The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses
in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Original Title
Surgical Endodontics / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses
in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses
in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The scope of endodontic surgery has expanded beyond apicocectomy to
include periapical curettage, redisectomy, replantation transplantation, implantation, trephination, incision for drainage and root submergence. The term apicoectomy meant the resection of the root apex, surgical procedures performed around the root is termed as periradicular surgery. Failure may occur in small percentage of cases with non-surgical endodontics therapy that eliminates periapical inflammation or infection and allows teeth to be retained in a free healthy state, when confronted with such cases the clinician should be prepared to initiate alternative procedure including surgery to enhance the rate of success. History according to Ingle Endodontic surgery has first recorded 15 years ago when !eticus, a "ree# physician dentist excised an acute apical abscess with a small scalpel. $ater the procedure was refined and populari%ed by &ullihen in 1'(). Fawas *1''+,, -hein *1')+, and "... /lac# *1''0, described root amputation techni1ues and in 1)1) "arvin demonstrated retrofillings radiographically. 1 Classification Endodontic surgery encompasses surgical procedures performed to remove the causative agents to radicular and periradicular disease and to restore these tissue to functional health. 2t can be classified as follows3 1. Surgical drainage a. 2ncision. b. Trephination 2. Radicular surgery a. !pical surgery i. 4urrettage and biopsy. ii. !picoectomy. iii. -etrofilling. b. 4orrective surgery i. 5erforative repair 6echanical -esorptive ii. 5eriodontal repair "T- -esection 3. Replacement surgery a. -eplant surgery 2ntentional 5ost traumatic 7 b. Endosteal implant surgery Endodontic 8sseointegrated ( According to Grossman periapical surgery can be classified as: 1. -oot resection or apical curettage following an orthograde filling. Either in one stage that is, immediate root resection, or in tow stages, in which multiple appointments separate non surgical and surgical procedures. 7. 8rthograde filling during root resection or periapical curettage. (. -oot resection and retrograde filling. +. -oot resection and retrograde filling following an orthograde filling *in one stage or two procedures,. Indications and Contra Indications 4lean well obturated canals are the biological basis of endodontic success mar#ed improvements in the non surgical techni1ues have improved the success rate, however if cleaning of the canal terminus root canal access is impossible, *a surgical approach should be considered, whenever a root canal cant be filled properly with an orthograde filling endodontic surgery should be considered. ! classical characteri%ation of specific indication and contraindication has developed by $eub#e, "lic#, and 2ngle. /ased on the classifications. Indications of endodontic surgery (Grossman) 1. !ny condition or obstruction that prevents direct access to the apical third of the canal such as3 + a. !natomic 9 calcifications, curvatures, bifurcations dens in dente and pulpstones. b. 2atrogenic 9 ledging bloc#age from debris, bro#en instruments old root canal fillings and cemented posts. 7. 5eriradicular disease associated with a foreign body, overfilled canals, bro#en instruments protruding into apical tissue and loose retrograde fillings. (. !pical perforations3 any perforation that can:t be sealed properly by a filling within the canal. +. 2ncomplete apexogenesis with blunderbus or other apices that do not respond to apical closure procedure. 5. &ori%ontally fractured root tip with periradicular disease. 0. Failure to heal following non surgical endodontic treatment. ;. 5ersistant and recurring exaggeration during non-surgical treatment or persistant, unexplainable pain after completion of non surgical treatment. '. Treatment of any tooth with a suspicious lesion that re1uires a diagnostic biopsy. ). Excessively large and intruding periapical lesion. 1. <estruction of apical constricture of root canal due to uncontrolled instrumentation. 5 Contra Indications for endodontic surgery 1. 2ndiscriminate surgery. 7. 5oor systemic health. (. 5sychological impact. +. $ocal anatomical considerations. Indiscriminate surgery : Endodontic surgeries should not be a cover up for every endodontic case or a cover up for the s#ill in non surgical endo techni1ue. =urgeries are not simply indicated because a periadicular lesion is present at the time of treatment, is because a large lesion is present or because the clinician believes a lesion may become cystic. Poor systemic health : ! complete medical history is mandatory. 2f a 1uestion exists about the patients health, medical consultation must be sought with the patients physician. 4ontraindications include blood dyscrasias is neurological problems, terminal illeness, diabetes, heart diseases, pregnancy in first and third trimestor. 5sychological emotionally distressed patient, a patient unable psychologically to withstand or cope with any surgical procedure. Limitations in the surgical skill and experience of the operators Local Considerations 1. $ocali%ed acute inflammation, whereas emergency procedure such as incision and drainage or trephination may be indicated, elective periapical surgery should be avoided. 0 7. !natomical considerations, procedures that penetrate the mandibular canal, maxillary sinus, mental foramen, floor of the noses or that sever the greater palatine blood vessels should be avoided whenever possible. (. 2naccessible surgical sites, inaccessible position and location of root apices especially in posterior teeth and the need to gain access to the surgical sites third dense layers of bone, such as the lingual surface of molars or the external obli1ue ridge of the mandible may preclude a successful result. +. Teeth with a poor prognosis short rooted teeth, with a advanced periodontal disease, vertically fractured teeth, non strategic and understorable teeth should not be considered for periapical surgery. 5. Finally, peripical surgery should not be considered as a cureall to compensate for inade1uate techni1ue that resulted in failure to heal, surgical treatment of teeth should not be done for experience alone. Anatomical considerations Maxilla - The maxillary incisors and the alveolar process are closely related to the floor of the nose. - ! combination of short alveolar process and long roots allows the incisor apices to contact either bony plane of the nasal floor. - The lateral incisors however are seldom or close to the nasal floor as are the central incisors. ; - The canine occupies a >neutral position? between the maxillary sinus and the nasal cavity and has no intimate relationship to either cavity. - The maxillary incisors and canines are often covered with little or no labial cortical plate. - =econd premolar are closer to the maxillary sinus wall wherever molars sometimes reach the floor and at times protrude into the sinus. - !lthough the maxillary sinus membrane perforation usually doesn:t cause postoperative problems, care must be ta#en to prevent root tips, bone or other foreign bodies being inadvertently pushed into the sinus. - ! prominent %ygomatic process may impede surgical access to the root of a maxillary molar tooth. - ! palatal root of the first or second molar that is closely aligned with the greater palatine foramen. The position and course of the palatine bundle must be carefully determined when placing a palatal approach to the palatal root. To avoid vessels, palatal access is gained by reflecting a flap created by ma#ing a vertical incision between the premolars and a short distal releasing incision of the tuberosity. Mandile - 2n gaining surgical access and isolating the apex of the lower incisors, one must ta#e care that the lingual alveolar plate is ' not also perforated anterior alveolar process is 1uite narrow in labiolingual dimension. - 5roximity of the mental foramen to the apices of mandibular premolars and on occasion to the first molar. - Thic# external obli1ue ridge in the second and third mandibular molar region. - The mandibular canal doesn:t interface with surgical access except when a shallow mandibular process is associated with long roots. @nowledge of the most common location of a maAor nerve, such as the inferior alveolar nerve in the mandibular canal, is of critical importance it allows better control of the surgery and less li#elihood of postoperative parasthesia. - $itter and associates found the average vertical distance from the upper border of the mandibular canal of the apices of the second molar and the first molar to be (.5 and 5.+ mm respectively. - !ccess for mandibular endodontic surgery from the lingual aspect is extremely clumsy and unnecessary. <amage to the lingual nerve or artery may occur, as well as the possibility of confronting a wide mylohyoid ridge. The buccolingual position of the canal can be determined by comparing a 285! exposed at right exposed at right angle to the long axis of the tooth with a second radiograph exposed at a vertical angulation of 75B and the central beam directed superiorly, if in the second film the mandibular canal waves ) inferiorly in relation to the roots apices, the canal is lingual in the apices, if it moves upwards on the roots it is buccal, is the apices minimal movement of canal indicates that it is in close proximity to the apices. re!operati"e consultation #ith the patient ! proper preoperative consultation is an essential part of the total surgical experience for both the patient and the clinician. The procedure should be described in detail as should are potential postoperative problems such as discomfort, swelling, bleeding, brushing, maxillary anterior penetration and rare possibility of parasthesia. 5atient should be as#ed to sign that attest to them understanding and treatment procedure, ris# and fees. re!operati"e preparation and medication 5remedication becomes necessary when a patient remains overly anxious and unaffected by the pre-operative consultation. The premedication drugs selected should reduce anxiety, enhance the anesthetic to be administered, and favourably reduce salivation *antisialagues,, bleeding *epinephrine, or secondary infection *antibiotics,. Antiseptic mouth#ash 4hlorhexidine gluconate reduces the levels of fracture in the oral cavity and plays a important role in healing following endodontic surgery, for this patient is instructed to rinse with the solution for 1 min twice daily for 5 days. This regimen should begin the day before surgery. $on steroidal anti!inflammatory drugs 1 !dministration of non-steroidal anti-inflammatory drugs before the surgical procedure helps to reduce postoperative pain and swelling. 2buprofen enacts its effects by inhibiting the en%yme cycle-oxygenase and preventing the formation of inflammatory mediators. 2ts analgesic and anti- inflammatory properties result from inhibition of peripheral prostaglandin synthesis. ! loading dose of 0mg 7 hours before surgery, and +mg every + hours postoperatively is advised short acting barbiturates, such as pentobarbital and secobarbital are fre1uently used for sedation. 4ommonly administered orally, 5, 15mg C ( min prior to the surgical treatment. Tran1uili%ers are effective drugs for surgical premedication because they reduce apherhension, are sedatives and act as miracle relaxants. Either meprobamite, +mg 9 + times daily for several days prior to treatment or dia%epam *valium, 5mg ta#en orally (0 min prior to treatment is an effective tran1uili%er and relaxant. Impro"ing "isibility Endodontic surgical procedures are delicate and precise. The 1uality of endodontic surgery improves dramatically when the surgical fields in well illuminated, magnified and bleeding is controlled. Illumination Dsing specially designed clips fibre-optic cable can attached directly to surgical retraction and aspiration, head lamps are also available with 1uart% bulbs clipped to surgical telescopes and operating from either direct current or battery pac#. 11 =urgical microscopes with a light source aimed directly at the site provide by far the best method of illumination. 17 %agnification 6agnification of the operative site ma#es it easier to differentiate root from bone to locate the entire root surface during root end resection to locate unfilled root canal systems and to better visuali%e root and preparations and fillings. &isors and loupes 6any inexpensive visors and loupes are available and provide magnification from 1.; upto 1+. !elescopes : are available with magnification capabilities between f7 and f', some models are attached to a headband, but in the most popular models the optics are affixed to specially designed spectacles. Telescopes can be obtained with varied fields of vision *standard, widefield, expanded field and extended range,. Eide field magnification is becoming the most popular choice among endodontic surgeons. %icroscopes =urgical microscopes provide magnification levels of between f+ and f+ after features such as through the lens fibre-optic illumination, (m magnification foot pedal focusing and accessory optics for dental assistants. !lthough these scopes provide crisp undistorted images proficiency in their use demands time and patience. 'urgical instruments and materials ! surgical setup should consists of all sterile instruments and materials needed to complete the contemplated procedure, too few instruments cause 1( consternation for the surgeon who cannot efficiently and effectively complete the tas#. Too many instruments lead to confusion and hesitation, the operator can supplement or replace any instrument listed to accommodate personal preference. 'urgical setup for periapical procedures 1. !naesthesia, aspirating syinge, disposable needle and several capsules of desired local anaesthesia such as lidocaine hydrochloride, 7F epinephrine 135,. 7. 2solation of the operative site. =terile 1x7 cotton gauge s1uares, and cotton pellets *alcohol sponges or topical antiseptic solution should be available to swap the operative site,. (. 2ncision 3 /and par#er handle, Go. 15 blade and periodontal probe *to help determine flap design,. +. Flap Elevation and retraction, periosteal elevator. 5. 5enetration and removal of cortical bone plate, root resection and preparation for retrograde filling is the root apex. !ssorbed straight hand piece burs had chisel, sterile saline or anaesthetic solutions for use as a coolant and for debridement. 0. 4urettage "oldman for H( curett, surgical excavator &u-Fiendly Go.-) or Go.-11. ;. -etrograde filling apical amalgam carrier, plastic instrument, apical amalgam plugger. 1+ '. =uturing, needle holder or hemostat, (- or +- sil# suture on an a traumatic needle and scissors. ). =urgical tray, cotton pliers, explorer, mirror and cotton or racellets. &aemostasis can be achieved by use of alugauage, gel form, bone wax or other physical barriers, cotton, cotton roll or gauge saturated with adrenaline are least desirable materials as the residual cotton fibres left in the crypt provo#e a latent foreign body resection. !stringents such as 15.5F ferric sulphate burnished into a area of fleeding promotes haemostasis rapidly. Anesthesia ! solution of lignocaine containing adrenaline 131, is used for a bloc#, and lignocaine containing adrenaline 135, is used for infiltration. 2nfiltration anesthesia, using a aspirating syringe is ade1uate for most maxillary periapical surgery. The anesthetic is inAected subperiosteally over the operative site, attempt to inAect deeper tissue may prove counter productive because of li#elihood of inAecting into s#eletal muscle for additional anesthesia during the surgical procedure, the anesthetic can be inAected directly into the bony madullary spaces inside the open wound. 4onduction anesthesia, in which the anesthetic solution is deposited near the mandibular foramen is used for mandibular periapical surgery. The infraorbital inAection, posterior superior alveolar bloc# is rarely needed for elective periapical surgery used only in emergency situations to 15 avoid inspiriting needles and depositing anesthetic solution into acutely inflamed and swollen tissue. (lap design 4ertain cardinal principles that apply to all flap design are3 1. The base of the flap should wider than the free end, to ensure ade1uate circulation into the flap. 7. The sutured flap margins should rests on solid cortical bone plate. (. 2ncisions should be made with a finer, continuous stro#e, perpendicular to the cortical bone plate the periosteum retracted with the flap, that is a full thic#ness flap of mucoperiosteum. +. The flap should be designed with continuous curvatures between the hori%ontal and vertical incisions to avoid sharp angles that tear. 5. ! sinus tract when present should be included in the flap. 0. -eleasing incisions should be made between the bony eminences because tissue even such structures is thin and stretches and tears when sutured. ;. 5roperly designed, a retracted flap can be held in position with passive pressure by means of a periosteal elevator pressed against underlying solid bone. '. Flap should generally extend one or two teeth laterally to allow for relaxed retraction and prevent stretching and tearing. ). !void incision over a bony defect. 10 )he basic flap designs used in endodontic surgery 1. Gingi"al flap : indicated in cervical area perforations, advantage is no vertical incision, ease of repositioning disadvantage of limited access and visibility difficult to reflect. 7. 'emilunar flap : when no underlying periodontal problems are present esthetic crowns present, trephination. The hori%ontal component of this flap rests on alveolar bone structure at least (mm apical to the gingival crest and ends in the attached gingiva. -educes incision and reflection time, maintains integrity of gingival attachment, eliminates potential crestal bone loss disadvantage of limited access and visibility crosses root eminences may not include active lesion healing is associated with scarring. (. )riangular flap : 2ndicated in midroot perforation repair, periapical surgery involving posterior areas and short roots has advantage of easily modifying with small retracting incisions, additional vertical incision and extension of hori%ontal component. <isadvantages of limited access and visibility to longer roots, tension is created on retraction, gingival attachment severed. +. *ectangular flap : Dseful in periapical surgery involving multiple teeth, large lesion, longer roots. 4an get maximum access and visibility, reduces retraction tension, facilities repositioning. <isadvantage reduces blood supply to the flap increased incision and reflection time, interface with gingival attachment causing gingival recession, crestal bone loss may uncover dehiscene and suturing is more difficult. 1; 5. alatal flaps : the rich vascular supply of the palatal area provides for excellent healing in most instances, palatal flap is prepared with a scalloped incision around the gingival margins. -elaxing incisions are generally placed between the cuspid and bicuspid to prevent severing of the anastomosis of incisive and palatine vessels. <istal incision is placed distal to second molar on the maxillary tuberosity to prevent severing the greater palatine vessels. The free end of the flap could be tied to the teeth on the opposite side of the arch with a suture material. 0. +chesenbein!luke flap : 2ndicated in periapical surgery involving the anterior regimen, longer roots, prosthetic crown present with wide band of attached gingiva advantage is in placing incision and reflection with enhanced visibility and access case of prepositioning, maintains intergrity of gingival attachment. 5revents gingival recession, avoid dehiscence prevents crestal bone loss. <ifficult to alter if si%e of the lesion misAudged, hori%ontal component disrupts blood supply, vertical component crosses microgingival Aunction and enter muscle tissues. ;. *ectangular, )rape-oidal flap : 2ndicated where maximum access and visibility is re1uired li#e in case of multiple teeth, large tension etc. 'urgical )echni.ues .ertical incision may be relieving or relaxing incision, should be continuous, linear and well defined. !void repeated incisions, do not ma#e an 1' incision on bony prominence. 2ntrasulcular invasion follows the contour of the labial surface of the teeth. *eflection 2s initiated with a sharp curves end of a Go. + molt curette or the &u friedly curette. The elevators are used to reflect both the mucous and periosteum. The elevator always on the bone and never on the flap. Hard tissue management The average thic#ness of the bone overlying the mesial root of the mandibular first molar is +.7mm. To penetrate the thic# cortical bone a rotating Go. 0 extra length surgical bur mounted in a high speed impact hand piece should be introduced slowly. This hand piece has an angled head that facilities easy entry and visibility and doesn:t blow air or oil into the surgical site. 4opious irrigation with a sterile saline accompany all attempts to remove bone, Iaccording to Fisher and "ross, 4uelle and EedgehoodJ, irreversible bone necrosis is reali%ed when temperature exceeds 50B4. ! window is cut which is created by preparing an openings in the bone with a long, round bur, =.&. Go. + or 0. Two of the opening penetrate the cortical plate adAacent to the mesial and distal sides of the root near its apical third. The ( rd openings are connected with a superficial cut by means and tissue burs, that is =.&. Go. ;1 or ;7. ! hand chisel &u-Fried% Go. 1 is used to elevate and to remove the cut bone of preparation of >the window? and exposure of the periapical tissue. 1) Fre1uently, especially in the maxillary anterior region, the cortical bone can be penetrated with hand chisels or hand trephines alone. 5enetrating the periapical tissue with hand instruments is more efficient than with burs, is less li#ely to gauge the root and is less frightening for the patient. The window can be extended by hand chisels. To determine the locale of the window use the radiograph as a >road mp?. The radiographic tooth length and root anatomy can be measured and transferred to the mouth for orientation. The osseous topographic features overlying the root, that is through in the mesial and distal aspects of the root itself, are useful. ! radiographic mar#er, such as a small piece of gutta-percha, can be placed on the cortical bone over the proAected site of the root apex, and a radiograph can be exposed in the usual mar#er. This method is accurate for determining which str is immediately beneath the mar#er, and it is accessibility is limited and orientation is uncertains. eriapical curettage and root resection 8nce apex has been located curette and remove all the pathologic soft tissue surrounding the root down to the hard surrouding bone with a "oldman- -d Go.( curette or a surgical excavator. 2f complete curettage is obstructed by the presence of the root, the tip should be reduced carefully by shaving if about 1-( mm with a tapered fissure no. ;4, until the granulation tissue can be removed for biopsy. 2t is suggested that the soft tissue of the lesion surrounding the root should be curetted in total. &owever this is not always possible or practical, 7 especially if the lesion involves the maxillary antrum viability of the adAacent teeth is Aeopardy, or the mandibular vessels. 8ccassionally, the root and apex are difficult to locali%e even after removing the cortical bone. The root can be distinguished from its surrounding by its color, morphologic features, and hardness. -oot structure is harder that the soft cancellous bone with a defined anatomic outline and a different color when viewed in a washed and debrided operative field, 4ambru%%i and associate described use of methylene blue to identify and isolate root apex. The decision to resect the apical tip depends on the 1uality of the seal between the root canal and the surrounding periodontium. 2f the seal is satisfactory, periapical curettage and removal of the pathologic tissue and the extruded filling material will suffice. The old concept of always resecting a root tip is no longer valid. ! root is resected when canals cant be properly obturated, such as an obturation inside the canal, other indication for root resection are3 1. -oot perforation. 7. !pical root fracture. (. 5athologic root defects. - !ny anatomic factors that prevent the proper preparation and sealing of the canal such as calcified, bifurcated, or lateral and accessory canals. &igh-speed fissure burs are used to resect the root end. ! lingual-to- labial bevel angled at (-+5B4 to the coronal aspect of the tooth and in line of 71 sight. The advent of small microscopic surgical mirrors and ultrasonic root end preparation techni1ues are enabled the cut in some cases to be reduced to B. *oot end preparation The basic preparation for a root end filling is best done with a small round bur micro contra angle handpiece. The canal can be located with a sharp explorer or horse scaler. The depth preparation should be 7 to ( mm and in center of the root. $ateral over preparation may result in a wea#ening of the apical root structure and development of crac#s upon condensation or dimensional change of silver amalgam. ! slot preparation is suggested where access is limited. The canal is located and prepared to a vertical length of ( to 5 mm with a no. ; bur and straight handpiece. -etention is placed with a inverted bur. The most commonly used retrofilling material are 2-6 super E/! cement, amalgam, #etac silver glass ionomer cement. (lap closure Following retrofilling procedure, the bone wax or ferric sulfate is removed and the surgical site is thoroughly debrided with irrigating solution to remove any loose particle of filling material, bone or root structure. /efore suture a radiograph should be ta#en to verify the removal of filling particles. -einAection of local anesthetic could help to control bleeding and extend comfort to the patient. 77 *epositioning of flap The flap is closed by gently placing the most apical position of the flap first. The flap is smoothened to place with a 7 x 7 gauge sponge so that the natural and incisional reference points are matched. &amision has recommended 7 to ( minutes of compression to develop a thin fabrin clot under flap. 'uturing The function of the suture is to secure the flap in its original or desired position. =utures that are tightly placed compromise circulation, increase changes of sutures to tear open once the tissues swell. =uturing needles traumatic *eyeless @uaged,, needles which are advantageous because of their reverse cutting edge. - The needle should penetrate 7 to ( mm from wound margin. - =uture materials are divided as3 1. !bsorbable *disposed by body en%ymes,. 7. Gonabsorbable *walled off, E.g. 3 !bsorbable 9 surgical gut *traps food, Gonabsorbable 9 =il# *ethicon, The flap is gently replaced and smoothened into position with a 7x7 gauge sponge until the incisional reference points match. The first suture 7( should pass through the most dependent unattached tissue and the incision can result in teasing of the tissue. ! surgeons #not that is most effective and less li#ely to slip. =ling suspensory or circumferential suturing is an effective techni1ue for maximum tissue adaptation. 2nterrupted sutures may also be placed. ost!operati"e se.uelae The following post-operative se1uelae can occur after endodontic surgery. /0 '#elling !lthough swelling doesn:t occur in all the cases, it is sufficiently common to warrant every effect to prevent it, such as by #eeping trauma to a minimum during operation. Effective method for reducing swelling is the application of control compress over the surgical area for 7 min. every hour post operatively. En%yme preparations and corticosteroids are used but are not recommended for routine use. 10 ain 5ain is usually minor complaint and can generally be controlled with mild analgesics. 20 3chymosis <iscoloration of the s#in from extravasation and brea#down of blood in that area, and can travel along facial tissue planes and may appear near the 7+ angle of the Aaw, under the eye, these >blac#-and blue? mar#s usually disappear within 7 wee#s. 40 arasthesia ! transient parasthesia sometimes lasts from a few days to a few wee#s after root resection in any part of the Aaw more li#ely to occur resection of teeth in the mandible patient should be advised of this possibility before the operation. 50 'titch abscess 8ccasionally a stitch abscess develops. 5ossible causes areK local laceration of tissue during suturing, accumulations of food debris at the site of suturing, typing the #not in the line of incisions or irritation by the suture material itself. 60 Hemorrhage =econdly hemorrhage is seldom observed when occur, a brea#down of the blood clot should be suspected. 2f cold compresses do not stop the bleeding an inAection should be made into the area, wound should be reopened, irrigated with local anesthetic solution, and sutured. 70 erforation 5erforation of the antrum may occur postoperatively in any of the maxillary teeth from cuspid to molar, it is not serious, provided no foreign bodies are introduced, a blood clot forms and a suitable flap has been coated and sutured properly, a prophyactic antibiotic should be considered. 75 80 Iatrogenic Ehen the area of rarefaction is extensive and intrusive it is always possible to disrupt the blood and nerve supply to adAacent teeth during curettage. To prevent this complication root canal treatment and filling may be done first. ost surgical instructions 1. The patient should be instructed to apply an ice pac# for 7-( min. each has the first day. 7. The patient should be raise the lip or engage in extended conversion because such activity can tear out the sutures. (. =hould avoid brushing the teeth near the surgical siteK the sutures can ripped out inadvertently by the toothbrush. +. ! softer or semisolid diet, should be prescribed for the first few days, after eating the patient should debride the wound by flushing it with a saline or bicarbonate soda mouthwash. 5. 5ost-operative pain can be controlled with mild analgesics. 0. Go unwanted, antibiotics should be prescribed, antibiotic of choice is penicillin ., orally administered 1mg to start, followed by 5mg + times daily for ( to + days. For penicillin allergic patient is erythomycin 5mg initially, then 75mg every 0 hr for ( to + days. 70 Additional instructions 1. 2n case of bleeding apply constant steady pressure, using an ice pac# on the face over the surgical site for 7-( min. 7. 2n the event of an emergency, call the dentist. (. -ecall approximately 1 day later for suture removal. *epair The initial repairs occur across the margins of the line of incision. &ealing by first intension usually occurs within 5 days, healing ta#es place across the incisional margin, the length of the incisions is not a factor, if the suture fails or tear, then healing will occur with the fixation of granulation tissue *second intention, lasting + to 0 wee#s. -epairs of periapical tissue is usually complete within a year, and progressive repair should be noticeable on a radiographs 0 months after the operation. Additional surgical procedures !t times, the endodontist is called on to perform other related surgical procedures by modifying and applying the previously described techni1ues using the surgical s#ills and #nowledge needed for periapical surgery. Incision and drainage Ehen the build up of exudates penetrates the cortical plate, swelling occur and pain diminishes, if the swelling persists, that is it locali%e into a soft, fluctuant, palpable mass it should be drained by the 1uic#, sharp thrust of the 7; scalpel that the center of the soft, fluctuant mass down to the solid cortical bone plate after attaining anesthesia *&ilton method,. )rephination ! procedure used to relieve pain, the cortical bone is perforated by engine-driven or hand operated terpine, to release the build up of pressure and exudates around the root apex of a tooth. Trephination will afford emergency relief because, in effect an artificial sinus that is prepared through which trapped exudates in the bone is released. The site must be anestheti%ed, an incision made to expose and penetrate the bone through the cortical plate with a large, round bur Go. +-', and with a sterile coolant. The path of penetration must be a direct line to the periapical tissue surrouding the root apex, any deviation can cause repairable damage to the root itself, such as from penetration into the mandibular canal or mental foramen. Trephination is therefore used infre1uently as a means of pain control. Hemisection and *adisectomy -adisectomy denotes the removal of one or more roots of a molar. &emisection refers to sectioning of the crown of a molar tooth, with either the removal of half the crown and its supporting root structure or the retention of both halves to be used after reshaping and splinting as two premolars. 7' Indications for radisectomy 1. Ehen periodontal involvement of one root is severe. a. Dntreatable furcation involvement. b. Extensive loss of bone has occurred. 7. Ehen endodontic treatment of one root is technically impossible or when such treatment has failed. (. Ehen root has been destroyed by extensive caries. +. Fractured root of an upper molar. Contraindications 1. Ehen loss of bone involves more than one root and the remaining would have inade1uate support. 7. Ehen bridge span is long and the abutment tooth would read inade1uate support. (. Ehen roots are fused. Armamentarium - =urgical length of long shan# fissure bur si%es ;, ;1, 55;, 5''. - $ong tapered fissure diamond stro#es to smoothen retained tooth segment. - Elevator 9 straight, apical elevator. - Forceps 9 upperClower forceps, universal forceps. 7) - Endodontic treatment should proceed root treatment. - ! flap need not be raised if root amputation performed on periodontally not involved teeth. - ! flap has to be reflected if the teeth is periodontally involved. )here are t#o methods by root amputations can be performed: 1. .ertical cut method 3 utili%e a long shan#, tapered fissure carbide bur in airotor to section through the entire crown and root to the furcea in gaining separation. Ad"antages of "ertical cut method 1. <irect visuali%ation of bur penetrates to ensure that preparation will be in the correct position. 7. -emoval of that portion of the crown that is over the root to prevent undesirable postoperative occlusal forces. (. 5osition of each cut, based on the anatomy of the furcea, to allow the root to cleave along desirable angles. +. Excellent visuali%ation of furcea after amputation. 10 Hori-ontal cut preparation &ori%ontal cut made through the tooth without the crown being altered in the preparation. 4utting the tooth in this manner leaves a deep trough between the crown and the alveolar mucosa which is obvious trap for food and debris. ( !ny occlusal forces over the amputed root will be tend to put severe stress from a undersirable direction on the remaining roots. *!mputation procedures on mandibular molars also #nown as bucispidation,. rocedure ! gentle curve is made in a + silver cone and inserted it through furca from the buccal to lingual. The rest of the procedure is as in vertical procedure for maxillary molar. Indications for hemisecton 1. Ehen periodontal involvement of one root is severe. 7. Ehen loss of bone is extensive in furcation area. (. Ehen caries involves much of the root. Contraindications are similar to that for radisectomy rocedure - The roots to be retained undergo endodontic therapy and the pulp chamber is filled with amalgam. - Go filling material is placed into the root to be removed for that entire half of the tooth will be extracted. - ! sharp contour explorer or periodontal probe is used to identify the buccal and lingual furcations. (1 - /y first placing the tip of a high speed tapered fissure bur in the furcation, the operator can effectively section the molar with usually. - !n elevator should be wedged between the two halves and slightly rotated to differentiate if the separation is complete. - The pathologic half is extracted with forceps or eased out with an elevator. - The soc#et area, is lightly curetted and pac#ed with bone waxCgelform. - This is followed by copious irrigation. 'ummary and Conclusion !ll endodontic procedures should ensure the placement of a proper seal between the periodontium and the root canal foramina. Ehen this seal can:t be achieved satisfactorily by wor#ing through the canal system, a surgical procedure presents visual and manipulative control of the area and placement of the seal through the surgical site. Ehen failure occurs in non-surgical endodontic therapy the clinician should be prepared to initiate alternative procedure including surgery to enhance the rate of success. (7 '9*GICAL 3$:+:+$)IC' C+$)3$)'Contents 2ntroduction &istory 4lassification 2ndication and 4ontraindication !natomic 4onsiderations 5reoperative 4onsultation with the patient 5reoperative preparation and 5remedication of the patient !rmamentarium Flap <esign =urgical techni1ue =uturing 5ostoperative se1uelae 5ostoperative management of the patient =ummary L 4onclusion ((