1. Relationship between conservative dentistry and periodontology, conservative dentistry and oral surgery. Not correct conservative procedures and their effects to periodontal tissues. Indications of the endodontic – surgical procedures.

2. Endodontics is an important discipline in dentistry with a high sucess rate All teeth with pulpal or periapical pathology are candidates for endodontics INDICATIONS FOR ENDODONTICS: When a tooth has lost the majority of coronal tissue and a crown is to be constructed When a tooth has lost the majority of coronal tissue and a crown is to be constructed

3. Preservation of the alveolar bone is important in prosthodontics, because the root retention in the Mandible is recommended Preservation of the alveolar bone is important in prosthodontics, because the root retention in the Mandible is recommended Teeth with doubtful pulps – vital teeth, which are to be restored with large cast restorations or porcelain – should be assessed endodontically beforehand. Teeth with doubtful pulps – vital teeth, which are to be restored with large cast restorations or porcelain – should be assessed endodontically beforehand.

4. Risk of pulp exposure during preparation Risk of pulp exposure during preparation Pulpal sclerosis following trauma Pulpal sclerosis following trauma Pulpotomy Pulpotomy

5. CONTRA – INDICATIONS TO ENDODONTICS: GENERAL: Small mouth Small mouth Poor oral hygiene Poor oral hygiene Patient´s general medical condition Patient´s general medical condition Patient´s attitude Patient´s attitudeLOCAL: Tooth not restorable Tooth not restorable

6. Insufficient periodontal support Insufficient periodontal support Non – strategic tooth Non – strategic tooth Root fractures. Root fractures. Massive internal or external resorption Massive internal or external resorption Bizzare anatomy. All teeth may show unusual anatomic variations. Bizzare anatomy. All teeth may show unusual anatomic variations.

7. The ways in which restorations fail (in conserv.dent.) New disease New disease -caries and tooth wear -caries and tooth wear Pulpal problems Pulpal problems Trauma Trauma Periodontal disease Periodontal disease Technical failure Technical failure Fractured restorations Fractured restorations Marginal breakdown Marginal breakdown Tooth fracture Tooth fracture Defective contours Defective contours Appearance Appearance Failure of retention Failure of retention

8. Problem areas This section contains problem areas which frequently confront the operator and pose particular difficulties with treatment planning. These will be divided into different categories but often several may appear together. OBSTRUCTED CANALS OBSTRUCTED CANALS Natural obstructions include pulp stones, calcified canals or anomalies which makes instrumentation impossible

9. Iatrogenic obstructions Include broken root canal instruments, posts, gutta percha or solid cement root filling Include broken root canal instruments, posts, gutta percha or solid cement root filling

10. Fractured instruments. Problem with larger sized instruments. Fractured instruments. Problem with larger sized instruments. As the size of root canal instruments increases their flexibility decreases. The larger sizes are stiff and problems arise when they are used to prepare the root canal. These problems are: The apical portion of many roots is narrow, so that if large instruments are used they could lead to perforation 1. 1. The majority of teeth have curved roots, particularly in the apical one third

11. As the patient is having symptoms there are three options: As the patient is having symptoms there are three options: 1. Extraction 2. Apicectomy with retrograde amalgam seals in both the mesial and distal canal 3. Removal of the crown and an attempt to re- root fill

12. PERFORATIONS There are three types of perforation according to their position: There are three types of perforation according to their position: Lateral wall of root. The use of engine-operated rotating instruments such as burs or reamers makes perforation of the wall of the root likely. Apex. Over- zealous instrumentation of a canal may result in perforation through the apical foramen. Calcium hydroxide may be used to provide an apical barrier

13. Floor of the pulp chamber. Perforations through the floor of the pulp chamber quickly become periodontal problems with furcal bone loss and pocketing, unless they are treated immediately.

14. ROOT FILLING The root filling is completed when the tooth is symptomless and the canal dry or capable of being with paper points. The root filling is completed when the tooth is symptomless and the canal dry or capable of being with paper points. Root cannal with periapical lessions, the accepted technique has been two or more visits Root cannal with periapical lessions, the accepted technique has been two or more visits

15. 21-years old woman-non successful endodontic treatment tooth N.22,apical clear radiolucency confirming an established lesion bigger than 3mm,it shows features of lamina dura disruption and bone structural changes

16. Measurement of the tooth canal length

17. Final endodontic treatment Foredent and gutapercha

18. ENDODONTIC SURGERY Is indicated in the caseses of failed conservative treatmented. Is indicated in the caseses of failed conservative treatmented. APICECTOMY APICECTOMY INDICATIONS: INDICATIONS: Access to the root canal is prevented due to dystrophic calcification The presence of large periapical lesion The presence of large periapical lesion

19. Chronic periapical infection associated with the introduction of a large quantity of root filling material into the periapical bone Chronic periapical infection associated with the introduction of a large quantity of root filling material into the periapical bone Fracture of the root with gross displacement of the apical portion Fracture of the root with gross displacement of the apical portion Perforation of the root, resulting from injudicious instrumentation, internal or external resorption Perforation of the root, resulting from injudicious instrumentation, internal or external resorption

20. When conservative treatment has failed, when symptoms persist despite numerous dressings, or after a canal has been filled with an irremovable filling When conservative treatment has failed, when symptoms persist despite numerous dressings, or after a canal has been filled with an irremovable filling In order to confirm the presence of a suspected fracture of the root In order to confirm the presence of a suspected fracture of the root

21. CONTRA-INDICATIONS: Individual anatomical problems, such as a small mouth, trismus, or severe facial scaring Individual anatomical problems, such as a small mouth, trismus, or severe facial scaring Proximity of inferior dental canal, mental nerve an maxillary antrum when operating on the roots of premolars and molars Proximity of inferior dental canal, mental nerve an maxillary antrum when operating on the roots of premolars and molars Systemic factors: neurosis, history of rheumatic fever or chorea, pregnancy, haemorrhagic diatheses, cardiac disease,.... Systemic factors: neurosis, history of rheumatic fever or chorea, pregnancy, haemorrhagic diatheses, cardiac disease,....

22. Poor oral hygiene associated with periodontal disease or severe caries Poor oral hygiene associated with periodontal disease or severe caries The strategic importance of the tooth and the subsequent possibility that cannot restored to full function The strategic importance of the tooth and the subsequent possibility that cannot restored to full function

23. Tooth resection Is often the treatment of choice in deep grade II and grade III furcation involvements. Is often the treatment of choice in deep grade II and grade III furcation involvements. It is also treatment of choice where teeth are to be included in a fixed prosthesis It is also treatment of choice where teeth are to be included in a fixed prosthesis Hemisection- the mesial root has been sectioned and the distal root, following endo and osseous surgery, has been utilized as a bridge abutment. (resection of mesial root on the mandibular first molar) Hemisection- the mesial root has been sectioned and the distal root, following endo and osseous surgery, has been utilized as a bridge abutment. (resection of mesial root on the mandibular first molar)

24. Osseous surgery is often necessary following both root amputation and tooth resection, so that osseous craters are eliminated and to blend the bony contours around the remaining root or roots into the adjacent bone, so that there is no precipitous drop in levels. Osseous surgery is often necessary following both root amputation and tooth resection, so that osseous craters are eliminated and to blend the bony contours around the remaining root or roots into the adjacent bone, so that there is no precipitous drop in levels. Where a tooth has been treated by resection, osseous surgery is often necessary around the remaining root to establish a biological width for the development of a new connective tissue and junctional epithelial attachment on root structure apical to the cut. Where a tooth has been treated by resection, osseous surgery is often necessary around the remaining root to establish a biological width for the development of a new connective tissue and junctional epithelial attachment on root structure apical to the cut.

25. RESECTION OF THE APEX It is considered essential to remove the apical third of the root in order to eliminate the apical delta and the zone of infected cementum.Contemporary attitudes favour minimum shortening of the root, consistent with the provision of access to the cut end, so that the apical seal can be verified or provided by cutting and filling an apical cavity., the majority of periapical lesions can be dealt with by the bodys defences, thus obviating the need for a surgical approach. It is considered essential to remove the apical third of the root in order to eliminate the apical delta and the zone of infected cementum.Contemporary attitudes favour minimum shortening of the root, consistent with the provision of access to the cut end, so that the apical seal can be verified or provided by cutting and filling an apical cavity., the majority of periapical lesions can be dealt with by the bodys defences, thus obviating the need for a surgical approach.

26. Intraoral image D.22-Cystis radicularis processus alveolaris maxillae reg.frontalis purulenta

27. 3months after the therapy- Cystectomio sec.PARTSCH II. et resectio apicis dentis N.22 Retrograde root canal endodontic therapy with amalgam Egalisatio,suturae