ENDODONTIC SURGERY

ENDODONTICS

2/28/2009 INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA Dr.Shawfekar Bte Hj Abdul Hamid

ENDODONTIC SURGERY
STUDY QUESTIONS FOR 2006 ORAL EXAMINATION: 1. Know endodontic surgical indications and rationale. 2. Why should failing RCT be retreated nonsurgically first, instead of surgically? 3. What are alternatives to apical surgery? 4. Discuss the various flap designs and indications for each. 5. Which flap design is indicated when gingival recession is a concern? 6. Why is the semilunar flap generally contraindicated? 7. Draw a Ochsenbein-Luebke flap design for #8, 9 with PFM crowns; discuss scalloping. 8. Discuss principles of vertical releasing incisions. 9. What is the rationale for root-end resection? How about for the amount removed, i.e. the level of cut? 10. What is the purpose of an apical bevel? Be able to draw location of root end resection, bevel and root-end preparation relationship. 11. Is it always necessary, and when should you prepare and fill the resected root end? 12. How do you manage a root-end with 2 foramina and interconnecting isthmus? Be able to draw the preparation design. 13. Describe the use of ultrasonics in endodontic surgery. 14. Discuss filling materials options. 15. Discuss mineral trioxide aggregate, its advantages, compressive strength, and setting time. Contrast with IRM and Super-EBA. Rationalize your material choice. 16. Compare ingredients of Super-EBA vs. those of IRM. 17. What are indications for surgical cortical plate trephination? Discuss the technique.

TYPES OF ENDODONTIC SURGERY

1. Fistulative a. Incision and drainage b. Surgical trephination Please refer to your INCISION AND DRAINAGE/SURGICAL TREPHINATION handout and briefing notes (discussed during the ENDODONTIC EMERGENCIES lecture), for specifics on these types of endodontic surgery. c. Cystic decompression 2. Corrective a. Perforation repair b. Resorption repair 3. Extraction-replantation 4. Periodontal a. Root amputation b. Hemisection 5. Periradicular

Apicoectomy:

Some patients need a surgical procedure called Apicoectomy. It involves an area at the tip of the root. Dr. Davis would make a small incision in the gum tissue, exposing the end of the root. The infected area of the root and its surroundings are then removed. A filling is placed inside of the root end and a few small sutures are placed. After a week, you will need to return to Dr. Davis to have your sutures removed and she will periodically check your healing progress thereafter.

Your Guide to Endodontic Surgery

You are probably reading this because your dentist or endodontist believes endodontic surgery may help save your tooth. To understand endodontic surgery, it helps first to know something about the nonsurgical endodontic procedure, or root canal. A root canal is necessary when the soft inner tissue, or pulp, of the tooth becomes inflamed or infected. This may happen as a result of deep decay, repeated dental procedures on the tooth or a blow to the tooth. Endodontic treatment removes the damaged pulp. Then the tooths canals are cleaned and filled to help preserve the tooth. In a few cases, however, nonsurgical endodontic treatment alone cannot save the tooth. In such a case, your dentist or endodontist may recommend surgery.

Who performs endodontic surgery? All dentists received training in endodontic treatment in dental school. However, because endodontic surgery can be more challenging than providing nonsurgical treatment, many dentists refer patients needing surgery to endodontists. Endodontists are dentists with at least two additional years of advanced education and training in root canal techniques and procedures. In addition to treating routing cases, they are experts in performing complicated procedures including surgery. They often treat difficult casessuch as teeth with unusual or complex root structured or small, narrow canals. This special training and experience can be very valuable when endodontic surgery is necessary. Why would I need endodontic surgery? Surgery can help save your tooth in a variety of situations.
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Surgery may be used in diagnosis. If you have persistent symtoms but no problems appear on your x-ray, your tooth may have a tiny fracture or canal that could not be detected during nonsurgical treatment. In such a case, surgery allows your endodontist to examine the root of your tooth, find the problem and provide treatment. o Sometimes calcium deposits make a canal too narrow for the cleaning and shaping instruments used in nonsurgical root canal treatment to reach the end of the root. If you tooth has this calcification, your endodontist may perform endodontic surgery to clean and seal the remainder of the canal.
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Usually, a tooth that has undergone a root canal can last the rest of your life and never need further endodontic treatment. However, in a few cases, a tooth may fail to heal. The tooth may become painful or diseased months or even years after successful treatment. If this is true for you, surgery may help save your tooth. o Surgery may also be performed to treat damaged root surfaces or surrounding bone.

Although there are many surgical procedures that can be performed to save a tooth, the most common is called apicoectomy or root-end resection. When inflammation or infection persists in the bony area around the end of your tooth after a root canal procedure, your endodontist may have to perform an apicoectomy.

What is an apicoectomy? In this procedure, the endodontist opens the gum tissue near the tooth to see the underlying bone and to remove any inflamed or infected tissue. The very end of the root is also removed. A small filling may be placed to seal to end of the root canal and a few stitches or sutures are placed in the gum to help the tissue heal properly. Over a period of months, the bone heals around the end of the root. Are there other types of endodontic surgery? Other surgeries endodontists might perform include dividing a tooth in half, repairing an injured root or even removing one or more roots. Your endodontist will be happy to discuss the specific type of surgery your tooth requires.
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In certain cases, a procedure called intentional replantation may be performed. In this procedure, a tooth is extracted, treated with an endodontic procedure while it is out of the mouth and then replaced in its socket. These procedures are designed to help you save your tooth. Will the procedure hurt? Local anesthetics make the procedure comfortable. Of course, you may feel some discomfort or experience slight swelling while the incision heals. This is normal for any surgical procedure. Your endodontist will recommend appropriate pain medication to alleviate your discomfort. Your endodontist will give you specific postoperative instructions to follow. If you have questions after your procedure, or if you have pain that does not respond to medication, call your endodontist. Can I drive myself home? Often you can, but you should ask your endodontist before your appointment so that you can make transportation arrangements if necessary. When can I return to my normal activities? Most patients return to work or other routine activities the next day. Your endodontist will be happy to discuss your expected recovery time with you. Does insurance cover endodontic surgery? Each insurance plan is different. Check with your employer or insurance company prior to treatment. How do I know the surgery will be successful? Your dentist or endodontist is suggesting endodontic surgery because he or she believes it is the best option for you. Of course, there are no guarantees with any surgical procedure. Your endodontist will discuss your chances for success so that you can make an informed decision. What are the alternatives to endodontic surgery? Often, the only alternative to surgery is extraction of the tooth. The extracted tooth must then be replaced with an implant, bridge or removable partial denture to restore chewing function and to prevent adjacent teeth from shifting. Because these alternatives require surgery or dental procedures on adjacent healthy teeth, endodontic surgery is usually the most cost-effective option for maintaining your oral health. No matter how effective modern tooth replacements areand they can be very effectivenothing is as good as a natural tooth. Youve already made an investment in saving your tooth. The pay-off for choosing endodontic surgery could be a healthy,

NONSURGICAL ENDODONTIC RETREATMENT IS INDICATED WHENEVER POSSIBLE PRIOR TO PERIRADICULAR SURGERY! Success rates are higher for nonsurgical retreatment than for surgical retreatment. Typically the nonsurgical retreatment is successful and endodontic surgery can be avoided. When surgery must follow nonsurgical retreatment, the potential for long-term success is much better than if the retreatment had not been accomplished, since the canal system will be as clean and leak-proof as possible. Nonsurgical retreatment optimizes the surgical environment for healing.

INDICATIONS FOR PERIRADICULAR SURGERY 1. General indications: a. Failure of previous nonsurgical retreatment (failure to heal) and minimal hope for success following another nonsurgical approach b. Nonsurgical retreatment is not possible 2. Specific indications (presuming nonsurgical RCT has failed to heal): a. Inability to debride apical canal system (1) Anatomic variation (anomalies, extreme curvature) (2) Impassable ledge (3) Canal transportation (4) Calcified canal (5) Irretrievable post b. Gross GP overextension c. Perforation d. Progressive root resorption e. Persistent postoperative pain f. A biopsy or periradicular exploration/inspection is necessary CONTRAINDICATIONS FOR PERIRADICULAR SURGERY 1. Relative contraindications a. No attempt made to nonsurgically treat or retreat. b. Anatomic considerations (1) Significant structures may be subject to a moderate or high risk of injury. (a) Mental neurovascular bundle (mental foramen) (b) Inferior alveolar neurovascular bundle (mandibular canal) (c) Maxillary sinus or floor of nose Sinus exposure usually causes few complications. Potential for sinus injury is rarely a surgical contraindication. (2) Deeply positioned root apices potentially pose a challenge/impediment to safe visual/instrument access. (a) Palatal roots of maxillary bicuspids and molars (b) Mandibular first/second molar roots beneath a thick external oblique ridge/buccal cortical plate 2. True contraindications a. Advanced periodontal disease of the tooth requiring periradicular surgery b. Patient unable to tolerate surgery (1) Medical/systemic/psychological reasons c. Lack of adequate surgeon skill and ability

INFORMED CONSENT 1. Potential intraoperative complications a. Neurovascular bundle damage and paresthesia b. Maxillary sinus/floor of nose perforation c. Damage to adjacent tooth roots d. Diagnosis of unsalvageable condition and need for extraction 2. Potential post-surgical sequelae a. Pain b. Hemorrhage c. Facial edema d. Ecchymosis e. Paresthesia (1) Mental (2) Inferior alveolar f. Maxillary sinus/floor of nose perforation and/or fragment complication g. Infection PRE-SURGICAL CONSIDERATIONS Systemic Considerations Review of medical history Consultations Psychological Evaluation Patient motivation Patient apprehension Esthetics Scarring; position of smile line Exposure of crown margins Prosthetic Considerations Presence of crowns and bridges Restorability Type of post material Anatomic Radiographic evaluation Periapical films at different angles and panoramic films to evaluate root length, location of adjacent roots, and location of major anatomical structures. Occlusal films may also be useful, especially for palatal lesions and root fractures. Phillips JL, Weller RN, Kulild JC. The mental foramen: part 1. Size, orientation and positional relationship to the mandibular second premolar. J Endodon 1990;16:221-3. Bottom line: mental foramen is directly below the buccal cusp tip of the 2nd premolar 63% of the time and within 2mm mesial or distal the other 37%. The mental foramen is generally located at a point that is 60% of the total distance from the buccal cusp tip of the 2nd premolar to the inferior border of the mandible. Lin L, Chance K, Skovlin F, Skribner J, Langeland K. Oroantral communication in periapical surgery of maxillary posterior teeth. J Endodon 1985;11:40-4. 7

Bottom line: possible involvement of the sinus must be evaluated and the patient informed about potential for sinus exposure and displacement of foreign bodies into the sinus. Maxillary 2nd premolar has the highest incidence of sinus involvement, followed by the maxillary molars. Clinical evaluation Limitations of opening Pre-existing scar tissue Extent of tori/exostoses Vestibular depth Quality of existing restoration(s) Depth of palatal vault Muscle attachments Periodontal evaluation Width of attached gingiva Fenestration/dehiscence Pocket depths Status of gingival health Height and width of alveolus

REGIONAL ANESTHESIA 2% lidocaine with 1:100,000 epinephrine for initial anesthesia 2% lidocaine with 1:50,000 epinephrine for hemostasis 0.5% bupivacaine with 1:200,000 epinephrine near end of procedure, for long-acting anesthesia and analgesic effects MUCOPERIOSTEAL FLAP CONSIDERATIONS Basic principles of flap design: Evaluate periodontal attachment levels carefully Maintain maximum blood supply to reflected and unreflected tissues Plan adequate flap size extend at least one full tooth to each side of the tooth undergoing surgery Ensure proper placement of horizontal and vertical incisions over sound bone place horizontal incisions on attached gingiva or in the gingival sulcus and vertical incisions in the trough between root eminences Place incisions over sound bone Avoid incisions over bony eminences Avoid creating sharp corners Do not reflect flap from sulcus. Apply undermining elevation begin reflection laterally in vertical releasing incision. Do not scale root surfaces or allow to desiccate. Preservation of root-attached tissues prevents epithelial downgrowth and loss of soft tissue attachment levels! Use care in retraction and handling soft tissues Size and geometry of flap depend upon many factors: Amount of access needed Number of teeth involved Length and shapes of the roots involved Presence of pathosis Dimensions of the pathosis Anatomic structures Depth of periodontal sulci/pockets 8

Amount of attached gingiva Esthetic considerations Patient factors Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery. I. The incisional wound. J Endodon 1991;17:425-435. Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery. II. The dissectional wound. J Endodon 1991;17:544-552. Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery. III. The osseous excisional wound. J Endodon 1992;18:76-81. The above series of studies by Harrison and Jurosky have suggested a new way of reflecting endodontic surgical flaps. During flap reflection, a thin layer of connective tissue and epithelium remains attached to the root surface above the alveolar crest. Preservation of these tissues is generally feasible in endodontic surgery because they are relatively healthy. Conversely, during periodontal surgery, the root surfaces are commonly scaled and root-planed to remove diseased cementum. Preservation of the healthy root attached tissues leads to very rapid re-attachment in endodontic surgery and virtually eliminates epithelial downgrowth from the incision. Consequently, the following flap reflection and flap management procedures are recommended for endodontic surgery when there is no need for concurrent periodontal treatment (i.e., root planing): Consider the use of microsurgical blades for intra-sulcular incisions. These small blades allow careful severing of the epithelial attachment with minimal trauma to the root surface and the root attached tissues. Reflection of flaps, particularly those with intra-sulcular incisions, should start at the releasing incision and undermine the tissues laterally. Then the papillae and coronal aspects of the flap are released by moving the periosteal elevator coronally and lifting the tissues from underneath. This will preserve the root attached tissues. The traditional technique of initiating reflection by pushing down into the sulcus or against the coronal flap margin with the periosteal elevator should be avoided! This technique damages the root attached tissues and can predispose the case to epithelial downgrowth. It also damages the edges of the flap and delays healing. Protect the root attached tissues during the surgery and keep them moist with frequent application of saline. Re-position the flap carefully. Consider suturing techniques like the vertical mattress to avoid piercing the papillae if possible. Use non-wicking sutures. Before suturing, clean the under-side of the flap to remove accumulated fibrin. After suturing, apply firm pressure with damp gauze for 3-5 minutes to help stabilize the flap and minimize the fibrin clot layer. Minimizing the fibrin layer will speed flap re-attachment and healing.

FLAP DESIGNS
Semilunar flap
Seldom used due to scarring, poor access and other problems

Advantages No primary advantages Fast, easy to reflect Marginal and interdental gingiva are not involved Unaltered soft tissue attachment level Crestal bone is not exposed Oral hygiene capability available immediately May be used for an extremely long root in rare situations (long maxillary canine) Disadvantages Disruption of blood supply to unflapped tissues Excessive scarring Flap shrinkage Difficult flap re-approximation and wound closure Delayed, secondary intention healing with more postsurgical sequelae Limited apical orientation (cannot visualize root eminences and other landmarks) May cross bony cavity Cannot extend flap Least amount of access and convenience

Triangular flap
One vertical releasing incision and a horizontal intrasulcular incision Normally the endodontic surgery flap of choice

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Advantages Excellent wound healing potential Minimal disruption of vascular supply to flapped tissues Excellent visibility Incisions not over bony defect Can view the entire root and overlying cortical and crestal bone Good for viewing and treating periodontal defects and root fractures Excellent apical orientation Easy to extend, if needed Minimal flap tension or tearing Good flap re-approximation Easy to suture Disadvantages Slightly difficult to incise and reflect Surgical access slightly limited due to the single releasing incision Possibility of slight gingival recession Negligible when tissues managed appropriately

Rectangular flap
Two vertical releasing incisions and a horizontal intrasulcular incision Indicated when additional access is needed

Advantages Enhanced surgical access 11

Minimal flap tension or tearing Excellent wound healing potential Minimal disruption of vascular supply to flapped tissues Does not deprive unreflected tissues of blood supply Trapezoidal design not recommended Excellent visibility Indicated for long roots, multiple-tooth surgery and retroclined teeth (e.g. mandibular incisors) Can view the entire root and overlying cortical and crestal bone Good for periodontal defects and fractures Excellent apical orientation Disadvantages More difficult to incise and reflect Flap re-approximation, wound closure and post-surgical stabilization are more difficult than with the triangular flap Possibility of slight gingival recession Negligible when tissues managed appropriately

Submarginal (Luebke-Ochsenbein) flap

Formed by scalloped horizontal incision in attached gingiva and two vertical releasing incisions. Scalloped incision corresponds to the contour of the marginal gingiva. There must be an adequate band of attached gingiva present (2 mm minimally) coronal to the horizontal incision. This requires a very careful analysis of attachment level along the entire length of the horizontal incision.

Advantages Does not involve marginal or interdental gingiva Does not expose crestal bone Minimizes gingival recession where crowns are in place and esthetics is a concern Minimizes crestal bone loss Disadvantages Unable to extend flap, if needed Disruption of blood supply to marginal gingival tissues, must rely on collateral circulation (which may not exist, resulting in sloughing of marginal gingiva) 12

Possible incision over bony lesion Limited use in mandibular surgery Possible delayed healing, especially vertical incisions Probably flap shrinkage and scarring Full root and crestal bone are not exposed, so apical orientation is limited, and periodontal defects and root fractures are difficult to visualize and treat Difficult flap re-approximation, wound closure and post-surgical stabilization

Gingival (envelope) flap

Intrasulcular horizontal incision without vertical releasing incisions. Generally not used for surgery in the apical area except occasionally for palatal roots of maxillary molars. Used for root resections, root amputations, hemisections and repair of cervical perforations or resorptive defects.

Advantages A gingivectomy can be performed Gingival levels can be changed Repositioning is simplified Disadvantages Flap can be difficult to reflect Tension on flap can be excessive Gingival attachment is disturbed Compromised access and visualization Palatal flap Only two flap designs for palatal surgery are recommended, triangular or envelope. Both provide for excellent healing. The triangular design provides greater access and visibility. To minimize hemorrhage, the releasing incision for the triangular palatal flap is placed where the smallest terminal branches of the anterior and posterior palatine arteries interdigitate. This incision is generally placed from the mesial of the first premolar to a point near the palatal midline.

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Releasing incisions in the posterior area are not recommended due to possibility of transecting the greater palatine artery! A small (2-4 mm) relaxing incision can be placed at the distal line angle of the maxillary second molar if necessary. Use of a post-surgical stent is recommended.

BONE REMOVAL AND EXPOSURE OF ROOT END Bone removal is best done using a high-speed handpiece (with rear air exhaust, e.g. the Impact #2 or #4 round bur and copious liquid coolant Air), a

No periradicular lesion intact cortical bone Ensure you have the necessary radiographic views in order to three-dimensionally localize the apex. Note the angle of the root and crown radiographically as well as clinically, with the flap reflected. Observe the cortical plate for any radicular eminence. Measure the tooths length and position of its apex from an accurate radiograph, and transpose this point to the tooth using a sterile ruler. Probe the bone with moderate force at this location, using an endodontic explorer, for any defect. Shave away a small amount of bone, using a bur or #15 blade, while carefully observing for the root. If necessary, place a sterile, radiopaque marker, and make a radiograph. Carefully bur away bone over the apex and adjacent to the root to create a window, of adequate size and orientation, which provides good visibility and working space. You will need room to curette any soft tissue present, to resect the root-end and to establish an apical seal. The root surface may be distinguished from bone by the observing the following: root structure is yellowish, does not bleed upon probing, its surface is smooth and it is entirely surrounded by periodontal ligament. Methylene blue dye may be used to facilitate identification and orientation. Periradicular lesion intact cortical bone It is often possible to penetrate the cortical plate using an explorer or sharp periosteal elevator tip. Undermined bone may be removed using bur, rongeur forceps, hemostat or sharp curette. Define the extent of the lesion and expose its osseous borders. If it is not possible to penetrate the bone by hand instrument, shave away the bone using a bur as previously described. Once the lesions position is identified, remove the bony cortex around the borders of the lesion laterally, as opposed to cutting into the lesion. If the lesion is extending toward adjacent tooth roots, terminate the bone removal before uncovering roots not involved in the surgical procedure. Generally an opening of a few millimeters on either side of the root apex will be sufficient. Periradicular lesion fenestrated cortical bone Removal of the remaining cortical plate over the apex proceeds as previously described. Extend the borders of the bony window slowly, without disturbing the underlying soft tissue. If indicated for hemostasis, you may inject anesthetic into the soft tissue mass. If possible, leave a shelf of bone apical to the lesion on which to place your tissue retractor.

CURETTAGE OF SOFT TISSUE PATHOSIS Submit specimen for histopathologic analysis, if available The diagnosis is usually periapical cyst, periapical granuloma or scar

ROOT-END RESECTION There appears to be little debate in the literature that when periradicular surgery is performed, apical resection of the root end is indicated. By resecting the root, you dramatically reduce the number of potential apical ramifications and anatomic variations, thus increasing the chance for success. 14

Additionally, your ability to see is improved, thus making the diagnosis of vertical root fractures or other reasons for failure easier to confirm. On the other hand, there is considerable debate about what to do with the resected root surface. Some authors believe that this surface should be sealed with cavity varnish while others prefer to remove the smear layer to promote better connective tissue healing. Bevel only as much as necessary for optimal visualization of the root face, in order to locate possible additional canals, isthmi, anatomic variations and vertical root fractures. Indications Removal of pathological processes and anatomic variations Increased number of accessory canals in apical 3 mm Removal of operator errors Iatrogenic complications prevent apical seal Enhance removal of soft tissue lesion Access the canal system Evaluation of adaptation of canal filling material Enhance adaptation of canal filling material Facilitates placement of root-end filling to produce an apical seal Reduction of apices which have penetrated bone Exploration for aberrant canal anatomy or root fractures Procedure The traditional 45 bevel has been replaced by a less steep angulation (0-20) Resect the entire root-end Remove 3mm if possible, but remember to leave 3mm for root-end preparation and root-end filling (may need to resect less if a post is close to the apex) Do not jeopardize crown-root ratio Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with root end resection and retrograde filling. J Endodon 1994;20(1):22-6. Bottom line: increasing the depth of root-end filling significantly decreased apical leakage and there was a significant increase in leakage as the amount of bevel increased. The minimum depths for a root-end cavity preparation (measured from the buccal aspect of the cavity) are 1.0 mm, 2.1 mm, and 2.5 mm for 0, 30, and 45 angles of resection, respectively.

ROOT-END PREPARATION Many endodontists feel that a root-end filling is required 100% of the time. Harrison and Todd have demonstrated that this is not true. The decision to place a filling needs to be based on the actual visualization of the nonsurgical filling once the root has been resected. If there is any doubt about the quality of the debridement or obturation of the root canal, a root-end filling should be placed. Armamentarium Microhead handpiece Too large for area Requires large osseous window or excessive root bevel Difficult to achieve preparation in long axis of root Makes large preparation (often too large for isthmus preparation) Ultrasonic tips There has been a natural progression to the utilization of ultrasonics for the preparation of the root end to receive a filling material. The literature suggests many advantages of ultrasonic debridement of the root end, including:

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Easier access (requires smaller osseous window), thus reducing the angle of the resection bevel Cleaner root-end preparations Smaller, easier to achieve preparation in long axis of root May create more microfractures of root than microhead handpiece Waplington M, Lumley PJ, Walmsley AD. Incidence of root face alteration after ultrasonic retrograde cavity preparation. Oral Surg 1997;83:387-92. Bottom line: Ultrasonic root-end preparations made using light pressure with instruments set at low to medium power cause fewer cavosurface chips than higher settings. The Neosonic instrument does not appear to cause root cracks. Note: this study used a machine of relatively low power (Neosonic). Some studies do show cracking with units that have more power and/or used for longer preparation periods, but other studies do not agree. The final answer is not known, but it is probably better to use lower power, light touch and minimal contact time. Another option is to remove the gutta percha with a heated instrument and then just refine the preparation with the ultrasonic instrument. Types of preparation Class I preparation - 3 mm deep into canal, centered in the long axis of root, and preparing the isthmus commonly found between canals Hsu YY, Kim S. The resected root surface - the issue of canal isthmuses. Den Clin N Amer 1997;41: 529-40. Bottom line: when a resected root exhibits more than one canal, assume an isthmus exists between them and design the root end preparation accordingly. C-shaped canal systems can have unusual configurations, calling for complex root-end preparations. Slot preparation - prepared on the side of the root in the long axis, including the entire depth of the canal - useful when carbide or diamond burs must be used to resect posts or other hard materials that cannot be cut with ultrasonic tips or conventional microhandpiece burs

HEMOSTASIS The best hemostatic agent is adequate infiltration of anesthetic solutions containing epinephrine (1:50,000 preferred). Additional hemostatic agents and methods include: Epinephrine-containing cotton pellets, ferric sulfate (Cut-Trol - 37% or Astringedent 15.5% - keep off soft tissue), bone burnishing and cautery. Ferric sulfate is cytotoxic. 15.5% works fine in endodontic surgery. There is really no need to use the more caustic 37.5%. Jeansonne BG, Boggs WS, Lemon RR. Ferric sulfate hemostasis: effect on osseous wound II. With curettage and irrigation. J Endodon 1993;19:174-6. Bottom Line: Ferric sulfate must be removed by curettage and irrigation before flap replacement or healing will be impaired. healing.

Aurelio J, Chenail B, Gerstein H. Foreign-body reaction to bone wax. Report of a case. Oral Surg Oral Med Oral Pathol 1984 Jul;58(1):98-100.

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Bottom line: The use of bone wax as a hemostatic agent is discouraged due to its likelihood of causing a foreign body reaction and interfering with repair of the surgical site.

ROOT-END OBTURATION The ideal root-end filling material should: Seal canal in three dimensions Be well tolerated, with no inflammatory reaction Be nontoxic Not promote, and preferably inhibit, the growth of pathogenic microorganisms Stimulate the regeneration of normal periradicular tissues Not be affected by moisture Not be absorbable within the confines of the tooth, but excess should be resorbable Be dimensionally stable Not corrode or be electrochemically active Not stain the tooth or tissues Be easily distinguishable on radiographs Adhere or bond to the tooth without undercuts Materials Contemporary options include IRM, Super-EBA mineral trioxide aggregate (ProRoot MTA), glass ionomer cement and resin bonded materials. Others include gutta-percha, Cavit and amalgam. IRM powder - zinc oxide 80%, polymethylmethacrylate 20% IRM liquid - eugenol 99%, acetic acid 1% Super EBA powder - zinc oxide 60%, alumina 30%, natural resin 6% Super EBA liquid - eugenol 37.5%, ortho-ethoxybenzoic acid 62.5% Dorn S, Gartner A. Retrograde filling materials: a retrospective success-failure study of amalgam, EBA and IRM. J Endodon 1990;16:391-4. Bottom line: In a retrospective study found a success rate for amalgam root end fillings to be 75%, compared to 91% success with IRM and 95% success with EBA. There was no significant difference between IRM and EBA. Bondra DL, Hartwell GR, MacPherson MG, Portell FR. Leakage in vitro with IRM, high copper amalgam, and EBA cement as retrofilling materials. J Endod 1989 Apr;15(4):157-60 Bottom line: Found IRM and EBA to have less dye leakage than amalgam with Copalite in retro-preparations. No statistical difference between IRM and EBA. MTA powder - 75% Portland Cement (tricalcium silicate, tricalcium aluminate, dicalcium silicate, tetracalcium aluminoferrite), 20% Bismuth Oxide, 5% Gypsum MTA liquid sterile water Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endodon 1995; 21(12): 603-08. Bottom line: less periradicular inflammation with MTA compared to amalgam. Also found that cementum will actually form on MTA surface.

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Frank A, Glick D, Patterson S, Weine F. Long-term evaluation of surgically placed amalgam fillings. J Endodon 1992;18:391-8. Bottom line: in a retrospective study found success rate for amalgams over 15 years to be only 57.7%. Placement of root-end filling materials Microcarrier or Prima Endo-Gun for amalgam and MTA Tip of wax spatula or plastic instrument for IRM or EBA Messing gun, Centrix syringe with tube tip or similar instruments may be useful Radiographs One or more before flap closure, to ensure all excess filling material has been removed and all aspects of surgery (multiple roots, resections, fillings, etc) are visible. Citric acid application Apply 50% citric acid (pH 1) to the root end for 2 minutes to demineralize the dentin and expose collagen for attachment and new cementum deposition. Questionable value. Craig K, Harrison J. Wound healing following demineralization of resected root ends in periradicular surgery. J Endodon 1993;19(7):339-47. Bottom line: resected root ends demineralized by application of 50% citric acid at a pH of 1.0 for 2 minutes showed more cementum deposition and better healing than undemineralized root surfaces. Note: study done in dogs may or may not happen in humans, but currently thought to be a good thing to do.

SITE DEBRIDEMENT AND CLOSURE Completely debride site (particularly of any ferric sulfate used) and irrigate copiously using sterile saline. Inject post-surgical bupivacaine-HCl/epinephrine 1:200,000. Reapproximate the flap and compress tissues against bone with moist 4x4 gauze for 5 minutes Suture from unattached to attached tissue Place minimum number of necessary sutures Place suture knots on fixed tissue Interrupted sutures are commonly used. Most techniques bisect papilla when suturing interproximal area. Consider vertical mattress to minimize trauma to papilla. Horizontal sutures for releasing incision can minimize trauma to small papilla at end of flap Avoid excessive tension Different types of sutures are available (non-wicking, monofilament are best) Hydration of some suture material is important (gut, silk) Apply firm pressure again for 3-5 minutes after suturing POST-SURGICAL CARE Post-op vital signs Post-op radiograph (consider making film before closure to minimize disruption of flap postsurgically and to rule out residual tooth fragments or restorative materials) Flap compression - place firm pressure on the flap for 5-10 minutes. Leave gauze dressing on surgical flap and instruct patient to remove in 30 minutes. Application of cold - provide patient with initial ice pack and demonstrate proper placement. 15-20 minutes on, 15-20 minutes off, for 3-4 hours (some references recommend 6-8 hours Discuss and reemphasize any medication regimens. Prescriptions 18

Analgesic (NSAID) Narcotics (rarely necessary if NSAID is given pre-operatively and tissues are managed carefully) Chlorhexidine mouth rinses Antibiotics, if needed Discuss post-surgical instructions with patient and escort (if applicable) and provide written post-surgical instructions, with your phone number in case of emergency. Schedule patient for removal of sutures in 2-4 days (no later than 5 days). Follow-up telephone call Recall (1, 3, 6, 12 months, yearly) Most patients do very well after endodontic surgery. A careful, minimally traumatic, and sterile technique will help to minimize complications. Optimizing use of the following adjuncts is also important. The use of Marcaine (bupivacaine) at the end of the procedure will often provide the patient 6-10 hours of postsurgical anesthesia/analgesia. A nonsteroidal anti-inflammatory agent, such as Motrin (ibuprofen) should be used pre-surgically, and continued post-surgically, unless contraindicated. Most patients state that they only needed to take the Motrin for 24-48 hours. Also, Peridex (chlorhexidine) will greatly minimize plaque formation on the surgical flap and in the wound margins.

RECENT ADVANCES IN ENDODONTIC SURGERY Surgical microscope Improved instruments for microsurgical preparation Ultrasonic tips for preparation Surgical Impact Air 45 high-speed handpiece Micro-mirrors, blades, condensers, and other instruments Stropko irrigator Improved root-end filling materials Use of regenerative techniques during endodontic surgery EXTRACTION-REPLANTATION (INTENTIONAL REPLANTATION) Indications: Nonsurgical endodontic therapy and conventional surgical endodontics are not possible and tooth would otherwise be lost Patient unable to tolerate or not a good candidate for lengthy conventional endodontic surgery Contraindications: Non-restorable tooth Severe periodontal disease Widely divergent or dilacerated roots that might fracture during extraction (a relative contraindication - it may still be possible to replant a tooth when a curved root has fractured during extraction) Technique Attempt nonsurgical endodontics as well as can be performed Restore access with amalgam or resin to prevent fracture (consider bonded restoration) Relieve occlusion Oral prophylaxis/degerming with chlorhexidine 19

Antibiotics, to prevent inflammatory resorption Atraumatic extraction (2 operators, one for endodontic procedures and one for extraction and socket). Avoid injury to cementum Keep tooth moist (Hanks Balanced Salt Solution best; saline 2nd choice) Minimize extraoral time Do not curette walls of socket Root-end resection and root-end filling or other procedures Replant, manually compress cortical plates over replant Splint, if necessary

CYSTIC DECOMPRESSION Indications Large lesion where surgery might devitalize the pulp of an adjacent tooth and healing may be slow if only nonsurgical endodontics was done Technique option Fabricate tube with collar using heated spatula and section of IV tubing (pediatric nasogastric tubing is even better. It is radiopaque and easier to visualize on radiographs or find if displaced) Aspirate lesion Create a small vertical incision into osseous fenestration Trim tube to fit into depth of lesion without protruding Insert tube and instruct patient in saline irrigation - 10 ml three times daily Monitor patient weekly and remove tube when no more debris is removed by flushing procedures Mucosal opening should heal within 1 week Follow resolution of lesion with radiographs every few weeks initially When radiographic evidence of lesion resolution is evident, follow every 3 months If lesion does not show evidence of healing, surgical treatment and biopsy are indicated

PERFORATION REPAIR Consider non-surgical repair if defect accessible from within tooth and significant bone would be removed for surgical access. Do not sacrifice bone support of adjacent teeth. Extraction may be prudent Access and visualization of the defect are essential for successful surgical repair. Consider extraction and replantation procedure if surgical access will be difficult/impossible Envelope or triangular flaps are best Excellent flap management, repositioning and suturing will minimize development of periodontal defect Refer to Endodontic Misadventures section for further details have to

PERIODONTAL MANAGEMENT Root amputation Must have smooth contour with no ledge or lip of root Two types: Vertical root amputation Horizontal root amputation Hemisection 20

Remaining root prone to fracture due to occlusal forces of restoration not in line with long axis of the root Consider minor tooth movement to align root so occlusal forces are along long axis Do not restore as a cantilever Regeneration Techniques Grafting materials: Demineralized Freeze-dried Bone Hydroxyapatite Calcium Sulfate (surgical plaster of paris) Ceramics Membranes Resorbable Non-resorbable Rankow HJ, Krasner PD. Endodontic applications of guided tissue regeneration in endodontic surgery. J Endodon 1996;22(1):34-43. Bottom line: the following are possible applications of GTR in endodontic surgery: Apical pathosis Apical pathosis that communicates to alveolar crest Dehiscence Proximal bone loss Developmental grooves Root or furcation bone loss caused by perforations Cervical root resorption Oblique root fracture Ridge augmentation in conjunction with root resection or extraction

INCISION AND DRAINAGE/SURGICAL TREPHINATION

STUDY QUESTIONS FOR 2006 ORAL EXAMINATION: 1. Understand and discuss coronal leakage and contamination of RCT, and its relationship to case failure. 2. Describe the pathogenesis for periradicular pathosis development. 3. Which bacteria are often associated with apical periodontitis and endodontic infections? Discuss the %s of the various types found in an endodontic abscess (i.e. gram +/-, aerobic/anaerobic). 4. Discuss potential sources of pulpal bacteria in a traumatized tooth with an intact, unrestored crown. 5. Describe the mechanism of anachoresis. 6. When do you consider performing an incision and drainage (I&D) procedure? 7. Discuss the various interfascial space infections and their boundaries. 8. Discuss the potential etiologies and dangers of cavernous sinus abscess. 9. List teeth potentially responsible for the various space infections. 10. Discuss the management of a medically compromised patient, e.g. a diabetic, with failing RCT and phoenix abscess; discuss diagnostic work-up and immediate treatment needed. Also discuss your antibiotic considerations/choice and rationale. 11. Discuss Garres osteomyelitis. 1. Odontogenic Infections

Maxillary Teeth
Most maxillary teeth erode 21

through cortical plate below muscle attachment Appear initially as vestibular abscess Occasional palatal abscess Lateral incisor Lingual inclination Maxillary first molar Palatal root Space infections Canine space infection Long maxillary canine Above levator anguli oris insertion Buccal space infection Maxillary molars Above buccinator muscle attachment

Mandibular Teeth
Mandibular incisor, canine and premolar infections usually erode Through facial cortical plate Above muscle attachment Result in vestibular abscess Mandibular first molars Drain either buccally or lingually Mandibular second molars Perforate either buccally or lingually Usually to lingual Mandibular third molars Infections almost always erode through the lingual cortical plate Infections that drain lingually Mylohyoid muscle attachment determines pathway Sublingual space above mylohyoid muscle Submandibular space below mylohyoid muscle Determine Severity of Infection How long has infection been present? Time of onset Duration Rapidity of progress Signs and symptoms Dolor pain Tumor swelling Calor warmth Rubor erythema Functio laseo loss of function How does patient feel? Malaise Patient feels fatigued, hot, sick, or out of sorts Generalized reaction to moderate or severe infection Vital Signs Severe Infection Temperature elevated to 101 to 102 F or higher May be lower if patient has taken aspirin or acetaminophen Blood pressure mild elevation in systolic pressure 22

Pulse rate increased above 100 beats per minute Respiratory rate elevated to 18-20 breaths per minute Intraoral examination Diagnostic tests Radiographic examination Diagnosis Pulpal diagnosis Necrotic pulp (or failing RCT) Periradicular diagnosis Acute apical abscess (has no periradicular radiolucency) Phoenix abscess (has periradicular radiolucency) Management Remove cause of infection Pulpectomy Extraction Establish surgical drainage Pulpectomy or extraction Incision and drainage Systemic antibiotic, if indicated Indications for systemic antibiotic Systemic signs of infection Immune-compromised host Infection refractory to conservative therapy Recurrent infection 2. Incision and Drainage Rationale for incision and drainage Decreases number of bacteria Reduces tissue tension Alleviates pain/trismus Improves circulation to region Prevents spread of infection Alters oxidation-reduction potential in tissue Accelerates healing! Technique Anesthesia Regional nerve block Infiltration Anterior and posterior to area to be drained Avoid needle track infection Mepivacaine has lowest pKa Obtain culture specimen, if indicated Indications for culture and antibiotic sensitivity testing Rapidly spreading infection Nonresponsive infection Recurrent infection Compromised host defenses Carried out as initial portion of surgery 23

Disinfect surface mucosa Betadine/Peridex scrub Dry with sterile gauze Insert needle into abscess cavity 18-gauge needle, 5 cc syringe Aspirate 1-2 cc pus Deliver specimen directly to microbiology lab This method permits Aerobic cultures Anaerobic cultures Gram staining Incision No. 11 blade Most dependent area of swelling Subperiosteal 1-2 cm opening Blunt dissection Periosteal elevator, curved hemostat Insert closed Open to separate tissues Extend into adjacent spaces Obtain specimen for culture, if indicated If no specimen obtained previously Copious sterile saline lavage Insert drain, if indicated Penrose drain Insert using hemostat Suture to healthy tissue Drain should remain until drainage stops Usually 2-5 days Postoperative care (Possible depressed host defense mechanisms) Maximize hydration High calorie nutritional supplements Warm saline rinses/soaks Optimize oral hygiene efforts Prescribe chlorhexidine gluconate rinses, analgesics Emphasize compliance with antibiotic regimen (if indicated) each visit Careful follow-up Daily follow-up (for infections with systemic signs) until symptoms subside Improvement should occur by 72 hours Consult early/provide referral in refractory cases 3. Cortical Plate (Surgical) Trephination When severe periapical inflammation or infection is present and the cortical plates of bone are intact, the patient may experience excruciating pain. There is little or no place for the exudate and the corresponding pressure to escape. Ideally, drainage would be created through the root canal space, by removal of obturating materials (if present) and apical trephination, if necessary (extending small files, up to size #25, 1 mm beyond apical foramen). Occasionally, however, the canal space is blocked (by a post, e.g.) and canal drainage is not possible. Surgical trephination is a procedure, which penetrates through the cortical plate of bone to allow drainage and relief of pressure to occur. This procedure can be accomplished with a small incision and penetration through bone with an endodontic hand instrument or bur. Surgical trephination is strongly considered when pain cannot be controlled through intracanal drainage procedures, and when systemic analgesics have proven ineffective. 24

Definition A surgical technique used to alleviate acute pain caused by an accumulation of purulent material, when drainage through the root canal is impossible. Cases requiring trephination Characteristic findings Tremendous pressure Excruciating pain Sometimes referred to as intraosseous acute apical periodontitis or apical abscess Example: Patient presents with Severe pain Extreme percussion tenderness No swelling Previous root canal treatment Post and core Periapical radiolucency Example: Patient presents with Severe pain Extreme percussion tenderness No swelling No previous root canal treatment Small periapical radiolucency No drainage from canal, upon opening and debridement Continued severe post-op pain

Technique Presurgical periapical radiograph Establish tooth length Detect Presence of lesion Status of the root canal Root angulations Relationship of adjacent teeth and significant anatomical structures Anesthesia Block anesthesia Infiltration anesthesia Incision Vertical mucoperiosteal incision to cortical bone Approximately mid-root Either M or D to apex, considering anatomy Avoid significant structures Choose interradicular region having greatest dimension/safety Avoid trephination into root eminence Tissue reflection Reflect tissue Expose cortical bone Inspect bone for fenestration Cortical bone penetration Penetrate cortical plate with endodontic explorer or round bur Create pathway through cancellous bone to apex using file 25

Floss tied to handle Confirm proper position with radiograph Be aware of anatomy! Inferior alveolar nerve Mental foramen Adjacent roots For additional orientation information Place lead foil into osseous wound Make radiograph Compare actual location with desired location Post-operative follow-up Same as with I&D Follow course of recovery Remember Cortical trephination only relieves symptoms and is not definitive treatment! 4. Antibiotics Choice of antibiotic Chosen empirically initially Drug of choice Penicillin Alternative drugs Clindamycin Metronidazole Penicillin First drug of choice Spectrum Gram (+/-) aerobic cocci Most anaerobic rods Dosage 1-2 gm loading dose 500 mg every 6 hours for 7-10 days Clindamycin Second drug of choice Allergy to penicillin No change in patient after 48 hours on penicillin Spectrum Gram (-) anaerobic rods Gram (+) aerobic streptococci Dosage 300-600 mg loading dose 150-300 mg every 6 hours for 7-10 days Potential problem Antibiotic related colitis (pseudomembranous colitis) Diarrhea 6 or more loose stools in 24 hours More common in debilitated patients on long-term antibiotics Metronidazole (Flagyl) Spectrum All anaerobic gram (-) rods 26

Anaerobic gram (+) cocci Facultative aerobes are resistant! Dosage 250 mg every 6 hours 500 mg every 8 hours Used in conjunction with other antibiotics Inactive against most aerobic bacteria Combine with penicillin Adverse effects Antabuse effects

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