ENDODONTIC

SURGERY
KIFAMULUSI ERISA
KISEMBO JIMMY
LUGAMBA VICENT

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Outline
• Definition
• Indications and contraindications
• Classification of Endodontic Surgery

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Definition
• Endodontic surgery encompasses surgical
procedures performed to remove the causative
agents of periradicular pathosis and to restore the
periodontium to a state of biologic and functional
health.

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Indications of Endodontic
Surgery
1. Need for surgical drainage
2. Failed nonsurgical endodontic treatment
3. Calcific metamorphosis of pulp space
4. Procedural errors.
5. Anatomic variations
6. Biopsy
7. Conservative procedures
8. Replacement

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Contraindications of Endodontic
Surgery

• 1. Poor periodontal health of the tooth with grade III

mobility (bone loss).
• 2. Poor patient’s medical status—systemic diseases like
leukaemia,uncontrolled diabetes, anaemia,
thyrotoxicosis, etc.
• 3. Local anatomical factors like nasal floor, maxillary
sinus, mandibular canal and its neurovascular bundle and
mental foramen.
• 4. Traumatic occlusion which can’t be corrected.
• 5. Short root length
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Classification of Endodontic
Surgery
• Surgical Drainage
• Periradicular Surgery
• Corrective Surgery
• Replacement surgery
• Implant surgery

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Surgical Drainage
• Surgical drainage is indicated when purulent and/or
haemorrhagic exudate forms within the soft tissue or
the alveolar bone forming a periradicular abscess.
• Pain relief and reduction of infection significantly
happens after drainage of exudates.
• Surgical drainage may be accomplished by:
• (1) incision and drainage (I & D) of the soft tissue.
• (2) trephination of the alveolar cortical plate
• (3) Apical trephination through the apical foramen.

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Surgical Drainage
INCISION AND DRAINAGE.
Fluctuant soft tissue swelling occurs when
periradicular inflammatory exudate exits through the
medullary bone and cortical plate and spreads into
surrounding soft tissues. An incision made through
the focal point of the localised swelling relieves
pressure, eliminate exudates and toxins and
stimulate healing.

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Surgical Drainage
INCISION AND DRAINAGE...
• It follows the following steps;
a. Local anesthesia
b. Incision
c. Drain placement

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Surgical Drainage
INCISION AND DRAINAGE...

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Surgical Drainage
CORTICAL TREPHINATION
• Cortical trephination is a procedure involving
perforation of the cortical plate to accomplish
release of pressure from accumulation of exudates
within the alveolar bone.
• Indicated for patients who present with moderate
to severe pain but with no intraoral or extraoral
swelling.

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Surgical Drainage
CORTICAL TREPHINATION
• Apical trephination which involves drainage from
the periradicular lesion into the canal space is an
alternative for such patients.

• The decision to perform apical or cortical

trephination is based primarily on clinical
judgement regarding urgency of obtaining drainage
and also on the feasibility of removing intra-
radicular post and root canal obturation material.
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Surgical Drainage
CORTICAL TREPHINATION
• Cortical trephination involves making an incision
through mucoperiosteal tissues and perforating the
cortical plate with a rotary instrument.
• A reamer or K type file is then passed through the
cancellous bone into the vicinity of the
periradicular tissues.

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Surgical Drainage
CORTICAL TREPHINATION.
• Good quality diagnostic radiographs and careful
clinical examination will aid in determining the
appropriate trephination site (at or near the root
apex).

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Surgical Drainage
CORTICAL TREPHINATION.

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Periradicular Surgery
• the contemporary term used to describe those
surgical interventions the aim of which is to
manage disease associated with endodontic and
extraradicular apical infection

• Examples include apicoectomy, root resection,

repair of root perforation or resorption defects,
removal of broken fragments of the tooth or a
filling material, and exploratory surgery to look for
root fractures.

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Periradicular Surgery
Principles of periradicular Surgery:
• Need for profound local anaesthesia and
haemostasis
• Management of soft tissues
• Management of hard tissues
• Surgical access, both visual and operative

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Periradicular Surgery
• Access to root structure
• Periradicular curettage
• Root-end resection
• Root-end preparation
• Root-end filling
• Soft tissue repositioning and suturing
• Postsurgical care

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Periradicular Surgery
PREMEDITATION
• Anti-inflammatory drugs
• Tranquilizers
• Antibiotics
• Antibacterial rinses

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Periradicular Surgery
LOCAL ANESTHESIA AND HEMOSTASIS
• Good local anesthesia that contains a
vasoconstrictor is appropriate. Lidocaine is
commonly used.

• Haemostasis can be considered in presurgical,

surgical and postsurgical phases.

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Periradicular Surgery
LOCAL ANESTHESIA AND HEMOSTASIS.
• Presurgically , hemostasis is achieved by
vasoconstrictoragents in local anesthesia eg
adrenaline,levonordefrin and noradrenaline.

• Surgically local haemostasis can be achieved by

pressure technique of pressing cotton pellets or
gauze in the bony crypt for a few minutes. However,
if bleeding persists, topical haemostats are
considered.
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Periradicular Surgery
LOCAL ANESTHESIA AND HEMOSTASIS
• Post-surgically haemostasis is achieved by an ice-
cold wet sterilised gauze placed over the sutures to
stabilise the flap and control oozing of the blood
from the surgical sites.

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Periradicular Surgery
SOFT TISSUE MANAGEMENT
• Consists of flap design, incision, elevation,
retraction, repositioning and suturing.

• These goals can be achieved by selecting a proper

flap design, making a precise incision, elevating and
retracting the flap with minimum trauma to the
tissue, repositioning and suturing the flap precisely
into its position.

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Periradicular Surgery
HARD TISSUE MANAGEMENT
• Hard tissue management of periradicular surgery
involves four stages: (1)osteotomy, (2) curettage
and biopsy, (3) root-end resection and (4) root-end
retropreparation.

• Osteotomy is the removal of the facial cortical plate

to expose the root-end. should be done with
careful assessment of the PA inorder accurately to
locate the apex.
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Periradicular Surgery
HARD TISSUE MANAGEMENT
• Heat generation during osteotomy is minimized by ;
a liquid coolant or short brush strokes..

• Visual and operative accesses are the factors that

determine the osteotomy size.

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Periradicular Surgery
HARD TISSUE MANAGEMENT

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Periradicular curettage
• Periradicular curettage involves removal of the
periradicular inflammatory tissue and is best
accomplished by using sharp surgical bone curettes and
angled periodontal curettes.

• Administering a local anaesthetic solution containing a

vasoconstrictor into the soft tissue mass reduces
patient discomfort and serves as haemostatic at the
surgical site.
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Periradicular Surgery
HARD TISSUE MANAGEMENT
Periradicular curettage

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end resection.
• Root-end resection is associated with root end
filling inorder to eliminate the cause of the
periradicular lesion.

• Three important factors to be considered before

performing a root-end resection include
Instrumentation, Extent of root-end resection,
Angle of root-end resection
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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end resection
• Instrumentation; Plain fissure burs, both high- and
low-speed, produce the smoothest resected root
surface

• Extent of root-end resection; amount of root to be

resected is depends on various factors that have to
be evaluated on an individual case by case basis.

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end resection
• Angle of root-end resection;root-end resection
must be done perpendicular to the long axis of the
root whenever possible.

• A 10 degree bevel may be used in situations where

90 degrees can't be achieved. Acute angles should
be avoided to avoid dentine exposure.

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end resection

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end retropreparation
• The purpose of a retropreparation is to create a
cavity to receive a root-end filling.

• An ideal retropreparation must be a class I

preparation with the following requirements:

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end retropreparation
1. Apical 3 mm of the root canal must be freshly cleaned
and shaped
2. Preparation must be parallel to the anatomic outline of
the pulp space
3. Adequate retention form must be created
4. All isthmus tissue must be removed

5. Remaining dentine walls should not be weakened

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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end retropreparation
• Can be achieved either by traditional techniques
using a high speed hand piece or by ultrasonic
technique using ultrasonic tips.

• Retrograde filling provides a tight, biocompatible

apical seal, which prevents the leakage of potential
irritants from the root canal into the periradicular
tissues.
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Periradicular Surgery
HARD TISSUE MANAGEMENT
Root-end retropreparation
• Commonly used materials include;Amalgam,Gutta
percha, Glass ionomers, Ketac silver, Zinc oxide-
eugenol,Cavit, Composite resins etc..

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Periradicular Surgery
Soft tissue repositioning and suturing
• A radiograph is taken to evaluate the placement of
the root-end filling and to check for the presence of
any root fragments or excess root-end filling
material.

• The inner surface of the flap is thoroughly

examined to removeany debris or foreign material
that may be present.

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Periradicular Surgery
Soft tissue repositioning and suturing
• Then the elevatedmucoperiosteal tissue then gently
appose with the incision lines approximated as
closely as possible

• A surgical gauze, slightly moistened with sterile

saline is applied gently with firm pressure to the
flap tissue for 2–3 min before suturing.

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Periradicular Surgery
Soft tissue repositioning and suturing
• The interrupted suturing technique provides far
better flap adaptation than the continuous
technique.

• Currently, removal of the sutures is recommended

within 48 h.

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Periradicular Surgery
Postsurgical care
Important components of postsurgical care include:
• (1) genuine expression of concern and reassurance
to the patients
• 2) good patient communication—postsurgical
instructions conveyed both verbally and inwritten
manner

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CORRECTIVE SURGERY
• Corrective surgery are surgical procedures that help
the patient by permanently restoring areas of the
face and body that have been affected by scaring,
deformity, genetic or medical conditions
• In dentistry it may be permanent or transient, It
includes the following
- Perforation repair
- Periodontal repair
- Root resection/hemisection
- Bicuspidisation
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Perforation repair
• Root canal perforation may be mechanically
created or as a result of resorption or root caries
a) Mechanical perforation
- Mid root perforations are sealed internally using
either calcium hydroxide or MTA placed as an
intracanal dressing at subsequent appointments
- If the perforation is excessively large or long
standing, a full mucoperiosteal flap should be
reflected, perforation site identified and the repair
made with an appropriate repair material
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Conti..
• If the perforation is located in the apical third of the root, a
root end resection, extending to the point of the perforation
and a root end filling should be done in an effective and
efficient clinical way .
b) resorptive(external or internal) and root caries
- Root repair depends on whether there is communication btn
resorptive defect and the oral cavity and or the pulp space
- When there is communication btn resorptive defect and the
oral cavity, the corrective surgery is indicated
- Incase the defect opens into the gingival sulcus , it is
approached from the buccal or facial side, a full mucoperiosteal
flap should be raised and extent of the defect visualized.

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Conti..
• If the defect extends into pulp space, a temporary
internal matrix (large gutta percha point) is placed
in the root canal and resorptive defect repaired
• After the flap is repositioned and stabilized with
sutures, endodontic treatment can be completed at
the same or subsequent appointments

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PERIODONTAL REPAIR
• Guided tissue(bon) regeneration
In teeth with extensive/ horizontal bone loss, GTR and
demineralized freeze dried bone allografts ate used to
improve the quality and quantity of the alveolar bone.
Root resection/hemisection
This refers to removal of one or more roots of a
multirooted tooth while other roots are retained
- It eliminates a weak diseased root to allow the
stronger root to survive which if retained together
would collectively fail
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Advantage of root resection
• Salvaging and retaining 2/3 or even one half of a
tooth might add sufficient support to maintain arch
integrity
• An aid to posterior abutment i.e retaining even half
of a tooth could avoid the need for removable
prostheses and enable the patient to use prosthesis
or a splint.

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Indications for root
resection/hemisection
• 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 process,
caries or mechanical perforation
• Surgically inoperable roots that are calcified,
contain separated instruments or grossly curved
• Fracture of one root that doesn’t involve the other
• Conditions that indicate surgery is technically
feasible to perform and prognosis is good.
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contraindications
• Lack of necessary osseous support for the
remaining root(s)
• 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

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General rules for root amputaion
• Either a servere periodontal defect is present or an
endodontic or restorative problem is involved to to justifiy
the amputation need
• Root anatomy must be ascertained in terms of length, width
and contour and the strength of the remaining root prior
• Endodontic therapy prior to amputation must be done
• Root amputation on periodontally involved teeth may not
require raising the flap
• Ocllusal height should be reduced to prevent strong occlusal
contact during mastication of tough or chewy foods

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Root amputation on teeth with
normal periodontal support
• Raise the flap and remove the bone around the root using
tapered fissured carbide bur with the airotor and water
spray
• Remove bone in the furcation area to allow direct
visualization of the position where the root joins the rest of
the tooth
• Using the vertical root technique separate the root to be
amputated from the remainder of the tooth at furcation
• For maxillary molar, both buccal and lingual bone may
require reduction
• Trim remaining segment prior to amputation and suture the
flap in place after root removal
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Caution to observe before
amputation procedure
• There should be sufficient support available for the
segment to be retained
- Bony septum of adjacent roots should be preserved
• Proper restoration of the retained segment must be
achievable

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Instruments for root amputation
• Surgical length or long shank fissure burs sizes 700, 701, 557
and 558 are used to separate roots and remove overlying bone
• Long tapering fissure diamond stones are used to smoothen
retained tooth segments
• Elevator- straight(wide and narrow tip), set of Potts or other
angle elevators, apical elevators are used
• Forceps – upper and lower universal forceps and root tip
forceps plus any other favorite forceps used for single rooted
teeth.
• If a flap is to be raised during the amputation, all the
instruments needed for periapical surgery are needed in
addition to those for root amputation
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Methods of root resection
1. Vertical cut method
Its used for hemi section where the pathologic root and
its associated portion of the crown is also removed
- Both bifurcation and trifurcations are some distance
from the Occlusal surface of the tooth, therefore a
deep preparation is required before an elevator is
used to check for separation
- Note ; premature use of elevator may snap off large
section of the crown and make subsequent
restoration more complex

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Advantages of vertical cut
method
• Direct visualization of bur penetration ensures that
the preparation will be in the correct position
• Removal of that portion of the crown that is over the
root prevents undesirable postoperative Occlusal
forces
• Position of each cut based on the anatomy of the
furcation allows the root to cleave along the desirable
angels
• Allows excellent visualization of furcation after
amputation for any needed trimming or smoothening
with long shank, tapered fissured diamond stone
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Conti..
2. Presurgical crown contouring method
- Useful in treating maxillary molars with periodontal
defects
- Occlusal reduction should be considered before
proceeding with crown contouring
- It involves trimming the portion of the crown over
the root to be amputated to gain separation
- Root to be amputated can be filled prior to the
surgery to provide guiding landmark

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Conti..
3. Horizontal preparation
- It utilizes a horizontal/oblique cut to amputate the
involved root at the point where it joins the crown
without the crown being altered in the preparation
- It is not a preferred technique because cutting the
tooth in this manner leaves a deep trough btn the
crown and the alveolar mucosa which acts as nidus
for food and debris. And also severe occlusal stress
from undesirable direction on the remaining root
can be detrimental

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BICUSPIDISATION
• This is the division of the crown leaving two halves and
ther respective roots
• A single molar tooth can be converted into 2 bicuspids
• It involves making vertical cut after endodontic therapy
and each half is restored separately with post and core
crowns with a superstructure that allows for adequate
hygiene in the area
Indications
- Severe bone loss affecting the bifurcation but with
excellent support on the nonfurcation side on each root
untreatable with regenerative
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Conti..
procedures
- Severe destruction of tooth structure in the
furcation area.
- Class II or III furcation invasion or involvement

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Replacement surgery(extraction
and replantation)
• This is the act of deliberately removing a tooth and
after examination, diagnosis, endodontic manipulation
and repair, returning the tooth to its original socket

Indications
- Inadequate Interocclusal space to perform non
surgical endodontic treatment caused by the patient’s
limited range of TMJ motion and associated muscles
- Non surgical treatment and retreatment are not
feasible because of canal obstruction

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Conti..
• Surgical approach for periradicular surgery is not
practical because of limiting anatomical factors
• Non surgical and surgical treatment have failed and
symptoms or pathoses persist
• Visual access is inadequate to perform root end
resection and root end filling
• Root defect exist in areas that are not accessible
through a periradicular surgical approach without
excessive alveolar bone loss.
• To thoroughly examine the root(s) on all surfaces to
identify or rule out the presence of a root defect
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Indications of replacement
surgery
• Poor periodontal condition
• Furcation involvement
• Widely divergent or curved roots
• Medically compromised patients
Prognostic factors (3)
- Keeping the external time as short as possible
- Maintaining the PL cells on the root surface moist with
saline or Hanks balanced salt solution
- Minimizing the danger to the cementum and PL cells
by gentle elevation and extraction of the tooth
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Procedure
1. Tooth is slowly and gently extracted
2. Appropriate forceps are applied and without injury to the
buccal, lingual and to the interradicular bone the tooth is
extracted atraumatically
3. Following the extraction, immediately cover the tooth with
gauze saturated with NS leaving only the apex exposed
4. Gauze should be frequently saturated during the procedure
to keep the roots wet
5. Resect the apical 3-5mm with a new, sharp, fissure bur
under copius irrigation. It provides an apical space for
pooling of fluids in the postoperative phase

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Conti..
6. Using a small round bur preparer a cavity 3 mm deep
into the apical foramen
7. Seal the root end cavity with a retro filling material
8. Curette the apical region of the socket to remove
granulation tissue and the recently ACCUMULATED
Blood. Irrigate thoroughly with 0.9 NS
Gently reinsert the tooth , pushing it back slowly into the
socket so that pooled blood will escape from the socket
9. Stabilize with wire or composite if the tooth is mobile.
If fixation is required it should be removed after 7
days
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Conti..
10. Reduce occlusal surface of the opposing maxillary
teeth to minimize Occlusal trauma. The patient is
advised not to chew on the tooth for up to 2 weeks

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Endodontic implants

• Endodontic implant is defined as

‘utilizing an existing tooth by placing
a metal post down into one of the
root canals of the tooth and
extending into the bone’. It is a rigid
structure which extends through the
root canal into the periapical osseous
tissue, to lengthen the existing root
anchorage and to provide stability to
the tooth.

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 Indications

• It is indicated in teeth with severe periodontal

disturbance and extensive bone loss.

• Teeth that have lost a good portion of alveolar

support can be stabilized and maintained by the
use of endodontic endosseous implants.

• Endodontic implant is also used as an aid to

pulpoperiodontal therapy. 66
 Technique
• A perfectly round preparation must be reamed
through the root apex and into the alveolar bone.
Failure to do so will result in leakage around the
implant-dentine interface and eventual failure of the
implant.

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 Critical consideration
• critical area to consider is structural weakening of the walls of the
root as a result of dentine removal in an attempt to create a round
apical orifice. This structural weakness may result in root fracture
either at the time of implant placement or as a result of functional
stresses on the tooth.
• It is also important that the periodontal condition that has led to the
periradicular bone loss be stabilized before endodontic implant
placement. If not, the case will fail as a result of continued progression
of the periodontal disease.

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 Advantages
 These implants are not exposed to the oral environment.
 The area of bone prepared for the implant will not be extensive.
 The angulations of the implant can easily be established through the
root canal.
 They act as stabilizers when the loss of periodontal support is more.
 Increases the crown-root ratio.
 They provide better anchorage and stability to mobile teeth.
 It helps to stabilize the overdenture abutment

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 Disadvantages

1.Root fracture.

2.Technique-sensitive procedure.

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 Root-form Osseo integrated
implants

• Osseointegration is defined as ‘the direct structural and

functional connection between ordered, living bone and the
surface of a load carrying implant’.(Branemark, Zarb, and
Albrektsson, 1985).

• The apparent direct attachment or connection of osseous

tissue to an inert, alloplastic material without intervening
fibrous connective tissue. GPT

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 Advantages

 Incorporation of two procedures into one appointment

 Expediency of total treatment time

 Minimization of osseous collapse as well as resorption, maintenance

of soft tissue architecture

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 Endodontic
microsurgery

• Microsurgery is limited to a surgical procedure on

exceptionally small and complex structures with the aid

of an operating microscope.

• Precision is a key element in endodontic microsurgery

because of the restricted access to the surgical field

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Indication for endodontic
microsurgery
• Adequately executed endodontics but failed with
persistent periapical radiolucent lesion.
• Adequately executed endodontics with constant pain with
or without swelling.
• Apical transportation, ledges and other iatrogenic
problems with persistent pathology and symptoms.
• Calcified canals with or without symptoms and periapical
radiolucency
• Broken instrument in apical half of the root.
• Failed traditional surgery.
• Overfilled canal with periapical radiolucency.
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Contraindications for
endodontic microsurgery
General

o medically compromised patients

o lack of operation skills and experience

Local

 Localized acute inflammation.

 Inaccessible surgical site.

 Teeth with poor prognosis

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Principles and concepts of
Microsurgery
• The principles of microsurgery are an amplification
of those applicable to any general surgical
procedures.
• Of prime importance are gentle handling of tissues
and passive wound closure aiding in primary
uneventful healing, making the procedure more
acceptable
• The concept of microsurgery is based on three
important elements which form the microsurgical
triad that includes; magnification, illumination and
instruments.

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Rational and objectives

Rational

 To remove the causative agents of peri radicular

pathology

 To restore the periodontium to a state of biological

and functional
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Advantages of surgical
operating microscope
o Visualizing the surgical field

o Evaluating the surgical technique

o Reducing the number of radiographs needed

o Expanding patient education through video use

o Providing reports to referring dentists and insurance

companies

o Creating documentation for legal purposes

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Traditional endodontic surgery
versus microsurgery
Procedure Traditional surgery microsurgery
Identification of apex difficult precise
Osteotomy size Large, greater than 10mm Small less than 10mm
Root surface inspection Imprecise Precise
Bevel angle Large(45degrees) Small less than 10degrees
Isthmus identification impossible Always possible
retropreparation approximate precise
Root end filling Imprecise precise

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References
• Oral and Maxillofacial Surgery, 3rd Edition ;SM
BALAJI; PADMA PREETHA BALAJI.

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