INTRODUCTION It is generally accepted that non-surgical endodontics therapy periapical inflammation or infection and allows teeth to be restored that previously might have been extracted. However failures does occur in a small percentage of cases. When confronted with such cases the clinician should be prepared to initiate alternative procedures including surgery to enhance the rate of success. The
scope
of
endodontic
apicocectomy
to
include
transplantation,
implantation,
surgery
crettage, trephination,
has
expanded
radisectomy, incision
beyond
replantation and
drainage.
Apicoectomy literally means ‘Resection of the root apex’ but for many years it has been injudiciously used to describe many types of endodontic surgical procedures. At present the more acceptable term when referring to surgical procedures performed around the root periradicular surgery. Chivian suggested using the terminology non-surgical or conventional verses surgical to describe the two endodontic procedures.
HISTORY ACCORDING TO INGLE • Endodontic surgery has first recorded 1500 years ago when Aeticus, a Greek physician dentist excised an acute apical abscess with a small scalpel.
1
• Later the procedure was refined and popularized by Hullihen in 1839. • Farrar (1884), Rhein (1894) and G.V. Black (1886) described root amputation
techniques
and
in
1919
Garvin
demonstrated
retrofillings radiographically.
PATHWAYS BE CONSIDERED WHEN REVALUATING AN ENDODONTICALLY TREATED TOOTH Classification Endodontic surgery encompasses surgical procedures performed to remove the causative agents to radicular and periradicular disease and to restore these tissue to functional health. It can be classified as follows: 1. Surgical drainage a. Incision. b. Trephination 2. Radicular surgery a. Apical surgery i.
Currettage and biopsy.
ii. Apicoectomy. iii. Retrofilling. 2
b. Corrective surgery i. Perforative repair
Mechanical Resorptive
ii. Periodontal repair
GTR Resection
3. Replacement surgery a. Replant surgery
Intentional Post traumatic
b. Endosteal implant surgery
Endodontic Osseointegrated
3
INDICATIONS AND CONTRA INDICATIONS Clean well obturated canals are the biological basis of endodontic success marked improvements in the non surgical techniques have improved the success rate, however if cleaning of the canal terminus root canal access is impossible, (a surgical approach should be considered) whenever a root canal cant be filled properly with an orthograde filling endodontic surgery should be considered. A
classical
characterization
of
specific
indication
and
contraindication has developed by Leubke, Glick, and Ingle. Based on the classifications. Indications of endodontic surgery (Grossman) 1. Any condition or obstruction that prevents direct access to the apical third of the canal such as: a. Anatomic – calcifications, curvatures, bifurcations dens in dente and pulpstones. b. Iatrogenic
–
ledging
blockage
from
debris,
broken
instruments old root canal fillings and cemented posts. 2. Periradicular disease associated with a foreign body, overfilled canals, broken instruments protruding into apical tissue and loose retrograde fillings. 4
3. Apical perforations: any perforation that can’t be sealed properly by a filling within the canal. 4. Incomplete apexogenesis with blunderbus or other apices that do not respond to apical closure procedure. 5. Horizontally fractured root tip with periradicular disease. 6. Failure to heal following non surgical endodontic treatment. 7. Persistant and recurring exaggeration during non-surgical treatment or persistant, unexplainable pain after completion of non surgical treatment. 8. Treatment of any tooth with a suspicious lesion that requires a diagnostic biopsy. 9. Excessively large and intruding periapical lesion. 10. Destruction of apical constricture of root canal due to uncontrolled instrumentation. Contra Indications for endodontic surgery 1. Indiscriminate surgery. 2. Poor systemic health. 3. Psychological impact. 4. Local anatomical considerations.
5
Indiscriminate surgery : Endodontic surgeries should not be a cover up for every endodontic case or a cover up for the skill in non surgical endo technique. Surgeries are not simply indicated because a periadicular lesion is present at the time of treatment, is because a large lesion is present or because the clinician believes a lesion may become cystic. Poor systemic health : A complete medical history is mandatory. If a question exists about the patients health, medical consultation must be sought with the patients physician. Contraindications include blood dyscrasias is neurological problems, terminal illeness, diabetes, heart diseases, pregnancy in first and third trimestor. Psychological Impact : Patients facing endodontic surgery may be terrified by the suggestion of surgery to seek masochistic addiction to polysurgery who is seeking the experience. Patients should be allowed to verbalize their thought and fear are they have been informed of the operation. Local Anatomical considerations : Short root length precludes apical root resection if the grown root ratio should becomes so disproportionate as to limit the useful future of the tooth. Poor bony support : An advanced periodontal disease may well dissuade one from endodontic surgery. On the other hand in these cases apical repair
6
can be expected to develop within the 2 years following successful endodontic treatment.
ANATOMIC CONSIDERATIONS Maxilla Anterior Facial Region -
The lateral incisors are seldom close to the nasal floor than the central incisors.
-
The maxillary incisors and canines are often covered with little or no labial cortical plate.
-
The maxillary sinus is in close proximities to the root apices. At times apices of the maxillary premolar and molars may penetrate the sinus floor and establish a communication
between
the
periodontal
ligament
and
mucoperiosteal lining of the sinus. -
Although the maxillary sinus membrane perforation usually doesn’t cause postoperative problems, care must be taken to prevent root tips, bone or other foreign bodies being inadvertently pushed into the sinus.
-
A prominent zygomatic process may impede surgical access to the root of a maxillary molar teeth.
7
-
A palatal root of the first or second molar that is closely aligned with the greater palatine foramen. The position and course of the palatine bundle must be carefully determined when placing a palatal approach to the palatal root. To avoid vessels, palatal access is gained by reflecting a flap created by making a vertical incision between the premolars and a short distal releasing incision of the tuberosity.
Mandible: -
Proximity of the mental foramen to the apices of mandibular premolars and on occasion to the first molar.
-
Thick external oblique ridge in the second and third mandibular molar region.
-
The mandibular canal doesn’t interface with surgical access except when a shallow mandibular process is associated with long roots.
The mean vertical distance from the mesial root apex of first mandibular molar to the superior border of the neurovascular bundle is about 5.3mm. The buccolingual position of the canal can be determined by comparing a IOPA exposed at right exposed at right angle to the long axis of the tooth with a second radiograph exposed at a vertical angulation of 8
25째 and the central beam directed superiorly, if in the second film the mandibular canal waves inferiorly in relation to the roots apices, the canal is lingual in the apices, if it moves upwards on the roots it is buccal, is the apices minimal movement of canal indicates that it is in close proximity to the apices.
PRE-OPERATIVE CONSULTATION WITH THE PATIENT The surgical procedure should be described in detail, as should all potential postoperative problems such as discomfort, swelling, bleeding, brushing, maxillary anterior penetration and rare possibility of parasthesia. -
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 attest to them understanding and treatment procedure, risk and fees.
PRE-OPERATIVE PREPARATION AND PREMEDICATION OF THE PATIENT Antiseptic mouthwash : According to Loe, JPS 1970, chlorhexidine gluconate reduces the levels of fracture in the oral cavity and plays a important role in healing following endodontic surgery.
9
Patient is instructed to rinse with the solution for 1 min twice daily for 5 days. This regimen should begin the day before surgery. Administration of non-steroidal anti-inflammatory drugs before the surgical procedure helps to reduce postoperative pain and swelling. Ibuprofen enacts its effects by inhibiting the enzyme cycle-oxygenase and preventing the formation of inflammatory mediators. Its analgesic and antiinflammatory properties result from inhibition of peripheral prostaglandin synthesis. A loading dose of 600mg 2 hours before surgery, and 400mg every 4 hours postoperatively is advised. Short acting barbiturates, such as pentobarbital and secobarbital are frequently used for sedation. Commonly administered orally, 50, 150mg / 30 min prior to the surgical treatment. Tranquilizers effectively reduce apprehension and act as muscle relaxants. Diazepam, 5mg taken orally 30 minutes prior to treatment. Narcotics can be effective premedication.
ARMAMENTARIUM The suggested surgical set up for periapical surgery: 1. Anesthesia – lidocaine HCL 2%, epinephrine 1,80,000 2. Sterile cotton gauze. 10
3. Periosteal elevator (molt 4 curette, the friedy). 4. Straight handpiece burs 2, 4, 6, 8, 33 ½ hand chisel, sterile saline, handpiece, (st and CA) and microhead contra angle. 5. Surgical curettage. 6. Apical amalgam carrier, plastic instrument, amalgam plugger and condenser. 7. Needle holder or hemostat, silk suture and scissors. 8. Surgical tray cotton pliers, explores, mirror etc. Fiberoptic light source could be used, which is attach to surgical aspirators or retractors. Magnification of operative site using visors and loupes. Surgical telescopes and microscopes also provide crisp undistorted images of operating site. High torque surgical drills are preferred to systems that rely on compressed air as these motor engine driven system prevents the phenomenon of cermicofacial subcutaneous air emphysema. Haemostasis can be achieved by use of Nu gauge geefoam, bone wax or other physical barriers.
11
Cotton, cotton wool or gauze saturated with adrenaline are least desirable materials as the residual cotton fibres left in the crypt provoke a latent foreign body reaction. Astringents such as 15.5% ferric sulphate burnished into a area of bleeding promoes homeostasis by rapidly. ANESTHESIA [A solution of 2% lignocaine and 1;80,000 adrenaline is an effective local Anesthetic in mirror oral surgery]. Buccal Infiltration The specific target sites of infiltration injections are the approximated levels of the root apices. Attempts to inject deeper tissue may prove counter productive, because of the likelihood of injecting into skeletal muscle. Palatal infiltration An increment of 0.3ml is sufficient. Mandible Conduction anesthetia, in which anesthetic solution is deposited near the mandibular foramen is used for mandibular periapical surgery.
12
FLAP DESIGN Requirements of an ideal flap: 1. Base is the widest point of the flap : The need for the width at the base is to afford sufficient circulation to the raised portion of the flap so that the edges do not become ischemic and later slough. 2. Avoiding incision over a body defect. 3. Include the full extent of the lesion. 4. Avoid sharp corners : Tips of sharp corners have a tendency to become ischemic before collateral circulation across the sutured tissues becomes established. 5. Avoid incisions across a bony prominence : Usually found in the maxillary cuspid region, since the mucosa 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. 6. Guarding against possible dehiscence : Maxillary molars and bicuspids. 7. Avoid the mucogingival junction : The junction of the attached gingiva and the alveolar mucosa had extremely friable tissues. Incisions plced here take much longer time to heal. 13
8. Flap should generally extend one or two teeth laterally : To allow for relaxed retraction and prevent stretching and tearing of tissue. 9. 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. 10. A full thickness mucoperiosteal flap : should be raised to maintain the integrity of the periosteum. The basic flap designs used in endodontic surgery 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. Seminar Flap
: Esthetic crowns present Trephination. Reduces incision and reflection time. Maintains integrity of gingival attachment. Eliminates potential crystal bone loss. 14
Disadvantages
: Limited access and visibility. Tendency to increase hemorrhage. Crosses root eminences. May not include entire lesion. Predisposed to stretching and tearing. Repositioning is difficult. Healing is associated with scarring.
3. Triangular Flap
:
Indications
: Midroot perforation repair. Periapical surgery.
Advantages
-
Posterior areas.
-
Short roots.
-
Small incisions.
relaxing
-
Additional incision.
vertical
-
Extension of horizontal component.
: Easily modified
Easily repositioned. Maintains integrity of blood vessels. Disadvantages
: Limited access and visibility to longer roots. Tension is created on retraction. Vertical incision penetrates alveolar mucosa. Gingival attachment severed.
15
4. Ochesenbein luebke flap Indications
: Prosthetic crown present Periapical surgery. -
Anterior region.
-
Longer roots.
Wide band of attached gingiva. Advantages
: Ease of incision and reflection. Enhanced visibility and access Ease of repositioning. Maintains integrity of gingival attachment.
Disadvantages
-
Prevents recession.
gingival
-
Avoids dehiscence.
-
Prevents crestal bone loss.
: 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 Indications
: Periapical surgery. -
Multiple teeth.
-
Large lesion.
-
Long roots.
Lateral root repairs. Advantages
: Provides maximum access and visibility. Reduces retraction tension. Facilitates repositioning. 16
Disadvantages
: Reduced blood supply to the flap. Increased incision and reflection time. Gingival attachment violated. -
Gingival recession.
-
Crystal bone loss.
-
May dehiscence.
uncover
Suturing more difficult. 6. Palatal Flaps
: The need to reflect the lateral 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 anastomose 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 17
a suture material. 7. Trapezoidal Flap
:
Indications
: Periapical surgery
Advantages
-
Multiple teeth.
-
Large lesions.
-
Long or short roots.
: Provides maximum access and visibility. Reduces retraction tension. Facilitates repositioning. Blood supply to flap is maintained.
Disadvantages
: Increased incision and reflection time. Gingival attachment violated. -
Gingival recession.
-
Crestal bone loss.
-
May uncover dehiscence.
Suturing is more difficult.
SURGICAL TECHNIQUE Vertical incision (Relieving, Relaxing) : Incision should be continuous, linear and well defined. Avoid repeated incisions. Do not make an incision on bony prominence. Intrasulcular incision: Incision follows the contours of the labial surface of the teeth.
18
Reflection Reflection is initiated with a sharp curves end of a No. 4 molt curette or the Hu friedly curette. The elevators are used to reflect both the mucous 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.
Retraction Retraction is placed the bone firmly above the bony defect. The reflected tissue should lie freely against the retraction and not be pushed or pulled against lip or cheek.
Hard tissue management The average thickness of the bone overlying the mesial root of the mandibular first molar is 4.2mm. To penetrate the thick cortical bone a rotating No. 6 extra length surgical bur mounted in a high speed impact hand piece should be introduced slowly. This hand piece has an angled head that facilities easy entry and visibility and doesn’t blow air or oil into the surgical site. Copious irrigation with a sterile saline accompany all attempts to remove bone, [according to Fisher and Gross, Cavelle and Wedgewood], 19
irreversible bone necrosis is realized when temperature exceeds 56째C. (A small window is cut and a sterile broken off head of a bar is placed in the depression, (sterile ruler) (window preparation).
Periradicular curettage: Once apex has been located curette 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. It is suggested that the soft tissue of the lesion surrounding the root should be curetted in toto. However this is not always possible or practical, especially if the lesion involves the maxillary antrum viability of the adjacent teeth is jeopardy, or the mandibular vessels. Occassionally, the root and apex are difficult to localize even after removing the cortical bone. The root can be distinguished from its surrounding by its color, morphologic features, and hardness. Root structure is harder that the soft cancellous bone with a defined anatomic outline and a different color when viewed in a washed and debrided operative field, Cambruzzi and associate described use of methylene blue to identify and isolate root apex. The decision to resect the apical tip depends on the quality of the seal between the root canal and the surrounding periodontium. If the seal is 20
satisfactory, periapical curettage and removal of the pathologic tissue and the extruded filling material will suffice. 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 pucture 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. In case of excess gutta-percha overfilling. It can be removed with a fast rotating No. 6 or 8 bur. The GP should be then burnished and compressed back into the canal space with a ball burnisher.
Root end Resection: 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 -
This segment is known for anatomical variations such as accessory canals, deltas and severe curve it is also the
21
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 anatom 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 REP. Matsura, Cummings has suggested that an apical resection of 2 to 3 mm to expose the canal and eliminate accessory canals 90째 resection care must be ensure that the resection is carried completely through the root from buccal to lingual.
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 root
22
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 5 mm with a # 700 bur and straight handpiece. Retention is placed with a inverted cone bur.
Ultrasonic Retropreparation 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 Âź mm in diameter and 3mm in length (about 1/10 th the size of conventional HP). The REP time is 1 to 2 minutes.
Retrofilling Materials The most commonly used retrofilling materials are IRM, Super EBA cement. Amalgam, Ketac Silver glass ionomer cement.
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 particle of filling material bone or root 23
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 the 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.
SUTURING The function of the suture is to secure the flap in its original or desired position. -
Sutures
that
are
tightly
placed
compromise
circulation, increases chances of sutures to tear open once the tissues swell. Suturing needles ďƒ 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: 24
1) Absorbable (digested by body enzymes). 2) Non-absorbable (walled off). E.g., Absorbable ďƒ Surgical gut (traps food). Non absorbable ďƒ Silk (ethicon). The flap is gently replaced and smoothened into position with a 2 x 2 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 tearing of the tissue. A surgerons 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. Interrupted sutures may also be placed.
25
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 post operative.
-
Enzyme preparations and corticosteroids are used.
2) Pain 3) Ecchymosis The discoloration of skin due to extravasation and breakdown of blood in that are can travel along fascial planes and may appear near angle of the jaw, under the eye, neck and even chest. These black and blue marks usually disappear within 2 weeks. 4) Parasthesia
26
Transient 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. 6) 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 cuspid 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 extrusive 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.
POSTOPERATIVE MANAGEMENT OF THE PATIENT 27
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 pressure 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 and inflammatory response that is essential for wound healing during the first and second post operative days.
Avoidance of activity It should be instructed to retrain 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. Not raise the lip and look at the operated area. 28
2. Do not brush in the opened area use mouthwashes.
29
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 An analgesic maintenance dose of 400mg every 8 hourly for first 3 operative days. Nacrotic through controversial can be prescribed hydrocodone (7.5mg) with 750 mg 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 to intervene and secondly obtaining adequate local analgesia. Ideally, the immediate area to be incised, the pointed area should feel soft and fluctuant under the examiner’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.
30
Learning the correct moment of surgical intervention is gained by experience. Some time 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 no thumb rule in the matter of incising and draining while the lesion is still in indurated stage. The second problem, that is of obtaining local analgesia exists because: 1. It is difficult to establish profound analgesia for an inflamed and abscessed area. 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. 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.
31
-
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 of rubber dam ‘T’ 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.
-
Aspiate immediately.
32
-
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.
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 lesion 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. 33
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.
34
-
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 tissue 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.
RADISECTOMY Synonyms : 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. 35
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 – to smoothen retained tooth segment.
-
Elevators ďƒ straight, apical elevators.
-
Forceps ďƒ upper / lower forceps, universal forceps.
36
Endodontic therapy is completed prior to the surgical procedure: -
A flap need to be raised if root amputation performed on periodontially involved teeth.
-
A flap has to reflected if the teeth is periodontially involved.
There are two method by root amputations can be performed : 1)
Vertical cut method -
Utilizers 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.
37
2)
Horizontal cut preparation Horizontal cut is made through the tooth without the crown being
altered in the preparation. 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 gentle 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 as in vertical cut method for maxillary molars.
38
SUMMARY AND CONCLUSION All endodontic procedures should ensure the placement of a proper seal between the periodontium and the root canal foramina. When this seal can’t be achieved satisfactorily by working through the canal system, a surgical procedure presents visual and manipulative control of the area and placement of the seal through the surgical site. When failure occurs in non-surgical endodontic therapy the clinician should be prepared to initiate alternative procedure including surgery to enhance the rate of success.
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CONTENTS Introduction History Classification Indication and Contraindication Anatomic Considerations Preoperative Consultation with the patient Preoperative preparation and Premedication of the patient Armamentarium Flap Design Surgical technique Suturing Postoperative sequelae Postoperative management of the patient Summary & Conclusion
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