CONTRAINDICATIONS OF ENDODONTIC SURGERY?
Endodontic surgery is defined “as removal of tissues other than the contents of root canal to retain a tooth with pulpal or periapical involvement”.
Indications
1. Need for surgical drainage 2. Failed non-surgical treatment:
a. Irretrievable root canal filling material.
b. Recurring exacerbations of non-surgical endo- dontic treatment.
3. Calcific metamorphosis of the pulp space.
4. Horizontal fracture at the root tip with associated periapical disease. 5. Procedural errors: a. Instrument separation b. Non-negotiable ledging c. Root perforation 6. Anatomic variations a. Root dilacerations
b. Non-negotiable root curvatures. 7. Biopsy 8. Corrective surgery a. Root resection b. Hemisection c. Bi-cuspidization 9. Replacement surgery a. Intentional replantation b. Post-traumatic replantation 10. Implant surgery a. Endodontic implants b. Osseo-integrated implants Contraindications
1. Poor periodontal health of the tooth 2. Patient’s health considerations
a. Recent cardiac or cancer surgery b. Very old patients
c. Uncontrolled hypertension d. Uncontrolled bleeding disorders
e. Immuno-compromised patients 3. Patient’s mental or psychological status:
a. Patient does not desire surgery b. Very apprehensive patient
4. Surgeon’s skill and ability—Clinician must be completely honest about their surgical skill and knowledge.
5. Short root length in which removal of root apex further compromises the prognosis.
6. Proximity to nasal floor and maxillary sinus 7. Miscellaneous
a. Non-restorable teeth b. Vertically fractured teeth.
CLASSIFY VARIOUS ENDODONTIC SURGERY PROCEDURES
1. Surgical drainage
a. Incision and drainage (I and D) b. Cortical trephination
2. Periradicular surgery a. Curettage
b. Biopsy
c. Root end resection d. Corrective surgery
i. Perforation repair ii. Root resection iii. Hemisection. 3. Replacement surgery
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4. Implant surgery
a. Endodontic implants
b. Root-form osseointegrated implants.
WHAT ARE PRINCIPLES AND GUIDELINES FOR FLAP DESIGNS? DISCUSS VARIOUS FLAP DESIGNS
1. Avoid horizontal and severely angled vertical incisions.
2. Avoid incisions over radicular eminences, for example in canines and maxillary first premolars. 3. Incisions should be placed and flaps repositioned over
solid bone.
4. Avoid incisions across major muscle attachment. 5. Extent of horizontal incision should be adequate to
provide visual and operative access with minimal soft – tissue trauma.
6. Avoid incisions in the mucogingival junction. 7. The junction of the horizontal sulcular and vertical
incisions should either include or exclude the involved interdental papilla.
8. The flap should include the complete muco- periosteum.
Triangular Flap
Earlier triangular flap was usually formed by giving two incisions, i.e. horizontal and vertical. Nowadays, intrasulcular incision is also given along with these two incisions. Vertical incision is usually placed towards the midline (Fig. 21.1).
Advantages
• Enhanced rapid wound healing. • Greater access and visibility. Disadvantages
• Limited surgical access. • Difficult to retract.
Rectangular Flap
Earlier a rectangular flap was made by giving only two vertical and a horizontal incision but nowadays, instrasulcular incision has also been added in this design (Fig. 21.2).
Advantage
Enhanced surgical access. Disadvantages
• Wound closure as flap re-approximation and post- surgical stabilization are more difficult than triangular flap.
• Potential for flap dislodgement is greater.
Trapezoidal Flap
Trapezoidal flap is formed by two releasing incisions which join a horizontal intrasulcular incision at obtuse angles (Fig. 21.3).
Fig. 21.1: Triangular flap
Fig. 21.2: Rectangular flap
Disadvantage
Wound healing by secondary intention.
Envelope Flap
It is formed by a single horizontal intrasulcular incision and is usually recommended for corrective endodontic surgery.
Advantage
Improved wound healing Disadvantage
Extremely limited surgical access.
Semilunar Flap
It is formed by a single curved incision. This flap is called as semilunar flap because horizontal incision is modified to have a dip towards incisal aspect in centre of the flap, giving resemblance to the half moon (Fig. 21.4).
Disadvantages
• Limited surgical access • Difficult wound closure
Ochsenbein-Luebke Flap
This flap is modification of the rectangular flap (Fig. 21.5). Flap design—in this scalloped horizontal incision is given in the attached gingiva which forms two vertical incisions made on each side of surgical site .
Advantages
• Marginal and inter-dental gingiva are not involved. • Crestal bone is not exposed.
Disadvantages
• Difficult flap re-approximation and wound closure • healing with scar formation
• Limited apical orientation.
WHAT IS PERIRADICULAR CURETTAGE?
It is a surgical procedure to remove diseased tissue from the alveolar bone in the apical or lateral region surrounding a pulpless tooth.
Indications
• Access to the root structure for additional surgical procedures.
• For removing the infected tissue from the bone surrounding the root.
• For removing overextended fillings. • For removing necrotic cementum.
Surgical Techniques
• Inject local anesthetic with vasoconstrictor into soft tissue.
• Expose the surgical site.
• Use the bone curette to remove the pathologic tissue surrounding the root.
• After removing the tissue from the bony area, grasp the soft tissue with the help of tissue forceps. • Send the pathological tissue for histopathological
examination.
Fig. 21.4: Semilunar flap
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WHAT ARE INDICATIONS OF ROOT-END RESECTION (APICOECTOMY, APICECTOMY)? HOW DO WE PERFORM IT?
Apicoectomy is the ablation of apical portion of the root- end attached soft tissues.
The current indications of root-end resection are: • Inability to perform nonsurgical endodontic therapy
due to anatomical, pathological and iatrogenic defects in root canal.
• Persistent infections after conventional endodontic treatment.
• Need for biopsy.
• For removal of iatrogenic errors like ledges, fractured instruments, and perforation which are causing treatment failure.
• For evaluation of apical seal.
• Blockage of the root canal due to calcific metamor- phosis or radicular restoration.
Factors to be Considered before Root-End Resection
Instrumentation
High speed handpiece with surgical length fissure bur usually results in satisfactory resection. Use of round bur may result in gouging of root surface whereas crosscut fissure burs can lead to uneven and rough surface.
Recently studies have shown the use of Er:YAG laser and Ho:YAG laser for root end resection but among these Er:YAG laser is better as it produces clean and smooth root surface. Advantages of use of laser in periradicular
surgery over the traditional methods include:
1. Reduction of postoperative pain. 2. Improved hemostasis.
3. Reduction of discomfort. Extent of Resection
Factors to be considered while performing root-end resection are:
1. Access and visibility of surgical site.
2. Anatomy of the root, i.e. its shape, length, etc. 3. Anatomy of the resected root surface to see number
of canals.
4. Presence and location of iatrogenic errors. 5. Presence of any periodontal defect.
According to Cohen et al, root resection of 3 mm at a 0° bevel angle eliminates most of the anatomic features that are possible cause of failure (Fig. 21.6).
Angle of Resection
Earlier it was thought that root-end resection at 30° to 45° from long axis of root facing buccally or facially provides:
• Improved visibility of the resected root-end. • Improved accessibility.
But nowadays 0° bevel with resection at the level of 3 mm is recommended.
Advantages of a Zero Degree Bevel (Fig. 21.7) • Maintains maximum root length.
• Reduced osteotomy size. • Lesser apical leakage.
Root-End Preparation
The main objective of root-end preparation is to create a cavity to receive root-end filling. Root-end preparation
Fig. 21.6: Frequency of ramifications at
different levels of root canal
Fig. 21.7: Bevelling of root end results in more exposure of
should accept filling materials so as to seal off the root canal system from periradicular tissues.
An ideal root-end preparation as “a class I preparation at least 3.0 mm into root dentine with walls parallel to a coincident with the anatomic outline of the pulp space”.
Traditional Root-End Cavity Preparation
Miniature contra angle or straight handpiece, with a small round or inverted cone bur is used to prepare a class I cavity at the root-end within confines of the root canal (Fig. 21.8). One of the main problems in root-end preparation is that these preparations seem to be placed
Fig. 21.8: Root end preparation using endopiece
in the long axis of the tooth, but they are directed palatally, ultimately causing the perforations.
Ultrasonic root-end preparation was developed to
resolve the main shortfalls of bur preparation. For this specially designed ultrasonic root-end preparation instruments have been developed.
Retrograde Filling
Root canal filling material is placed in the prepared root- end in a dry field. To place a material in the retro- preparation, it is mixed in the desired consistency, carried on the carver and placed carefully into the retro- preparation and compacted with the help of burnisher (Fig. 21.9).
Fig. 21.9: Removal of excess material
WHAT ARE IDEAL PROPERTIES OF ROOT-END FILLING MATERIALS?
Ideal properties of a root-end filling material are that it: 1. Should be well tolerated by periapical tissues 2. Should adhere to tooth surface.
3. Should be dimensionally stable. 4. Should be resistant to dissolution. 5. Should promote cementogenesis. 6. Should be bactericidal or bacteriostatic. 7. Should be non-corrosive.
8. Should be electrochemically inactive.
9. Should not stain tooth or periradicular tissue. 10. Should be readily available and easy to handle. 11. Should allow adequate working time, then set
quickly.
12. Should be radioopaque.
Commonly used root-end filling materials are:
1. Amalgam 2. Gutta-percha 3. Glass ionomers 4. Zinc oxide eugenol 5. Cavit
6. Composite resins 7. Polycarboxylate cement 8. Poly HEMA
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WHAT ARE POSTSURGICAL COMPLICATIONS?
Postoperative Swelling
Postoperative swelling usually reaches maximum after 24 or 48 hours. It usually resolves within a week. Management
1. Inform the patient earlier as it reduces the anxiety. 2. Application of ice packs should be advocated for next
6-8 hours to decrease the swelling.
3. Application of hot moist towel is recommended after 24 hours.
Postoperative Bleeding
Postoperative bleeding can be reduced by compression of the surgical flap both before and after suturing. Management
1. First and foremost step in managing bleeding is applying firm pressure over the area for 10-20 minutes.
2. If bleeding still continues, then sutures should be removed and then search for blood vessels causing bleeding. Cauterization should be done.
Extraoral Ecchymosis (Extraoral Discoloration)
Discoloration/ecchymosis usually results when blood has leaked into the surrounding tissues. This condition is self limiting in nature and lasts up to 2 weeks and does not affect the prognosis.
Pain
Postoperative pain is usually maximum on the day of surgery and it decreases thereafter.
Management
1. Pain can be managed by prescribing NSAIDs. 2. If severe pain is present, opoid analgesics may be
combined with NSAIDs.
Infection
Postoperative infection usually occurs due to inadequate aseptic technique and improper soft tissue handling, approximation and stabilization.
Management