crest TriangularTriangular TrapezoidalTrapezoidal GingivalGingival
Luebke-OschenbeinLuebke-Oschenbein
Semi-Lunar FlapSemi-Lunar Flap
In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva
Semi-Lunar FlapSemi-Lunar Flap
In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva
Poor accessPoor access Incision often over the lesionIncision often over the lesion Difficult moisture control Difficult moisture control (haemorrhage)(haemorrhage) Difficult to repositionDifficult to reposition Uncomfortable during healingUncomfortable during healing Leaves scarsLeaves scars
Gingival FlapGingival Flap
Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision
No access to apexNo access to apex May be useful for coronal May be useful for coronal
third perforations third perforations Used for palatal flapsUsed for palatal flaps
But difficult !But difficult !
Gingival FlapGingival Flap
Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision
Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision
Triangular FlapTriangular Flap
Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision
““First choice” flap for endodontic surgeryFirst choice” flap for endodontic surgery Good accessGood access Good visionGood vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition
Triangular FlapTriangular Flap
Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions
Trapezoidal FlapTrapezoidal Flap
Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions
““Second choice” for endodontic surgerySecond choice” for endodontic surgery
Trapezoidal FlapTrapezoidal Flap
Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions
““Second choice” for endodontic surgerySecond choice” for endodontic surgery
Begin as a triangular flap and then do 2Begin as a triangular flap and then do 2ndnd vertical incision if extra access required vertical incision if extra access required
Good access & visionGood access & vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition
Trapezoidal FlapTrapezoidal Flap
Luebke-Oschenbein FlapLuebke-Oschenbein Flap
Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin
Luebke-Oschenbein FlapLuebke-Oschenbein Flap
Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin
Vertical incisionsVertical incisions 1 or 21 or 2
Depends on howDepends on how much access much access is required is required
Luebke-Oschenbein FlapLuebke-Oschenbein Flap
Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin
Vertical incisionsVertical incisions 1 or 21 or 2
Depends on howDepends on how much access much access is required is required
Little, if any, scarringLittle, if any, scarring
Luebke-Oschenbein FlapLuebke-Oschenbein Flap
Use for anterior teeth with crownsUse for anterior teeth with crowns To avoid gingival recessionTo avoid gingival recession
No. 15 - for periosteal flapsNo. 15 - for periosteal flaps
No. 11 - for incision and drainageNo. 11 - for incision and drainage Stabbing actionStabbing action
Scalpel BladesScalpel Blades
Materials– Past and PresentMaterials– Past and Present
AmalgamAmalgam CavitCavit IRMIRM Super-EBASuper-EBA Composite resinsComposite resins Gutta perchaGutta percha Glass ionomersGlass ionomers MTA (ProRoot)MTA (ProRoot)
CorrosionCorrosion Galvanism (with posts)Galvanism (with posts) Tattoo on mucosaTattoo on mucosa ExpansionExpansion Dimensional changesDimensional changes Marginal breakdownMarginal breakdown Excess not absorbableExcess not absorbable Mercury releaseMercury release
Difficult to condenseDifficult to condense Condensation scatterCondensation scatter Cavity largeCavity large Undercuts neededUndercuts needed Poor adaptation to wallsPoor adaptation to walls No anti-bacterial actionNo anti-bacterial action Difficult to remove for Difficult to remove for
re-treatment re-treatment
Amalgam
Disadvantages & Problems
Poor tissue compatibilityPoor tissue compatibility Due to continuous release of eugenol Due to continuous release of eugenol Fibrosis of adjacent tissueFibrosis of adjacent tissue
SolubleSoluble
Large cavity requiredLarge cavity required
Difficult to handle materialDifficult to handle material Esp. Super-EBAEsp. Super-EBA
IRM + Super-EBA
Disadvantages & Problems
Low tissue toxicityLow tissue toxicity Bone appositionBone apposition
Good sealing abilityGood sealing ability Chemical bond to dentineChemical bond to dentine RadiopaqueRadiopaque Easy to mix & placeEasy to mix & place Colour contrast to toothColour contrast to tooth Short setting timeShort setting time
Moisture controlMoisture control HaemorrhageHaemorrhage
Relatively large Relatively large cavity required cavity required
Glass Ionomer
Advantages Disadvantages
Gutta Percha + Sealer
Low tissue toxicityLow tissue toxicity
Good sealing abilityGood sealing ability
RadiopaqueRadiopaque
Colour contrast to toothColour contrast to tooth
Conservative cavity onlyConservative cavity only
Anti-bacterial (sealer)Anti-bacterial (sealer)
Advantages
Easy to mix & placeEasy to mix & place
Good physical propertiesGood physical properties
Satisfies requirements of Satisfies requirements of
root filling materials root filling materials
Proven and acceptable Proven and acceptable material for RCF’s for material for RCF’s for over 120 years over 120 years
ReferenceReference FavourableFavourable Uncertain UnfavourableUncertain Unfavourable
Nordenram Nordenram et alet al 1970 1970 56 %56 % 36 %36 % 8 % 8 %
Harty Harty et alet al 1970 1970 9090 - - 1010
Rud Rud et alet al 1972 1972 8383 1414 3 3
Malmström Malmström et alet al 1982 1982 7474 1717 9 9
Forsell Forsell et al et al 1988 1988 6868 2121 1111
Amagasa Amagasa et alet al 1989 1989 9595 - - 5 5
Grung Grung et alet al 1990 1990 8585 1414 1 1
Friedman Friedman et alet al 1991 1991 7070 3030 - -
Rapp Rapp et alet al 1991 1991 5656 3333 1111
Abbott 1999Abbott 1999 92.392.3 4.24.2 3.53.5
Treatment Outcome StudiesTreatment Outcome Studies
All re-treats after retro. amalgam
Endodontic Surgery - StagesEndodontic Surgery - Stages
a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan
b)b) Local AnaesthesiaLocal Anaesthesia
c)c) Periosteal FlapPeriosteal Flap
d)d) CurettageCurettage
e)e) ApicoectomyApicoectomy
f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling
g)g) Wound Closure - suturesWound Closure - sutures
h)h) Post-operative InstructionsPost-operative Instructions
i)i) Follow-up & ReviewFollow-up & Review
Post-Operative InstructionsPost-Operative Instructions
ALSO:ALSO:
1.1. Post-op RadiographPost-op Radiograph
2.2. Suture RemovalSuture Removal
4-5 days4-5 days
3.3. ReviewsReviews 3-4 months3-4 months 12 months12 months 3 years3 years
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