Principles of endodontic surgery Yaser Baroud

Who can do endodontic surgeries ??? Endodontic surgery ((Endodontic surgery is the management or prevention of periradicular pathosis by a surgical approach. Abscess drainage Periapical surgery Corrective surgery Intentional replantation Root removal Who can do endodontic surgeries ???

In 10% to 15% of cases, symptoms can persist or recur. A recent consensus conference, however, concluded that endodontic therapy and implant procedures are considered equally successful. ??? Additional procedures reduce long term success rate of the tooth. ( structure loss).

Algorithm for apical surgery

Post operative

Signs of failed RCT Pain Swelling Fistula Radiolucent lesion ( might be incidental) ***It is important to tell the patient preoperatively that endodontic surgery is exploratory.

Periapical surgeries Steps: 1. Appropriate exposure of the root and the apical region 2. Exploration of the root surface for fractures or other pathologic conditions 3. Curettage of the apical tissues 4. Resection of the root apex 5. Retrograde preparation with the ultrasonic tips 6. Placement of the retrograde filling material 7. Appropriate flap closure to permit healing and minimize gingival recession

Indications of periapical surgery 1-Anatomic problems preventing complete débridement or obturation. (Calcifications or other blockages, severe root curvatures, or constricted canals.) If retreatment is not possible, removing or resecting the uninstrumented and unfilled portion of the root and placing a root end filling may be necessary.

2-Restorative considerations that compromise treatment Retreatment through crowns (lower incisor). Post and core

3-Horizontal root fracture with apical necrosis

4- Irretrievable material preventing canal treatment or re-treatment (Broken instruments, fractured posts, filling materials)

5- Procedural errors during treatment (Broken instruments, ledging, gross overfills,and perforations.)

6- Large periapical lesions that do not resolve with root canal treatment

Contraindications (cautions) If other options are available, periapical surgery may not be the preferred choice !! 1- Unidentified cause of treatment failure Surgical management of all periapical pathoses, large periapical lesions, or both is often not necessary because they will resolve after appropriate root canal treatment. This includes lesions that may be cystic; these also usually heal after root canal treatment..

2- When conventional endodontic treatment is possible.

3-Simultaneous root canal treatment and apical surgery It is preferable to perform only the conventional treatment without the adjunctive apical surgery. In certain cases where conventional RCT is insufficient to relive symptoms, simultaneous surgery may be done.

4- Anatomic consideration Maxillary sinus Known consequence Caution is necessary not to introduce foreign objects into the opening and to remind the patient not to exert pressure by forcibly blowing the nose until the surgical wound has healed ** Choose proper flap design (sulcular- envelope) Mental nerve The nerve may have an anterior loop of 2 to 4 mm. :

5- Poor crown- root ratio Surgery may compromise crown-root ratio Shorter roots may support a relatively long crown if the surrounding cervical periodontium is healthy

6- Medical complications: No specific contraindications for endodontic surgery exist that would not be similar to those for other types of oral surgical procedures.

Surgical procedures Preoperative prophylactic administration of antibiotics is indicated. (2 gm of penicilllin, Clindamycin 600 mg). Perioperative corticosteroids may be prescribed but should be accompanied with prophylactic antibiotics.

Flap Design Surgical access is a compromise between the need for visibility of the surgical site and the potential damage to adjacent structures The most common incisions are Submarginal curved (semi-lunar), Submarginal Full mucoperiosteal (sulcular). The submarginal and full mucoperiosteal incisions have either a three-corner (triangular) design or a four-corner (rectangular) design.

Semilunar incision Disadvantages: Slightly curved half-moon horizontal incision in the alveolar mucosa. Should be avoided. Disadvantages: Limited access Alvelar mucosa heals more slowly than attatched mucosa (dehiscence). Incision may be carried at the inflamed area .

Submarginal incision The horizontal component of the submarginal incision is in attached gingiva with one or two vertical incisions. The incision is scalloped in the horizontal line, with obtuse angles at the corners. Used mostly in the anterior area and premolars. 4 mm of attatched gingiva and good periodontal health are prerequisites.

Submarginal incision Advantages : Esthetic because it leaves the gingiva intact around the crown. Provides better access and visability Disadvantages: Heals by scarring and hemorrhage Sometimes ,, the access is limited ?!!!

Full mucoperiosteal incision The procedure includes elevation of interdental papilla, free gingival margin, attached gingiva, and alveolar mucosa. One or two vertical releasing incisions may be used, creating a triangular or rectangular design. This design is preferred over the previous designs.

Full mucoperiosteal incision Advantages: Maximum access and visibility Not incising over bony defect Lower risk for hemorrhage Less scar Disadvantages: Difficult to replace and suture Gingival recession

Anesthesia Mandible: IAN block Infiltration for hemostasis Maxilla: ***Sedation