ENDODONTIC SURGERY

SEMINAR BY Dr. N.Upendra Natha Reddy Postgraduate Student

CONTENTS
Page No INTRODUCTION/HISTORY CLASSIFICATION INDICATIONS CONTRA-INDICATIONS PRE-OPERATIVE ASSESSMENT/ PRE-MEDICATION SURGICAL KIT FLAP DESIGNS TECHNIQUES OF ENDODONTIC SURGERY INCISION AND DRAINAGE TREPHINATION APICAL CURETTAGE AND !IOPSY APICOECTOMY ROOT END CAVITY PREPARATION ROOT END CAVITY O!TURATION ROOT END FILLING MATERIALS CORRECTIVE SURGERY REPLACEMENT SURGERY IMPLANT SURGERY SUTURING POST-OPERATIVE INSTRUCTIONS POST-OPERATIVE SEQUELAE SUCCESS AND FAILURE REFERENCES 1 6 7 9 9 12 15 28 28 1 6 8 "7 56 59 6 71 7 77 82 8 87 96

INTRODUCTION
According to the strictest definition of the word surgery, most endodontic treatment falls into the category of a surgical procedure, since removal of tissues, such as vital pulp, necrotic debris, or dentin, is involved. However, as commonly used, the term endodontic surgery refers to the removal of tissues other than the contents of the root canal space to retain a tooth with pulpal and/or peri apical involvement.

HISTORY
!ndodontic surgery was first recorded 1"## years ago when Aetius.$., %ree& physician dentist, e'cised an acute apical abscess with a small scalpel. (ater the procedure was redefined and populari)ed, although one may *uestion whether Hullihen+s contribution in 1,-. was a refinement over Aetius. /0a&e an incision through the gum, along the entire length of the fang1, stated Hullihen, /then apply a roasted fig or bruised raisins to the gum1. 2arrar 31,,45, 6hein 31,.75, and %.8.9lac& 31,,:5 described root amputation techni*ues, and in 1.1., %arvin demonstrated retrofillings radio graphically.

;urrently, endodontic surgery falls into more than one domain. 0any general practitioners and most oral surgeons routinely perform various types of endodontic surgery. !ndodontists should be able to perform peri apical surgery on any root in the dental arch, including mandibular molars. Periodontists may become involved in the endodontic surgery, peri apical or amputational, when a tooth re*uiring periodontal surgery has a peri apical problem of pulpal origin in addition.

;urrently endodontic surgery is a predictable and integral part of comprehensive endodontic services. $childer, as president of the American Association of !ndodontists, editoriali)ed that endodontic surgery has advanced and currently plays a ma<or role in

/retreatodontics1. However, the surgical approach to endodontics can be badly misused. 2or some, periradicular surgery automatically follows root canal obturation and at times is performed in lieu of filling the root canal. =thers refuse to perform or recommend endodontic surgical procedures. 9oth groups lac& an appreciation of comprehensive dental care. >here are two ma<or areas of endodontic surgery at this time? peri apical and amputational. >he two have certain basic similarities but have considerable differences as well.

2or many years the term conservative treatment has been used as a synonym for non surgical treatment. ;hivian correctly protested that using conservative to mean without surgery would indicate that surgery is radical treatment. $ince peri apical surgery usually saves a tooth that could not be retained by other methods, it too is conservative. @eine also agrees that peri apical surgery should not be considered radical therapy, in contrast, tooth retention by any method is conservative.

2or

years,

many

dentists

unaccountably

have

separated

endodontists into two divisions? conservative and surgical. >his classification inappropriately implies that surgery is a radical approach. $urgical treatment should be considered an e'tension of therapy, a means of preserving teeth that otherwise would have to be e'tracted, and is therefore no less conservative than what we consider to be routine, non surgical root canal treatment.

>he definition of conservative, /tending to preserve e'isting conditions1, supports this position. How did the erroneous perception of surgery as a radical and last resort treatment originateA Apparently this idea began in 1,,4, when 2arrar described /radical and heroic treatment of alveolar abscess1. Bn outlining a plan of treatment, 2arrar used the term
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radical. Bn a perusal of the endodontic literature of the past 1## years, the term conservative is used to describe non surgical treatment. >his archaic terminology is still found in current te'tboo&s and <ournal articles. However, because a surgical endodontic approach is often the only method of salvaging otherwise hopeless teeth, it is indeed conservative.

=ther important factors that have enhanced the success and increased the applications of surgery are research and education. >hrough e'perimental investigations, surgical approaches and outcomes are better understood. Advanced endodontic programs have increasingly

emphasi)ed surgical training in response to the need for this treatment approach.

!ndodontic surgery encompasses surgical procedures performed to remove the causative agents of radicular and peri radicular disease and restore these tissues to functional health.

@ith the recent advent of magnification and illumination, coupled with ultra sonic root end canal preparations and sealing with new retro grade filling materials, the success of surgical endodontic treatment will provide the answer to solving myriad problems that were once considered hopeless. >he e'panded scope of surgical endodontics includes apical
:

curettage, apicoectomy, root end filling, root resections, hemisections, replantation, transplantation, and guided tissue regeneration, with more advances on the hori)on. >his gives the clinician a wide range of choices in this conservative approach.

6oot canal treatment is a relatively successful procedure if diagnosis and technical aspects are carefully performed. 0ost pulpal and peri apical disease is best managed nonsurgically. >here is a common belief that if root canal treatment fails, surgery is indicated for correction. >his is not necessarily true, as most failures are best corrected by retreatment. >here are however, situations in which surgery is necessary to retain a tooth that would otherwise be e'tracted.

CLASSIFICATION OF ENDODONTIC SURGERY

Bt can be classified as follows?

1. S#$%&'() *$(&+(%, Bncision >rephination 3fistulative surgery5 2. R(*&'#)($ -#$%,$. A. Apical surgery. ;urettage and biopsy 3peri radicular surgery5. Apicoectomy. 6etro filling. 9. ;orrective surgery. 1. Perforative repair. 0echanical. 6esorptive. 2. Periodontal repair. %uided tissue regeneration. 6esection. / R,0)(',1,+2 -#$%,$./ A. 6eplant surgery Bntentional

 Post traumatic. 9. !ndosteal implants surgery. !ndodontic =sseo integrated 3endosseous5

INDICATIONS FOR ENDODONTIC SURGERY 1/ S#$%&'() D$(&+(%, A. Necessity for drainage 1. !limination of to'ins 2. Alleviation of pain 2/ A0&'() -#$%,$. A. Brretrievable root canal fillings 1. =bviously inade*uate filling 2. Apparently ade*uate filling 9. ;alcified canals ;. Procedural errors 1. Bnstrument fragmentation. 2. Nonnegotiable ledging. -. =ver instrumentation and apical fracture. 4. $ymptomatic overfilling. C. Presence of dowels !. Anatomic variations

2. Apical cyst %. 9iopsy H. 2alse indications. 1. Presence of an incompletely formed ape', ma&ing hermetic sealing of the ape' impossible. 2. 0ar&ed overfilling. -. Persistent pain. 4. 2ailure of previous treatment. ". !'tensive destruction of peri apical tissue and bone involving one third or more of the root ape'. :. 6oot ape' that appears to be involved in a cystic condition. 7. Presence of crater shaped erosion of the root ape', indicating destruction of apical cementum and dentin. ,. Bnability to gain negative culture. .. Bnternal resorption. 1#.!'treme apical curvature. 11.2racture of root ape' with pulpal death. / C3$$,'2&4, -#$%,$. A. 6oot anomalies 9. Perforating carious and resorptive defects ;. Periodontal endodontal defects %uided tissue regeneration.
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 6oot resection, hemi section, bisection. ;orrection, radicular gingival groove. "/ R,0)(',1,+2 -#$%,$. A. 6eplant surgery Bntentional. Post traumatic. 9. Bmplant surgery !ndodontic. !ndosseous.

CONTRA-INDICATIONS TO ENDODONTIC SURGERY

1. Bndiscriminate surgery. 2. Poor systemic health. -. Psychological impact. 4. (ocal anatomic factors $hort root length. Poor bony support. $ite of surgery.

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PRE-OPERATIVE ASSESSMENT >he *uality of endodontic surgery, and in many respects the final successful out is dependent on proper patient assessment, diagnosis and treatment planning. Bt is during this process that the facts surrounding the case in *uestion must be obtained and integrated into a meaningful diagnosis and treatment plan. ;ontraindications involving the patient+s psychological or systemic ma&eup can be identified as well as patient acceptance of, and cooperation with, the anticipated surgical procedure. =ften this will include procedures to minimi)e stress with patients who are particularly susceptible to pain and an'iety. =ral soft and hard tissue conditions, including patient compliance with oral hygiene practices, can be ascertained and reinforced.

(ocal patient factors focus on the nature of the previous root canal treatment, if any, and the ultimate management of both soft and hard tissues during surgical entry and wound closure. >hese include the

potential need to remove previous dental restorations, which are failing, and to attempt non surgical pretreatment as part of overall management. >he removal of lea&ing crowns, restorations with deep decayed margins, poorly adapted inter pro'imal restorations and root fillings of silver comes or pastes is common. 2avoring results have been obtained when root canal systems are retreated prior to surgical management.
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6adiographic e'aminations are also essential, using prior radiographs if available, along with additional films e'posed at the consultation visit. @hen posterior teeth are involved it is common to

ta&e several radiographs from different angles, identifying the number, curvature and angle of the roots re*uiring surgery. (i&ewise, anatomical structures, which may impair surgical or visual manipulation of the surgical site, are identified, such as the mental foramen, )ygomatic process, anterior nasal spine and e'ternal obli*ue ridge.

;rucial to the success of the surgical procedure will be communication with the patient concerning the need for surgery, the prognosis, the use of preoperative medication or mouth rinses, the actual procedures to be performed, the potential for postoperative discomfort, the use of postoperative palliative procedures, the need for suture placement and removal, follow up care and long term assessment. Bt is recommended that the following pretreatment regimens be considered.

1. A periodontal e'amination should be performed prior to surgery and, if necessary, scaling and/or root planing performed. >he

patient+s oral hygiene practices should be assessed and reinforced.

1-

2. Patients can be placed on chlorhe'idine rinses 1 day before surgery, to continue for 2 - days afterwards. -. Patients can begin ta&ing a non steroidal anti inflammatory medication 1 day before surgery, or at the latest one dose 1 h beforehand. 4. Patient should be advised to refrain from smo&ing. ". Bf sedative pre medication is to be used the patient must bring an accompanying person, who will be responsible for escorting home and compliance with postoperative instructions.

G,+,$() M,*&'() C3+*&2&3+Hypertension $table angina Bnfective endocarditis Asthma !pilepsy Adrenal insufficiency =rgan transplant ;oronary artherosclerotic disease 0yocardial infarction ;hronic obstructive pulmonary disease ;erebrovascular accident Ciabetes $teroid therapy Bmpaired hepatic or renal function

SURGICAL KIT 9asic instruments for surgical intervention have changed little in the past century. 0any manufacturers have attempted to duplicate or
14

enhance these instruments, but few ma<or changes e'ist. >he clinician must be familiar with the different types of instruments, and how and why they are beneficial in the performance of endodontic surgery. Bt is well accepted that there is more than one way to achieve high *uality in the delivery of surgery. >herefore, instruments must be chosen which best allow the surgeon to perform as well as possible. Bnstruments must be sharp, undamaged and permit total control of the surgical site. 9ac& up instrument support for indispensable items must also be considered.

P$,--#$%&'() (--,--1,+2 0irror and curved e'plorer $traight and curved periodontal probes

S352-2&--#, &+'&-&3+6 ,),4(2&3+ (+* $,5),'2&3+ $harp scalpels D numbers 1", 1"c, 11 and 12 9road based periosteal elevator 9road based periosteal retractor >issue forceps $urgical aspirator Brrigating syringes and needles

1"

P,$&-$(*&'#)($ '#$,22(%, $traight and angled bone curettes $mall endodontic spoon curette Periodontal curettes 2ine, curved mos*uito forceps $mall, curved surgical scissors

!3+, $,134() (+* $332-,+* $,-,'2&3+ $urgical length round and tapered fissure burs $traight hand piece ;ontra angled hand piece/slow and high

R332-,+* 0$,0($(2&3+/0)(',1,+2 35 $332-,+* 5&))&+%/5&+&-7 35 $,-,'2,* $332 ,+* 0iniature contra angle or ultrasonic unitE sonic hand piece 9urs very small inverted cone or roundE angled ultrasonic or sonic tips

R332-,+* 5&))&+% 1(2,$&() Haemostatic agent 3avoid bone wa'5 0iniature material carriers and condensers

1:

 $mall ball burnished Paper points or fine aspirator tip ;itric acid 1# "#F and sterile cotton pellets $mall, fine e'plorer

S#2#$&+% (+* -352-2&--#, ')3-#$, $urgical scissors Hemostat or fine needle holders 8arious suture types and si)es 3- # to " #5 $terile gau)e for soft tissue compression

M&-',))(+,3#- 83$ $,(*&). (4(&)(9),: Ade*uate aspiration e*uipment Additional light source 0agnification 6oot canal filling materials Anaesthetic syringes and anaesthetic.

FLAPS- FUNCTION AND DESIGN

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FUNCTIONS OF A FLAP >he most important function of a flap is to raise the soft tissue overlying the surgical site to give the best possible view to the operator and sufficient e'posure of the area to be operated on. $ince the free and attached gingiva and the underlying mucosa have considerable vascularity attempting to wor& through them would lead to increased blood loss and obstructed view.

!ndodontic surgery has had a great advantage over gingivectomy gingivoplasty and push bac& procedures D methods of periodontal surgery that were in vogue for some time until recently. >hese types of surgery left raw, bleeding tissues in addition to uncovered bone in some cases. >hey were characteri)ed by considerable postoperative pain and re*uired surgical pac& placement. Bn endodontic surgery the overlying tissue was stripped bac& and could be replaced after the procedure to give the best possible covering to the surgical site. >herefore the second important function of a flap is to provide healthy tissue that will cover the area of surgery, decrease pain by eliminating bone e'posure, and aid in obtaining optimal healing.

Bt is no wonder that sophisticated periodontal surgery has incorporated the use of flaps, and most operations now involve that type
1,

of approach. >he split thic&ness flap, apically repositioned flap, sliding flap and others have been found invaluable in the treatment of periodontal disease. Any of the new improvements in endodontic flap design and methods of flap retraction have been gleaned from the e'perience of Periodontists. @henever endodontic surgery is to be performed an

e'tremely careful periodontal evaluation must be ascertain the most desirable flap. Additionally when the site is opened for endodontic

surgery, the operator should concomitantly perform any periodontal surgery necessary in the area. Bn many cases the e'posure afforded by flap retraction for endodontic surgery e'poses periodontal defects that would otherwise remain undetected. R,;#&$,1,+2- 35 (+ &*,() 5)(0 0a&ing sure base is widest point of flap Avoiding incision over a bony defect Bncluding the full e'tent of the lesion Avoiding sharp coroners Avoiding incision across a bony eminence %uarding against possible dehiscence Placing a hori)ontal incision in the gingival sulcus or &eeping it away from the gingival margin Avoiding incisions in the mucogingival <unction

1.

 Avoiding improper treatment of periosteum >a&ing care during reaction.

TYPES OF FLAPS $emi lunar flap, 2ull vertical flaps Couble vertical incisions 0odified envelope flaps Palatal flaps

=chsenbein (ueb&e flaps.

1. Semilunar flap (Refer Fig.1) >he semilunar flap has been used for many years in endodontic surgery. >he chief advantage of this flap is its simplicity, re*uiring merely a straight, hori)ontal incision firmly through the soft tissues to the underlying bone. 9ecause the incision is placed away from the gingival margin, the semilunar flap does not cause the uncovering of gingiva from the gingival margin of crown restorations or disturb the healing of gingiva after periodontal surgery. Bt is referred to as semilunar because

2#

the hori)ontal incision is slightly modified to have a dip toward the incisal aspect in the center of the flap, giving resemblance to a half moon.

>he *&-(*4(+2(%,- of this flap have caused it to be replaced by types of vertical incisions. Among these disadvantages are the following. ;onsiderable lateral e'tension is re*uired to e'pose sufficient area at the surgical site. Bf sufficient lateral e'tension is not provided, the incision may tear at the edges during retraction and create areas that heal poorly and with considerable scar formation. Bf minimal attached gingiva is present, the flap may encroach on the sulcus depth of the teeth to the flapped. $ince the edges to be sutured are held apart during surgery, the healing is not as rapid as healing with other flaps and may result in considerable scar formation. Bf the lesion is larger than anticipated, the incision may end up being over the surgical defect. @hen the cuspid or ad<acent tooth is involved in the surgery, the cuspid eminence is violated by the incision. >his flap usually originates in or is placed in the mucogingival <unction, often leading to retarded healing and scar formation.

21

I+*&'(2&3+- for use of the semilunar incision are situations in which the contour and shape of the marginal gingiva must be preserved, as in patients with complete <ac&et crowns in the area or for use after periodontal surgery.

>his type of flap is '3+2$(&+*&'(2,* where deep periodontal poc&ets are present, where minimal attached gingiva is present, when a very large lesion is anticipated, and when other types of flaps are deemed to be more desirable.

Bt is especially important that the gingival sulcus of all teeth involved in a semilunar flap be e'plored with a periodontal probe before the incision is made. >he hori)ontal incision must be made a minimum of 2mm from the greatest sulcus depth. 2/V,$2&'() 5)(0- (Refer Fig.1) Although referred to as vertical flaps because of the vertical incisions made to aid in the raising of the tissues, these flaps are always made in con<unction with a hori)ontal incision. >he hori)ontal incision is usually placed in the gingival sulcus. ;utting the epithelial attachment around the nec&s of the teeth and across the interdental papillae develops this portion of the incision. @hen pushed bac& by a periosteal elevator, the gingival edge of the flap has a scalloped border. @hen periodontal surgery is to be performed in addition to the endodontic surgery a reverse

22

bevel may be used to remove the diseased gingival tissue around the nec&s of the teeth and to return more healthy tissue to that area during closure.

Bf one vertical incision is used, the flap is referred to as a -&+%), 4,$2&'() whereas the term *3#9), 4,$2&'() implies the use of two vertical incisions. >he vertical incisions greatly aid in the retraction of the tissue overlying the defect and have been recommended for use by periodontics. Bf the =chsenbein (ueb&e incision is considered to be a vertical type, which it truly is, vertical flaps have ta&en over almost completely as the most desirable type in endodontic surgery.

>he chief (*4(+2(%,- of vertical flaps are that are optimal healing usually occurs, since no edges of the flap are manipulated during surgery, and the visuali)ation of the surgical site is e'cellent because of the ma'imal uncovering of the area. Bn addition, any necessary minor >he

periodontal surgery may be performed at the same time.

*&-(*4(+2(%,- are that the gingival areas of many teeth are uncovered, the possibility of opening a dehiscence is present, careful flap design must be adhered to in order to avert having the base too small, and sharp corners may be present at the <unction with the hori)ontal portion of the incision.
2-

>he only '3+2$(&+*&'(2&3+ for the use of vertical flaps are the cases in which the shrin&age that may occur during gingival healing might lead to the uncovering of gingival margins of crowns of cases in which gingival tissues are still healing after periodontal surgery. Bf the possibility of a dehiscence is present, the gingival portion of the flap may be prepared to be a split thic&ness flap leaving the periosteum covering undisturbed. $ince vertical flaps are much more complicated o prepare and reflect than semilunar flaps, only those familiar with periodontal and surgical techni*ues should utili)e them during the initial attempts at endodontic surgery. As greater e'perience and confidence are gained, improved results may accrue with the use of the vertical flaps. Bn the typical flap double vertical incision are used when anterior teeth are treated. >he incisions are placed to the farthest edge of each tooth ad<acent to the tooth to be treated. Bf the defect is e'pected to be very large or if the terminal end of the incision would normally appro'imate an attachment to be avoided, the vertical incisions may be placed two teeth over from the surgical site. Bn the posterior areas, generally only one vertical incision is used, located mesially to the tooth one or two teeth anterior to the one to be treated.

24

Bn mandibular molars a scalloped incision is developed around the nec&s of the ad<acent teeth, e'tending anteriorly to the first bicuspid or cuspid in which a short, single vertical incision is placed to rela' the flap and aid in visuali)ation of the area of defect.

$ome vertical flaps suggested for use are designed with an e'tremely wide base compared to the edge of the flap. >his is to ensure that there will be sufficient blood circulating to all portions of the flap, which may be a problem if a vertical flap is not correctly designed. >he base e'tends the width of two ad<acent teeth, with two vertical incisions coming down at an obli*ue diagonal angle to the mesial and distal edges of only the tooth with the defect. Although this method does minimi)e the area of bone uncovered during the surgery, it may prove to be too restrictive if the bone defect is larger than anticipated. >his type of flap is often referred to as an envelope flap since it resembles the bac& of an envelope.

3. Palatal flaps (Refer Fig.1) >he use of a flap to retract the palatal tissues of the ma'illa may be needed in certain cases. >hese include reverse filling, perforation repair, apicoectomy or root amputation of the palatal root of a ma'illary bicuspid or molar, and perforation or resorption repair of the palatal surface of
2"

anterior teeth. As in any flap, all rules for flap design must be satisfied for best results. However, the rich vascular supply of the palatal area provides for e'cellent healing in most instances.

>he typical palatal flap is prepared with a scalloped incision around the gingival margins. Normally at least two teeth to the mesial and to the distal aspects of the tooth that is to be operated on must be included in the flap retraction for desirable visuali)ation. 6ela'ing

incisions are best placed between the first bicuspid and cuspid to diminished the change for severance of the palatal blood vessels and resultant hemorrhage problems. >he blood vessels from the incisive

canal and greater palatine foramen anatomi)e in this area are not as large as they are farther anteriorly or posteriorly. >he bone topography in the posterior area of the palate is inclined to be pebblier than the labial or buccal surface of either the ma'illa or mandible. >his ma&es periosteum elevation more difficult as the elevator stri&es humps or peduncles of bone during retraction. >he scalpel may be used to partially dissect the tissue for a modified split thic&ness flap in these cases. !ven with the mucosa retracted, e'amination of the surgical site with a palatal flap is difficult. !ven with assistance it is very

comple' to retract the flap, use a mouth mirror for visuali)ation of the area, and use a hand piece or hand instrument for preparation, curettage
2:

or filling. >herefore it is wise to obtain retraction by placing a suture at the edge of the flap and tying it tightly to the teeth on the opposite side of the arch. >his tissue on the opposite side need not be penetrated, but the suture material is merely tied around the gingival margin of the bicuspid or molar. @hen the surgery is completed, the suture is cut and routine replacement afforded to the flap.

. O!"sen#ein Lue#$e flap (Refer Fig.1) Ceveloped by a Periodontist and an !ndodontist, this flap has been designed to combine the advantages of the vertical flaps with those of the semilunar flaps. $ince the hori)ontal portion of this flap is placed a minimum of 2mm from the depth of the gingival sulcus, those gingival tissues covering <ac&et crowns or healing after periodontal surgery are unaffected. >he site of surgery has e'cellent e'posure and yet less tissue is reflected, since the flap does not e'tend to the marginal gingiva. >he e'act width of the flap may have greater variability, since the flap does not have to terminate at a particular edge of any tooth. >he edges of the flap are not manipulated during the surgeryE therefore the blood supply to the area of suture margins remains e'cellent. $uturing is easier than when the hori)ontal incision lies in the gingival sulcus. >here is no chance of opening a dehiscence.

27

>he main *&-(*4(+2(%, of this flap is that e'treme care must be e'ercised so no sharp points occur at the <unction of the vertical and hori)ontal incisions. >here are only a few '3+2$(&+*&'(2&3+- to this type of flap. Bf minor periodontal surgery is to be performed around the gingival sulcus, the double or single vertical incision is to be placed across a prominent eminence, vertical incisions avert the problem. Bf minimal attached gingiva is present, the hori)ontal incision may approach the mucogingival <unction.

2,

F&%/ 1/ F)(0 *,-&%+-

2.

F&%/ 2/ F)(0 *,-&%+-

>riangular tissue flap design with single vertical releasing incision. >he vertical releasing incision can be performed in different ways. !ither 3A5 the incision leaves the interdental papilla intact or 39E insert5 the incision includes the interdental papilla. Bn

6ectangular tissue flap design with double vertical releasing incisions. As with the triangular flap design, variations can be used with the vertical incisions 3A and 95E a

description has been included.

either case the incision line should meet the tooth at .#.

>rape)oidal tissue flap design. Note vertical releasing incisions are angled towards the base of the flap.

Hori)ontal tissue flap design. No vertical releasing incisions are used initially but they can be added later to enhance surgical access if necessary.

$emilunar tissue flap design. Note that the scope of this flap limits e'tension if necessary.

(ueb&e D =chsenbein 3$ubmarginal5 tissue flap design. >his flap may have one or two vertical releasing incisions, or may be limited to a hori)ontal incision, only if sufficient surgical and visual access can be obtained.

-#

TECHNIQUES OF ENDODONTIC SURGERY

I/ S#$%&'() D$(&+(%, $urgical drainage usually involves emergency procedures and acute lesions. 9oth re*uire patience in diagnosis and &indness in treatment.

I+'&-&3+ A+* D$(&+(%, (Refer fig.3) Bncision And Crainage 3B G C5 is the standard method to drain apical abscesses. Although the techni*ue is relatively easy, two problems always accompany an B G C. 2irst, is the problem of timingHthe optimal time to intervene. $econd is the problem of obtaining ade*uate local analgesia.

(earning the correct moment for surgical intervention is gained by e'perience. I*,())., the immediate area to be incised, the <03&+2,*= area should feel soft and fluctuant under the e'aminer+s fingertips. >he ape' of the swelling may appear whitish or yellowish. >his is the ideal time at which to anestheti)e, incise and drain.

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=btaining local analgesia is difficult because? 1. Bt is difficult to establish profound analgesia for an inflamed and abscessed area. 2.>here is some reluctance to in<ect into the area. Not only is it initially very painful to increase the fluid pressure by in<ecting into the region, but it is also unwise to ris& spreading the infection by the pressure of the in<ection.

=rder of operation after anesthesia is as follows? A. Arrange the instruments. 9. Place the gauge sponges to catch the flow. ;. $wab the area with disinfectant. C. >est the dept of anesthesia with the end of the swab stic&. !. Perform a sweeping vertical incision with a No?11 scalpel through the pointed area down to the bone and irrigate copiously with anesthetic solution. 2. Have assistant aspirate immediately. %. =pen the incised area widely by following out the tract with a hemostat. $pread the handles of the hemostat to separate the bea&s. 0ore irrigation with anesthetic solution washes out the to'ic elements and reduces remaining sensitivity.

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H. Place a />1 drain with the bar of the />1 inside the incision. Placement of a drain is optional because the initial epithelial and connective tissue bridging brea& down under moderate pressure. B. $uture the drain in position if necessary.

2igure -

2ig. -. Bncision and drainage of acute apical abscess. A. %ood level of anesthesia is established. 9. $weeping incision made. ;. $calpel carried through to bone. C. curved hemostat used. !. Positioning of /> drain1. 2. Bf drain not in place it may be sutured.

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TREPHINATION (Refer fig. ) >his surgical form is used to secure drainage and alleviate pain when e'udate in the cancellous bone is dammed up behind the cortical plate. >he tremendous pressure leads to the e'cruciating pain of an intraosseous acute apical periodontitis or apical abscess. >he intraosseous pressure can be released and the area decompressed through trephination, which provides a pathway to empty pus and other acid e'udates.

A mini vertical incision provides ade*uate access and landmar& visuali)ation. >he focal area of the lesion is pin pointed by e'amination. @or&ing through the retraction of the soft tissue, the overlying cortical plate of bone is grossly removed with No? , bur to identify the involved root ape'. >he bone is then penetrated at the ape' with a No?4 bur. Bn certain cases entrance can be made through the cortical plate with a file because of the resorptive activity of the periradicular lesion.

=ne must be careful to avoid structures, such as inferior alveolar nerve, mental foramen or the roots of non affected teeth in that area. A

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lead shot, a bro&en bur head, or a pellet of gold foil in the incision is an e'cellent way to pinpoint by radiograph the proper location for entrance. 2igure D4

2ig. 4. $urgical trephination of intact labial cortical plate.

II/ R(*&'#)($ S#$%,$. 6adicular surgery involves root structures and may be divided into apical surgery and corrective surgery. Apical surgery is a procedure designed to modify and curette the ape' and peri radicular tissues. 0ost cases re*uire filling of the root end following a - mm 3 5 apical resection. ;orrective surgery involves the repair of the perforated root structure per se.

2our basic steps are common to apical and corrective surgery, whether one stops at curettage or proceeds to perform an apicoectomy, a retro filling, a root repair, or a resection. Ade*uate flap design

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 !'posure of surgical site ;urettage of inflammatory tissue ;losure of the flap TECHNIQUES

1/ T7, 2>3--2,0 3$ 5&))&+% 5&$-2 1,273* 2/ P3-2-$,-,'2&3+ 5&))&+% 2,'7+&;#,

A. >wo Dstep or 2illing 2irst >echni*ue T>3 '(-,- $,;#&$, '(+() 5&))&+% 0$&3$ 23 0,$&(0&'() -#$%,$. 1. 2ailing case with a canal filling that may be removed. 2. A case where the need for surgery had become apparent during the course of routine therapy before the filling appointment.

R,2$,(21,+2? A heavy condensation techni*ue will give important additional information helpful during the surgery. $uch disclosures include? Position of apical foramen !'istence of significant lateral canals 6esorptive defects 9ifurcated canals

-:

 >he proper time for this filling is either immediately before the surgery or during the surgical e'posure.

!. P3-2-$,-,'2&3+ 5&))&+% 2,'7+&;#, ;urrently as a result of the reports of D3$+ (+* G($2+,$ (+* F$(+? ,2 ()6 one +3 )3+%,$ ,10)3.- (1()%(1 as a material for canal reverse filling.

In%i!ati&ns f&r Re'erse Filling 1. >eeth with clinical and/or radiographic symptoms and no negotiable canal. 2. Presence of a well fitting post and core that might cause root fracture during removal. -. Presence of a sectioned silver point. 4. Presence of an irretrievable bro&en instrument or filling material with lac& of apical seal.

Any of these situations may occur without clinical or radiographic evidence of damage being present

-7

(isa%'antages 1. >he time spent with the tissue reflected and bone uncovered is greater than with the two step techni*ue, since both canal filling and curettage are performed after the flap is opened. 2. $ince the degree of pain and edema is usually proportional to the time the flap is retracted, this method would appear to cause greater post operative problems. -. >he presence of blood from the per apical tissues can interfere with the condensation of the cones. 4. >he final filling is usually less dense, as there is no solid dentinal matri' to pac& against. ". >he additional information derived form viewing the radiograph of the canal filling is not available. :. $ince no rubber dam is placed, it is possible for the patients to taste any of the canal irrigants. 7. >he possibility of swallowing or aspirating a file or reamer is present.

A%'antages
1. >ime for total procedure is lessened because no immediate

disinfection is performed, no application of rubber dam is

-,

necessary, and no master gutta percha cones need to be verified radiographically.

2. Bt is easier to locate a difficult Dto

find ape', since a large

instrument may be placed through the canal and into the peri apical tissue as a landmar&.
-. Bf an instrument or filling material is bro&en off in the apical

portion of the canal or partially into the per apical tissues, the fragment may be surgically removed before canal filling.

R,134() 35 *&-,(-,* -352 2&--#, 80,$&-$(*&'#)($ '#$,22(%,: (+* !&30-. >his procedure can often be performed before or in con<unction with root end resection. >he purpose is to remove the bul& of the soft tissues, which may be present at various root canal orifices on the root surface. >his adverse tissue response has been described as reactive or protective. >herefore, omitting to remove every remnant of soft tissue will not lead to failure, as the tissue elements in the periphery of these lesions are often productive in nature and contain fibroblasts, vascular buds, new collagen and bone matri'. Bn those cases in which the soft tissue mass is e'posed upon flap reflection or initial bone removal upon flap reflection, curettage can proceed prior to root end resection. Bn other cases resection is necessary to gain access to most of the tissue.

-.

$traight and angled surgical bone curettes are necessary, along with angled periodontal curettes. At times it may be necessary to in<ect #." ml of anesthetic solution to control haemorrhage and ensure patient comfort if the lesion is e'tensive. Bnitially the bone curettes are used to peel the soft tissue from the lateral borders of the bony crypt. >his is accomplished with the concave surface of the curette facing the bony wall, applying pressure only against the bone. ;are must be ta&en to avoid penetration of the soft tissue, which may share the tissue, server the vascular networ&, and increase local haemorrhage. =nce the tissue is freed along the lateral margins, the bone curettes can be turned and used in scraping fashion along the deep walls of the crypt. >his will detach the soft tissue from its lingual or palatal base. =nce loosened, tissue forceps are used to grasp gently the tissue, which is teased from its position with a bone curette. >he tissue sample is placed directly into a bottle of 1#F neutral buffered formalin for biopsy. Bn those cases, which re*uire root end resection prior to curettage, one must ma&e sure that the root structure is sufficiently e'posed to minimi)e shredding of the soft tissues during resection.

Bn the presence of large lesions, care must be e'ercised during curettage of the lateral surfaces of the bony crypt to avoid e'posure of ad<acent roots and their pulpal vasculature. Pre surgical radiographs

4#

should reveal this possibility, and tissue in these areas may need to be left in position. ;aution must also be e'ercised when close to the ma'illary antrum, mental foramen or mandibular canal to prevent damage to vital structures. @hen soft tissue is adherent either lingually to the root or in the furcation region, periodontal curettes are essential for thorough removal. @hilst retention of root structure is necessary for tooth stability and strength, rarely should peri radicular surgery be limited to <ust curettage. >herefore root end resection is usually needed.

APICOECTOMY (Refer fig.)) >he term root end resection refers specifically to the removal of the apical portion of the root. >here are many indications for resection of the root end during peri radicular surgery, each designed to eliminate aetiological factors and to enhance the sealing of the root canal at the resected root surface. >hese indications vary from case to case, but support the stated purpose.

S.+%'#? K&1 used the H!$$ model of root anatomy to find out the incidence of lateral canals and apical ramifications when resection was performed at 1, 2 and - mm. >he incidence of lateral canals was found to be "2, 7, and .,F respectively.
41

Intil early 1..#+s bevel angle of 4" was taught in all schools of dentistry with the following reasons for its use. 1. %ain visual and operating access for root tip resection, 2. !ase of placing retrofilling materials, -. !ase of inspection. Bn recent years 4" bevel angle was found to have no biological basis. 6esection at .# was found to eliminate .,F of the apical

ramifications and .-F of lateral canals. Hence root resection must be done perpendicular to long a'is of the root whenever possible. However, a 1# bevel is allowed where perpendicular bevel may not be possible.

M(--&13 G(%)&(+& ,2 () 81998: evaluated the apical root resection angle and cavity made by ultrasonic retrotips and its influence on apical seal, >hey found that .# angle showed less dye lea&age for dentin than 4" angle and that a -mm or more apical cavity produces a safe and effective seal.

>he ideal root end preparation according to P,2,$ G&))7,(+. and associates should be? Parallel to the long a'is of the root,

42

 - mm deep and centered.

>he optimum depth of the retrograde cavity should be -mm, because as the depth increased the lea&age decreased. >his was attributed to the occlusion of the apical tubules by the retrofilling material 8M(--&+3 G(%)&(+&,2 () 1998:. >he root end can be resected and beveled tin one of two ways. =nce the root end has been e'posed, the bur 3narrow or constringe5 is positioned at the desired angle and the root is shaved, beginning from the ape', cutting caronally. >he bur is moved from mesial to distal at the desired angle, shaving the root smooth and root outline. >he approach allows for continual observation of the root end during cutting.

>he second techni*ue of resection is to predetermine the amount or root end to be resected. >his approach, however, may remove more root structure than is necessary. >he bur and hand piece are positioned at the chosen angle and cutting through the root from mesial to distal resects the ape'. =nce the ape' is removed, the root face is gently shaved with the bur is smooth the surface and ensure complete resection and visibility of the root face. >his techni*ue wor&s well when an apical biopsy is desired or to gain access to significant amounts of soft tissue located lingual to the root.
42ig. ". >wo ways of performing apicoectomy

2igure D "

>he appearance of the root face following root end resection will vary, based upon the type of bur used, the e'ternal root anatomy, the anatomy of the canal system e'posed at the particular angle of resection, and the nature and density of the root canal filling material. 8arious types of burs have been recommended for root end resection, such as round burs, straight fissure burs, diamond burs, and cross cut fissure burs. !ach will leave a characteristic anatomical imprint on the root face from rough grooved and gouged to regularly grooved and smooth. >o date, no study has clearly defined the advantages of one type of bur over the other, although for year+s clinical practice as favoured a smooth flat root surface.

>he e'tent too which the removal of the root end should occur will be dictated by the following factors. Access and visibility to the surgical site.

44

 Position and anatomy of the root within the alveolar bone. Anatomy of the cut root surface relative to the number of canals and their configuration. Need to place a root end filling into sound root structure. Presence and location of procedural error, e.g. perforation. Presence of an intra alveolar root fracture. Presence of any periodontal defects. Anatomical considerations, e.g. pro'imity of ad<acent teeth, or level of remaining crestal bone. Presence of significant accessory canalsE roots with such anatomical aberrances would be li&ely to receive more e'tensive resection.

=nly when - mm of the ape' is resected are lateral canals reduced by .-F. Additional resection reduced the percentage insignificantly. A root resection of - mm at a # degree bevel angle removes the ma<ority of anatomic entities that are potential causes of failure. Any remaining lateral canals are sealed during retrograde filling of the canal. >herefore removing the ape' beyond - mm is of marginal value and compromises a sound crown / root ratio.

4"

6egardless of the rationale for the e'tent of root end removal, there is no reason to resect to the root to the base of a large peri radicular lesion, as was previously advised. (i&ewise, resection to the point where little 3J1mm5 or no crestal bone remains covering the buccal aspect of the root may very well doom the tooth to failure. =n the other hand, failure to remove sufficient root structure to be able to inspect the resected root surface and establish an apical seal may also contribute to failure. Bn this case, root canals may be missed, or they may be so e'tensive that they cannot be properly managed within the confined space.

>he complete root face must be identified and e'amined subse*uent to resection. >he e'amination is done with a fine, sharp probe, e.g. C% 1:, guided around the periphery of the root and the root canal. >he e'ternal root anatomy will determine the ultimate shape of the cut root end, ad oval, round, dumbbell shaped, &idney shaped, or teardrop shaped. =utlines will vary depending on the tooth, angle of the bevel and position of the cut on the root. =nce cut, however, the entire surface must be visible. Bf visibility or access is impaired, or the root possesses an unusual cross sectional outline, 1F methylene blue dye can place on the root surface to help identify the periodontal ligament that surrounds the root. A small cotton pellet containing dye is wiped over the root face for " 1#s. $ubse*uently the area is flushed with sterile water or saline.
4:

>he dye will stain the periodontal ligament dar& blue, highlighting the root outline. A potential drawbac& to the techni*ue may be deposition of cotton fibres on the resected surface or on bone. 6esidual remnants of cotton fibres have been shown to induce a foreign body reaction in healing tissues.

>he shape of the e'posed canal system will very depending on the angle of the bevel and the canal anatomy at the level of the cut. ;anal systems will generally assume a more elongated and accentuated shape as the angle of the bevel is increased buccally. =ften, canal systems will be irregular and e'tend further than anticipated.

Also visible on most resected root ends is the presence of the root canal filling material. 8ariations in *uality of the filling will be seen in both type of filling material, e.g. gutta percha, silver cones, pastes, and the nature of the obturation techni*ue, e.g. lateral condensation, vertical condensation or thermoplastic filling. (i&ewise, the different burs

advocated for resection will create discrepancies in the surface of the filling material and adaptation to the canal walls. 2or e'ample ;oarse diamond burs will tend to rip and tear at the gutta percha root canal filling, spreading the gutta percha over the edge of the canal aperture and
47

onto the resected root face. Bnvariably this will create gaps between the originally adapted gutta percha and the root canal wall. $imilar findings are noted with metal burs. Bn order to prevent this, surface finishing with an ultra fine diamond is recommended.

2igure D :

2ig. :. A. ;leaning and shaping of the root canal with file tips through the resected root end. 9. ;ondensation of the gutta percha filling with the tip through the root end. ;. 6emoval of e'cess filling material and finishing of the root surface with an ultrafine diamond bur.

>he presence of additional foramina anatomi)es between foramina, fracture lines and the *uality of the apical adaptation of the root canal filling must be chec&ed on the resected root surface. Bf methylene blue has been used, it will also have a tendency to stain the periphery of the canal system and highlight fracture lines. Nitromersol, a dental

disinfectant which strains reddish brown, can also be used when e'amining the root face or a fibreoptic light can be aimed at or behind the
4,

root end to enhance visibility. Bf these methods do not wor&, it may be necessary to remove additional root structure to identify the canal system or, in the case of a fracture line, to enhance its direction and e'tent.

A ma<or area of concern following root end resection and dentinal tubule e'posure is the possibility that these tubules may serve as a direct source of contamination from un cleaned root canals into the peri radicular tissues, especially if there is coronal lea&age. 6oot ends

resected from 4"o to :#o have a many as 2,### tubules/mm2 at a point immediately ad<acent to the canal. At the dentinocemental <unction, an area which may communicate with the root canal even in the presence of a root end filling, an average of 1-### tubules/mm 2 are found. (i&ewise, due to angular changes in the tubules at the ape', there could be patent communication with the main canal if the depth of the root end preparation the buccal aspect of the cavity is insufficient to compensate for these anatomical variations. 6oot end resections in older teeth have shown less lea&age than that seen in teeth from younger patientsE this corroborates the findings of sclerosis and reduced patency in apical dentinal tubules. Bt has been suggested that, if the apical ramifications commonly found in young teeth are dismissed as a rationale for root end resection, then resection would be inadvisable due to the patency of the apical dentinal tubules.
4.

Another concern following root end resection is the presence of a contaminated smear layer, containing tissue debris and possibly microorganisms, over the resected root end. >his may serve as a source of irritation to the peri radicular tissues, primarily preventing the intimate layering of cementum against the resected tubules. ;utting usually

creates a thic&er smear layer without water spray than with a heavy air water spray, or by using coarse diamond burs than tungsten carbide burs. >herefore it is recommended that root end resection be performed under constant irrigation, which assists the partial removal of the dentinal smear layer from the surface. Also, if diamond burs are used to resect the root, medium grit is preferred, followed by a fine or ultra fine grit diamond. Bf there is a gutta percha root canal filling, resection without irrigation should be avoided as it may promote the lodging of dentine chips in the gutta percha, which would serve as a source of irrigation if contaminated. >hese chips may not be removable during the elimination of the smear layer with a dentinal cleanser.

ROOT END CAVITY PREPARATION (Refer fig.*) 8arious instruments are being used for retro preparation li&e 1. ;onventional slow speed handpiece, 2. Hi speed handpiece,
"#

-. Iltrasonics and 4. $onics.

;onventional slow speed handpiece and burs are bul&y to handle, re*uire e'cessive removal of bone and tooth structure and can result in shallow misaligned cavities.

>he ideal root end preparation suggested by C37,+ should be 11 deep and centered.

=ne of the advancements in endodontic surgery that allowed greater efficiency was the adaptation of pie)oelectric ultra sonic for root end preparations. Iltrasonic tips are available in various configurations 3Analytic !ndo, $atelec / Amadent ;o. and $partan / =btura ;o.5 to accommodate virtually all access situations. $pecially designed tips

produce smooth cutting with relatively little chatter when the tips are activated against the dental walls of the apical preparations. >hese micro tips are very a narrow in diameter 3i.e., about one teeth the si)e of a conventional micro head hand piece5.

>he first ultrasonic tips for endodontics and endodontic surgery were the ;> tips made of stainless steel 3$$5 and designed by Cr. %ary
"1

;arr. >hey were first available in early 1..#. >he ;> tips were the most popular tips and have been widely used until recently. Bn 1..# Ki$ tips were introducedE these provided improvements in many areas, including cutting efficiency by coating the tip with )irconium nitride, more convenient angles, and relocation or irrigation port. Bt shows a

comparison of the two tips? the ;> tips are short more angled than the Ki$ tip. >he location of the ultrasonic irrigation port, which is on the tip rather than on the shaft, delivers ma'imum irrigation volume directly into the cutting site. Ki$ tips are also different from ;> tips in terms of shaft angle, tip angle and length.

Bn summary, the advantages of ultrasonic tips over micro head burs are? 9etter access, especially in difficult to reach areas 3e.g., a lingual ape'5 0ore through debridement of tissue debris. ;onservative preparations tracing the long a'is at a precise depth of - mm. Precise isthmus preparations with parallel canal wall for better retention of filling materials.

"2

6oot !nd Preparation is accomplished under the microscope at low to mid magnifications 34 1: 5. 2irst, a number of appropriate tips are pre selected, depending upon the location of each ape'. $econd, the resected root surface, stained with methylene blue, must be critically e'amined at high magnification 31: to 2" 5 to see the microanatomy. >hird, at low magnification 34 to : '5, the selected ultrasonic tip is positioned parallel with the long a'is of the root. >o accomplish this the surgeon must e'amine the position of entire tooth at low magnification 34 5, including the crown and root eminence and compare this with the position of the ultrasonic tip. 2ailure to ma&e this comparison will ris& an off angle root end preparation or perforation. 2ourth, the ultrasonic tip is activated and the apical canal is retro prepared with copious water coolant to a depth of - mm. Bf an ultrasonic tip is pressed too firmly it is dampened to deactivation, thus a light sweeping motion using short forward and bac&ward and up and down stro&es is all that is needed for effective cutting action. Cepending on the canal configuration, a typical - mm retro preparation should ta&e less than 1 minute with Ki$ tips.

=nce the retro preparation is completed, the cavity preparation is inspected with a micro mirror at high magnification of 1: to 2" . A thorough inspection should include the interior canal walls for remnants

"-

of gutta percha, especially on the difficult to reach facial wall, and confirmation that the parallel walls are sharply defined and smooth.

2B%7

2ig.7. 6oot end cavity preparation

TYPES OF PREPARATION >wo types of preparations have been in routine use for some timeE the C)(-- I (+* 27, -)326 3$ M(2-#$(6 2.0,/ An additional preparation also has been described and is referred to as the 5&%#$, ,&%72 2.0, 35 $,4,$-, 5&)) 0$,0($(2&3+/

9efore any preparation is begun, the root to be reversing filled must be beveled. Placing a filling in an un beveled ape' is similar to placing a filling at the point of a pyramid. No flat table would be present to pac& against, and the filling material would merely fall down the sides and not seal the tip. Ising a fissure bur in the airotor or straight hand piece and cutting the root tip from mesial to distal surface at appro'imately a 4" degree obtain beveling on the tooth, allowing for
"4

visuali)ation of the entire root face. >eeth that have a palatal or lingual inclination may re*uire a greater angle of beveling for ease of preparation and filing placement.

9eveling of the root tip may be accomplished without significant reducing root length and thus retaining almost the same crown root ratio. Bf the crown root ration is highly unfavorable, but the strategic importance of the tooth warrants its retention, the slot preparation should be made, which re*uires little, if any root length reduction. After beveling, the outline of the root face will have one of two configurations, either oval or figure eight. >he most common shape will be a slightly irregular oval, with the canal having a smaller oval shape in the appro'imate center. >he ideal reverse fill preparation for this shape is similar to the typical ;lass B occlusal amalgam preparation of operative dentistry, only in miniature. Bt is prepared by using a no--L bur or ultrasonic tip down into the canal for a minimum of 1mm but preferably at least 2 to - mm. Bt is important to remember that the bevel of the root face is at appro'imately 4" degrees and that if the preparation is made with the bur perpendicular to the root face, there is a good chance for perforation of the root lingually. >herefore the bur must come down along the long a'is of the tooth and remain within the confines of the canal while the preparation is made. Bf insufficient room is available to
""

come down the long a'is, greater beveling of the root face or removal of periapical bone should be performed. Bf this is not desirable, the slot preparation should be utili)ed.

>he other root face configuration developed after beveling is the figure eight shape with a long oval or slot canal in the center. >his shape may be found when two canals are present in one root of a tooth, such as the mesio buccal root of a ma'illary first molar, ma'illary and mandibular bicuspids and mesial roots of mandibular molars and mandibular anterior teeth. @hen these roots have one canal in one root, the configuration of the root face after beveling will be oval.

>he proper preparation for teeth having one root and two canals is the figure eight preparation. A no.--L bur or ultrasonic tip is used and two round but touching preparations are made, with care ta&en to &eep the bur along the long a'is of the root. >his type of preparation should be made in any one rooted tooth when it is suspected that two canals may be present, even if only one canal was previously filled.

T7, 27&$* 2.0, of preparation is the slot type, also referred to as the 0astura preparation, from the name of its early advocate. >his should be used where it is inconvenient to utili)e the other types of preparations
":

that involve access along the long a'is of the tooth. >he slot preparation is made with the bur used perpendicularly to the long a'is of the tooth and re*uires much less tooth and / or periapical bone removal. >he most common needs for the slot preparation are in those teeth where removal of root structure will lead to an inade*uate crown root ratio or removal of periapical bone sufficient to gain access will infringe on ad<acent vital structures. !'amples of the latter are ma'illary bicuspids and molars near the ma'illary sinus, mandibular molars near the mandibular canal, and ma'illary anterior teeth near the nares. Bn addition, teeth with palatal or lingual inclinations, such as ma'illary lateral incisors and mandibular anterior teeth, may be easier to prepare and fill by using the slot preparation.

>he preparation is made by using a no.7## bur in the straight hand piece or airotor ma&es the preparation. $tarting at the ape' of the tooth, the bur is brought toward the cervical margin appro'imately 2mm, leaving a trough of tooth structure missing. >hen a no.--L of -" burs or ultrasonic tip is used to sharpen the corners of the preparation to afford undercuts for the retention of the filling material. @hen a slot

preparation is used, much less root face beveling is re*uired, since the retention is obtained in the undercut areas near the base of the preparation.
"7

M&'$3-1&$$3$=ne of the &ey instruments in microsurgery is the micro mirror. >he reflective surface is made of either highly polished stainless steel or sapphire. >he mirrors are small enough to fit into an osteotomy

measuring no larger than 4 to " mm in diameter. Bnspection of root ends cannot perform thoroughly without the aid of micro mirrors. >he

anatomy of the root surface is reflected in the micro mirror into the viewing range of the microscope before and after the retro preparation. INSPECTION OF THE ROOT END PREPARATION 2or depth of field purposes, the root end is best prepared that low to mid magnification 3, to 12 5. However, the preparation must be inspected at high magnification 31: to 2" 5. Incommonly, retro preparations can also be inspected by direct view. Bn addition to

e'amining the completed preparation for clean, sharply defined walls, it should also be e'amined one last time for important anatomic structures 3e.g. accessory canals, micro fracture5 that may have escaped detection during the initial inspection.

",

DEPTH OF THE ROOT END PREPARATION >he optimal depth of the root and preparation should be -mmE however, depths of 1,2 and 4 mm have also been studied. Ising the Hess model slides provided by Cr. N. Perrini, the incidence of lateral canals and apical ramifications in the natural ape' have been studiedE over ."F of these anatomic entities are found within the apical - mm. Although a retro preparation deeper than - mm does not provide any greater benefits, a retro preparation shorter than - mm may <eopardi)e the long term success of the apical seal. >he management of the apical : mmE - mm root resection perpendicular to the long a'is of the root and retro preparation and retro filling of - mm parallel the long a'is of the root. !ach is essential to ensure an ade*uate seal of the root ape'. ROOT END CAVITY O!TURATION >o clean and obturate the root canal before root end resection or to do it at the time of surgery has been controversial for many years. $ome authors have found greater success when the canal is obturated in con<unction with surgery, less often when a previous root canal filling was left in place, and least often when the canal was filled immediately prior to surgery. =n the other hand a better prognosis has been identified when the root is cleaned and filled prior to surgery. 2avourable results with root canal obturation either before or during surgery have been demonstrated. Bn a recent evaluation of the surgical management of non
".

surgical endodontic failures, cleaning, shaping and obturation of the root canal prior to surgery resulted in the highest rate of success. Bn the cases that could be managed this way the root end was not resected, and surgical procedures were limited to curettage. ;ases in which root end resection was performed and root end filling placed resulted in a higher number of failures. @hat is important is that the canal system is cleaned and sealed as well as possible. Bn many respects this necessitates that old root canal fillings should be redone as well as possible. Inder these circumstances many cases may be successful without the use of a root end filling.

Bn some cases in which a radiolucency e'ists and time is a factor, or cases in which there are persistent e'acerbations between visits or failing root canal treatment which has been treated non surgically in an assumed optimal manner, canal re preparation and refilling can be done at the time of surgery. A tissue flap is reflected, the root ape' e'posed and resected. >he canal preparation is performed with the file tips

protruding through the resected root end. $mall aspirators can bleached ne't to the apical opening to present root canal irritant 3#." 2."F sodium hypochlorite5 entering the bony cavity. After ade*uate preparation, the canal is dried with paper points. =bturation should allow with gutta
:#

percha and sealer condensed from the coronal access apically.

Any

condensation techni*ue is acceptableE however, the master gutta percha point should not be pulled through the ape', as point retraction may occur. >he e'cess gutta percha can be removed with an ultra fine bur, which usually creates a well adapted root canal filling on the resected surface. Bn these situations the placement of a root end filling will >his is common with gutta percha fillings,

usually be unnecessary.

especially those placed immediately before or at the time of surgery. An ultra fine diamond bur can be run over the root surface with a sterile water or saline spray. Bf the canal is properly obturated the result will be a very smooth, well adapted root canal filling. Paste fillings acceptable because of fre*uent voids, the irritating nature of most pastes and the potential for paste dissolution. 0etal fillings 3e.g. silver points5 are also unacceptable because of poor adaptation and the potential for corrosion.

@hen a root end cavity is to be obturated it must be isolated to ensure moisture control. >his is usually done with a haemostatic

collagen based agent, such as Hemofibrine or Hemocollagene, which can remain in the osseous cavity or be removed prior to closure. Also used is a solution of ferric sulphate, which must be removed from the bone cavity prior to tissue closure.

:1

Presently there are no commercially available materials, which will provide a perfect seal, therefore the materials that are used must be carefully prepared and placed to ensure the best possible adaptation to the root cavity walls. ;oupled with the attempt to seal the apical end off he canal system, attention must also be directed to the coronal end. Bt is illogical to place a filling material, which is imperfect at the root end of the tooth and neglect the potential for coronal lea&age around root canal fillings, and coronal restorations with carious lesions, imperfect margins, or through e'posed dentinal tubules in the cervical area.

2igure ,

2ig. ,. $tep by step procedure of apical surgery. A. Pen grasp of scalpel is used to ma&e vertical incision. 8ertical and hori)ontal incisions of scalloped flap have been made and flap is retracted. ;. $harp curette is used to test density of cortical plate. C. Bf cortical plate is solid M , bur is used. !. Bnflammatory tissue and bone are probed with :2 sharp curette. 2. Cebridement of inflammatory tissue done, ape' is beveled and lesion irrigated. %. 6etro preparation with ultrasonic tips. H. Amalgam placed. B. 6adiograph ta&en sutures placed.

ROOT END FILLING MATERIALS 0aterials used? %utta percha, %oldfoil, Amalgam, Poly

carbo'ylate cements, Ninc o'ide eugenol paste, Cia&et, ;avit, $uper !9A ;ement, 0ineral trio'ide aggregate, 9one cement etc. =ne of the ma<or re*uirements of an ideal retrofilling material is its close adaptability to the cavity walls of the retro preparation. However, when non adhesive materials are used for apical sealing, a microscopic space always e'ists between the restoration and the tooth interface, which leads to microlea&age 8M T3$(9&+,@(* 1995:/ 1.:2, Nicholls showed preference to )inc o'ide eugenol cements, but these cements showed increased solubility and tissue irritation 8P(#) D !$,+2 ,2 1999:. $uper !9A was introduced by 3.+&'? (+* 3.+&'? &+ 1978 the strength of mi'ture.

:-

 $tudies 8F$(+? A V,$2#''& ,2 () 1986: showed that the tissue response to super !9A in replanted teeth was less severe and less e'tensive when compared to amalgam. >his was attributed to the antibacterial action of eugenol, which may account for the success of endodontic surgery by &illing the bacteria 8A R(&+>(2,$ ,2 () 2BBB:/ Adhesion to dentin is an interesting property of glass ionomer cement and therefore it has been advocated for use as a rootend filling material. $everal studies 8K(1$(+ S(5(4& ,2 () 1999: have shown superior biocompatibility, fluoride release and marginal adaptation of glass ionomer cements and hence it has been incorporated in this study. 6ecently newer materials li&e M&+,$() T$&3C&*, A%%$,%(2, (+* !3+, ',1,+2 have been used for retrofilling. 0ineral >rio'ide Aggregate has been proven to be biocompatible, have good sealing ability, dimensionally stable, insensitive to moisture and promote tissue regeneration. T3$(9&+,@,* ,2 () 1995 reported that 0ineral >rio'ide Aggregate lea&ed significantly less than all the other materials li&e Amalgam, B60 and $uper !tho'y 9en)oic Acid.

:4

MTAD I+*#',- 3-2,3%,+,-&- (+* ',1,+23%,+,-&-/ $tudies showing Amalgam causing more microlea&age ? 6ichard 0 0oodni& et al 31.7"5, Oames >. Kimura 31.,25, $atoshi Bnoue et al 31..15, 6ahmat A 9ar&hordar et al 31.,.5. =thers studies also

suggesting the same? Oohn C 9ramwell and 0 ( Hic&o 31.,:5

$tudies suggesting 0>A to be superior? 0ahmoud >orabine<ad et al 31.."5 several studies, Oames C Kettering and 0 >orabine<ad 31.."5, >orabine<ad and > 6 Pittford 31..:5

$tudies suggesting %B; to be superior? Noriyasu Hosoya et al 31.."5 than amalgam and heated gutta percha.

$tudies suggesting $uper !9A to be superior? Oohn > 9iggs et al 31.."5 better than amalgam

F$(+? G,$7($*- (+* E&)5$&,* E(%+,$ 81996:D Harvard cement, Cia&et, %old leaf, Ketac !ndo and, amalgam in human teeth. Ketac !ndo showed significantly less lea&age compared with amalgam. Harvard

cement and gold foil showed more lea&age than amalgam and was no significant difference between Cia&et, Amalgam, %old foil and Harvard cement.
:"

P3-230,$(2&4, $(*&3%$(07&' (--,--1,+2 As previously indicated, a postoperative radiograph should be ta&en before closure of the surgical site. 0ista&es can be rectified and procedures altered more easily at this point. Bn some cases, especially posterior teeth, several angled radiographs should be considered. 6adiographs ta&en with specific film holding devices are preferred. @hen review e'amination radiographs are ta&en with the same device, healing can be assessed more accurately. $ome points for the clinician to consider are ? 1. Bs there scattered radiopa*ue material within the surgical siteA 2. Are the correct root ends surgically obturatedA -. Co the root end fillings appear ade*uate in depth and adaptionA 4. Are the fillings well condensedA ". Bs there un resected root structure, or have the wrong roots been inadvertently damagedA :. Has root end filling material been pushed into the ma'illary sinus or mandibular canalA 7. Bs there a fracture visible that was not seen clinicallyA

::

CORRECTIVE SURGERY ;orrective surgery is categori)ed as surgery involving the correction of defects in the body of the root other than the ape'. @hen the coronal and middle thirds of the root are involved, it is imperative to physically observe, diagnose, and repair the defect. A full flap, such as the single or double vertical design, must be utili)ed to gain ade*uate vision and access. 6eparative defects of the root and associated

procedures are classified as follows? B. Perforation repair A. 0echanical 9. 6esorptive BB. Periodontal repair A. %uided tissue regeneration 9. 6esection

PERFORATION REPAIR M,'7(+&'()/ Perforations generally occur when the dentist is disoriented as to the direction of the bur and its relationship to the anatomy of the pulp chamber or root. High potential areas for perforations are the furcal floor of molars and two rooted ma'illary premolars roots that are narrow mesiodistally and broad bucco lingually with curved canals.
:7

/$tripping1 of a canal is the overcutting of root structure resulting in a longitudinal opening that can all too easily occur on the furcal surface of mandibular molars or any narrow root. >his lesion is often caused by overwidening a canal orifice through aggressive use of Peeso or %ates %lidden drills. Bf the perforation that occurs at the present appointment is small and the bleeding is well controlled, the root canal filling can be condensed as the seal. 9ecause large strippings are usually surgically inaccessible, a hemisection where restoratively indicated may save the case.

0idroot and apical third perforations should be immediately sealed if possible, or calcium hydro'ide should be used prior to sealing. Bf the perforation is e'cessively large or long standing, a full vertical flap should be reflected and the area repaired with $uper !9A. Bf the location of the perforation is near the root ape', an apicoectomy is a more effective and efficient way of handling the case.

R,-3$02&4, !ventual repair of a defect on the root surface, from either internal or e'ternal resorption, depends to a large part on whether there is complete communication from the pulp to the oral cavity. Bf the lesion
:,

has destroyed an area of the root into the periodontal structures, but has not communicated with the oral cavity, it can generally be repaired by placing calcium hydro'ide into the cleaned and prepared root canal to promote cementogenesis. =ne should e'pect new cementum and bone repair to follow, and finally the internal and e'ternal defects may be obturated by non surgical root canal filling alone.

Bn the event cemetogenesis and new bone formation do not occur to serve as a matri' for the internal filling of the canal and defect, or in the event the lesion has bro&en through to communicate with the oral cavity and will not respond to cementogenesis, corrective radicular surgery is in order.

P,$&3*3+2() R,0(&$ G#&*,* T&--#, R,%,+,$(2&3+ Bn the past, e'tensive periodontal defects re*uired e'traction or root amputation. >oday, with techni*ues of guided tissue regeneration, many teeth can be saved without root resection. >his concept is based on an inert barrier membrane, such as %orete', providing the retention of blood clot in a relatively undisturbed environment of the walled off
:.

periodontal poc&et. >his allows the local undifferentiated cells of the periodontal ligament and surrounding bone to form new bone that bridges across the surgical wound with the potential of forming a new periodontal attachment, thereby bloc&ing the down growth of epithelial migration. Bn the event this procedure proves ineffective, the root severely involved in periodontal disease may have to be amputated.

R332 A10#2(2&3+ 6oot amputation procedures are a logical way to eliminate a wea&, diseased root to allow the stronger to survive, whereas if retained together they would collectively fail. $elected root removal allows

improved access for home care and pla*ue control wit resultant bone formation and reduced poc&et depth. I+*&'(2&3+ 53$ R332 A10#2(2&3+ 1. !'istence of periodontal bone loss to the e'tent that periodontal therapy and patient maintenance do not sufficiently improve the condition. 2. Cestruction of a root through resorptive processes, caries, or perforations. -. $urgically inoperable roots that are calcified, contain bro&en instruments, or are grossly curved. 4. >he fracture of one root that does not involve another.
7#

". ;onditions that guarantee that the surgery will be technically feasible to perform and that give evidence for a reasonable prognosis. >eeth that do not fit these criteria are contraindicated for root amputations.

;ontraindications for 6oot Amputation 1. >eeth not strategically located. >hese teeth are better served with a bridge. 2. (ac& of necessary osseous support for the remaining root or roots, inade*uate root structure, or a poor crown? root ratio. -. 2used roots or roots in unfavorable pro'imity to each other. 4. !ndodontically inoperable roots. ". (ac& of patient motivation to effectively clean and maintain the furcal areas and follow through with proper restorative procedures. >wo different approaches to resection are available. =ne approach is to amputate hori)ontally or obli*uely the involved root at the point where it <oins the crown, a process termed root amputation. >he other approach is to cut vertically the entire tooth in half from mesial to distal in ma'illary molars and premolars, and from buccal to lingual in mandibular molars removing in either case the pathologic root. >his procedure is termed 7,1&-,'2&3+/

71

9isection or /bicuspidi)ation1 refers to a division of the crown that leaves the tow halves, yet forms a more favorable position for the remaining segments that leaves them easier to clean and maintain. Bf the remaining roots are too close to each other, minor orthodontic movement may be necessary to property align them.

A10#2(2&3+ T,'7+&;#, 53$ M(+*&9#)($ M3)($>reatment planning is critical when evaluating mandibular molars for root removal. Bf it is not a terminal tooth in the arch, and there are sound ad<acent abutment teeth, a fi'ed bridge may be <ust as satisfactory, and possibly stronger and more economical. $ome outstanding

successes, however, are seen involving three unit bridges. Anatomically, the mesial and distal roots are about the same length. >he mesial root is slightly wider bucco lingually, more curved, and its cross section appears as a figure eight.

Hemisection is the most common method of removing a pathologically involved mandibular molar root. A terminal second

mandibular molar is ideally suited for hemisection provided there are opposing teeth. >he remaining root and crown structure is then restored as a premolar.
72

>echnically, the preparation procedure is the same as that for the ma'illary molars. >he roots to be retained undergo endodontic therapy, and the pulp chamber is filled with amalgam. No filling material needs to be placed into the root to be removed, for that entire half of the tooth will be e'tracted.

A sharp cowhorn e'plorer or periodontal probe is used to identify the buccal and lingual furcations. 9y first placing the tip of a high speed tapered fissure bur 3No. 7#2 P(5 in the furcation, the operator can effectively section the molar with accuracy. $ufficient pro'imal furcal floor should be left to establish a restorative finish line, as well as sufficient crown for retention. Again, the sectioning is done at the

e'pense of the part to be e'tracted. ;are must be e'ercised not to gouge the remaining stump.

An elevator should be wedged between the two halves and slightly rotated to determine if the separation is complete. >he pathologic half is then e'tracted with forceps or eased out with an elevator. >he soc&et area is lightly curetted and pac&ed with bone wa' or gel foam while the remaining hemisected half is trimmed and smoothed with a blunt tapered

7-

diamond. >he pac&ing should be removed from the soc&et and followed by copious irrigation and debris removal with a 21 ' 21 gau)e sponge.

9isection or /bicuspidi)ation1 is successful in molars in which periodontal disease has invaded the bifurcation. >he type of cut is the same as that used in hemisecting, e'cept the location is centered to evenly divide the crown at the center of the furcation. >he furcal is then turned into an interpro'imal space where the tissue is more manageable by the patient.

$ingle root amputation in the mandibular arch may on occasion be indicated where a splint or bridge is in place. 2or the most part, however, an uneven e'ertion of occlusal forces tends to e'ert a force on the remaining root, thereby causing a fracture. $ome cases are treated

successfully by single root amputation, and when economic factors dictate, it is indicated.

REPLACEMENT SURGERY R,0)(+2 S#$%,$. - I+2,+2&3+() R,0)(+2(2&3+ >he primary reason for intentional replantation is based on the inability to perform ade*uate non surgical rot canal therapy on a tooth, as well as on the inadvisability of performing endodontic surgery.
74

$ome teeth re*uiring root canal therapy are absolutely inoperable in situ. 0ouths with such a small orifice that finger instrumentation of pulpless molar teeth is impossible are candidates for e'traction and intentional replantation. 6oots with obstructed canals resulting from

calcification, silver points, posts, or separated instruments, although indicated for retrofillling, may need to be e'tracted and intentionally replanted be cause of an oversi)ed e'ternal obli*ue ridge that bloc&s safe access.

Pulpless teeth have also been encountered with so many perforations or lateral aberrations of the canal that repair in site is impossible. Bf e'traction appears to be the only alternative in these cases, one is right to pose the *uestion /@hat have we to lose1 reported survival periods of up to 22 years for replanted teeth and have also made recommendations for case selection.

Bntentional replantation should be considered when it is the only alternative to e'traction.

7"

S2,0- &+ I+2,+2&3+() R,0)(+2(2&3+ 1. >he tooth should be e'tracted as atraumatically as possible and received in a sterile gau)e sponge saturated with normal saline solution. Bt should be held in the moist sponge throughout treatment, and the roots and attached periodontal tissue should be fre*uently irrigated with saline. 2. Bf the canals are not bloc&ed, standard access is made to the pulp chamber, and the canal or canals are prepared and filledE the coronal access sealed in hand as carefully as in site. A slight 31 to2 mm apicoectomy, prior to retrofilling, is done to reduce the hydrostatic pressure buildup during replacement. -. 6oots containing bloc&ed canals are retrofilled in the usual manner. 4. Preparations in teeth with perforation or resorptive defects are similarly done. 6oot canal filling in these cases should be completed before the repair of defects. ". 9efore replantation, the alveolus should be gently curetted and irrigated with saline to remove the clot and /freshen1 the soc&et, being careful not to promote e'cessive bleeding or detach viable periodontal ligament attachment to the alveolar bone. :. >he tooth is replanted and stabili)ed with a splint if necessary. Posterior teeth normally are well retained and do not need splinting.

7:

Anterior teeth may be splinted with a coronal acid etch techni*ue using a direct bonding plastic.

IMPLANT SURGERY >wo types of endosteal implants fall under the purview of endodontics endodontic implants and ossointegrated implants, also called endosseous implants.

+n%&%&nti! Implants Bt ma&es great sense that, if a rigid implant can safely e'tend out the ape' of the tooth into sound bone, and by so doing stabili)e a tooth with wea&ened support, the patient is well served and perhaps has avoided a fi'ed bridge. $uch is the reasoning behind the endodontic implant, many of which have proven *uite successful.

Placing endodontic implants is a techni*ue sensitive operation. A perfectly round preparation must be reamed through the tooth ape' and into periradicular bone. Infortunately, there were three errors to

commission by those caught up in the /glamour1 of this new innovation. >he worst was a failure to prepare a perfectly round preparation so that the e'truding implant would perfectly seal the ape', much as a cor& seals a bottle. >rying to prepare a perfectly round preparation in an ovoid
77

canal caused tow problems, the most obvious being that the apical opening remained ovoid. 0icrolea&age eventually developed because the ape' was not properly /cor&ed1.

>he second problem was fractured roots. >o /round out1 the ovoid ape', larger and larger preparations were made, thus materially wea&ening the root. >hen, when the tapered implant was forced into place, it acted as a wedge and a vertical fracture developed.

>he third cause of failure was overloo&ed second canals, particularly in mandibular anterior teeth, and an error of omission was in not correcting or controlling the periodontal condition that led to the alveolar bone loss in the first place. R&&t F&rm Osse&integrate% Implants A new option has opened for replacing teeth lost because of a hopeless prognosis. >he osseointegerated root form implant has now achieved a success rate approaching that of conventional endodntics. 9ranemar&+s 1.," definition of osseointegration D the direct structural and functional connection between ordered, living, bone and the surface of a load-carrying implant trumpeted the advent of successful osseointegration, and the usage of implants s&yroc&eted.

7,

Although 9ranemar&1s paper of 1.77, reporting on the first 1# years of implant research, dealt e'clusively with mandibular anterior implants in the edentulous arch, subse*uent usage has e'panded to fi'ed and removable prosthesis abutments and single tooth replacement. Although single tooth replacements are the most common indication in the endodontic environment, there are often indications for two or more replacements in an endodontic milieu. !ndodontic graduate programs are now teaching osseointegerated implants.

I+*&'(2&3+>he patient who presents himself for endodontic treatment but has a non treatable tooth that is a candidate for removal and an implant include? 1. 8ertical root fractures. 2. Hori)ontal root fractures in the coronal 1/- to L of the root. -. Non reparable resorption, either e'ternal or an e'tra canal invasive resorption. 4. Non treatable endodontic failures. ". Non treatable endo perio lesions. :. Non treatable retained primary teeth. 7. %ross post perforations. ,. Non restorable teeth.
7.

C3+2$(&+*&'(2&3+- 53$ P)(',1,+2 35 I10)(+21. (ac& of special training by the surgeon. 2. Incontrolled or brittle diabetes mellitus. -. Patient psychiatric factors. 4. Postmenopausal women on thyroid medication and without estrogen replacement therapy 3according to a preliminary report5.

>here is an increased li&elihood of failure 3absence of integration of the implant5 if the following si' re*uisites for success are not observed? 1. >he implant must be fabricated form an alloplastic biocompatible material such as titanium alloy, or hydro'yapatite. 2. >he preparation of the bony soc&et must be done with a gentle surgical techni*ue. !lectric handpieces that revolve at slow 6P0s are designed specifically for implant surgery. -. >he implant must closely fit the precise bony preparation throughout its length. 4. >he implant must be mechanically fi'ed to the bone, by either threads or a roughened surface on the implant.

,#

". >he implant must remain unloaded during the healing phase of - to . months, depending on which <aw received the implant and the e'tent of bone grafting that was necessary. :. >he implant must be properly restored with an even distribution of occlusal forces, both wor&ing and balancing. >he restoration must not overta' the system.

SUTURING Ade*uate well placed sutures will aid in the healing process. Bmproper, insufficient, poorly placed sutures will diminish the rate of healing and may lead to uncomfortable or unesthetic scar or &eloid formation. 2or placing sutures in the most desirable manner, the

following suggestions are made.

1/ (igitall, press t"e flap #ef&re suturing. After the surgery is completed, the flap is returned to its original position and firm but not overly forceful digital pressure is applied for full minutes. >his allows the fibrin networ& to begin its formation so that an adherence develops between the raised and underlying tissues.

2/ Ne'er #e s$imp, -it" sutures.

,1

>he function of a suture is to &eep the edges of the flap in contact during the period immediately after the surgery. Bn this way the tissues attach across the lines of incision and optimal healing is gained. Bf the tissues are not apposed, granulation tissue will grow in, which is most undesirable. Also, the sutures prevent the underlying bone from being e'posed to the oral environment and thereby lessen postoperative pain.

Bn order for these ob<ectives to be accomplished enough sutures must be placed to &eep the edges of the flap in apposition. Bt is almost impossible to place too many sutures, and it is much better to err on the side of too many than too few. Bf any *uestion arises as to the need for additional sutures after the surgeon observes t initially sutured flap, the answer is to place more.

/ Ta$e %eep #ites -it" t"e nee%le int& t"e tissue. Placing the sutures close to the incision lines may cause problems. is difficult to avoid placing the &nots over the lines of incision, and when the sutures are tightened one side or the other may pull through the tissue. >he answer is to ta&e deep bites with the needle for enough from the lines of incision.

,2

"/ (& n&t pull t"e stit!"es t&& tig"tl,. @hen deep bites are ta&en to place each suture, care must be e'ercised in tying the &not so that the edges are brought <ust into contact with each other and that no further tightening is allowed. >here is room to tighten more, but this will cause a bunching of the edges and may lead to decreased blood circulation in the area.

). A'&i% pla!ing t"e $n&ts &'er t"e lines &f in!isi&ns. >he &nots of each stitch should be placed close to either of the puncture sites in the tissue rather than in the center. (eaving the &not in the center will place it right over the line of incision. >he bul& of the &not, when pushed by the lip or chee&, will cause additional irritation and delay healing in the already inflamed areas.

Bf possible, the most desirable position for the &not is over the puncture site on the non raised side of the incision, which is the most normal segment. Bf, after the suture is tied, it is noticed that the &not is over the line of incision, it can be moved easily. >he &not is grasped by the teeth of the miniature hemostat and gently pulled toward the un flapped segment.

.. (& n&t lea'e sutures in pla!e f&r t&& l&ng.

,-

Bndividuals heal with different speeds, and it is impossible to predict with any accuracy the rate in a particular case. However, leaving sutures in place for too long always causes a local inflammation and may lead to overgrowth of tissue., embedding the thread. >herefore " days after the operation seems to be the average and thus ideal time to remove sutures, with the ma'imum being 7 days postoperatively.

*. /e sure t& s!"e%ule a suture rem&'al app&intment0 As ridiculous as it seems, in the e'hilaration of a <ob well done, the surgeon may forger to schedule an appointment for suture removal at " to 7 days after surgery. 0any patients have had resorbable sutures used in other surgical procedures and are not aware that the same type is not used in dentistry. $ome wee&s later the patient may call to complain of

irritation in the area of the surgery, and an embedded suture is discovered, much to the chagrin of the surgeon. $imilarly, the number of sutures placed must always be recorded on the patient+s chart so the surgeon can be certain that no stitches have been left behind.

1. C"&&se t"e t,pe &f suture material. 0any companies mar&et pac&aged disposable presterili)ed suture material. >here are a myriad of varying choices in thic&ness and type of material to replace the formerly used gut or sil& material. Polyester fibers
,4

are woven and treated with a chemical that prevents oral fluids, bacteria and other contaminants from being absorbed by the thread. Bt appears that this foreign matter that accumulates within the suture material causes the local inflammatory response fre*uently noted. $uture material is also produced in a monofilament but is more difficult to tie. 9oth new

materials, being so smooth, re*uire the placing of three s*uare &not ties to prevent unraveling.

Knots are no longer needed to attach the thread to the metal, but a traumatic needle is available so that a much smaller puncture hole is made. Bndividual pac&ages are &ept ready for the surgical procedure. @hen needed the material is removed from its outer wrapper and dropped onto the surgical tray.

2. Use a !ir!umferential tie. 2or use with vertical flaps, the circumferential tie, so named because of its similarity to the circumferential periodontal ligament fibers is a valuable. After the vertical incisions are sutured, thee

circumferential tie is used to bring the scalloped gingival margin to place.

,"

P3-230,$(2&4, 0(2&,+2 &+-2$#'2&3+@hen the soft tissues are properly managed and surgical time is minimi)ed, healing is generally uneventful. ;areful attention to

postoperative instructions, however is essential for patient comfort and tissue healing during the ne't few days. Postoperative instructions should be given verbally and supported in writing for the patient+s easy reference. 1. $trenuous activity should be avoided, along with drin&ing alcohol and smo&ing. 2. An ade*uate diet consisting of fruit <uices, soups, soft foods and li*uid food supplements should be consumed. Avoid hard, stic&y or chewy foods. -. Co not dug at or unnecessarily lift the facial tissues. 4. =o)ing of blood from the surgical site is normal for the first 24h. $light and transient for the first 24 h. $light and transient facial swelling and bruising may be e'perienced. ". Post surgical discomfort is minimal but the surgical site will be tender and sore. >he use of analgesics for 24 2, h will help to alleviate this occurrence. surgically. Normally, continue with the analgesics given pre

,:

:. 2or the first day place ice pac&s with form pressure directly on the face over the surgical site for 2# min and remove for 2# min. 6epeat until retiring that evening. 7. >he day following surgery and for the ne't - 4 days, chlorhe'idine rinses are used twice daily. Alternatively warm salt water rinses are used every 1 2 h if possible 3half a teaspoon of salt in a glass of water5. ,. $utures will be removed in 4, 72 h. .. 9rushing of the surgical site is not recommended until the sutures are removed. Prior to that the surgical area can be cleaned using a large cotton puff or ball saturated with warm salt solution. 1#.>elephone numbers are provided for your convenience should complications arise.

POSTOPERATIVE SEQUELAE $urgical se*uelae include pain, swelling, ecchymosis, laceration, premature separation of sutures, infection, ma'illary sinus perforation, and transient paresthesia. ;alling the patient at home the evening after surgery and the ne't day is always deeply appreciated. >o minimi)e post surgical se*uelae, oral and written postoperative instructions must be given to the patient and the person accompanying the patient. 9ecause of an'iety and nervousness, patients sometimes misunderstand or simply do
,7

not remember the verbal instructionsE for this reason written instructions allay confusion or further an'iety.

P(&+ Pain is usually not a serious problem. (ong acting anesthetic

agents, such as bupivacaine 3i.e., 0arcaine5 or etidocaine 3i.e., Curanest5 can be in<ected postoperatively into the surgical site to control pain for a period of up to , hours. >he reader is referred to ;hapter 1, for the preventive ibuprofen or acetaminophen regimen that almost always ensures that any pain will be minimal and transient. 6arely are narcotic analgesics re*uired.

H,13$$7(%, Postoperative hemorrhage is rare. >o prevent it from occurring, two 2P2 sterile gauge pads are folded in half and moistened with chilled sterile water. >his pac& is placed over the sutured flap in the buccal fold and pressed by the surgery with moderate pressure for several minutes. >he patient is provided an ice pac& to press lightly against the chee& or <aw for at least -# minutes to constrict the cut micro vasculature, minimi)es swelling and promotes initial coagulation.

,,

S>,))&+% $welling is common surgical se*uelae and is a ma<or concern for the patient. Patients must be informed that the surgical site and face may swell regardless of the home care. Also, patients must be assured that the degree of swelling is not an indication of the success or failure of the surgery or the severity of the case. Bntermittent application of ice pac&s, 1# minutes on and " minutes off, for the 2 days almost always minimi)es swelling.

E''7.13-&!cchymosis is the discoloration of facial and oral soft tissues because of the e'travasation and subse*uent brea&down of blood in the interstitial subcutaneous tissues. >his is basically an esthetic problem. Bt is more prevalent in elderly patients with capillary fragility and patients with fair s&in. 2re*uently, ecchymosis occurs below the surgical site because of gravity. 2or instance, the surgical site may be a ma'illary premolar, but the ecchymosis may be found in the nec& area. >he patient should be assured that the ecchymosis has no bearing on the success or severity of case. P($,-27,-&( @hen paresthesia occurs, it is when the mental nerve presents near the second premolar and first molar. However, transient paresthesia may
,.

occur even if the surgical site is far from the nerve.

Bnflammatory

swelling of the surgical site may cause temporary impingement on the mandibular nerve causing transient paresthesia. Bf the nerve has not been severed, normal sensation generally returns within a few wee&s. Bn rare instances, however, it may ta&e a few months to regain normal sensation. >he patient should be assured of the probable return of sensation in the affected sideE however, on rare occasions paresthesia can be permanent.

M(C&))($. S&+#- P,$53$(2&3+ Perforation of the $chneiderian membrane covering the sinuses may occur. Bf perforation of the sinus occurs, utmost care should be ta&en to prevent any material from entering the sinus.

>he patient should be cautioned not to blow his or her nose and should be instructed to elevate the head during the night. Prophylactic antibiotic therapy with Augmentin "##mg every : hours along with $udafed for 1wee& should be prescribed. >he patient should return for a post surgical chec&up in 1 wee&.

P3-230,$(2&4, ,C(1&+(2&3+ (+* $,4&,> 6e e'amination of the patient, both clinically and radiographically, is normally scheduled at : months and 1 year. Bn most cases osseous
.#

repair is virtually complete at 1 year. !vidence of this as well as clinical healing has been considered as a valid criterion for continued success. >herefore, no additional follow up may be necessary. 2ailure to observe complete repair or delayed healing should complete repair or delayed healing should warrant additional evaluation for as long as 4 years, until repair is evident, or signs and symptoms indicate failure.

6adiographic interpretation is highly variable and can easily be influenced by the *uality and angulation of the film and processing irregularities. >herefore, the clinician should use a film holding device for all follow up radiographs. (i&ewise, familiarity with radiographic classifications of healing 3success failure5 is essential. >his will enable case outcomes to be based on a sound, logical and consistent decision ma&ing process.

S#'',-- (+* 5(&)#$, F (,2&3)3%. (+* ,4()#(2&3+ @hilst many studies have attempted to determine success failure rates for perpendicular surgery, none have been able to integrate fully all parameters of evaluation with techni*ues performed, materials used, patient compliance and clinician e'pertise, variability and interpretative s&ills. Attempts at multivariate analysis have provided some trends and

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correlations, but even these findings may only be applicable to specifically controlled cases.

$uccess 3complete healing5 with peri radicular surgery has been reported to range from 2"F to .#F using mi'ed populations, less than ideal percentages of review e'aminations and minimal evaluation periods. 9ecause of the significant variability in results, comparison of studies is not possible. However, the identification of factors that have contributed to the success or failure of peri radicular surgery is essential, and these should be integrated into all phases of case assessment and treatment. =ften the aetiology of failure may be difficult to identify and may encompass the integration of multiple factors. 2or peri radicular surgery, most failures can be attributed to specific causes. At the same time, when failure cannot be e'plained, speculation may lead to uncertain aetiological factors and treatment. >able lists aetiological factors often cited as valid or uncertain in the failure of peri radicular surgery.

!valuation of success or failure following root end surgery is limited to clinical and radiographic e'aminations. ;linical criteria for success or failure are most commonly used and are integrated with the radiographic findings. ;linically patients are classified into one of three categories at the time of review e'aminations.
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Patient assessment,

however, must be made after integrating both clinical and radiographic parameters of evaluation. Bf the only goal of peri radicular surgery is to retain the tooth in ade*uate clinical function, then many cases can be classified as successful. 0any factors, however, such as case selection, evaluator bias and patient factors, can s&ew levels of success or failure. (i&ewise, many clinically symptom free teeth may have histo pathological changes at the root apices along with minimal or e'tensive radiographic changes. !ven in the presence of an apparently normal radiographic appearance, a clinically symptom free tooth may e'hibit histo pathological changes in the peri radicular tissues. >his is especially true ad<acent to resected root surfaces which are difficult to assess radiographically.

F('23$- &+5)#,+'&+% -#'',-- 3$ 5(&)#$, 35 0,$& $(*&'#)($ -#$%,$.

V()&* '(#-,- 53$ -#$%&'() 5(&)#$, 2ailure to debride the root canal space thoroughly 2ailure to seal the root canal space three dimensionally >issue irritation from to'ic root canal or root end fillings 2ailure to manage root canal or root end materials properly $uperimposition of periodontal disease

.-

 8ertical root fracture 6ecurrent cystic lesions Bmproper management of the supporting periodontium

U+',$2(&+ '(#-,- 53$ -#$%&'() 5(&)#$, Bnfected dentinal tubules Bnfected periradicular lesions 2ailure to use antibiotics Accessory or lateral canals (oss of alveolar bone 6oot resorption >iming of root canal obturation 3before or during surgery5 >ype of root end filling

C)&+&'() -#'',- No tenderness to percussion or palpation Normal mobility and function No sinusitis or par aesthesia No sinus tract or periodontal poc&et No infection or swellings
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 Ad<acent teeth respond normally to stimuli 0inimal to no scarring or discoloration No sub<ective discomfort

C)&+&'() #+',$2(&+2. $poradic vague symptoms Pressure sensation or feeling of fullness (ow grade discomfort on percussion, palpation or chewing Ciscomfort with tongue pressure $uperimposed sinusitis focused on treated tooth

C)&+&'() 5(&)#$, Persistent sub<ective symptoms Ciscomfort to percussion and/or palpation 6ecurrent sinus tract or swelling !vidence or irreparable tooth fracture !'cessive mobility or progressive periodontal brea&down Bnability to chew on the tooth.

."

R,-2$,(21,+2 35 -#$%&'() 0$3',*#$,Not all surgery is successful. @ith astute case analysis the

aetiological factors may be identified and further surgery performed. @hen this is not the case, some patients undergo this is not the case, some patients undergo multiple operations only to have persistent signs or symptoms of failure. =ften these teeth will be e'tracted, or last ditch efforts will be made with intentional replanation.

R(*&3%$(07&' ,4()#(2&3+ 35 -#'',-- (+* 5(&)#$, R(*&3%$(07&' -#'',- Normal periodontal ligament width or slight increase Normal lamina dura or elimination of radiolucency Normal to fine meshed osseous trabeculae No resorption evident

R(*&3%$(07&' #+',$2(&+2. $light increase in periodontal ligament width $light increase in width of laminadura $i)e of radiolucency static or slight evidence of repair 6adiolucency is circular or asymmetrical !'tension of the periodontal ligament into radiolucency

.:

 !vidence of resorption R(*&3%$(07&' 5(&)#$, Bncreased width of the periodontal ligament and lamina dura ;ircular radiolucency with limited osseous trabeculae $ymmetrical radiolucency with funnel shaped borders !vidence of resorption

@hen a case has been identified as failing it is necessary to use all tests and information available to determine the cause before further surgery is underta&en. >able lists some of the more common

unsuspected, anatomical and technical causes for failure. Not all of these causes are amenable to further surgery, and often a tooth may re*uire e'traction and prosthetic replacement.

8ery few studies have evaluated the results of peri radicular surgery that was performed subse*uent to previous surgical failure. $uccess rates of surgeon have been "#F or less with little subse*uent alteration in healing after 1 year. !ven poorer results have been reported when the peri radicular lesion at the time of the first surgery was Q " mm in diameter. ;auses of surgical failure Insuspected 6oot fracture not readily visible
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 Post D hole perforation, especially on the buccal or lingual surface Bnstrument perforation coronal to the resected root end Persistent infection in the apically resected tubules ;orrosion of previously placed amalgam root end filling

A+(231&'() 2enestrations or dehiscence+s D loss of marginal bone Aberrant root anatomy or canal space Pro'imity of root of ad<acent teeth Pro'imity of ma'illary sinus

T,'7+&'() Poor canal cleaning and obturation Bnade*uate root end resection Bnade*uate root end preparation and obturation >o'icity of root end filling materials Bmproper soft tissue management

>he primary reason for failure following peri radicular surgery is the presence of necrotic tissue debris in uncleaned and obturated canal

.,

space.

>he primary cause for failure with non surgical root canal

treatment has been identified as coronal lea&age due to poor *uality of the coronal restoration. >herefore, it is essential to access, clean and obturate as much of the canal space as possible and to seal thoroughly the coronal aspects of the root canal system before resorting to surgical intervention. Bf this is not adhered to, failure will inevitably.

..

REFERENCES

1. M(--&+3 G(%)&(+&6 S&)4&3 T(-'7&,# (+* R(55(,))( M3)&+(,&/ Iltrasonic root end preparation. Bnfluence of cutting angle on the apical seals. Journal of Endodontics. 1..,E 243115? 72: 7-#. 2. M T3$(9&+,@(*/ ;omparative investigation of marginal adaptation of 0ineral trio'ide Aggregate and other commonly used root end filling materials. Journal of Endodontics. 1.."E 21 3:5? 2." 2... -. M T3$(9&+,@(*6 H3+%6 P&22 F3$*6 K,22,$&+%/ Antibacterial effects of some root end filling materials. Journal of Endodontics. 1.."E 213,5? 4#- 4#:. 4. I+%), I/A/6 L,&5 K/ !(?)(+*/ !ndodontics, 4th !dn, @illiam and @il&ins? 1..4E :,. 7:-. ". M T3$(9&+,@(* (+* T R P&22 F3$*/ 6oot end filling materials. A review. Endod Dent Traumatol. 1..:E 12? 1:1 17,. :. P,2,$ A G&)7,(+.6 D(4&* F&*%3$ (+* M($2&+ A T.(-/ Apical dentin permeability and microlea&age associated with root end resection and retrograde filling. Journal of Endodontics. 1..4E 2# 315? 22 2". 7. ;ohen. $, 9urns 6;. /Pathways of the Pulp1, 7th !dn. $t.(ouis. >he ;8 0osby ;ompany. 1..7E :,- 72:.

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,. A R(&+>(2,$6 ! G A,(+-3++, (+* N S($?($/ !ffects of ultrasonic root end preparation of microcrac& formation and lea&age. Journal of Endodontics 2###E 2:325? 72 7". .. F$(+? A V,$2#''& (+* R&'7($* G !,(22./ Apical lea&age associated with retrofilling techni*ues? A dye lea&age study, Journal of Endodontics. 1.,:E 12? --1. 1#. K(1$(+ S(5(4&6 R,G( K(G,1& (+* D#*),. E(2?&+-/ Adherence of enamel derivatives on root end filling materials. Journal of Endodontics 1...E 2"? 71#. 11. T/ R/ P&2235$*6 A O A+*$,(-3+6 S O D3$+ (+* S P K($&.(>(-(1/ !ffect of B60 root end filling on healing after replantation. Journal of Endodontics. 1..4E 2#? -,1. 12. A(1,- D K,22,$&+% (+* M T3$(9&+,@(*/ Bnvestigation of

mutagenecity of 0>A and other commonly used root end filling materials. Journal of Endodontics. 1.."E 21? "-7. 1-. N3$&.(-# H3-3.(6 C#%,+, P/ L(#2,+-'7)(%,$ (+* E4(+ H G$,,+,$/ A study of the apical microlea&age of a %allium Alloy as a retrograde filling material. Journal of Endodontics. 1.."E 213.5? 4": "",. 14. F$(+? G,7($*- (+* E&)5$&,* E(%+,$/ $ealing ability of five different retrograde materials. Journal of Endodontics. 1..:E 223.5? 4:- 4::.
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1". F$(+?)&+ S/ E,&+,/

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"th !dn, 0osby

;ompany? 1..:E "2- :#". 1:. E()23+ R/E6 T3$(9&+(@,* M/ /Principles of !ndodontics1, 2nd !dn, @.9. $aunders ;ompany. 1.,.E 4#1 422. 17. T R P&22 F3$*/ /Harty+s !ndodontics in ;linical Practice1, 2 nd !dn, @right Publishers? 1"4 1".. 1,. L3#&- I G$3--1(+/ 2ebiger. 1..1E 2,. -12. /!ndodontic Practice1. 11th !dn, (ea and

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