CONTENTS INTRODUCTION HISTORICAL PROSPECTIVES OBJECTIVES INDICATIONS / CONRAINDICATIONS CLASSIFICATION OF ENDODONTIC SURGERY SURGICAL DRAINAGE Incision and Drainage Cortical Trephination PERIRADICULAR SURGERY SOFT TISSUE MANAGEMENT HARD TISSUE MANAGEMENT SOFT TISSUE MANAGEMETN Principles of flap design Classification of flap Full Mucoperiosteal flap Limited Mucoperiosteal flap Incision Flap reflection Flap retraction HARD TISSUE MANAGEMENT Periradicular curettage
Indication of periradicular curettage Root end dissection Angle of resection Root end preparation Root end filling POST SURGICAL PATIENT MANAGEMENT CORRECTIVE SURGERY Root resection Hemisection Intentional replantation Endodontic implants CONCLUSION REFERENCES
INTRODUCTION
Endodontic Has Seen A Dramatic Shift In The Application In The Field Of Surgical Endodontics And Plays A Vital Role In Deliverying Endodontic Treatment The scope of Endodontic surgery has expanded beyond apicoectomy (Root resection, root amputation) to include periapical curettage, radiosectomy, replantation, transplantation, implantation, trephination, incision and drainage. Phillips and Maxmen claimed a 99% success rate in more than 600 cases. Oliet and Grossman reported that periapical surgery when combined with endodontic treatment was considered successful to about 90-99% Harty and associates have reported a success rate of 90% postoperatively. Sommer reported a 95% success rate in more than 100 cases of root resection.
HISTORICAL PERSPECTIVE Endodontic surgery is not a concept developed in the twentieth century. A mandible found in Egypt from 4 dynasty in 2900-2750BC contained holes. The first recorded endodontic surgical procedure was the incision and drainage of the acute endodontic abscess performed by Aetius, a Greek Physician – Dentist, over 1500 years ago. Apical resection by Farrar and rhein in 1884 and 1890 in anterior teeth Faulher and Neumann reported •Apical resection in molar teeth in 1912 First comprehensive report on apical resection was presented at a meeting of Silesian dental society in Breslau in 1897 by partash Shamberg performed root resection in 1884 Abulcasis,fauchard,hullihan, partisch,black
OBJECTIVE The placement of a proper seal between the periodontium and the root canal foramina. The better the seal, the better the endodontic prognosis of the tooth INDICATION Failed non-surgical endodontic treatment –Irretrievable root canal filling materials –Irretrievable intraradicular post
Calcify metamorphism of the pulp space Procedural errors – Instrument fragmentation – Non-negotiable ledging – Root perforation – Symptomatic overfilling Anatomic variations –Root dilacerations –Apical root fenestration Biopsy Corrective surgery –Root resorption defects –Root caries –Root resection –Hemi section –Bicuspidization Replacement surgery –Intentional replantation –Post traumatic Implant surgery Contraindications : The patient’s medical status Anatomic considerations
The dentist’s skill and experience General Considerations: Medically compromised or brittle patients Emotionally-distressed patient Limitations in the surgical skill and experience of the operation Local Considerations : Localized acute inflammation Anatomic considerations Inaccessible surgical sites. Teeth with a poor prognosis Periapical surgery should not be considered as a cure to compensate for inadequate technique that resulted in failure to heal. CLASSIFICATION ACCORDING TO INGLE Surgical drainage Incision and drainage (I & D) Cortical trephination (Fistulative surgery) Periradicular surgery Curettage Biopsy Root end resection Root end preparation and filling
Corrective surgery Perforation repair Mechanical (Iatrogenic) Resorption (Internal and external) Replacement surgery (Extraction / Replantation) Implant surgery Endodontic implants Root form osseointegrated implants According to Cohen 1. Class A : Absence of peripical lesion 2. Class B : Presence of small periapical lesion with no periodontal pocket 3. Class C : Presence of large periapical lesion with no periodontal pocket 4. Class D : Presence of large lesion with periodontal pocket 5. Class E : Presence of periapical lesion with endodontic and periodontal communication but no root treatment. 6. Class F : Tooth with an apical lesion and complete dendement of the buccal plate. According to Gutmann : 1) Periadicular surgery a) Curettage b) Root end resection c) Root end preparation and filling
2) Fistulative surgery a) Incision and drainage b) Cortical trephination c) Decompression 3) Corrective surgery a) Perforative repair i.
Resorptive and carious
ii.
Mechanical
b) Periodontal management c) Intentional replantation Surgical Drainage : Surgical drainage is indicated when purulent and/or hemorrhagic exudates forms within the soft tissue and the alveolar bone a result of a symptomatic Periradicular abscess. Surgical drainage maybe accomplished by ; Incision and drainage (I and D) cortical Trephination Incision and Drainage : Fluctuant soft tissue swelling occurs when periradicular inflammatory exudates exits through the medullary bone and the cortical plate. If the swelling is intraoral and localized, the infection may be managed by surgical drainage alone.
IF the swelling is diffuse (or) has spread into extraoral Musculofascial tissue or spaces, surgical drainage should be supplemented with appropriate systemic antibiotic therapy Local Anesthesia : Whenever possible nerve block injection is the preferable method for obtaining local anesthesia. In some cases, block injections must be supplemented with local infiltration to obtain adequate local anesthesia. Local anesthesia should be deposited peripheral to the swollen mucoperiosteal tissue. INCISION : The incision should be horizontal and placed at the dependent base of the fluctuant area. Such as No.11 and No.12 rather than a rounded No.15 blade. Cardinal Rule I : The incision must be made with a firm, continuous stroke. Pen grasp is the most preferred hand position. Types of Incision : -
Partial thickness
-
Full thickness
Partial Thickness : Cut is made through mucosa and submucosa and separates superficial tissue deep tissue.
Full thickness : Made through mucosa, connective tissue and periosteum until bone is felt. Cardinal Rule II : -
An incision should not cross an underlying bony defect that existed prior to surgery or produced by surgery.
Cardinal Rule III : -
Vertical incisions should be made in the concvities between bony eminences (tissue in thcikness and more blood supply)
Cardinal Rule IV : The termination of the vertical incision at the gingival crest must be at line angle of tooth. This will provide firm, attached tissue for suturing, will not split the papilla and will minimize the chances of causing a tissue cleft. Cardinal rule V : The vertical incision should not extend into the mucobuccal fold. It an result in serve bleeding.
To aviod incising through the fold, the vertical
incision line should create an obtuse angle with the horizontal incision line. Cardinal VI : The base of the flap must always be wider than the width of the free edge. This will maximize the blood supply. Cardinal VII : The periosteum must be reflected as an integral part of the flap. Cardinal Rule VIII : Any tissue retractor must rest on bone and not impinge on soft tissues.
Cardinal Rule IX : All suturing begins by insertion of needle through the unattached tissue to the attached tissue. Cortical Trephination Cortical trephination is a procedure involving the perforation of the cortical plate to accomplish the release of pressure from the accumulation of exudates within the alveolar bone. Patient who complains of pain with no swelling, the treatment of choice is apical trephination but they are limited in certain cases (post and core, fractured instruments, ledging). Cortical trephination is the only option. Trephination is a surgical technique used to all eviate acute pain caused by accumulation of purulent material when drainage through root canal is impossible. The cortical trephination procedure involves an incision through mucoperiosteal tissues, exposure of the surface of cortical bone, penetration of the cortex with a rotary (round bur) instrument and creating a pathway through cancellous bone to the vicinity of involved periradicular tissues.
Periradicular surgical procedures regardless of their indications, share a number of concepts and principals The need for profound local anesthesia and haemostasis Management of soft tissue Management of hard tissues
Surgical access both visual and operative Access to root structure Periradicular curettage Root end resection Root end preparation Root end filling Soft tissue repositioning and suturing Post surgical care Anesthesia and Hemostasis : L.A with adrenaline •To obtain profound and prolonged anesthesia •To provide good hemostatsis both during and after the surgical procedure. SOFT TISSUE MANAGEMENT PRINCIPLES OF FLAP DESIGN 1) Making sure base of the flap should be wider than the free end. 2) Avoiding the incision over a bony defect 3) Including the full extent of the lesion. 4) Avoiding sharp corners 5) Avoiding incision across a bony eminence 6) Guarding against possible dehiscence 7) Avoiding incision in the mucogingival junction. 8) Taking care during retraction.
9) Incision should be made with firm, continuous firm stroke perpendicular to the cortical bone plate. 10)The sutured flap margin should rest on solid cortical bone plate. CLASSIFICATION OF FLAP ACC TO GUTMANN AND HARRISON 1. Full mucoperiosteal flaps a. Triangular b. Rectangular c. Trapezoidal d. Horizontal 2. Limited mucoperiosteal flaps a. Submarginal curved (semilunar) b. Submarginal rectangular (Luebke - Ochsenbein) Advantages of Full Mucoperiosteal Flaps 1. Rapid wound healing 2. Good surgical access 3. Minimal disruption of blood supply 4. Minimal untoward post-surgical sequelae 5. Optimal apical orientation and 6. Primary intentional healing. Disadvantages 1.Loss of soft tissue attachment
2. Loss of crestal bone height 3. Post surgical flap dislodgement Advantages of limited mucoperiosteal flap 1. Marginal and interdental gingiva not involved 2. Unaltered soft tissue attachment level 3. Crestal bone is not exposed 4. Adequate surgical access and 5. Good would healing potential Disadvantages
1. Disruption of blood supply to unflapped tissues 2. Flap shrinkage 3. Difficult flap reapproximation 4. Delayed secondary wound healing. 5. Limited apical orientation
TRIANGULAR FLAP
INDICATION MIDROOT PERFORATION REPAIR PERIAPICAL SURGERY
POSTERIOR AREAS SHORT ROOTS ADVANTAGES EASILY MODIFIED SMALL RELAXING INCISION ADDITIONAL VERTICALINCISION EXTENSION OF HORIZONTAL COMPONENT EASILY REPOSITIONED MAINTAINS INTEGRITY OF BLOOD SUPPLY
DISADVANTAGES LIMITED ACCESS AND VISIBILITY TO LONG ROOT TENSION IS CREATED ON RETRACTION VERTICAL INCISION PENETRATES ALVEOLAR MUCOSA GINGIVAL ATTACHMENT SEVERED
SEMILUNAR FLAP
INDICATION ESTHETIC CROWNS PRESENT TREPHINATION
ADVANTAGES REDUCES INCISION AND REFLECTION TIME MAITAIN INTEGRITY OF GINGIVAL ATTACHMENT ELIMINATES POTENTIAL CRESTAL BONE LOSS DISADVANTAGES LIMITED ACCESS AND VISIBILITY TENDENCY FOR INCREASE HAMORRAGE CROSSES ROOT EMINENCES MAY NOT INCLUDE ENTIRE LESION PREDISPOSED TO STRETCHING AND TEARING REPOSITIONING IS DIFFICULT HEALING IS ASSOCIATED WITH SCAR
RECTANGULAR FLAP
INDICATIONS PERIAPICAL SURGERY MULTIPLE TEETH LARGE LESIONS LONG OR SHORT ROOTS LATERAL ROOT REPAIRS FULL LENGTH ROOT VISUALIZED
ADVANTAGES PROVIDES MAXIMUM ACCESS AND VISIBILITY REDUCES RETRACTION TENSION FACILITATES REPOSITIONING
DISADVANTAGES REDUCED BLOOD SUPPLY TO FLAP INCREASED INCISION AND REFLECTION TIME GINGINVAL ATTACHMENT VIOLATED
GINGIVAL RECESSION
CRESTAL BONE LOSS MAY UNCOVER DEHISCENCE
SUTURING IS MORE DIFFICULT OCHSENBEIN- LUEBKE FLAP
INDICATION PROSTHETIC CROWNS PRESENT PERIAPICAL SURGERY ANTERIOR REGION LONGER ROOTS WIDE BAND OF ATTACHED GINGIVA
ADVANTAGES EASE IN INCISION AND REFLECTION ENHANCED VISIBILITY AND ACCESS EASE IN REPOSITIONING MAINTAINS INTEGRITY OF ATTACHMENT PREVENT GINGIVAL RECESSION AVOID DEHISCENCE PREVENT CRESTAL BONE LOSS
DISADVANTAGE HORZONTAL COMPONENT DISRUPTS BLOOD SUPPLY VERTICAL
COMPONENTS
CROSSES
MUCOGINGIVAL
JUNCTION AND MAY ENTER MUSCLE TISSUE DIFFICULT TO ALTER IF SIZE OF LESION MISJUDGED INCISIONS
Incisions for the majority of mucoperiosteal flaps for periradicular surgery can be accomplished by ; No.11, NO.12, No.15, No.15C, micro surgical blade.
FLAP REFLECTION
Flap reflection is the process of separating the soft tissue (Gingiva Mucosa and Periosteum) from the surface of the alveolar bone. This process should begin in the vertical incision a few millimeter apical to the junction of the horizontal and vertical incisions. Periosteal elevator for flap reflection are ; No.1 and No.2 (Thompson Dental Manufacturing Co) No.2 (Union Bronch) No.9 (Union Bronch Co) FLAP RETRACTION
ďƒ˜ Flap retraction is the process of holding in position the reflected soft tissues.
Flap retractions : No.G3 (HuFriedy) No.3 (Hu Friedy) Rubinstein (jedmed Co St.Luis Co) HARD TISSUE MANAGEMENT
Following reflection and retraction of the mucoperiosteal flap, surgical access must be made through the cortical bone to the roots of the teeth. Barnes identified from ways in which root surface can be distinguished from the surrounding osseous tissue. Root structure generally has a yellowish color Roots does not bleed when probed Root texture in smooth and hard as opposed to the granular and porous nature of bone The root is surrounded by the PDL
Periradicular curettage
A surgical procedure to remove disease tissue from the alveolar bone in the apical or lateral region surrounding a pulp less tooth
Indications for periradicular curettage: 1. To remove contaminated tissues. 2. To remove the necrotic cementum 3. To gain access to the root for surgical purpose
4. To remove over extended root canal fillings 5. To remove long standing, persistent lesion if cyst is suspected. 6. To eliminate persistent sinus tract. 7. To obtains specimen for biopsy. 8. To manage wide open apex teeth with necrotic pulps.
Root-end resection (Root end amputation, apical amputation): The ablation of the apical portion of the root and attached soft tissue. INSTRUMENTATION Ingle et al recommended the root end resection is best accomplished by the No.702 tapered fissure bur or No.6 or No.8 round bur in a low speed straight band piece. LASER : Komori and Associates reported in-vitro study to evaluate Er-YAG laser for root end resection. They reported that Er-YAG laser produced smooth, clean, resected root surfaces free of any signs of thermal damage. Moritz and associates reported that CO2 laser treatment optimally prepares the resected root end surface to receive a root end filling because it seals the dentinal tubules, eliminates niches for bacterial growth and sterilizer the root surfaces Miserendino stated that the rationale for laser use in endodontic periradicular surgery includes ;
•Improved homeostasis and concurrent visualization of operation field •Potential sterilization of the contaminated root apex •Potential education in permeability of root surface dentin •Reduction of post-operative plan •Reduced risk of contamination of the surgical site through elimination of the use of ceresol producing air turbine hand pieces. Angle of Root End Resection : Historically, the recommended the angle of root end resection used in periradicular surgery should be 30 degree to 45 degrees from the long axis of the root filling toward the buccal or facial aspect of root. The purpose for the angled root end resections was to provide enhanced visibility to the resected root end and operator access to enable the surgeon to accomplish root end preparation They concluded that by increasing the angle of the root end resection from the long axis of the root, the number of exposed dentinal tubules. Vertical Slot Preparation
Slot preparation done up to 3-5mm apically
Root-end preparation - root-end filling (retrograde fill, retro fill): A method of sealing the apical extent of the root canal system through the cavity preparation in the resected root-end and placement of a restorative sealing material.
Root end preparation
5 requirements that a root end preparations must fulfill. The apical 3 mm of the root canal must be freshly cleaned and shaped. The preparation must be parallel to and coincident with the anatomic outline of the pulp space. Adequate retention form must be created. All isthmus tissue, when present must be removed Remaining dentin walls must not be weakened.
Ultrasonic root end preparation The use of ultrasonic instrumentation during periradicular surgery was first reported by Richman in 1957 when he used ultrasonic chisel to remove bone and root apices. This concept was further developed by Bertrand and Colleagues in 1957 when they reported on the use of modified ultrasonic periodontal scaling tips for root end preparations in periradicular surgery
Recently, specially designed ultrasonic root end preparation instruments have been developed. Ultrasonic tips developed by De Gary Carr- Available with plain and diamond coated tips.
Kis Microsurgical Ultrasonic Instruments – The tips are coated with zirconium nitrite for faster dentin cutting with less ultrasonic energy
Advantages over traditional bur type preparation Smaller preparation size Less need for root end beveling A deeper preparation More parallel walls for better retention of the root end filling material
Root End Fillings : The purpose of a root end filling is to establish a seal between the root canal space and the periapical tissue. According to Gartner and Dom, a suitable REF should be Able to prevent leakage of bacteria and there by products into the periradicular tissues. Non-toxic Non-carcinogenic Biocompatible with the host tissue Insoluble in tissue fluids Dimensionally stable Unaffected by moisture during setting Easy to use Radiopaque
Root End filing materials : Gutta percha Amalgam Cavit IRM Super EBA Glass Ionomer Composite resins Carboxyl ate cements •Zinc phosphate cements Zinc oxide eugenol cements Mineral trioxide aggregation (MTA) POST SURGICAL PATIENT MANAGEMENT
1) Avoid strenuous activity for the remainder of the day. 2) It is essential that you maintain an adequate diet with proper solid and fluid intake during the first 3 day following surgery. 3) Avoid manipulation of the facial tissue as much as possible. Do not raise the lip or retract the cheeks to inspect the surgical site as you may dislodge the sutures (stitches) 4) Some oozing of blood from the surgical site is normal during the day and evening of surgery.
5) To minimize the above, apply an ice bag with firm pressure to the face directly over the surgical site. You should apply the ice bag alternately 20 minutes on, 20 minutes off, for 6 to 8 hours following surgery. 6) Post surgical discomfort should be minimal, but the surgical site will be tender and sore. 7) The suture (stitches) that have been placed must be removed to ensure proper healing. 8) Rinse with no tablespoon of chlorhexidine mouthrinse twice each day for 5 days following surgery. 9) Recall visits are necessary. 10)Should any complications arise, do not hesitate to call
CORRECTIVE SURGERY Involves the correction of defects in the body of the root other than the apex. Corrective surgical procedures may be necessary as a result of procedural accidents , resorption (internal or external) root caries, root fracture and periodontal disease. Corrective surgery may involved periradicular surgery, root resection (removal of an entire root from multirooted teeth leaving clinical crown intact) , hemisection or intentional replantation. Representative Defects of the root and associated procledures are classified as;
1) Perforation repair a) Mechanical b) Resorptive / Caries 2) Periodontal repair a) Guided Tissue Regeneration b) Root Resection / Hemisection c) Surgical Correction of Radicular lingual groove Perforation Repairs : Mechanical : Are procedural accident that can occur during root canal or post space perforation common sites are pulp chamber floor of molars and distal aspect of mesial root of mandibular molars and distal aspect of mesial root of mandibular molars and mesiobuccal roots of maxillary molars. Perforations can be caused by two errors: 1) Creating a ledge in the canal wall during initial instrumentation and perforating through the side of the root at the point of canal obstruction of root curvature. 2) Using too large or too long an instrument and either perforating directly through the apical foramen or creating a hole in the lateral surface of the root by over instrumentation (Canal stripping ) Certical Canal Perforations :
The cervical portion of the canal is most often perforated during the process of locating and widening the canal orifice or inappropriate use of Gates – Glidden burs. Diagnosis : Sudden appearance of blood. Correction includes both internal and external. Small perforations may e sealed from inside the tooth. If the perforation is large, it may be necessary to seal first from the inside and then surgically exposed the external aspect of the tooth and repair the damaged tooth structure. MTA has been used with excellent results. Mid Root Perforations : The occur mostly in curved canals during instrumentation. It can be recognized as sudden appearance of bleeding. Access to midroot perforation is most often difficult and repair is not predictable. Two step method is used wherein the root canal are first obturated and then the defect is repaired surgically. MTA has been sued. Prevention : In lower first molars at 1.5 mm below the bifurcation, they found the dentin of the rot to be 1.5 – 1.3 mm thick from the canal to the cementum. The mesiobuccal canal is in most danger of being striped. Anticurvature filling – maintaing mesial pressure on enlarging instruments to avoid delicate danger zone of distal wall where root is very
thin. Stripping can be prevented by exercising caution: Careful use of rotary instruments inside the root canal. Apical Perforations : Cause : The instrument not negotiating a curved canal, or not establishing accurate working length and over instrumentation. It is as a result of ledging, apical transportation , apical zipping. The term apical zip is defined as an elliptical shape that may be formed in the apical foramen during preparation of a curved canal and subsequently transports the apical foramen to the outer wall. Sites are mesiobuccal and palatal root of maxillary molars and mesial roots of mandibular molars. Diagnosis : Patient may complains of the pain during treatment and bleeding is seen. Treatment : If apical zip is created , there will be two foramen : One natural and other is iatrogenic. In this case, obturation of both these foramin and main body of the canal requires of the canal requires the vertical compacting techniques with heat softened gutta percha, often surgery is necessary if a lesion is present apically. If the perforation is caused by over instrumentation, treatment includes re-establishing tooth length short of original length and then enlarging the canal with larger instruments to that length.
Creating an apical barrier is another technique that can be used to prevent over extensions during root canal filling, materials used to develop such barriers include dentin chips, calcium hydroxide power, proplast, MTA. Post Space Perforation : A well done root canal procedure can be destroyed in a few seconds by a misdirected post space preparation. Treatment The use of resin composite bonded to adjacent root dentin with a bonding agent. Preparing the space at the time the root canal is obturated reduces the risk of perforating. It is safer to do so with a hot instrument or a file that with a round bur on an end cutting bur. Gates Glidden and Peeso drills are not likely to be at risk in causing perforations. Resorption (External / Internal ) Repair of a defect on root surface depends on whether there is a communication between resorptive defect and the oral cavity / pulp space. When there is communication between resorptive defect and oral cavity, surgical procedure is required. When the defect communicates with pulp space, there is excessive bleeding present. Treatment :
Before repairing the defect, gutta percha point may be placed in root canal to prevent the repair material from obstructing the root canal. The gutta Percha point acts as an internal matrix. The pulp space can either be obturated at the same appointment or a later date. If the resorptive defect has extended into the gingival sulcus, then mucoperiosteal flap should be raised and defect is established and repaired an dflap is repositioned and stabilized with sutures. If resorptive defects are on lingual / palatal surface accessibility is difficult. Treatment international replantation or extraction should be considered. Periodontal Repair : Guided Tissue Regeneration : In the past, extensive periodontal defects required extraction or root amputation. Today with techniques of guided bone regeneration and dimeneralized freze – dried bone allografts, many teeth that were previously untreatable can be saved. Can be resorbable and non resorbable type. Resorbable type :
Collagen membrane, polylactic acid,
polyglycolic acid. Non resorbable Type : Latex, Expanded polytetrafluoroethane.
ROOT AMPUTATION Root amputation are procedures to eliminate a weak, diseased root to allow the stronger root to survive, whenever if retained together would
collectively fail. Selected root removal allows improved access of home care and plaque control with resultant bone formation and reduced pocket depth. Indication 1) Existence of Peridontal bone loss to extend that periodontal therapy and patient maintenance do not sufficiently improve the condition 2) Destruction of a root through resorptive process, caries or mechanical perforations. 3) Surgically inoperable roots that are calcified , contain broken instruments. 4) Fracture of one root that does not involve the other. Contraindications : 1) Lack of necessary osseous supports for remaining root. 2) Fused roots or roots in unfavorable proximity to each other 3) Remaining roots not favourable endodontically 4) Lack of patient motivation 5) Poor crown : root ratio AMPUTATION TECHNIQUE FOR MAXILLARY MOLARS : Maxillary molars typically have mesiobucall roots that are broad buccolingualy, narrow mesiodistally and extend 2/3 of the distance to
lingual root. Distobucal roots are more conical in shape. Palatal canal imparts stability. Amputation is performed with 701 XL bur because of its length. Especially in mesiobuccal roots. Pershaping crown with a bur so that large crown structure is removed over the root to be extracted To resect the root involving abutment, it is horizontally resected at oblique angle. Osseous recontouring is done Finally reshaping of crown is done with diamond stones. Morphologic factors : The length, width and contour of roots are important factors in determining where the resective cut is made and strength of remaining tooth structure. Two different approaches to resection are available. ON approach is to amputate horizontally or obliquely the involved root at the point where it joins the crown, a process called root amputation . The other approach is to cut vertically the entire tooth in half form mesial to distal of crown in maxillary molars, and form buccal a lingual of crown in mandibular molars – removing in either case the pathologic root. This procedure is called hemisection. Indications for Hemisection
1. Furcal invasion by inflammatory periodontal disease not amenable to correction by root planning , oral hygiene procedures. 2. A carious lesion involving one root of a multirooted tooth . 3. Fracture of a single root of multirooted toth. 4. Perforation of a root during endo treatment. 5. Partical calcification of root canal not amenable to conventional endodontic reatment 6. Severe dilacerations. CONTRAINDICATIONS ; 1. Extensive bone loss 2. Pronounced pre-operative mobility 3. Fusion of roots at or near the apices 4. Inoperable canals 5. Ineffective oral hygiene 6. Furcal involvements where the furcation is far apical or CEJ that gaining surgical access is difficult with loss of osseous support.
HEMISECTION : The radiographi is examined to determine that the fusion of the roots is not present. Endodontic treatment is completed on the root to be
retained.
The chamber and root to be resected is condensed with
amalgam. The area is anaesthetized and the coronal segment of the tooth is sectiond with a fissure bur. The bur is placed in the bifurcation and moved in the buccal and lingual direction until the entire crown is severed. The bur is then move dint eh apical direction to severe the furca. When the crown and furca are severed, a periosteal elevator is used to release the periodontal attachment and luxate the root. Extraction forceps are used to grasp and luxate the section to be removed. Smoothen the shape, furca with a blunt tapered diamond. A radiograph is taken to determine all of the overhanging furca is removed.
The buccal and
lingual plates are compressed with finger pressure.
Sutures are not
usually required. Tooth is restored with a crown. Bisection / Bicuspidization – Refers to a division of the crown that leaves the two halves and their respective roots. They are designed to form a favourable position for the remaining segments that leaves them easier to clean and maintain a god oral hygiene. Procedure : - Endodontic treatment should be carried on the root to be retained - The occlusion should be adjusted to eliminate the trauma of lateral excursion.
- After endodontic treatment , post endodontic restoration has to be placed. SOFT TISSUE MANAGEMENT CONTROL OF HAEMORRHAGE LOCAL AND SYSTEMIC LOCAL CONTROL a) Topical a) Adrenalin – Nor A- adrenaline b) Absorbable agents * Cellulose – Oxidized Cellulose (Oxycel) * Oxidized regenerated cellulose * Absorbable gelatin sponge * Human fibrin foam * Calcium Alginate c) Thromboplastin agents * Thrombin – Human and Bovine * Russel Viper Venom – Powder and solvent d) Chemical agents * Tannic Acid (2-5%) * Tine ferric chloride (15%) * Zinc chloride (6-10%) * Alum (5%)
* H2O2 (Dilute) e) Socket plugs * Ethicon bone wax * Horpley’s wax * White head varnish * Bismuth iodophor paste * ZnO and Eugeno on cotton wool f) Electrocautery – When tissues are touched with cautery, it causes precipation of protein elements in the end of the wound resulting in sealing of the vessel. g) Cold compressor – Ice application h) Mechanical measures * Pressure (Use of wet gauze) * Splints i) Ligation and sutures * Atraumatic needles and silk * Absorbable suture Bone Punch – Occlude the orifice of bone canal for intraosseous bleeding. SYSTEMIC CONTROL 1. Adrenochrome monosemicarbozone dehydrate (available in Tab . Inj)
2. Prenarin (Conjugated estrogen) 20-40 mg. 3. Vitamin K – 5 Mg Tab. TDs , 2 Mg / iv 4. Vitamin C + Rutin 5. Calcium Gluconate 6. Ehtamsylate 7. Styptobion Tab / IM 8. Fresh frozen plasma (20-300 C storage) 9. Freezed dried human AHG 10.Epsilon Amino Caproic Acid 11.Cyelocapron Classification of Topical Hemostatic Agents : 1) Mechanical agents (Non resorbable) a) Bone wax 2) Chemical agents a) Vasoconstructors : Epinephrine b) Ferric sulphate 3) Biologic agents Thrombin 4) Absorbable hemostatic agents a) Mechanical agents i)
Calcium sulphate
b) Intrinsic action agents
i)
Gelfoam
ii)
Absorbable collagen : Collatape
iii)
Microfibrillar collagen hemostats : Avitene
C) Extrnisic action agents i) Surgical Bone wax : Composition : Beewas + Softening agent + Conditioning agent Mechanism of action : when placed under pressure, lugs the vascular openings Draw back :Presence of persistent inflammation vasoconstrictors. Epinephrine is commonly used. Cotton pellets containing recemic epinephrine (1.9 mg) Ferric sulphite (Monsel’s Solution ) Mechanism of Action : Agglutination of blood proteins and acidic pH of the solution . Advantages : Easy to apply, does not require pressure. Disadvantages : Known to be cytotoxic and cause necrosis and tattooing Thrombin : Mechanism of Action :
Initiate the extrinsic and intrinsic clotting
pathways. (NB) it is designed for topical application only. Disadvantages : ďƒ˜ Difficulty in handling
Cost factor Calcium Sulphate : Consist of power and liquid component which is mixed into a thick putty like consistency and placed in bony walls . Mechanism of Action : In plugs the vascular channel of action . Advantages : It resorbs in 2-4 weeks It is porous which allows fluid exchange and does not allow flap necrosis In expensive Gelfoam and Spongostan : Hard, gelatin based sponge that are water insoluble and resorbable. Mechanism of Action : They promote the disintegration of clot causing subsequent release of thromboplastin. Collagen : Mechanism of Action : 1) Stimulation of platelelt adhesion, aggregation and release reaction 2) Activation of Factor VIII 3) Mechanical temponode action 4) Release of Serotonin
Applied directly to heeding site while using pressure. Haemostasis achieved in 2-5 minutes.
Microfibrillar Collagen Hemostat : Avitene and Instat are 2 popular forms It is derived form purified bovine dermal collagen, shredded into fibrils and converted into an insoluble partial hydrochloride acid salt. Mechanism of action : It functions through topical hemostasis, providing collagen framework for platelet adhesion, which initiates platelet plug formation. Disadvantages : - Difficult to apply to wet surface - Inactivated by autoclaving - Their contamination may enhance infection - Expensive Surgical : Prepared by oxidation of regenerated cellulose, spun into threads and woven into a gauze that is sterilized with formaldehyde. Mechanism : Act as a barrier to blood and then as an artificial coagulum as plug. Suturing : To secure the flap in its original position should not pull or stretch the tissue and should not compromise circulation . Suture kit : Thread, needles, scissors, haemostat, cotton tips.
Suture Materials a) Silk Non resorbable Twisted or braided Increased strength Easy to handle Least expensive - Disadvantage : Oral Hygiene b) Catgut suture :
Collagen made from submucous layer of small
intestine of sheep . * Resorbable
Disadvantages : Takes atleast 24 days to resorb, so oral hygiene is a problem. c) Monofilament (Polyester) Advantages : Strength Disadvantages : Can tear the tissue like wire cut cheese. Complications: - Haemotoma formation - Ecchymosis - Stichabscess Removal of suture done after 7 days
1) Incision : In order to gain access to bone soft tissue must be incised (No.15 BP Blade) 2) Elevation : A most fracture 9 periosteal elevator is used to reflect or elevate tissue.
A total exposure of the lesion is the most
important objective in elevation . 3) Retraction : to hold the soft tissue way from the surgical area without impinging upon the circularly system of the flap. 4) Ostectomy : Removal of the overlaying bone at the root apex of the offending teeth.
For greatest efficiency in cutting bone, carbide should be used with a heavy water spray to cool or cleanse the bone and bur. For endodontic surgery, assorted round burs ranging from size # 2 to #8 and the round ended tapered fissure burs sizes # 402 and # 458 efficiently accomplished most entries into bone. The bony window should be large enough to permit access to all dimensions of the lesion and facilitate total nucleation. 5) Curettage :
The purpose of removing the pathologic tissue is to
eliminate the zone of irritation and contamination and take the specimen for histologic examination . The All is forceps is an excellent instrument to remove the tissue without damaging it. Three efficient curettes - #4, #50C , #11.
6) Apicectomy : 7) Closure : Before re-attaching th reflected tissue, it is advisable to examine the surgical site radiographically.
Haemorrhage has to be
controlled before patient is dismissed . Various techniques has been employd. ď ś Reinject L.A. solutions containing 1:50,000 epinephrine and suture the flap ď ś Pack the bony cavity with iodoform gauze and apply pressure for 5-10 minutes ď ś Pack the bony cavity with bone wax for 5-10 minutes, remove the wax and suture the flap. Pack the bony cavity with artificial clotting agents. The most commonly used preparations are Gelfoam and surgical. Gelfoam is a specially used preparations are Gelfoam and surgical. Gelfoam is a specially treated sterile porous gelatin sponge. It is inert and when packed in bone and it is absorbed in 4-6 weeks. Overfilling is avoided as the material expand an contact with blood. Prophylactic antibiotic session is recommended to reduce the potential for postoperative sensitivity. Surgical, a modified carboxymethyl cellulose , an oxidized, regenerated cwellulose and is also effective in controlling bleeding, from bony cavities. Once in contact with blood, the cellulose develops and
products which can cause an artificial clot. This material is not absorbed and its low pH has been suspected to be cause of postoperative pain. Suture Materials : 3 types Catgut suture : Collagen made from submucous layer of small intestine of sheep Advantages : Absorbability i.e, suture removal is not necessary. Disadvantages : It takes atleast 24 days to resorb, so oral hygiene is a problem. Monofilament (Polyester ) plastic Advantages : Strength Disadvantages : Can tear the tissue like a wire cuts cheese. The cut ends are sharp and can lacerate the lip and cheeks .
POST – OPERATIVE INSTRUCTIONS 1. It is normal for blood to seep from site of a surgical procedure for several hours after the operation. Mouth rinses are avoided, as they stimulate bleeding. Cleanse the mouth with ½ teaspoon of table salt and ½ glass of hot water. Try to locate the bleeding spot and apply pressure with a piece of gauze. If this fails to stop, call the surgeon’s office. 2. Swelling may be seen which may last form few hours to several days. Following surgery, an icepack should be applied to swollen
area, at 10 minutes interval for first 6-8 hours and heating pad should be applied for 30-60 minutes 4 times a day on second, third and fourth days. 3. Pain may be present following surgery using ice pack and taking two aspirin tablets every 3-4 hours will help reduce this pain. 4. Careful brushing is desired and promotes healing. 5. Post – operative infection may be seen . Hot saline rinses are taken. 6. Patient may experience loss of appetite as the teeth may e tender and certain foods may be difficult to chew. Treatment – high protein diet as well as multivitamin capsule. 7. If one or more stitches loosens and hangs free, It should be trimmed with scissors.
REPLACEMENT SURGERY INTERNATIONAL REPLANTATION Replantation is defined as the replacing of a tooth in its socket following deliberate or traumatic avulsion . The only true indication for intentional replantation is when three is absolutely no other treatment available to maintain a strategic tooth.
The major contraindications include unrestorable , fracture or non strategic teeth, presence of periodontal disease, irregular root structure and lack of patient compliance. Technique :
Ensure proper removal of all debris and irritating substances from the tooth Root canals should be cleaned, shaped and obturated to the extent possible. It is advisible to fill the endodontic access opening with an amalgam to strength the crown, so it can withstand the forces of extraction Patient premedication with antibiotics and anti-inflammatory agents. After anesthesia, the tooth to be extracted is isolated and surrounding area is cleaned with an antiseptic solution. Elevators should be carefully used to loosen the tooth, minimizing injuries to the investing tissues and root surface. Extraction forceps should make minimal contact with tooth structure. The tooth is gently lifted form its socket and base of socket is carefully curetted to remove any foreign debris. circumstances , should the walls of socket be curetted.
Under no
Socket can then be covered with a sterile gauze. Examine the tooth for fracture, extra roots or foramina or any unusal configurations such a C – shaped roots. When the tooth is ready to be replaced in its socket, the walls should be gently flashed with saline to remove the blood clot. The totoh is carefully and slowly placed into its socket allowing for a slow escape of blood which has build up in the socket. Slight pressure is applied to the buccal and lingual cortical plates to ensure adaptation. The occlusion is re=checked and a splint is palced if necessary. Splints are removed within 5-7 days. Analgesics are used as necessary , with NSAID’s being the drug of choice. INDICATIONS : 1. Inadequate interocclusal space is perform non surgical endodontic treatment. 2. Canal obstruction 3. Surgical approach not possible. 4. Non – surgical and surgical treatment have failed 5. Visual access is inadequate to perform root end resectin 6. Root defects (Resorption , perforation ) Factors Affecting the Outcome :
1. Keeping the out of socket time as short as possible. 2. Keeping the periodontal ligament cells on root surface moist with saliva. 3. Minimizing damage to cementum and periodontal ligament cells. Contraindications: 1. Periodontal involvement with excessive mobility of tooth. 2. Buccal or lingual palate that is destroyed or missing 3. Septal bone at bifurcation and trifurcation that is destroyed or missing 4. Extraction may cause fracture of crown. IMPLANT SURGERY Can be divided into root form osseointegrated implants and endodontic implants. ROOT FORM OSSEOINTEGRATED IMPLANTS : Osseointegration is defined as the direct structural and functional connection between ordered, lining bone and surface of load carrying implants. Biomechanical as well as bacterial factors have long been recognized to play a substantial role in osseointegration maintenance. Immediate Implant Placement : Implant placement is done immediately following tooth extraction . Advantages :
Incorporation of two procedures into the appointment The expediency of total treatment time. Minimization of osseous collapse as well as resorption and maintenance of soft tissue architecture. Indications for Root form osseointegrated Implants : 1. Vertical root fracture 2. Horizontal root fracture in coronal 1/3 to ½ of the root. 3. Non – repairable resorption 4. Non – Treatable endo-perio lesions 5. Non treatable endodontic failures 6. Non – treatable retained primary teeth 7. Gross post perforations 8. Non – restorable teeth. Contraindications : 1. Lack of special training by surgeon 2. Uncontrolled diabetes mellitus 3. Psychiatric factor 4. Post menopausal women on thyroid medication and without estrogen replacement factors . Procedure :
The tooth should be extracted with as little trauma as possible. It is important to retain the cortical bone buccal and lingual to the extraction socket. The implant apex should be stabilized in atleast 3 to 4 mm of bone and implant head should be positioned to confirm to either central fossa, in posterior teeth or cingulum in anterior teeth, for screw retained prosthesis. Bone graft materials. Soft tissue closure and supportive therapy. ENDOSSEOUS IMPLANTS Partially enclosed and submerged within the bone. They are in varying designs and composition Shapes : Blades, spirals, screws, hollow cylinders, cones or cylinders with porous surfaces. Endosseous implants with polymeric inserts, which acts a shock absorber. Coated with ceramic such as hydroxyapatite or Ti-plasma stage to enhance their interaction to biological environment . To replace a removal prosthesis with fixed prosthesis in posterior edentulous area of mandible. To lend support to middle of a long span bridge. To support either a usually complete denture or fixed prosthesis in a totally edentulous mandible. Types :
a) Subperiosteal implants : Is a framework specially fabricated to fit on top of supporting areas in mandible or maxilla under mucoperiosteum with perimucousal extensions for support and attachment of a prosthesis b) Transosteal implants – are inserted through an extraoral incision below the chin with series of projection that penetrate the mandible from its inferior border and connected by a bone plate that rest on inferior border of mandible. c) Endosteal implants – Surgically placed within alveolar and basal bone, they are further divided into root form and blade form implants. Requirements of an implant : 1. The implant must be fabricated from an alloplastic biocompatible matrials such as titanium, titanium alloy or hydroxyapatite. 2. The preparation of bony socket must be done with a gentle surgical technique. Electric handpiece revolve at slow RPM’s are designed specifically for implant surgery. 3. The implant must closely fit the precise bony preparation throughout its length. 4. The implant mut be mechanically fixed to bony by either threads or a roughened surface on the implant.
5. The implant must remain unloaded during healing phase of 3 to 9 months 6. The implant must be properly restored with an even distribution of occlusal forces. Factors affecting the Placement : Severity of initial infection Local of root relative to the alveolus Residual bone buccolingually and coronally apically Vascularity of residual bone. Density of residual bone Quantity of cancellous marrow spaces Availability of bony walls to contain the bone graft material Volume of bone regeneration necessary Soft tissue available for closure Experience of the operator. ENDODONTIC IMPLANTS Definition : Is a metallic extension of the root with the object of increasing the root to crown ratio, to give the tooth better stability in the arch. Indications : 1. Transverse root fracture 2. International resorption involving apex
3. Pathologic resorption involving apex 4. Periodontally weak tooth 5. When there is less root length compared to crown Contraindications : 1. Recently erupted tooth 2. Impacted teeth 3. Cyst/tumors of maxilla and mandible 4. Complete lingual spiny ridge 5. Carcinoma of oral tissue 6. Drug addictions 7. On going radiation therapy 8. Extensive neuralgic disease 9. Pregnancy 10.Alcoholism 11.Blood diseases. Procedure : The equipment needed for endodontic implantation is the same as for endodontic treatment, with the addition of a series of extra – long reamers, 40 mm, in sequential sizes and implants of corresponding size. First, anesthetize the tooth and involved area with a local anesthetic. Next, with the rubber dam in place, aseptically complete the usual treatment of access preparation, enlargement, and irrigation of the
root canal. The access preparation should differe from the usual in the it must be larger and wider in the clinical crown, to accommodate the placemetn of a rigid implant that requires “straight – line “ insertion into the canal. In addition, the root canal must be enlarged to at least the size of a No.60 instrument . In a tooth with multiple canls or an apical root curvature, the canals should be filled and sealed with gutta percha and cement in the usual manner. Unfilled canals or a partially unfilled canal in a curved rot tip, as occurs with penetration of the osseous layer form the root canal in a straight line preparation, will result in failure and formation of subsequent periapical rarefaction. A marker is then set on the 40mm reamers at a level equivalent to the length of the tooth plus the number of millimeters the implant will extend beyond the root apex. The first 40mm reamer used to perforate the root apex should be several sizes smaller than the last sized instrument used to complete the preparation of the root canal. The last 40mm reamer used should be at least equivalent in size to the last endodontic instrument used in the root canal alone and the bone is reamed to the desired length . Irrigate theroot canal with anesthetic solution or sterile saline solution rather than sodium hypochlorite, which can irritation the periapical tissue. Irrigation of the canals debrides as well as
controls hemorrhage within a few minutes. Dry the canal with sterile absorbent points. Select an implant of equivalent size to the last instrument used, score it lightly to indicate the desired length, that is, form the occlusal tip through the root canal to the exact length cut into the cancellous bone, and insert it into the root and bone. The implant must fit tightly and must penetrate the bone to the prepared length. If necessary , enlare the root canal a little more to accommodate the implant, bu the implant must fit at the apical foramen. Dry the root canal again . Shorten the implant at its apical tip by 1 mm , to ensure that will seat snuggly and wil not bind in the cut osseous bed. Insert a plugger into the access opening until it binds, and measure the exact length it can be inserted unimpeded into the canal. This plugger will be used to seat the implant during the cementation; because the butt end of a Vitallium or chrome cobalt implant must be cut off prior to insertion into the tooth because of the hardness of the metal. Using a diamond or carborundum disc, cut the butt end of the fitted implant and remove a length equivalent to the measurement obtained by insertion the plugger blade into the root canal. Insert cement into the dried canal (Grossman suggests a polycarboxylate cement; Frank suggests AH 26 cement), and try to avoid cement , insert the implant slowly not the canal and bone. Seat the implant until it binds completely
in the canal. When a post type crown is to be made, seat the implant to the level corresponding to the midroot and leave sufficient space to cement a post-core crown afterward. TRANSPOANTATION It is not as successful as international replantation because of the immunologic factors. Autotransplantation is a transplantation of a tooth in the same individual . It is a method of choice. Allotransplantation is from one person to another is still considered as experimental procedure. VALID CAUSES FOR SURGICAL FAILURE : 1) Failure to debride the root canal space thoroughly. 2) Failure to seal the root canal space three – dimensionally 3) Tissue irritation from toxic root – canal fittings or root end fillings 4) Failure to manage root canal or root end filling materials properly. 5) Superimposition of periodontal disease 6) Vertical fractures 7) Recurrent cystic lesion 8) Improper management of the supporting periodontitum QUESTIONABLE CAUSES FOR SURGICAL FAILURE 1) Infected dentinal tubules and surgical site. 2) Antibiotics
3) Accessory and lateral canals 4) Loss of alveolar bone : The loss of alveolar bone, especially the buccal cortical plate, has been shown to render a poor postoperative prognosis following periradicular surgery 5) Root resorpton 6) Timing of root canal Obturation : Always put in the root filling first, because if you cut off th root tip first it will be difficult to make a successful root filling; but if you fill the root canals first and then cut off the rot tip you will heave a clean , oval surface. On the other hand, a better prognosis has been identified by many authors when the root is filled prior to surgery. Studies conducted using ultrasonics for canal debridement during surgical treatment have shown a greater reduction in bacterial populations.
Anatomic Factors : 1) Fenestration – Dehiscence 2) Aberrant root anatomy or canal space 3) Root proximity in the alveolar bone 4) Maxillary sinus. 5) Focal myositis 6) Loss of osseous structure Technical Factors :
1) Quality of canal cleaning and obtruration 2) Quality of root end resection . a) Root apices which are not completely resected, exhibiting a smooth flat root face, may severe as a source of irritation to the surrounding periradicular tissues. b) Roots or root systems not completely resected from buccal or lingual may hide obscure roots canals, canals extensions anastomoses, or coronal canal exiting. c) Extensive resection without regard for adjacent teeth may cause needles pulp devitalization or damage to adjacent root structure resulting in possible resorptive defects. 3) Quality of root end cavity preparation a) Failure to include an isthmus or portion of canal extension in the preparation b) Failure to achieve a minimum or ideal depth of cavity preparation based upon the particular anatomic situations. c) Lack of retention in the root end preparation d) A palatal, lingual or lateral perforation of the root. e) Choosing an improper cavity preparation design for a particular root anatomy without considering all the anatomic factors, e.g., a long axis prepared ina deeply platally placed root a maxillary first
premolar, or a slot preparation when the buccal crystal bone is already compromised and f) Inadverent preparations of a cavity in bone which resembles root structure. Quality of the root End filling materials and techniques ; 1) Poor adaptation and condensation . 2) The biologic breakdown of root end filling materials. 3) Excess material left in the surgical site, either as overhangs, overcontours, or scattered debris, has also been implicated in case failures . 4) Cytotoxic root filling materials which have been expressed beyond the apex of which are left or placed the rot end filling aterial can cause damage to the surrounding vital structures (antrum, alveolar nerve) and periradicular surgery will invariablynot be able to correct the damage because of the irreversible tissue destruction Improper soft tissue Management Failures in periradicular surgery can also be attributed to improper flap design, tissue reflection, retraction and repositioning, and suturing.
CONCLUSION Endodontic surgery is dynamic and it is imperative that scientific investigation continue, concepts, techniques and materials used in endodontic surgery must be continually evaluated and modified and more emphasis must be placed on the assessment of long-term outcome.
REFERENCE 1) Endodontics , 5th Edn - Ingle & Bakland 2) Gutmann’s Surgical Endodontics – James L Guttmann , John W. Harrison 3) Pathway of pulp - Cohen and Burns, 8th Edn. 4) Endodontic Therapy - Franklin S Weine : 6th Edn, 5) Endodontic Microsurgery - KIM 6) Endodontics - C Stock, R Walker, K. Gulabivala : 3rd Edn 7) Louis T. Grossman – Endodontic Practice : 8th Edn.
CONTENTS INTRODUCTION HEMODYNAMICS ARTERIAL BLOOD PRESSURE VENOUS PRESSURE CORONARY CIRCULATION CEREBRAL CIRCULATION CAPILLARY CIRCULATION FETAL CIRCULATION AND RESPIRATION HEMODYNAMIC ASPECT OF DENTAL PULP CONCLUSION REFERENCE