History seminar/ dental implant courses by Indian dental academy by indiandentalacademy

HISTORY  Endodontic surgery was first recorded 1500 years ago when AETIUS, excised an acute apical absess with small scalpel.  HULLIHEN in 1839 stated: 

“Make an incision through the gum, along the entire length of the fang”.



Then apply a reasted fig / bruised raisins to the gums”. This was a refinement over AEITUS.

 The other contributors were Farror (1884); Rhein (1897); G.V. Black (1886) and Garvin (1919).  CURRENTLY, endodontic surgery is predictable, and often necessary procedure which is generally accepted.  Surgical procedures play an extremely important role in the management of endodontic problems.  As failure does occur in a small percent of cases which are nonsurgically treatment with conventional endodontic therapy,

clinicians should be prepared to initiate alternative procedures, including surgery to enhance the rate of success.  Nevertheless, GROSSMAN stated that, it is indicated in fewer than 5% of all endodontic patients.  The success rate of endodontic surgery, however is high, from 73% to 99%.  PERSSON reported a successful result following root resection in 73% of 26 teeth. SOMMER reported 95% of success rate in more than 100 root resected eases. PHILLIPS & MAXMAN claimed 99% success rate in more than 600 cases. GROSSMAN AND OLEIT reported 90 to 99% of success rate. Confusion in Terminology / Misnomers ! 

“Apicectomy” was the term used injudicrously for years to describe many types of endodontic surgical procedures.



The terminology has been modified to more accurately describe the specific procedures encompassed under the heading “Surgical Endodontics”. At Present – “Periradicular Surgery” is more acceptable term when referring to surgical procedures performed around the root.

Root End Resection; “Apicetomy” Old Term - is used to describe the removal of the apical portion of the root. Root End Filling – describes the procedure of placing a filling into a prepared apex. “Placement of retro-filling / reverse filling” – Micromer and grammatically incorrect. Endodontic Surgery: Is defined as a surgical procedure related to problems of the pulpless / periodontally – involved tooth requiring root amputation and endodontic therapy. I. Endodontic Surgical Techniques can be Classified as follows: (Classification by Ingle). i) Surgical Drainage

(a) Incision (b) Trephination

ii) Radicular Surgery (A) Apical Surgery

(B) Corrective Surgery

1. Curettage & Biopsy

1. Miscellaneous corrective

(Periapical surgery) 2.Apicoectomy

2. Root resection

3. Intentional Replantation

3. Hemisection 4. Bisection

II. Another Classification: 1) Surgical Drianage

Trephination Incision

2) Radicular surgery Apical surgery -

Corrective surgery

Curettage and biopsy Mechanical

- Perforative repair Resorptive

- Periodontal repair

GTR Resection

Apicoectomy

Retrofilling 3) Replacement surgery Replant surgery

Endosteal implant surgery 5

Intentional

Post traumatic

Endodontic Osseointegrated

Most endodontic problems can be treated / retreated by conventional therapy and peri-radicular surgery should not be considered a panacea when endodontic problems arise. Clean, well obturated canals are the biological basis of endodontic success. If the canal terminus can be reached through a coronal access, then these are the pathways to be considered. Endodontically Treated Tooth

Failure No

Access

Success Yes

Poor Yes

Evaluate fill

Restorative Need

Good

Considerations Surgery

RC treatment

Recall

No treatment

ď&#x192;&#x2DC; If the canal terminus through the coronal access cavity is impossible, a surgical approach should be considered. ď&#x192;&#x2DC; Even then, the pulp chamber and as much of the root canal(s) as possible, should be instrumented and obturated before surgery to reduce the critical concentration of the irritant within the root

canal system and conventionally close off portals of exit that exist coronal to the apex.  These are very few contraindications to Pa surgery. -

Psychological / systemic problems of the patients.

The practitioners experience / expertise in the procedures.

Inaccessibility.

Anatomical

problems

i.e.

unusual

bone

root

configurations. Anatomical Considerations:  Surgical procedures to anterior teeth are generally uncomplicated and uninhibited.  With the exception of the nasal spine and the rare nasal fistula.  In the posterior region the following critical structures make access to root apices difficult.  Proximity of the mental foramen to the apices of mandibular premolar at times to the first molar.

 A thick external oblique ridge – in the 2nd and 3rd mandibular molar region (traumatic and difficult). (In such cases the apex of a tooth is located in the center / lingual aspect of the mandibule, the thick cortical plate and the shallowness of the vestibule make access to the apex difficult and trauma).  The location of the mandibular canal: (If the radiograph shows canal moving inferiorly in relation to the root apices, the canal is lingual to the apices. If it moves upwards on the roots, it is buccal to the apices. Minimal movement of the canal indicates that it is in close proximity to the apices). (I Madi M) Mesial root apex – to the superior border of the neurovascular bundle is about 5.3mm.  The maxillary sinus in close proximity to the root apices. Premolar, molar – maxillary (May penetrate the sinus floor and establish a communication between the periodontal and the mucoperiosteal lining of the sinus).

ď&#x201A;&#x2020;

A prominent zygomatic process that impedes surgical access to the rest of the maxillary molar teeth.

ď&#x201A;&#x2020;

A palatal root of the first and 2nd molar that is closely aligned with the greater palatine foramina. Good-quality radiographs are essential if a critical assessment of

the position, location and angulation for root apices and of local anatomical structures is to be of value before surgery. COMMUNICATION WITH PATIENT: -

The surgical procedure should be described in details, as should all potential postoperative problems such as discomfort, swelling, bleeding, brushing, maxillary antrum penetration and rare possibility of paraesthesia.

A hand drawn illustration is often useful.

Alternative to surgery such as no treatment, tooth extraction and referral should also put forward.

Patient should be asked to sign that at tests to their understanding and acceptance of procedure, risks and fees.

PREOPERATIVE PREPARATION AND PREMEDICATION OF THE PATIENT: Antiseptic

mouthwash:

According

Leo

JPS

1970,

chlorehexidine gluconate 0.2% reduces the levels of bacteria in the oral cavity and play an important role in healing following endodontic surgery. -

Patient is instructed to rinse the solution for 1 minute twice daily for one week prior to the surgery.

ADMINISTRATION OF non-steroidal anti-inflammatory drugs before the surgical procedures helps to reduce post-operative pain and swelling. Ibuprofen exerts its effect by initiating the enzyme cyclooxygenase and prevents the formation of inflammatory mediators. A dose of 600mg  to 2 hours Before surgery. And 400mg – 4 hours postoperatively. However the maximum daily dose should not exceed – 3200mg. Ibuprofen – causes: -

Mild gastrointestinal irritation (so should be taken with food). 10

Contraindicated: -

In patients with peptic ulcer.

PARACETAMOL: is an acceptable alternative for patients who need to avoid ibuprofen, but it exhibits an anti-inflammatory dynamics. SHORT ACTING BARBITURATES: such as pentobarbital and secobarbital are frequently used for sedation, oral administration is most common, 50-150mg, 30 minutes prior to the surgical treatment. Transquilizers effectively reduce apprehension and act as muscle relaxants. Diazepam – 5mg – orally – 30 minutes prior to the treatment narcotics can be effective premedication. ARMAMENTARIUM The suggested surgical setup for periapical surgery: 1) Anaesthesia – lidocaine, epinephrine. 2) Sterile cotton gauge – 2x2. 3) Periosteal elevator. 4) Straight handpiece burs – 2, 4, 6, 8, 33 ½ hand chisel, sterile saline, handpiece (st and CA) and microhead contra-angle. 5) Surgical curette. 11

6) Apical amalgam carrier, plastic instrumentation, amalgam plugger and condenser. 7) Needle holder / hemostat, silk suture and scissors. 8) Surgical tray cotton pliers, explores, mirror etc.

IMPROVED VISIBILITY: -

Fiberoptic light source could be used, which is attached to surgical aspirators / retractors.

Magnification of operative site using visors and loupes.

Surgical telescropes and microscopes also provide cresp and undistorted images of operating site.

High tongue surgical drills are preferred â&#x20AC;&#x201C; as they prevent subcutaneous air emphysema.

HAEMOSTASIS: -

The injection of a local anesthesia into the oral tissues before Pa surgery has 2 important purposes:

Anaesthesia.

Haemostasis.

ANAESTHESIA IN UPPER JAW: -

Lignocaine (between 2 and 4ml) containing 1:50,000 adrenaline (2% lignocaine â&#x20AC;&#x201C; 1:80,000 adrenaline is effective local anaesthetic in minor oral surgery).

INFILTRATION: -

The approximated levels of the root apices (buccally).

Attempts to inject deeper tissues may prove counter productive, because of the likelihood of injecting into skeletal muscle (because Î˛ receptors are presents and causes vasodilatation) increased bleeding rather than haemostasis.

PALATAL INFILTRATION: -

An increment of 0.3ml is sufficient. Along with nerve blocks.

MANDIBLE: Lignocaine with 1:80,000 adrenaline for: -

Infiltration alveolar block.

Buccal n block.

Lingual infiltration-?

Lignocaine with 1:50,000 adrenaline not used for palatal injections – ISCHAEMIA. PACKING: -

Packing foreign agents into the bony cavity is a controversial method of producing haemostasis.

Cotton, cotton wool/ gauge saturated with adrenaline are least desirable materials (the fibres left in the crypt cause – latent foreign body reaction, if trapped along the margins of the root end filling – impair the apical seal).

Agents like

GELFOAM SURGICEL

(Inflammatory treatment

COLLAPLUG

if left in the surgical site)

BONE WAX

are advocated as local haemostatic agents

Collaplug (Biocompatible and excessive cost).

15.5% ferric sulphate (astringent).

WHATEVER, haemostatic technique is chosen, bleeding must be re-established before – reapproximating and suturing flap. SURGICAL PROCEDURE -

Flap design. 14

Exposure of the site. Incision Flap reflection Flap retraction Osteotomy

Curettage and biopsy.

Apicoectomy.

Retropreparation.

Retro-filling.

Flap closure. Flap repositioning. Suturing.

GENERAL PRINCIPLES FOR FLAP DESIGN: 1.

Incision should be placed in a single firm stroke lying on bone.

Extend the flap so as to allow design to be wider at base for better vascularity.

Include adjacent Â˝ normal teeth in flap for adequate mechanical accessibility and visibility.

Always place flap over sound bone. Avoid bony defects as flap in these areas will undergo necrosis. 15

Avoid placing incision lines over areas of bony prominences as mucosa here is very thin and can undergo fine strations.

Do not extend incision beyond attached gingiva to alveolar mucosa â&#x20AC;&#x201C; As healing takes longer at the alveolar mucosa junction.

Avoid sharp margins.

While raising flap care should be taken to include full thickness flap including periosteum.

THE

BASIC

FLAP

DESIGNS

USED

SURGERY CURRENTLY ARE: -

Gingival flap.

Semilunar flap (curved flap).

Triangular flap (single vertical flap).

Ochesenbein cuebke flap.

Rectangular flap.

Minivertical flap.

Trapezoidal flap.

Modified flap.

Palatal flap.

ENDODONTIC

Triangular flap / single vertical: Indications: -

Midroot perforation repair.

Periapical surgery. Post areas. Short roots.

Advantages: -

Easily modified. Small relaxing incision Additional vertical incision. Extension of horizontal components.

Easily repositioned.

Maintains integrity of blood supply.

Disadvantages: -

Limited access and visibility to long roots.

Tension created on retraction.

Vertical incision penetrate alveolar mucosa.

Gingival attachment served.

OCHEENBEIN-LUEBKE FLAP / SCALLOPED Indications: -

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 gingival attachment. Prevents recession. Avoids dehiscences. Prevents crestal bone loss.

Disadvantages: -

Horizontal component disrupts blood supply.

Vertical components crosses MGT and may enter muscle tissue.

Difficult to alter if size of lesion misjudged.

Rectangular flap / Double vertical Indications: -

Periapical surgery. Multiple teeth. Large lesions. Long / short roots.

Lateral root repairs.

Full length root visualized.

Advantages: -

Provides maximum access and visibility.

Reduce retraction tension.

Facilitates repositioning.

Disadvantages: -

Decreases because to the flap.

Increases incision and reflection TIMC

Gingival attachment violates.

Suturing is difficult.

Trapeziodal flap / Double vertical: Indications, Advantages and disadvantages: -

Similar to rectangular flap.

Gingival flap: Indications: -

Cervical resorptive defects.

Cervical area perforations.

Periodontal procedures.

Advantages: -

No vertical incision.

Ease of repositioning.

Disadvantages: -

Limited access and visibility.

Difficult to reflect and retract.

Stretching and tearing.

Gingival attachment violated.

SEMILUNAR FLAP / CURVED Indications: -

Esthetic crowns present.

Trephination.

Advantages: -

Reduces incision and reflection time.

Maintaining integrity of gingival attachment.

Eliminates crestal bone loss. 20

Disadvantages: -

Limited access and visibility.

Increases hemorrhage.

Crosses root eminences.

May not include entire lesion.

Stretching and tearing.

Repositioning is difficult.

Healing is associated with scarring.

Mini vertical Indications: -

Trephination.

Advantages: -

Decreased tissue damage.

Good healing.

Less vessels and nerves are rest.

Disadvantages: -

Decreased visibility and accessibility.

PALATAL FLAP: Indicated: -

Overextended palatal obturation / perforation.

Review for: -

Maxillary sinus.

Root length.

Advantages: -

Of sling suture.

It holds the palatal flap in operating position and increase access and visibility.

Disadvantages: -

Crimping of the tough palatal tissue.

Decreased BS.

Leads to necrosis.

Sloughing of the flap.

After the surgical site is exposed by: Incision, flap reflection, retraction, the clinicians can consider the many advances in endodontic surgical techniques and materials into their practice in order to ensure more predictable results. The following aspects are: -

Hard tissue management / osteotomy.

Root end resection and preparation / apicecotomy.

Root end filling materials.

Postoperative care of the patient.

FLAP DESIGN Requirements of an ideal flap: 1) Should allow good visual and mechanical accessibility. 2) Good vascularity wide base. 3) Should be placed on sound bone on no bony defects. 4) Should be so placed such that adjacent 1-2 teeth be included in flap design. 5) Incisions should not be placed over bony prominences. 6) Avoid sharp corners. 7) Avoid placing extending over MCJ at it takes longer limits heal. 8) Base is the widest point of the flap: The need for the width at the base is to afford sufficient circulation to the raise portion of the flap so that the edges do not become ischemic and later slough. 9) Avoiding incision over a bony defect. 10)Include the full extent of the lesion. 23

11)Avoid sharp corners: Tips of sharp corners have a tendency to become ischemic before collateral circulation across the sutured tissues becomes established. 12)Avoid incisions across a bony prominence: Usually found in the maxillary cuspid lesion, since the mucosa covering the eminence is thinner than that covering the eminence is thinner than that covering the interdental bone, less circulation is available to provide nutrition to the edges of a flap placed on eminence. Also, unesthetic scar formation develops. 13)Guarding against possible dehiscence: Maxillary molars and bicuspids. 14)Avoid the mucogingival junction: The junction of the attached gingiva and the alveolar mucosa has extremely friable tissues. Incisions placed here take much longer time to heal. 15)Flap should generally extend one or two teeth laterally to allow for relaxed retraction and prevent stretching and tearing of tissue. 16)Care during retraction should be taken after the flap is opened the tissue retracted from the underlying bone must be held away from the surgical site.

17)A full thickness mucoperiosteal flap should be raised to maintain the integrity of the periosteum. The basic flap designs used in endodontic surgery currently are: 1. Gingival flap Indications: -

Cervical resorptive defects.

Cervical area perforations.

Periodontal procedures.

Advantages: -

No vertical incision.

Ease of repositioning.

Disadvantages: -

Limited access and visibility.

Difficult to reflect and retract.

Predisposed to stretching and tearing.

Gingival attachment violated.

2. Semilunar flap (curved flap): Indications: -

Esthetic crowns present.

Trephination. 25

Advantages: -

Reduces incision and reflection time.

Maintains integrity of gingival attachment.

Eliminates potential crestal bone loss.

Disadvantages: -

Limited access and visibility.

Predisposed to stretching and tearing.

Tendency to increase hemorrhage.

Crosses root eminences.

Repositioning is difficult.

May not include entire lesion.

Healing is associated with scarring.

3. Triangular flap (single cervical flap): Consists of a single vertical incision and a horizontal crevicular incision. Vertical incision is placed 2 teeth away from affected tooth. Extends from mucobuccal junction obliquely to a point to interest the gingival interproximally at 90째. The horizontal incision is placed crevicularly to form the base of the flap for adequate visibility and accessibility.

In case of greater accessibility another vertical relining incision is placed distally. Indications: 1. In case of mid root perforations (resorption /caries). 2. Short roots. 3. Posterior teeth. -

Can be easily modified by i. Including relaxing vertical incisor. ii. Extending horizontal incisors. iii. Can be easily repositioned. iv. Good vascularity maintain.

Can not be utilized for in case of longer roots i. Tension on retractor. ii. Involves alveolar mucosa – healing decay. iii. Gingingival attachment altered.

Advantages: -

Easily modified.  Small relaxing incisions.  Additional vertical incision.  Extension of horizontal component.

Easily repositioned.

Maintains integrity of blood vessels. 27

Disadvantages: -

Limited access and visibility to longer roots.

Tension is created on retraction.

Vertical incision penetrates alveolar mucosa.

Gingival attachment severed.

4. Ochsenbein luebke flap – scalloped. The horizontal scalloped incision is placed on premolar attached gingiva. Vertical incisions are then extended back into alveolar mucosa. Indicated in cases of: 1. Esthetic crowns. 2. Wide band of attached gingiva present. 3. Long roots, wide lesions. Indications: -

Prosthetic crown present.

Periapical surgery.  Anterior region (maxillary).  Longer roots.

Wide band of attached gingiva.

Advantages: -

Good visibility and accessibility.

Preserves attached gingival health.

Prevents recession.

Prevents crestal bone loss.

No scar tissue formation.

Longer time for reflection and retraction.

Involves alveolar mucosa hence relaxation is delayed.

Blood supply may be compromised.

Disadvantages: -

Horizontal component disrupts blood supply.

Vertical component crosses mucogingival junction and enter muscle tissue.

Difficult to alter if size of lesion misjudged.

5. Rectangular flap: This flap is usually carried out when: 1. Multiple teeth are involved. 2. Large periapical lesions. 3. teeth with long roots. -

Good accessibility and visibility.

Violation of gingival attachment.

Crevicular bone loss.

Advantages: -

Increased reflection and retraction time.

Vascularity compromised.

Flap undergoes recession.

Difficult to reposition.

Disadvantages: -

Suturing is difficult.

6. Mini vertical flap: This flap involves a single vertical incision proximal to the involved apex. Indicated in cases of trephination: -

Less tissue damage.

Visibility and accessibility reduced.

Good healing as less vessels and served one cut.

7. Palatal flaps: The need to reflect the palatal tissues of the maxilla may be needed in certain cases. As in any flap all rules for flap design are applicable however, the rich vascular supply of the palatal area provides for excellent healing in most instances.

Palatal flap is prepared with a scalloped incision around the gingival margins.

Relaxing incisions are generally placed between the first cuspid and bicuspid to prevent severing of the anatomose of incisive and palatine vessels.

Distal incision is placed distal to second molar on the maxillary tuberosity to prevent severing the greater palatine vessels. -

The free end of the flap could be tied the teeth on the opposite side of the arch with a suture material.

8. Trapezoidal flap: To there rectangular flap but with added obliqueness of the vertical incision. Indicated in cases of: 1. Multiple teeth involvement. 2. Large periapical lesions. 3. Long / short roots. Advantages: 1. Better visibility and accessibility.

2. Blood

supply

compromised

large

number

mucoperiosteal vessels are intererupted â&#x20AC;&#x201C; increased haemoma. 3. Flap undergoes extraction, shrinkage. 4. Gingival attachment is compromised. 5. Crestal bone compromised. 6. Recession seen. 7. Difficult to approximate. 8. Increased reflection and retraction time.

Modified trapezoidal flap by Vneeland 1-2mm of

crest of

gingiva a scalloped incision (horizontal is given to maintain the crevicular gingiva intact foramen healing. The horizontal incision given is a reverse bevel incision from here a full thickness mucoperiosteal flap is reflected. 1. Incision allows primary healing to take placed as incision is attached gingiva i.e. rich in collagen fibres. 2. Can be easily repositioned. 3. Suturing done only on vertical incision lines.

Surgical Technique: i)

Incision

Vertical incision (relieving, relaxing) -

Incision should be continuous, linear and well defined.

Avoid treated incisions.

Do not make an incision on bony prominence.

Intrasulcular incision -

Incision follows the contours of the labial surface of the teeth.

ii)

Reflection â&#x20AC;&#x201C; UBECO No. 2 double ended periosteal elevator, periosteal elevator ď&#x192; molt curette, Hu friedy. -

Reflection is initiated with a sharp convex end of a no. 4 molt curette or the Hu friedy curette.

The elevators are used to reflect both the mucosa and periosteum.

The elevator always on the bone and never on the flap.

A thin gauze may be used for reflection to prevent tearing on the flap. 33

iii)

Retraction: Retraction is placed on the bony firmly above the bony defect.

The reflected tissue should lie freely against the retractor and not be pushed or pulled against lip or cheek. The size of the retractor should secret the size of the flap. Too small retractions will allow the tissue to flap over whereas too large retractors will traumatize the surrounding tissues. Small retractors â&#x20AC;&#x201C; periosteal elevator. Large â&#x20AC;&#x201C; anistin, Minnesota Hanchan. Hard tissue management: The average thickness of bone overlying the mesial root of the mandibular first molar is 4.2mm. To penetrate this thick cortical bone a rotating No. 4 extra length surgical bur mounted in a high speed Impact hand piece (Palisades Dental) should be introduced slowly. This handpiece has an angled head that facilitates surgical entry and visibility and does not blow air or oil into surgical site. Copious irrigation with a sterile physiological saline should accompany all attempts to remove bone. (according to Fister and Gross, Cavelle and Wedgewood) irreversible bone necroses is realized when temperature exceeds 56Â°C. (A small window is cut and a sterile 34

broken off head of a bar is placed in the depression, (sterile ruler) (window preparation). iv)

Curettage and biopsy: Once apex has been located curettage is performed with a sharp

(Molt 4) / Goldman Fox-3 curette. First the back side of a curette is used to loosen the fibrous capsule from the wall. Then the loosened inflammatory tissue is scooped out of the cavity with a curette or using Allis tissue holding forceps. It is suggested that the soft tissue of the lesions surrounding the root should be curetted in toto. However, this is not always possible or practical, especially if the lesions involves the maxillary antrum, vitality of adjacent teeth is in jeopardy, or the mandibular vessels. The old concept that cementum must be curetted away is not based on scientific fact. A biopsy of soft tissue curettements is recommended as a safeguard. Use of instruments that crush tissue, such as hemostats or needle holders is discouraged. Instruments that puncture and grasp such as the allis forceps are more favourable for the removal of sizeable specimens. The tissue is placed in a specimen bottle of 10% formalin and sent to the laboratory for diagnosis. 35

In case of excess gutta-percha overfilling exists. It can be removed with a fast rotating No. 6 or 8 bur. The GP should be then burnished and compressed back in the canal space with a ball burnisher. v)

Apicoectomy: Root end resection refers to the removal of the apical portion of

the root best accomplished by obliquely resecting the most apical portion of the involved root with a large round bur size 702 or # 6 or # 8. Reasons for RER: a)

This segment is known for anatomical variations such as accessory canals, deltas and severe curve it is also the area in which operator errors such as zips, ledges and perforation are likely to occur.

Some apices close to the maxillary sinus, nasal cavity and mental neurovascular bundle may require RER to provide working room for apical curettment or place retrofilling. By resecting the apex a buffer area of bone can fill in so the apex is not in immediate proximity to the anatomic entity.

Selden has described the endoantral syndrome caused by irritation of an apex to the sinus even though the tooth was endodontically treated and needed RER. Matsura, Cummings has suggested that an apical resection of 2 to 3mm to expose the canal and eliminate accessory canals 90° resection care must be ensure that the resection is carried completely through the root from buccal to lingual. Preparation with microscopic ultrasonic tips – Preparation has a 5-3mm depth in 2-3 minutes with continuous irrigation to cool the surface and maximize cutting. High speed burs are used to resect the root end. A lingual-to-labial bevel angled at 30 to 45° to the coronal aspect of the tooth – (enhances surgical visibility and accessibility). vi)

Root end preparation: Retropreparation is best done with a small round bur micro contra

angle handpiece. The canal can be located with a sharp explorer or morse scaler. The depth of penetration should be 2 to 3mm and in center of the root. Lateral over preparation may result in a weakening of the apical 37

root structure and development of cracks upon condensation or dimensional change of Ag amalgam A slot preparation is suggested by Matsura where access is limited. The canal is located and prepared to a vertical length of 3 to 5mm with a # 700 bur and straight handpiece. Retention is placed with a inverted cone bur. Ultrasonic Retropreparation: Sonically/ ultrasonically drives microsurgical retrotrips because commonly available in the early 1990’s. The pioneers in the field of ultrasonic cavity preparation under enhanced visibility using a surgical operating microscope are Buchanan, Carr, Rubinstein, Reuben and others. Preparation is done with ultrasonic unit and special tips that are only ¼mm in diameter and 3mm in length (about 1/10 th the size of conventional HP). The REP time is 1 to 2 minutes. CaPO4 cement is a mixture of 2 Ca PO4 compounds – overextend, one basic – when combined sets to form hydroxyapatite. vii)

Retrofilling materials:

viii)

The most commonly used retrofilling materials are IRM, Super EBA cement, Amalgam, Ketac silver glass ionomer cement. Amalgam is carried to the apex with a small K-G retrofilling carrier sized for retropreparations. Small K-G retrofilling caries. Messings gun Messings gun to place amalgam in deeper hand to reach areas.

Dr. Raymonds carrier and condensor caries and condensor retrofilling instrument developed by Dr. Raymond. Microscopic endodontic surgeries carried out using operating microscopes first proposed by: -

Buchanan

Carr

Rubinstein.

Reuben.

Advantages: -

Surgical microscope â&#x20AC;&#x201C; it reveals:

Tiny #

Exists of accessory canals.

Isthmuses.

Fins preparation done with piezoelecitric ultrasonic units and special.

The advent of small microscopic surgical mirrors and ultrasonic root end preparation techniques has enabled the cut in some cases to be reduced to 0째. If the obturation coronal to the defect has been performed satisfactorily, it may be appropriate to resect only the unacceptable segment of the root and not place a root end filling. (If the apical gutta-percha is seen, it can be well burnished to the resected root tip). But if there is ever any doubt about the quality of the apical seal a root end filling should be used. ix)

Flap closure Following retrofilling procedure, the bone wax or ferric sulfate is

removed and the surgical site is thoroughly debrided with irrigating solution to remove any loose particles of filling materials bone or root structure. Before suture a radiograph should be taken to verify the removal of filling particles. Reinjection of local anesthesia could help to control bleeding and extend comfort to the patient.

Repositioning of the flap: The flap is closed by gently placing the most apical portion of the flap first. The flap is smoothed to place with a 2 x 2 gauge sponge so that th natural and incisional reference points are matched. Harrison has recommended 2 to 3 minutes of compression to develop a thin fibrin clot under the flap. x)

Suturing The function of the suture is to secure the flap in its original or

desired position. Sutures that are tightly placed compromise circulation, increase changes of sutures to tear open once the tissues swell. Suturing needles  traumatic (eyeless / swaged) needles which are advantageous because of their reverse cutting edge. The needle should penetrate 2 to 3mm from wound margin. Suture materials are divided as: 1. Absorbable (digested by body enzymes). 2. Non-absorbable – (Walled off). E.g. Absorbable  Surgical gut (traps food); Non-absorbable  Silk (Ethicon). 41

The flap is gently replaced and smoothened into position with a 2x2 gauge sponge until the incisional reference points match. The first suture should pass through the most dependent unattached tissue and the proceed through the attached tissue and be tied. A puncture too close to the incision can result in teasing of the tissue. A surgeons knot is most effective and least likely to slip. Sling suspensory or circumferential suturing is an effective technique for maximum tissue adaptation. Because the lingual anchor is lingual surface of the tooth. There is no tearing of the weaker lingual tissue as the suture thread settle obstrusively against linguo-gingival surface of the crown. Postoperative Sequelae The following postoperative sequelae can occur after endodontic surgery. 1)

Swelling: Although swelling does not occur in all the cases, it is sufficiently

common to warrant every effort to prevent it, such as by keeping trauma to a minimum during operation.

Effective method of reducing swelling is the application of cold compress over the surgical area for 20 minutes every hour postoperative.

Enzyme preparations and corticosteroids are used.

Pain.

Ecchymosis The discoloration of skin due to extravasation and brakdown of

blood in that area can travel along fascial planes and may appear near angle of the jaw, under the eye, neck and even chest. These back and blue marks usually disappear within 2 weeks. 4)

Parasthesia: Transparent parasthesia sometimes lasts for a few days after root

resection in any part of the jaw. It is very rare in the maxilla. 5)

Stitch abscess Possible causes are local laceration of tissue during suturing

accumulation of food debris or irritation of suture material itself.

Hemorrhage Secondary hemorrhage is quite usual following root resection. If

hemorrhage occurs time to time a cold compress is placed over the site. 7)

Perforation Perforation of the antrum may occur postoperative in a maxillary

teeth from cusp to molar. It is not a serious sequale unless foreign bodies are introduced. A suitable flap is coated and sutured properly followed by an antibiotic coverage. 8)

Iatrogenic When rarefaction of area is extensive and intrusive it is always

possible to disrupt blood and nerve supply to the adjacent tooth. To prevent this complication endodontic therapy should be initiated prior to surgical and Advances in Endodontic Surgeries 1. Use of microscopy and ultrasonic technology for retro preparations. 2. Use of carr surgical micromirror (Microns 3mm diagram in different shapes and angulations). This mirror allows to check for

completeness of canal wall preparation and removal of old fillings. 3. Use of specialized carriers and pluggers to carry and condense the retrofilling material. 4. Super EBA is material of choice caused with No. 12 poor â&#x20AC;&#x201C; excavator condensed with minute pluggers 025mm diagram, burnished and trimmed and finished. 5. Surgical microscope allows is deotaping for post surgery patient education videoprints can be made by a micro computer video printer. Causes for inadequate apical seal according to Carr: 1. Inadequate extent of apical preparation in a buccal-lingual direction. 2. Apical preparation not in the long axis of the cnal. 3. Inadequate retention. 4. Failures to remove isthmus in between canals. These failures can be overcomed by microscopic endodontic surgeries. 45

POSTOPERATIVE MANAGEMENT OF THE PATIENT Preferably the instructions should written and explained to the patient. Ice pack and pressure: -

Patient should be instructed to apply an ice pack over the surgical site and firmly, but gently press the pack on the facial tissues.

The pressures and reduction in temperature slows the flow of blood promotes coagulation in severed vessels and ultimately decreases post-operative bleeding and swelling.

Cold reduces sensitivity of peripheral nerves endings and acts as an analgesic.

Application of moist heat: Application of moist heat on the surgical site is acceptable after 18 to 24 hours. Heat promotes the flood flows and enhances an inflammatory response that is essential for wound healing during the first and second postoperative days.

Avoidance of activity: It should be instructed to restrain from strenuous activity for the remainder of the day on which the surgery was performed. To prevent tearing of the sutures patient is instructed. 1. No a raise the lip and look at the operated area. 2. Do not brush in the operated area use mouthwashes. Diet: An adequate balanced diet, preferable soft foods such as eggs, mashed potatoes fruit juices, soap, malted milk. Oral hygiene: Chlorhexidine mouthwash thrice daily for a week after the surgery. Pain management â&#x20AC;&#x201C; At 3 levels: An analgesic maintenance dose of 400mg every 8 hourly for first 3 operative days. Narcotic though controversial can be prescribed hydrocodone (7.5mg) with 750mg paracetamol every 4 to 6 hours.

Incision and Drainage: It is a standard procedure to drain an abscess. There are two problems that accompany this procedure firstly, optimal time to intervene and secondly obtaining adequate local analgesic. Ideally, the immediate area to be incised, the pointed area should feel soft and fluctuant under the examinerâ&#x20AC;&#x2122;s fingertips. There should be a fluid thrill that is when pressure is applied the feeling should be transmitted through the fluid. The apex of the swelling may appear whitish or yellowish. This is the ideal time to incise and drain. Learning the correct moment of surgical intervention is gained by experience. Sometime a lesion may be in the indurated stage. In such cases the patient is prescribed antibiotics and hot saline rinses half hourly to bring the abscess to a head. But there is not thumb rule in the matter of incising and draining while the lesions is still in indurated stage. The second problem, that is obtaining local analgesia exists because: 1. It is difficult to establish profound analgesia for an inflamed and abscessed area. 48

2. Reluctance to inject into the area is because initially it is very painful due to increase in fluid pressure by injecting into the region, but it also unwise to risk the spread of infection by the pressure of injection. LA can be of 3 types: -

Short acting – procaing 2-3 hours.

Intermediate acting – Prilocaine, Lignocaine 3-5 hours.

Long acting – Eliodocaine, bupivocaine 8-10 hours.

3. Acting on CNS by prevents modulating pain at CNS. By use of opoids like morphine, iodine 60-120mg, pestidine, Treatment of pain -

Preoperative AIDS or conclusteroids.

Long acting LA

Centrally acting opoids.

The following guidelines for administering anesthesia should be followed: -

Topical anesthesia should be applied liberally followed by conduction analgesia peripheral to the site of infection.

Block anesthesia followed by conduction anesthesia is best. 49

A intramucosal wheal infiltration around the perimeter of the lesion is given.

Armamentarium: 2" x 2" gauge sponges. Three cotton swabs. One scalpel with No.11 blade. One small curved haemostat. One needle holder. One half curved cutting needle with 000 silk thread. One suture scissors. One aspirator tip. Selection rubber dam â&#x20AC;&#x2DC;Tâ&#x20AC;&#x2122; drain. -

Gauge is placed to catch the flow.

Swab the area with disinfectant.

Test the depth of anesthesia and perform a sweeping vertical incision with a No.11 scalpel through the most pointed area to the bone and irrigate copiously with anaesthetic solution.

Aspirate immediately.

Open the incised area widely by following out the tract with a haemostat. Spread the handles of haemostat to separate the beaks.

Place a T drain with the bar of the drain inside the incision.

Suture the drain in place if necessary.

HEMISECTION Hemisection refers to sectioning of the crown a molar tooth, with either the removal of half of the crown and its supporting root structure or the retention of both halves, to be used after reshaping and splinting as two premolars. Indications for hemisection: 1. When periodontal involvement of one root is severe. 2. When loss of bone is extensive in furcation area. 3. When caries involves much of the root. Contraindication for hemisection: 1. When loss of bone involves more than one root, and the remaining root would have inadequate support.

2. When bridge span is long, and the abutment tooth would rend inadequate support. 3. When roots are fused.

Procedure: -

The roots to be retained undergo endodontic therapy and the pulp chamber is filled with amalgam.

No filling material is placed into the root to be removed, for that entire half of the tooth will be extracted.

A sharp cowhorn explorer or periodontal probe is used to identify the buccal and lingual furcations.

By first placing the tip of a high speed tapered fissure bur in the furcation, the operator can effectively section the molar with accuracy.

An elevator should be wedged between the two halves and slightly rotated to determine if the separation is complete.

The pathologic half is then extracted with forceps or eased out with an elevator. The socket area is lightly curetted and packed with bone wax /gel foam. This is followed by copious irrigation.

TREPHINATION This surgical form is used to secure drainage and alleviate pain when exudates in the cancellous bone is dammed up behind the cortical plate. The tremendous pressure leads to excruciating pain of an intraosseous acute apical periodontitis or apical abscess. This intraosseous pressure can be released and the area decompressed through trephination, which provides a pathway to empty pus and other acid exudates. After a good local anesthesia is obtained, a mini vertical incision provides adequate access and landmark visualization. -

The focal area of lesions is pinpointed by examination, and working through the soft tissue cortical plate of bone is grossly removed with a No. 8 bur to identify the root apex.

The bone is then penetrated at the apex with a no. 4 bur.

Trephination speeds relief and healing, but may not be accompanied by a great flow of exudates or pus.

Bicuspidation: carried out when only furcation area is involved and remaining tooth structure is normal. In such cases the tooth usually cover mandibular molars are split in half buccolingually at furcation area to give 2 premolars which are recontoured and capped to allow proper cleaning at interdental area. RADISECTOMY Synonymous : Root Amputation Radisectomy denotes the removal of one or more roots of molar. This procedure is often done for periodontal reasons. Indications for Radisectomy: 1. When endodontic treatment of one root is technically impossible or when such treatment has failed. 2. When untreatable furcation involvement is present and removal of root will facilitate oral hygiene in that area. 3. When extensive loss of bone has occurred around one root of an upper molar. 4. When a fractured root of an upper molar is present.

5. When a root has been perforated and root be treated endodontically. 6. When a root has been destroyed by extensive decay. Contraindications: 1. When loss of bone involves more than one root and the remaining root would have inadequate support. 2. When roots are fused. Armamentarium: -

Surgical length or long shank fissure bur sizes 700, 701, 557 and 558.

Long tapered fissure diamond stones â&#x20AC;&#x201C; to smoothen retained tooth segment.

Elevators ď&#x192; straight, apical elevators.

Forceps ď&#x192; upper / lower forceps.

Endodontic therapy is completed prior to the surgical procedure: -

A flap need not be raised if root amputation performed on periodontally involved teeth.

A flap has to reflected if the teeth is periodontally involved.

There are two methods by root amputations can be performed: 1. Vertical cut method: Utilizes a long shank, tapered fissure carbide bur in airrotor to section through the entire crown and root to the furca in gaining separation. Advantages of vertical cut method: 1. Direct visualization of bur penetration to ensure that preparation will be in the correct position. 2. Removal of that portion of the crown that is over the root to prevent undesirable postoperative occlusal forces. 3. Position of each cut, based on the anatomy of the furca, to allow the root to cleave along desirable angles. 4. Excellent visualization of furca after amputation. 2. Horizontal cut preparation. Horizontal cut is made through the tooth without the crown being altered in the preparation. 57

Cutting the tooth in this manner leaves a deep trough between the crown and the alveolar mucosa which is obvious trap for food and debris. Any occlusal forces over the amputated root will tend to put severe stress from a undesirable direction on the remaining roots. Amputation procedures on mandibular molars: -

Also known as bicuspidization.

Procedure: A gently curve is made in a size 40 silver cone and inserted it through furca from the buccal to lingual. The rest of the procedure is as in vertical procedure is an in vertical cut method for maxillary molars. Storage media: 1. HBSS 2. Vtaspan â&#x20AC;&#x201C; decreased incidence of root resorption after re implantation.

Corrective surgeries: 1. Perforative repairif in coronal 3rd of root can be sealed using Super EBA. If in middle 3rd and communicating with periodontium

then RCT followed by packing canal with Ca(OH)2 to promote cementogenesis. -

If the resorptive defective is communicating to oral cavity then a connective radicular surgery has to be performed.

Raised flap â&#x20AC;&#x201C; perform RCT fil up resorptive site using amalgam / Super EBA (Then obdurate canal completely in next setting). 2. Periodontal repair: Guided tissue regeneration: This is based on the principle of placement of a banus membrane that prevent epithelial migration and down growth of junctional epithelium into healing periodontium. Thus allows blood clot to undergo regeneration in a stable environment with the proliferation of indifferent mesenchymal cells to form fibroblasts, cemento and osteoblasts. Thus allowing plug films to get reattached onto the surface of a new cementum. These barrier membranes may be

resorbable or non-resorbable (has to be removed after 6 weeks) of banner membrane cortex. Endodontic Implants: ď&#x192;&#x2DC; It is a metallic extension of the root with the object of increasing. 1. The root to crown ratio. 2. To give the tooth stability in the arch. ď&#x192;&#x2DC; Endo implants are useful for the treatment of: 1. Periodontally involved teeth requiring stabilization. 2. Transverse root # involving loss of the apical fragment / the presence of 2 fragment that cannot be aligned. 3. Pathologic resorption of the root apex incident to chronic abscess. 4. A pulpless tooth with an unusually short root. 5. Internal resorption affecting the integrity and strength of the root. 6. A tooth in which additional root length is desired for improving its alveolar support. The success of an Endodontic implant depends on:

 Proper case selection and close adherence to the following criteria.  Normal root anatomy without curvature / defelctions.  Alveolar bone is sufficient for retention and stability of both the tooth and the implant. Contraindicated: 1. When multiple incisors are periodontally involved and the adjacent teeth would serve as satisfactory abutment. 2. When anatomic structures are close to the apex. 3. The inclination of the tooth. 4. h/o bleeding problems. 5. h/o bone infection (month/any extremities). 6. h/o rheumatic heart disease, diabetes and other systemic illness. The disadvantages of Endo implants, which can result in failure:  Poor apical seal resulting in Pa rarefaction around the root apex.  Extrusion of excessive sealer.

 Perforation of the lateral root surface / perforation of a curved root near the root apex.  A structurally weakened tooth.  Limitations : Because of the local anatomic factors.

Instruments: Special instruments and filling materials are required for the successful outcome: 1) Extra long (40mm) reamers in standardized size 70 to 140. 2) Special intraosseous drill. 3) Standard chrome-cobalt endodontic implant sizes 70 to 140. Technique:  Anaesthetic the tooth and involved area with a local anaesthetic.  Rubber dam is applied.  Access preparation, enlargement and irrigation of the root canal is carried out.  Larger and wider access preparation in the clinical crown-toaccommodate the placement of the rigid implant “straight line”. 62

 In addition, the root canal should be enlarged to at least the size of a No. 60 instrument.  A marker is then set on the 40mm reamer at a level equivalent to the length of the tooth plus the number of ---- the implant will extend beyond the root apex.  Thus the bone is reamed to the desired length.  Irrigate with anaesthetic solution / saline as NaOCl may irritate the Pa tissue).  Irrigation – debrides the canal, controls haemorrhage.  Dry the canal with sterile absorbent points.  Select the implant to the least equivalent instrument used, score it lightly to the desired WL (occlusal tip to cancellous bone).  Implant must fit tightly and must penetrate the bone to the prepared length. Implant – must fit at the apical foramen. If not adjustments should be made by cutting of the implant 1mm of the tip and then tried out.  With the help of a plugger seat the implant during cementation. 63

 Then the coronal portion is replaced by crown / post-type crown (seat the implant to the level corresponding to the midroot, so as to provide sufficient space to cement post-core crown later.  Replantation / reimplantation is the insertion of a tooth in its socket after its complete avulsion resulting from traumatic injury.  Intentional replant: is the intentional removal of a tooth and its reinsertion into the socket after orthograde obturation and resection of the root tips, resection of the root tips followed by retrograde obturation teeth.  Transplantation is removal of a tooth / tooth bud from one socket and transplanting it into another socket. Autotransplantation

Allotransplantation

From one socket to another

From one person to another

Socket of the same person 3 types of materials are used: -

Metals.

Ceramics.

Polymers and composites.

Metals: -

Stainless steel.

Co-Cr-Mo.

Ti & Ti-Al vanadium.

Metal with surface coating.

Hydroxyapatite

Bioglass

Non reactive

Aluminium O2

Conclusion Keeping in mind, the degree of difficulty and complexity of endodontic cases we are currently challenged to treat demand all our resources to include surgical endodontics.