ENDODONTIC

SURGERY
INTRODUCTION
Endodontic surgery is not “oral surgery” in the
traditional sense. Rather, it is actually
“endodontic treatment through a surgical flap.”
Simply cutting off the apex of a root and
placing a filling in the vicinity of the canal does
not accomplish the goals of endodontic surgical
treatment.
The purposes of endodontic surgery include
sealing of all portals of exits to the root canal
system and the isthmuses, eliminating bacteria
and their byproducts from contaminating the
periradicular tissues, and providing an
environment that allows for regeneration of
periradicular tissues.
DEFINITION
 A surgical procedure related to problem of the pulpless or
periodontallly involved tooth, requiring root amputationand
endodontic therapy.
(John I Ingle)

 Removal of tissues other than the contents of the root canal space
to retain a tooth with pulpal and/or periapical involvement.
(Franklin Weine)
 HISTORY

The first recorded endodontic surgical procedure was

incision and drainage of an acute endodontic abscess
performed by Aetius, a Greek physician over 1500 years
ago. Since then, Endodontic surgery and Endodontic
surgical procedures have been developed and refined by
many pioneers in dentistry.
Pre 1900:
• Abucalcis had the 1st recorded treatment in
11th century
• Fauchard , Pare And Hunter in the 17th century
described the techniques and implications of
replantation
• Harris introduced the method of surgical
drainage in 18th century
• Hullihen 1845: ‘Hullihen’s surgery’ or
‘Rhizodontrophy’ or Trephination
• Rhein 1897: Surgical management of alveolar
abscess, Root amputation and Marsupialization
Root end preparation 1st introduced by Saville
1900-1939
• Evolution of focal infection theory by Hunter
• Surgical flap details and review of endodontic
surgical literature: Peter
• Protective dressing by Killian
1940-59
• Cyrus Jones: technique for single visit root
canal fill followed by surgical curettage
• Use of amalgam as root end filling material
1960-90
• Expansion of surgical techniques by Maxmen
• Development of root end filling materials
• Biologic rationale for disease
1990 onwards
• Development of microsurgery with electron
microscope
• Introduction of MTA
• Use of ultrasonic instruments
• Concepts of tissue engineering
Rationale
 To remove the causative agents of periradicular pathology.

 To restore the periodontium to a state of biologic and functional

health.
CLASSIFICATION OF ENDOODNTIC
SURGERY

According to Guttman:
PERIRADICULAR SURGERY
a) Curettage
b) Root-end resection
c) Root-end preparation and Filling

FISTULATIVE SURGERY
a) Incision and drainage
ENDODONTIC SURGERY
b) Cortical trephination
c) Decompression

CORRECTIVE SURGERY
a) Perforation repair.
b) Resorptive, carious, and mechanical perforations.
c) Periodontal management.
d) Root resection.
e) Tooth resection.
f) Intentional replantation.
 ACCORDING TO INGLE
ENDODONTIC
SURGERY

Replacement
Periradicular
Surgical drainage Corrective surgery surgery (extraction/ Implant surgery
surgery
replantation)

Incision and Endodontic

Curettage Perforation repair
drainage (I & D) implants

Cortical
Mechanical Root-form Osseo
trephination Biopsy
(iatrogenic). integrated implants
(fistulative surgery)

Resorptive (internal
Root-end resection
and external)

Root-end
preparation and Hemisection
filling

Root resection
 KIM’S CLASSIFICATION

Class A- Absence of periapical Class B- Presence of a Class C- Presence of a large

lesion, but resolution symptoms small periapical lesion periapical lesions progressing
after non surgical approaches and no periodontal coronally but without
have been exhausted. pockets. periodontal pocket.

Class D- Clinical picture
similar to Class C with a
periodontal pocket.
Class E- Periapical lesion with an Class F- Tooth with an apical
endodontic and periodontal
lesion and complete loss of the
communication but
no root fracture.
buccal plate.
INDICATIONS
1. Need for surgical drainage
 Incision and drainage
 Trephination
2.Failed nonsurgical endodontic treatment
 Irretrievable root canal filling,material
 Irretrievable intraradicular post
3.Calcific metamorphosis of the pulp space
4.Procedural errors
 Instrument fragmentation
 Non-negotiable ledging
 Root perforation
 Symptomatic overfilling
5.Anatomic variations
 Root dilaceration
 Root Fractures
6.Biopsy
7.Corrective surgery
 Root resorptive defects
 Root caries
 Root resection
 Hemi section
 Bicuspidization
8.Replacement surgery
 Replacement surgery
 Intentional replantation
(extraction/replantation)
 Implant surgery
 Endodontic
 Osseo integrated
Relative Contraindications
1. Patient’s medical status
 Major system disorder – Cardiovascular, Respiratory, Digestive,
Hepatic, Renal, Immune, Skeleton-muscular
2. Anatomical considerations
 Nasal floor
 Maxillary sinus
 Proximity to neurovascular bundles of mandibular canal and
mental foramen
 limitations to adequate visual and mechanical access

3. Practitioner’s skill and experience

Surgical instruments
CLASSIFICATION (by Kim et al)
Based on sequence of use:
 Examination instruments
 Incision blades
 Elevation instruments
 Tissue retraction instruments
 Curettage instruments
 Osteotomy instruments
 Inspection instruments
 Retro fill carriers
 Retro fill Pluggers
 Miscellaneous instruments
 Suturing instruments
 Suction tips
 Irrigation instruments
 Ultrasonic instruments
 Surgical operating microscope
Examination Instruments

 Dental mirror Tip of microexplorer used to –

• Search for leak in root-end
 Periodontal probe filling
 Endodontic explorer • Distinguish canal or craze
line from microfracture line
 Micro explorer
Incision blades

15C blade in use

Bard Parker Blades:

 Microblade
 No. 15c
 No. 15
 No. 12
 No. 11
Microblades
Elevation Instruments

Traditional Microsurgical

Enlarged tips of soft Molt’s curette (above)

tissue elevators Periosteal elevator No. 9 (below)
Tissue Retraction Instruments

Cats paw retractor

 Arens tissueretractor
 Selden retractor
 University of Minnesotaretractor
Curettage Instruments

•Minicurettes
•Mini jacquette 34/35
•Columbia 13- 14
•Miniendodontic curettes
•Minimolten curettes Enlarged tips of
minijacquettes and mini-
endodontic curettes
 Osteotomy Instruments

Microhead Handpiece

Straight Handpiece

Impact air 45o handpiece with H161 Lindemann bone cutting bur
– instrument of choice for osteotomy
 No. 4 round bur
 No. 6 round bur
 No. 8 round bur
 No. 57 fissure bur
 Multipurpose bur
 Endo-Z bur
Inspection Instruments

Stainless steel (top and bottom) Micro mirrors

Scratch-free sapphire mirror surface Round and modified
(centre two) rectangular Flexible neck
Retro fill
Carriers
Retro fill Pluggers
 Surgical Operating Microscope
The surgical operating microscope was used first time in neurosurgery and ophthalmology in
1960 and Endodontic microsurgeries in 1980s

Magnification Range = 2X - 30X

MAGNIFICATION RANGE
Low: 3 - 8 X
Medium: 10 – 16 X
High: 20 – 30 X
Advantages
 High magnification
 Surgical technique can be performedprecisely
and accurately

 Surgical technique can be easily evaluated

 Fewer radiographs needed

 Video recordings possible

Surgical Drainage :

Surgical drainage is indicated when purulentand/or

hemorrhagic exudates forms within the soft tissue
and the alveolar bone; a result of a symptomatic
Periradicular abscess.

 Surgical drainage maybe accomplished by;

 Incision and drainage (I and D)
 cortical Trephination
TREATMENT PLANNING FOR PERIRADICULAR
SURGERY
1 Presurgical patient management
.2. Need for profound local anesthesia and hemostasis
3. Management of soft tissue
4. Management of hard tissues
5. Surgical access, both visual and operative
6. Access to root structure
7. Periradicular curettage
8. Root-end resection
9. Root end preparation
10 Root-end restoration
.11 Soft-tissue repositioning and suturing
.
12. Postsurgical care
PRESURGICAL PATIENT MANAGEMENT
Patients medical status
 Proper history taking is first key for success of
any surgical procedure.
 Patient should be evaluated for major system disorders
(cardiovascular, renal, hepatic, digestive, immune and
skeletal muscle) which may contraindicate or alter
approach to surgery.
 Also premedication for patient in normal or in
presence of any of the above medical conditions
should be given priority and consulted with physician.
Patient preparation
 Patient preparation starts with patient communication
regarding reason for surgery, risks involved, also factors
which improve prognosis for successful outcome of surgical
procedure.
 There may be necessity of premedication (sedatives
or hypnotics, systemic antibiotics) for patient in order
to improve accessibility also postsurgicalhealing.
 Presurgical mouth rinse with chlorhexidine gluconate
(Peridex) may improve surgical environment bydecreasing
tissue surface bacterial contamination.
 Mouth rinse should be started a day before surgery,
immediately before surgery, and up to 4 to 5 days post
surgically. This reduces bacterial contamination of surgical
site and improve wound healing.
Anaesthesia

 Objectives:
 obtain profound and prolonged anaesthesia
 provide good hemostasis both during and after
the surgical
procedure

 Selection based on:

 Medical status of the patient
 Desired duration of anaesthesia
TYPES OF LOCAL ANALGESIA
 Topical analgesia (surface analgesia)
 Sub mucosal infiltration
 Sub periosteal infiltration
 Nerve block analgesia
 Intra ligamentary analgesia.
 Intra osseousanalgesia.
 LOCAL ANESTHESIA FOR SURGERY

LOCAL ANESTHETICS FOR PERIRADICULAR SURGERIES:

Lidocain
e Articaine
 Rapid onset,
 increased ability to
 Profound anesthesia,
penetrate bone
 Prolonged duration of
action,
 Low toxicity & allergic Bupivacaine

potential,  Long duration of action

 Excellent diffusion rate postoperative pain
HOMEOSTASIS
 Adequate homeostasis is a pre requisite for endodontic
surgery
1. Mechanical agents: Bone wax
2. Chemical agents
a. Vasoconstrictors
b. Ferric sulfate
3.Biologic agents : Thrombin
4. Resorbable hemostatic agents
i. Calcium sulfate
ii.Gel foam
iii.Absorbable collagen
iv.Microfibrillar collagen hemostats
v.Surgicel
MANAGEMENT OF SOFT TISSUE
• The surgeon's goal must always be to minimize
trauma to both the soft and hard tissues involved in
the surgical procedure.
• Most periradicular surgical procedures require the
raising of a mucoperiosteal flap.
• Surgical access is fundamentally dependent on the
selection of an appropriate flap design.
• It muse be noted, however, that no one flap design
is suitable for all surgical situations. Therefore, it is
necessary to know the advantage and disadvantages
of each flap design, and to be able to select and
employ the most appropriate design for each surgical
case
PRINCIPLES OF FLAP DESIGN

1. Incision should be made parallel to the

supraperiosteal vessels in the attached
gingiva and submucosa
2. Avoid incisions over radicular and bony
eminence.
3. Incisions and flaps should be placed and
repositioned over solid bone.
4. Including the full extent of the lesion.
5. Avoid incisions across major muscle
attachments.
7. Avoiding incisions in the mucogingival junction.
8. Tissue retractor should rest on solid bone.
9. The junction of the horizontal sulcular and
vertical incisions should either include or exclude
the involved interdental papilla.
10. Extent of the horizontal incision should be
adequate to provide visual and operative access
with minimal soft-tissue trauma.
Classification
 Full thickness (Mucoperiosteal) - Epithelium + Connective tissue+
Periosteum
Partial thickness (Split) - Epithelium + Connectivetissue
(According to Gutmann & Harrison)

Full mucoperiosteal Limited mucoperiosteal

Full mucoperiosteal flap – no attached Limited mucoperiosteal showing -

Gingiva around neck of crown Remaining attached gingiva
 Full mucoperiosteal flap
 Triangular
 Rectangular
 Trapezoidal
 Horizontal/Envelope
 Papilla base

 Limited mucoperiosteal
 Sub marginal curved/Semilunar
 Sub marginal scalloped rectangular/Luebke
Ochsenbein
Advantages of Full Mucoperiosteal Flaps
1. Rapid wound healing
2. Good surgical access
3. Minimal disruption of blood supply
4. Minimal untoward post-surgical sequelae
5. Optimal apical orientationand
6. Primary intentional healing.

Disadvantages
1. Loss of soft tissueattachment
2. Loss of crestal bone height
3. Post surgical flap dislodgement
Advantages of limited mucoperiosteal flap
1.Marginal and interdental gingiva not involved
2.Unaltered soft tissue attachment level
3.Crestal bone is not exposed
4.Adequate surgical access and
5.Good would healing potential

Disadvantages
1.Disruption of blood supply to unflapped tissues
2.Flap shrinkage
3.Difficult flap re-approximation
4.Delayed secondary wound healing.
5.Limited apical orientation
 Triangular flap…

Advantages
 easily modified
- small relaxing incision
- additional vertical incision
- extension of horizontal components
 easily repositioned
 maintains the integrity of blood supply

Indications Disadvantages

 midroot perforation repair limited accessibilty

 periapical surgery tension created on retraction

- posterior area gingival attachment detached

- short roots
 Rectangular flap…
Indications

 periapical surgery
- multiple teeth
- large lesions
- long or short roots
 lateral root repairs
Disadvantages

Advantages reduced blood supply to flap

increased incision &reflection time
gingival attachment violated
 maximum access &visibilty
 reduces retraction tension - gingival recession

 facilitates repositioning - crestal bone loss

-may uncover dehiscence
suturing is more difficult
 Horizontal flap…

Indications

 cervical resorptive defects

 cervical area perforations
 periodontal procedures

Advantages Disadvantages

 no vertical incision limited access &visibiltiy

 ease of repositioning difficult to reflect &retract
predisposed to streching &tearing
gingival attachment violated
 Semilunar flap…

Indications

 esthetic crowns present

 trephination

Disadvantages
Advantages
limited access &visibiltiy
predisposed to streching &tearing
 reduces incision &reflection time
tendency for increase hemorhaging
 maintains integrity of gingival
crosses root eminences
attachment
may not include entie lesion
 eliminates potential crestal bone loss
repositioning is difficult

healing is associated with scarring

 Ochsenbein-luebke flap…
Indications

 esthetic crowns present

 periapical surgery
- anterior region
- long roots
 wide band of attached gingiva
Advantages
Disadvantages
 ease in incision & reflection
 enhanced visibilty &access Horizontal component disrupts blood supply
 ease in repositioning vertical component crosses mucogingival

 maintains integrity of junction

gingival attachment difficult to alter if size of lesion misjudged

Endodontic microsurgery
 DEFINITION
 A surgical procedure on exceptionally small and complex structures
with an operationmicroscope.
(Kim etal)

 The microscope has changed surgical endodontics from a “blind”

technique to one that is visually dominated.

 It enables the surgeon to assess pathological changes more precisely

and to remove pathological lesions with far greater precision, thus
minimizing tissue damage duringsurgery.
Indications
 Failure of previous nonsurgical endodontictreatment
 Failure of previous endodonticsurgery
 Anatomic deviation
 Procedural errors

Contraindication
 Periodontal health of the tooth
 Patient health consideration
 Surgeons skill and ability
COMPARISON OF TRADITIONAL V/S MICROSURGERY

PROCEDURE TRADITIONAL MICRO-SURGERY

Identification of Difficult Precise
apex
Osteotomy Large (=>10 Small (<5mm)
mm)
Root surface None Always
inspection
Resection angle Large (45o) Small (<10o)
Isthmus Nearly impossible Easy
identification
Retro Approximate Precise
preparation
Root end filling Imprecise Precise
HARD TISSUE
MANAGEMENT
Osteotomy
 Following reflectionand retraction of the mucoperiosteal
flap, surgical access must be made through the cortical bone to the
roots of the teeth.
 Methods to locate the root apex

 Methylene bluedye

 Visual and tactile method(Barnes)

1. Root structure generally has a yellowish color
2. Roots does not bleed whenprobed
3. Root texture in smooth and hard as opposed to the granular and
porous nature of bone
4. The root is surrounded by the PDL
OPTIMAL OSTEOTOMY SIZE

 Traditional endodontic surgery - approximately 10 mmin

diameter.

 Should be just large enough to manipulate ultrasonic tips freely

within the bonecrypt.

 Since the length of an ultrasonic tip is 3 mm, the ideal diameter

of an osteotomy is about4mm.
Periradicular curettage
A surgical procedure to remove diseased or reactive tissue
from alveolar bone in the periradicular area or lateral region
surrounding a pulp less tooth (AAE 1994)

 Purpose:
• To remove pathological periradicular tissues for visibility
and accessibility for treatment of apical root canal system
•To remove foreign material present in periradicular
tissues
 To accomplish removal of entire mass, the largest bone curette,
consistent with the size of the lesion, is placed between the soft
tissue mass and lateral wall of the bony crypt with concave surface of
curette facing the bone.

 Once soft tissue has been freed along the periphery of the lesion, the
bone curette should be turned with concave portion towards the soft
tissue and used in scraping fashion to free tissue from deep walls of
bony crypt.
Root End Resection
Indications
 Eliminating
 Anatomical variations
 Ledges
 Canal obstructions
 Resorptive defects
 Perforation defects
 Separated instruments

 Visualize seal created by orthograde treatment and need for root-

end seal

 Gain access to pathological tissue trapped along lingual surface of

root
INSTRUMENTS
 Ingle et al recommended the root end resection is best accomplished by
the No.702 tapered fissure bur or No.6 or No.8 round bur in a low speed
straight hand piece.

Lasers
 Komori and associates evaluated the use of the Er:YAG laser for root-end
resections:

 Er:YAG laser - smooth, clean, resected root surfaces free of any signs

of thermal damage.
 Moritz and associates

 CO2 laser treatment optimally prepares the resectedroot-end

surface to receive a root-end filling

 seals the dentinal tubules

 eliminates niches for bacterial growth

 sterilizes the rootsurface

 Advantages of the laseruse:

 Absence of discomfort andvibrations

 Less chance forcontamination of the surgical site

 Reduced risk of trauma to adjacenttissue

Rationale for laser use in endodontic periradicular surgery includes

(Miserendino etal)

(1) improved homeostasis and concurrent visualization of the

operative field

(2) potential sterilization of the contaminated root apex

(3) potential reduction in permeability of root-surface dentin

(4) reduction of post-operative pain

(5) reduced risk of contamination of the surgical site through
elimination of the use of aerosol-producing air turbine hand
pieces.
EXTENT OF APICAL RESECTION
 BEVEL ANGLE
 Historically – 30-45o: to gain visual and operating access to the root tip for
resection, placement of retro filling materials, and inspection.

 Present - 90o Maximum= 10o degree bevel

Advantages:
•Exposes fewer dentinal tubules, thus preventing
excess leakage and contamination.
ROOT END PREPARATION
Purpose:

• Tocreate a cavity to receive a root-end filling.

Objective: It must be placed parallel to the long axis of the root.

Instruments Used:

 Small round or inverted coneburs

 Ultrasonic tips
IDEAL ROOT END PREPARATION

 The apical 3 mm of the root canal must be freshly cleaned and

shaped.
 The preparation must be parallel to and coincident with the
anatomic outlineof the pulp space.

 Adequate retention form must be created.

 All isthmus tissue, when present, must beremoved.

 Remaining dentin walls must not be weakened.

Traditional root-end cavity preparation technique
 Miniature contra-angle or straight hand piece

 Small round or inverted conebur.

 Class I cavity preparation along the long axis of the root within the
confines of the rootcanal.
 Recommended depth - 2 to 3 mm being the most commonly
advocated. (Gutmann and Harrison)

 Disadvantage: Apical perforation due to difficulty in aligning the bur

 Recently, specially designed ultrasonic root end preparation
instruments have been developed.

 Ultrasonic tips developed by De Gary Carr- Available with plain and

diamond coated tips.

 Kis Microsurgical Ultrasonic Instruments – The tips are coated with

zirconium nitrite for faster dentin cutting with less ultrasonic
energy
Advantages of Ultrasonic tips over micro head burs

 Need for beveling eliminated

 Tip stays centered in root and follows canal space

 ↓ chances of lingual orlateral root perforations

 Conserving greater thickness of root canal wall

 Better access to surgical areas, especially difficult to reach areas such as
lingual apices

 Deeper root-end preparationachieved

 Less dentinal tubulesexposed

 Cleanercavity than bur – smoother, less debris and smear layer

 Ultra precise isthmuspreparations.

 Parallel canal walls preparation for better retention of filling
materials.

Drawbacks:
Creation of micro cracks due to vibrations produced
RETROGRADE RESTORATIVE MATERIALS AND TECHNIQUES

Purpose:

Toseal the apex so that no bacteria or bacterial by products can enter or

leave from thecanal

Properties of ideal retrograde restorative materials :

 Well tolerated by periapical tissues

 Bactericidal or bacteriostatic

 Adhere to thetooth

 Dimensionally stable

 Readily available and easy to handle

 Not stain teeth or periradicular tissue

 Non corrosive

 Resistant todissolution

 Electrochemically inactive

 Promote Cementogenesis

 Radiopaque
Root End filing materials :

 Gutta percha
 Amalgam
 Cavit
 IRM
 Super EBA
 Glass Ionomer
 Composite resins
 Carboxylate cements
 Zinc phosphatecements
 Zinc oxide eugenolcements
 Mineral trioxide aggregation (MTA)
The prognosis ultimately depends on factors such as:
 An accuratebevel
 Adequate access
 Homeostasis
 Accurate retrogradepreparation
 Accurate retrograderestoration
 Existent periodontal disease
 Occlusal trauma
 Missed vertical fractures
 Quality of the orthogradefilling
 Individuals host response.
SOFT TISSUE REPOSITIONING AND COMPRESSION

 The elevated muco periosteum gently replaced to its original position

with the incision lines approximated as closely as possible.

 Type of flap design will affect the ease of repositioning.

 Tissue compression: Using a surgical gauze moistened with sterile

saline, gently apply firm pressure to the flapped tissue for 2 to 3

minutes (5 minutes for palatal tissue) before suturing.

 Enhances intravascular clotting in the severed blood vessels

SUTURING
Purpose: To approximate the incised tissue and stabilize the flapped muco
periosteum until reattachmentoccurs.

CLASSIFICATION OF SUTURE MATERIALS

 Based on material:

Synthetic fibers Natural

Nylon Collagen
Polyester Gut
Polyglactin Silk
Polyglycolic acid

 Absorbency:

Absorbable Non absorbable

Polyester Silk
Polyglactin Nylon
Polyglycolic acid
Collagen
Gut
 Size:
USP size: 3-0, 4-0, 5-0, 6-0.
The higher the first number, the smaller the diameterof the
suture material.

 Structure: Monofilament and Multi filament

Twisted and Braided
Silk Sutures: Non absorbable, multi filamentous, and braided.
High capillaryeffect

Enhances movement of fluids and Plaque accumulation on thefibers

microorganisms between fibers

Severe oral tissuereactions

Prevented by postoperative rinse withchlorhexidine

Advantage: Ease of manipulation

Gut: Collagen is the basic component of plain gut suture material

 derived from sheep or bovineintestines.

 The collagen is treated with diluted formaldehyde to increase its
strength

 Shaped into the appropriate monofilamentsize.

 Gut sutures are absorbable in 10 days

Chromic gut: plain gut treated with chromium trioxide.

 delayed absorption rate

 Gut suture material is available in sterile packets containing isopropyl
alcohol.
Polyglycolic Acid (PGA): made from fibers of polymerized glycolic acid-
absorbable. The rate of absorption is about 16 to 20 days.

 Multi-filament, braided and handling characteristics similar to silk.

 First synthetic absorbable suture and it is manufactured as Dexon.

Polyglactin (PG): Developed by Craig and coworkers In 1975

 Copolymer of lactic acid and glycolic acid

 Called polyglactin 910 (90 parts glycolic acid and 10 parts lactic acid).

 Sutures of polyglactin are absorbable, braided and multi filament.

 Commercially available asVicryl

NEEDLES
 Needle with reverse cutting edge (the cutting edge is on the outside of the
curve) is preferable.
 Available in arcs of 1/4, 3/8, 1/2 and 5/8 of a circle, with the most useful
being the 3/8 and 1/2 circle.
SUTURING TECHNIQUES
SINGLE INTERRUPTED SUTURE
INTERRUPTED LOOP (INTERDENTAL) SUTURE
POST OPERATIVE INSTRUCTIONS AND CARE

 Do not lift up lip or pull back the cheek to look at where the surgery was
done.

 A little bleeding from surgical is normal. This should only last for a few
hours.

 A little swelling and bruising face may be evident which may last for a few
days.

 Do not drink alcohol or use tobacco (smoke or chew) for the next 3 days.
 Have a good, soft diet and drink lots of liquids for the first few days after
surgery.
 Place an ice bag (cold) on face where the surgery was done. Leave it
on for 20 minutes and take it off for 20 minutes. Continue this for 6
to 8 hours.

 Take the prescribed medicines asrecommended.

 Rinse the mouth with 1 tablespoon of the chlorhexidine mouthwash
twice daily for 5days.

 Suture removal after 5-7 days by the dental personnel only.

 Maintain post operative follow up recall visits

 If any problems exists inform and visit your dentist immediately.

BARRIER MEMBRANE TECHNIQUES IN ENDODONTIC SURGERY

 Regeneration: is the replacement of destroyed tissue with new tissue

formed by the cells of the same origin. This new tissue reacts in a
similar manner against pathologic stimuli as the original tissues.

 Repair: is the restoration of the destroyed tissue by disease with new

tissue consisting of cells different from the original cells. These cells
react differently from the original cells against pathologic stimuli.
Materials used:
 GTR membrane

 Calcium sulphate

 Periosteal graft

 Platelet rich plasma

 Tri calcium phosphate

Objective: To enhance the quality and quantity of bone regeneration
in the peripheral region and to accelerate bone growth in
circumscribed bone cavities after endodontic surgery.
GTR Membrane

Indication
 Through and through periapical lesion.

 Large periapical lesion

 Endo-perio lesion

Periapical lesion communicating with the alveolar crest

Furcation involvementas a result of perforation

Root perforation with bone loss to alveolar crest

Advantages:
○ Barrier function in case of lack of periosteum.

○ Greater concentration of osteogenic cells in the healing area

○ High successrate.

Disadvantages:
○ Cost

○ Possibility of infection

○ Need for a second surgery (non resorbable materials only)

○ Need for a space-maintaining device in largedefects

○ Problems in the application of thebarrier.

○ Operator skill (e.g. , high surgical skill required when a palatal flap is
raised)
CALCIUM SULFATE
Indications :
 Post apicoectomy bonedefects
 Through and through lesions
 Periapical lesions with furcation involvement
 Post surgical endo-periocommunications.
Advantages:
 Inexpensive
 No inflammatory reaction
 Absence of post operativecomplications.
 Possibility of using the materials even in a septic environment
 Ability to achieve secondary closure of soft tissue on the exposed material.
 Stabilization of blood clot.
 Adhesion to rootsurface.
 Biocompatible
 Complete absorption.
PERIOSTEAL GRAFT AS BARRIER MATERIAL: (Kwan et al 1998)
Actions: 1. Periosteum
Osteo progenitorcells

Osteogenesis
2.Barrier for epithelial infiltration
Indications: multifaceted endodontic- periodontic problems

Advantages:
○ Highly vascular
○ Easily harvested
○ Configuration adjusted to shape of recipientsite
Disadvantages:
○ Profuse bleeding
○ Difficulty in obtaining the split thicknessgraft
PLATELET RICH PLASMA + TRI CALCIUM PHOSPHATE
Platelet rich plasma – Rich source of growth factors
Properties and Advantages:
•Decreased intra operative and post operativebleeding
•Rapid soft tissue healing
•Rapid vascularization
•Decreased post operativepain
•Osteo conductive
•Hemostatic properties
•Safe
•Affordable
(Demiral et al JOE , 30 (11) , 2004)
Corrective
surgery
 Corrective surgery is categorized as surgery involving the correction of
defects in the body of the root other than the apex.

 Corrective surgical procedure may be necessary as a result of

procedural accidents, resorption (internal or external), root caries, root
fracture, periodontal disease.

Corrective surgery mayinvolve

 Root resection.
 Hemi section.
 Intentional replantation.
ROOT
AMPUTATIO
NRoot amputation procedures are a logical way to eliminate a
weak, diseased root to allow the stronger root(s) to survive when, if
retained together, they would collectivelyfail.
 Distance between pulp chamber floor and coronal aspect of the root
separation= 3mm (Minimum)

 2 mm allow for establishment of supra crestal attachment apparatus

and 1 mm for placement of crownmargins
INDICATIONS FOR ROOT AMPUTATION:
(Rosenberg et al)
 Existence of periodontal bone loss to the extent that periodontal
therapy and patient maintenance do not sufficiently improve the
condition.

 Destruction of a root through resorptive processes, caries, or

mechanical perforations.

 Surgically inoperable roots that are calcified, contain separated

instruments, or are grossly curved.

 The fracture of one root that does not involve the other.

 Conditions that indicate the surgery will be technically feasible to

perform and the prognosis isreasonable.
CONTRAINDICATIONS FOR ROOT AMPUTATIONS:

 Lack of necessary osseous support for the remaining root or roots.

 Fused roots or roots in unfavorable proximity to each other.

 Remaining root or roots endodontically inoperable.

 Lack of patient motivation to properly perform home-care procedures.

HEMISECTION

 Hemi section is defined as separation of a multi rooted tooth and

the removal of a root and the associated portion of the clinical
crown.

Deep periodontal pocket Flap raised

Resected root Sutures placed

BISECTION OR “BICUSPIDIZATION”

Refers to a division of a crown that leave the two halves and

the respective roots.

 BS should be considered in mandibular molars in which

periodontal disease has invaded the bifurcation andrepair
of internal furcation perforation has beenunsuccessful.

 The furcation is then turned into an interproximal space

where the tissue is more manageable by the patient
BICUSPIDIZATION
INTENTIONAL
REPLANTATION
 Defined as the act of deliberately removing a tooth and following
examination, diagnosis, endodontic manipulation and repair
returning the tooth into its original socket.

INDICATIONS
 Difficult access
 Anatomic limitations
 Perforation in areas not accessible surgically.
 Failed apical surgery
 Apical surgery creatingdefect
 Accidental avulsion( unintentional replantation)
Contraindication

 Pre-existing moderate to severe periodontaldisease

 Curved and flared roots
 Non restorable tooth
 Missing interseptal bone

• 3 factors that directly affect the outcome of intentional

replantation.
 Extra oral time
 Keeping PDL cells viable
 Minimizing damage to the cementum and pdl ligament cells during
elevation and extraction
 SURGICAL SEQUELAE
Pain:
- Minimal and of short duration, if the tissue management is adequate
- Long acting Local anesthetics
- Analgesics and Anti inflammatorydrugs
Swelling:
Causes:
○ Post surgical edema
○ Hematoma
○ Infection
Management:
Inform patient
Reassure patient
Cold pack application
Bleeding

•Improper elevation and Retraction •Inadequate suturing

•Incision into muscle attachment •Trauma due to brushing, mastication

MANAGEMENT:
Cold pack application
Pressure packs: 2X 2 inch gauge or wet tea bag held with moderate pressure
for 10- 15 minutes.

If severe return to the dental clinic - Resuturing and use of hemostatics

(Tannic acid: hemostatic)
Ecchymosis
Discoloration of the facial or oral soft tissues caused
by extravasation and subsequent breakdown in the
subcutaneous tissue

Common in elderly patients with fragile capillaries

Causes:

•Bruising
•Soft tissue compression
Depends on: site
degree of trauma
complexion
CONCLUSION
Endodontic surgery is dynamic and it is
imperative that scientific investigation
continue, concepts ,techniques and materials
used in endodontic surgery must be continually
evaluated and modified and more emphasis
must be placed on the assessment of long-term
outcome
REFERENCE
 Pathways of the Pulp by Stephen Cohen, Richard C. Burns,7th,8th Edition

 Endodontics by John I. Ingle, Leif Bakland 5th Edition

 Microsurgery in Endodontics: Syngkuc Kim

 Surgical Endodontics: Guttman and Harrison: Mosby:1994.

 Contemporary surgical endodontics: Stockdale: 2 Edition

 Contemporary oral and maxillo facial surgery:Peterson: 5th Edition.

 Colour Atlas of surgical endodontics: Barnes

 Colour atlas of endodontic surgery: Loushine

 Microscopes in endodontics: DCNA: Syngkuc Kim, July; 41 (3)1997.

 Ultrasound real time imaging in the differential diagnosis of periapical lesions: Cotti
et al. IEJ; 36; 2003.