ENDODONTICSURGERY

ENDODONTICENDODONTICSURGERYSURGERY

What is Endodontic Surgery ?What is Endodontic Surgery ?What is Endodontic Surgery ?

Endodontic surgery is a Endodontic surgery is a surgical procedure performed surgical procedure performed

to to removeremove or or correctcorrect the the causative agents of radicular causative agents of radicular and periradicular disease and and periradicular disease and

to restore these tissues to to restore these tissues to functional health.functional health.

It is often the last hope for retention of a tooth and therefore requires the greatest skill.

It is often the It is often the last hopelast hope for retention of a for retention of a tooth and therefore requires the greatest tooth and therefore requires the greatest skill.skill.

Endodontic Surgery

INDICATION FOR ENDO. SURGERY

INDICATION FOR ENDO. INDICATION FOR ENDO. SURGERYSURGERY

-- Inability to Eliminate Pathology by Inability to Eliminate Pathology by Conventional RCT.Conventional RCT.

e.g : e.g : calcified canal , perforation .calcified canal , perforation .-- Inability to Clean and Fill the Entire Inability to Clean and Fill the Entire

Root Canal by Conventional Method .Root Canal by Conventional Method .e.g : e.g : severe dilaceration , post & core .severe dilaceration , post & core .

-- Iatrogenic Problems .Iatrogenic Problems .e.g : e.g : broken instrument , perforation .broken instrument , perforation .

CONTRAINDICATIONS FOR ENDO. SURGERY

CONTRAINDICATIONS FOR CONTRAINDICATIONS FOR ENDO. SURGERYENDO. SURGERY

1.1. Pathology Resolved by Conventional Pathology Resolved by Conventional RCT.RCT.

2.2. Health ContraindicationsHealth Contraindicationse.g: e.g: severly debilitated patients or taking severly debilitated patients or taking anticoagulantsanticoagulants

3.3. Anatomic Considerations ???Anatomic Considerations ???e.ge.g: : proximity to great palatine foramen.proximity to great palatine foramen.

4.4. Periodontal Considerations.Periodontal Considerations.

PRESURGICAL PREPARATIONPRESURGICAL PREPARATIONPRESURGICAL PREPARATION

11. Referral Data2. Record Review3. Medical History Review4. Preoperative Radiographs5. Diagnosis6. Case Presentation to The Patient7. Post Surgical Complication8. Preoperative Patient Preparation9. Surgical Preparation

FLAP DESIGN FLAP DESIGN FLAP DESIGN

Rules For Flap Design Rules For Flap Design Rules For Flap Design

-- The The basebase is wider than the free margin.is wider than the free margin.-- Incision must not be placed over any Incision must not be placed over any bony bony

defectdefect..-- Incisions that traverse a Incisions that traverse a bony eminencebony eminence

should be avoided .should be avoided .-- Sharp points at the Sharp points at the cornerscorners of the flap of the flap

should be avoided .should be avoided .

FLAP DESIGN FLAP DESIGN FLAP DESIGN

Types of Flaps Used in Endo. surgery- Gingival- Semilunar- Triangular- Rectangular- Snbmarginal {Ochsenbein – Luebke}

GINGIVAL (envelope)GINGIVAL (envelope)

1.1. IntrasulcularIntrasulcular horizontal horizontal incision incision without without vertical vertical releaserelease

2.2. Not used for apical Not used for apical surgerysurgery

3.3. Used for root resects, root Used for root resects, root amps, amps, hemisectionshemisections, , repair of cervical repair of cervical perfsperfs. . or or resorptiveresorptive defectsdefects

Gingival (envelope):Gingival (envelope):

ADVANTAGESADVANTAGES1.1. Good for Good for perioperio

surgery surgery 2.2. Can convert to Can convert to

rectangular flap if rectangular flap if neededneeded

DISADVANTAGESDISADVANTAGES1.1. Limited Limited endoendo useuse2.2. Not for apical Not for apical

surgerysurgery3.3. No releasing incisionsNo releasing incisions

SEMILUNAR FLAPSEMILUNAR FLAP1.1. FullFull--thickness flap in thickness flap in

alveolar mucosa at alveolar mucosa at level of tooth apexlevel of tooth apex

2.2. Indication for long Indication for long tooth only (maxillary tooth only (maxillary canine)canine)

3.3. Seldom used due to Seldom used due to poor access & scarringpoor access & scarring

4.4. HemostasisHemostasis may be may be problemproblem

SemilunarSemilunarSemilunarADVANTAGESADVANTAGES

1.1. Fast & easy to reflect; Fast & easy to reflect; no exposure of no exposure of crestalcrestalbonebone

2.2. Unaltered soft tissue Unaltered soft tissue attachment levelattachment level

3.3. No involvement of No involvement of marginal & marginal & interdentalinterdental gingivagingiva

DISADVANTAGESDISADVANTAGES

1.1. Poor access (least), Poor access (least), excessive excessive scarringscarring & flap & flap shrinkageshrinkage

2.2. Blood supply Blood supply interruption to adjacent interruption to adjacent tissuestissues

3.3. Limited use in mandibleLimited use in mandible4.4. Unable to extend; may Unable to extend; may

cross bony cavitycross bony cavity

1.1. Most commonly used Most commonly used Endo SX flapEndo SX flap

2.2. One vertical releasing One vertical releasing incision; can extend to incision; can extend to rectangular flaprectangular flap

3.3. FullFull--thickness flapthickness flap4.4. Keep 2 teeth away from Keep 2 teeth away from

pathosispathosis

TRIANGULAR (Intrasulcular)TRIANGULAR (TRIANGULAR (IntrasulcularIntrasulcular))

Triangular (Intrasulcular):Triangular (Triangular (IntrasulcularIntrasulcular):):DISADVANTAGESDISADVANTAGES1.1. More difficult to More difficult to

incise & reflectincise & reflect2.2. May be limited May be limited

access due to single access due to single releasing incisionreleasing incision

3.3. Possible slight Possible slight gingival recessiongingival recession

ADVANTAGESADVANTAGES1.1. Excellent wound Excellent wound

healing potentialhealing potential2.2. Minimal disruption Minimal disruption

of vascular supplyof vascular supply3.3. Excellent visibility Excellent visibility

& access to defects& access to defects4.4. Good flap Good flap

reapproximationreapproximation5.5. Easy to sutureEasy to suture

RECTANGULAR or TRAPEZOIDAL RECTANGULAR or TRAPEZOIDAL ((intrasulcuarintrasulcuar))

1.1. Extension of triangular Extension of triangular flapflap

2.2. Two vertical releasing Two vertical releasing incisionsincisions

3.3. Horizontal Horizontal intrasulcularintrasulcularincisionincision

4.4. Use if increased reflection Use if increased reflection is neededis needed

Rectangular or TrapezoidalRectangular or Trapezoidal

ADVANTAGESADVANTAGES1.1. Enhanced surgical Enhanced surgical

accessaccess2.2. Excellent visibilityExcellent visibility3.3. Excellent wound Excellent wound

healing potentialhealing potential4.4. Minimal disruption Minimal disruption

of vascular supplyof vascular supply5.5. Good to view Good to view

dehiscensesdehiscenses & & fenestrationsfenestrations

DISADVANTAGESDISADVANTAGES1.1. More difficult to incise More difficult to incise

& reflect& reflect2.2. Possible gingival Possible gingival

recessionrecession3.3. More difficult wound More difficult wound

closure than triangular closure than triangular flapflap

SUBMARGINAL (SUBMARGINAL (OchsenbeinOchsenbein--LuebkeLuebke))

1.1. Scalloped horizontal Scalloped horizontal incision in attached incision in attached gingivagingiva & two vertical & two vertical releasing incisionsreleasing incisions

2.2. Must be adequate Must be adequate attached attached gingivagingiva (3(3--5mm)5mm)

3.3. Best for epithelial wound Best for epithelial wound closureclosure

SUBMARGINAL (SUBMARGINAL (OchsenbeinOchsenbein--LuebkeLuebke))

ADVANTAGESADVANTAGES1.1. Does not involve Does not involve

marginal or marginal or interdentalinterdentalgingivagingiva nor expose nor expose crestalcrestal bonebone

2.2. Minimizes Minimizes crestalcrestal bone bone loss & gingival recession loss & gingival recession (esthetics)(esthetics)

3.3. Easy flap Easy flap reapproximationreapproximation

DISADVANTAGESDISADVANTAGES1.1. Unable to extend flap if Unable to extend flap if

neededneeded2.2. Disruption of blood Disruption of blood

suppltysupplty to marginal to marginal tissues; must rely on tissues; must rely on collateral *collateral *

3.3. Limited mandibular useLimited mandibular use4.4. Possible flap shrinkage Possible flap shrinkage

& scarring& scarring5.5. Limited visibility for Limited visibility for

root & root & crestalcrestal bonebone

SUTURING SUTURING SUTURING - To approximate the tissue - Provide strength to the wound- Eliminate tissue spaces within the wound

Types:1. Absorbable gutAbsorbable gut = catgut “ plain gut “

manufactured from collagen obtained from the small intestine of cheep or cattle

2. SilkSilk - made from the protein-rich spun by silkworm larvae.

TYPES OF ENDODONTIC SURGERY TYPES OF ENDODONTIC SURGERY TYPES OF ENDODONTIC SURGERY

1. Incision for drainage - soft tissue2. Trephination - I & D through the bone3. Periaradicular surgery:

- apical curettage- apicoectomy- apicoectomy with retrograde filling

4. Repair of perforation5. Hemi-section and root amputation6. Intentional replantation

INCISION FOR DRAINAGE

INCISION INCISION FOR DRAINAGEFOR DRAINAGE

Designed toDesigned to1.1. Release accumulated byproducts of tissue Release accumulated byproducts of tissue

breakdownbreakdown2.2. Collect samples for bacteriologic analysisCollect samples for bacteriologic analysis3.3. Provide a more favorable gradient and Provide a more favorable gradient and

pathway for drainagepathway for drainage

RELIEF OF ACUTE RELIEF OF ACUTE SYMPTOMSSYMPTOMS

ER TX ONLYER TX ONLY

TREPHINATIONTREPHINATIONTREPHINATIONA surgical technique used to A surgical technique used to

alleviate acute painalleviate acute pain caused by an caused by an accumulation of purulent material accumulation of purulent material

when drainage through the root when drainage through the root canal is impossible.canal is impossible.

Trephination is usually performed as an emergencyprocedure in the absence of

soft tissue swelling

Trephination is usually Trephination is usually performed as an performed as an emergencyemergencyprocedure in the absence of procedure in the absence of

soft tissue swelling soft tissue swelling

PERIRADICULAR SURGERY

PERIRADICULAR PERIRADICULAR SURGERYSURGERY

REPAIRE OF PERFORATIONREPAIRE OF REPAIRE OF

PERFORATIONPERFORATION

HEMI-SECTIONHEMIHEMI--SECTIONSECTION

ROOT AMPUTATION

ROOT ROOT AMPUTATIONAMPUTATION

INTENTIONAL REPLANTATIONINTENTIONAL INTENTIONAL

REPLANTATIONREPLANTATION

INTENTIONAL REPLANTATIONINTENTIONAL REPLANTATIONINTENTIONAL REPLANTATION

50 / 50 Success at best

Indication :

1. lateral perforation that can not betreated surgically.

2. Anatomy make surgery risky e.g:mental foramen , maxillary sinus

REMMEMBER :

1. Do orthograde fill if possible2. Do not touch the root3. Work fast “ less than 30 min. “4. Stabilize if necessary5. Reduce occlusion before extraction6. Extraction should be non-traumatic.

INTENTIONAL REPLANTATIONINTENTIONAL REPLANTATIONINTENTIONAL REPLANTATION

POSTSURGICALINSTRUCTION

POSTSURGICALPOSTSURGICALINSTRUCTIONINSTRUCTION

POSTSURGICAL COMPLICATIONSPOSTSURGICAL COMPLICATIONSPOSTSURGICAL COMPLICATIONS1.1. Pain2.2. Swelling3. Infection4. Bleeding5. Hematoma6. Tissue trauma7. Incomplete root resection8. Malalignment of retrograde filling9. Foreign debris in the surgical site10. Parasthesia

FOLLOW UPFOLLOW UPFOLLOW UP

““A minimum of A minimum of 2 years2 years was was considered to be sufficient to considered to be sufficient to evaluate the success or evaluate the success or failure of the treatment.failure of the treatment.””

Rud et al 1972Rud et al 1972

““The The typetype of endodontic surgical treatment of endodontic surgical treatment seemed not to influence the prognosis of seemed not to influence the prognosis of endodontic surgery.endodontic surgery.

The success rate is higher with the use of The success rate is higher with the use of retrofillretrofill in periapical surgery.in periapical surgery.””

Molven & Hals 1991Molven & Hals 1991

““ Prognosis is decreased to about Prognosis is decreased to about 3030--40% in cases where 40% in cases where

endodontic endodontic surgical retreatmentsurgical retreatmenthas been performed. has been performed. ””

Block et al 1979Block et al 1979Block et al 1979

http://http://faculty.ksu.edu.sa/alnazhan/default.aspxfaculty.ksu.edu.sa/alnazhan/default.aspx