1. Endodntic surgery 2
Yaser Baroud

2. 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.

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

4. 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.

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

6. 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.

7. 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

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

9. Inscision and elevation of the flap
Full thickness flap (down to the bone).
Start elevating the vertical incision first, then the horizontal.
Avoid flap stretching.

10. Periapical exposure
Sometimes the bone is resorped and the root exposed.
In cases of intact buccal plate, a measurement may be made with a periodontal probe on the radiograph and then transferred to the surgical site to determine the apex location.
Bone is better removed by electrical surgical handpeice.

11. Copious irrigation
Bone should be removed to expose the area around the apex and at least half the length of the root (expose ,,,, then cut).
Lower incisor roots are carefully exposed because proximity with adjacent teeth could lead to treatment of the wrong apex.
Be careful of the root curvatures.

12. Curettage
Most of the granulomatous, inflamed tissue surrounding the apex should be removed to:
Gain access
Histopathology (if indicated)
Minimize hemorrhage
Tissue should be enucleated with a suitably sized sharp curette.

13. Tissue removal should not jeopardize the blood supply to an adjacent tooth.
((Portions of inflamed tissue or epithelium may be left, without compromising healing; total removal is not necessary.))
Hemorrhage control can be achieved by holding direct pressure over a bleeding site with gauze soaked in local anesthetic solution with epinephrine and by minimizing suction at the site of a bleeder.

14. Root end resection
Root end resection is indicated because it removes the region that most likely had the poorest obturation and more accessory canals.
Before sectioning, a trough is created around the apex with a tapered fissure bur to expose and isolate the root end.
A bevel of varying degrees is made in a faciolingual direction.

15. The amount of root removed depends on the reason for performing the resection.
In general, approximately 2 to 3 mm of the root is resected—more, if necessary, for apical access or if an instrument is lodged in the apical region; less if too much removal would further compromise stability of an already short root.

16. Retrograde filling
Filling seals the canal system, preventing further leakage.
The depth of the preparation must be at least 1 mm deeper than the bevel to seal the apex adequately.
Ultrasonic tips are used.

17. Ultrasonic tips The ease of use and special angulations require less
of a bony opening and less beveling of the apical region and permit a deeper, denser fill.

18. Root end filling material
Filling should seal well and should be tissue tolerant, easily inserted, minimally affected by moisture, and visible radiographically.
The root end–filling material must be stable and nonresorbable indefinitely.
Amalagam (zinc free)
IRM
Super ethoxy benzoic acid EBA

19. No single, all-purpose, superior root end–filling material exists.
**Mineral trioxide aggregate (MTA) has shown favorable biologic and physical properties and ease of handling.
MTA is conductive to bone formation
MTA is hydrophilic
Working time for 10 minutes.
No single, all-purpose, superior root end–filling material exists.

20. Irrigation Copious irrigation
With MTA, irrigation is done before the filling to avoid washing out the filler.
Radiographic evaluation
Flap replacement and suturing
Instructions
Suture removal

21. Corrective surgery
Corrective surgery is the management of defects that have occurred by a biologic response (i.e., resorption) or iatrogenic (i.e., procedural) error.
Many defects are accessible; others are difficult to reach
The procedure involves exposing, preparing, and then sealing the defect.

22. Indications for corrective surgery
1-Procedural errors:
Openings through the lateral root surface created by the operator, typically during access, canal instrumentation, or after space preparation.
((Perforations))
If the defect is on the interproximal aspect, in the furcation, or close to adjacent teeth or to the lingual aspect, adequate repair may not be possible

23. Corrective surgery 2- Resorptive perforation: Causes :
May originate internally or externally
Result in a communication between the pulp and the periodontium.
Causes :
Trauma
Internal bleaching procedures
Orthodontic tooth movement
Restorative procedures

24. Contraindications of Corrective surgery
Anatomic considerations
Nerves, vessels, bone (external oblique ridge)
Location

28. Other types of endodontic surgery
Root amputation:
Removal of one or moor roots of multirooted tooth.

29. Hemisection: Surgical division of a multirooted tooth.
In mandibular molars the tooth is divided buccolingually through the bifurcation .
In maxillary molars the cut is made mesiodistally, also through the furcation.

30. Bicuspidization: Surgical division of a mandibular molar.
The crown and root of both halves are retained.
Indicated when there is furacational pathosis or envolvement.