Endodontic Surgeries

ENDODONTIC
MICROBIOLOGY
DR NYCIL PAUL
Dept. of Conservative Dentistry and Endodontics

A.J. Institute of Dental Sciences
TOOTH
REPLANTATION
DR NYCIL PAUL

GERIATRIC
ENDODONTICS
DR NYCIL PAUL

MANAGEMENT OF
DISCOLOURED TOOTH
DR NYCIL PAUL

SYNCOPE
DR NYCIL PAUL

4
ISOLATION :
INSTRUMENTS AND
TECHNIQUE
DR. DILU DAVIS

DENTAL
AMALGAM
DR. DILU DAVIS

SPEEDS IN
DENTISTRY
DR. DILU DAVIS

7
MERCURY
TOXICITY
DR. DILU DAVIS

8
ROOT CANAL
IRRIGANTS
DR. DILU DAVIS

9
ENDODONTIC
SURGERY
DR. DILU DAVIS

10
CONTENTS
INTRODUCTION
HISTORY
INDICATION
CONTRAINDICATION
o LOCAL CONSIDERATION
o SYSTEMIC CONSIDERATION
PHARMACOLOGIC CONSIDERATION
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS
CLASSIFICATION OF SURGICAL ENDODONTICS
o ACCORDING TO INGLE
o ACCORDING TO COHEN
o ACCORDING TO GUTTMAN
BASIC STEPS IN ENDODONTIC SURGERY
o INCISION
RULES FOR INCISION
FLAP DESIGNS
o FLAP REFLECTION
o FLAP RETRACTION
o OSTEOTOMY
o PERIRADICULAR CURETTAGE
o APICECTOMY
o FLAP CLOSURE
PERIRADICULAR SURGERY
o PERIRADICULAR CURETTAGE
o ROOT END RESECTION
o ROOT END FILLING
FISTULATIVE SURGERY
o INCISION AND DRAINAGE
o CORTICAL TREPHINATION
o DECOMPRESSION
CORRECTIVE SURGERY
o PERFORATION REPAIR
MECHANICAL
RESORPTIVE / CARIOUS
o PERIODONTAL REPAIR
GUIDED TISSUE REGENERATION
ROOT RESECTION / ROOT AMPUTATION
HEMISECTION
SURGICAL CORRECTION OF RADICULAR LINGUAL GROOVE
CONTROL OF HAEMORRHAGE
o LOCAL
o SYSTEMIC
SUTURE MATERIALS
POST-OPERATIVE INSTRUCTION
REPLACEMENT SURGERY
o INTENTIONAL REPLANTATION
IMPLANT SURGERY
o ROOT FORM OSSEOINTEGRATED IMPLANTS
o ENDODONTIC IMPLANTS
o ENDOOSSEOUS IMPLANTS
TRANSPLANTATION
CAUSES OF FAILURE IN ENDODONTIC SURGERY
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CONCLUSION
REFERENCES
12
INTRODUCTION :
Not all dental problems are treatable by conventional procedures. A
number of conditions, particularly those following trauma and disease, demand
innovation and ingenuity. Endodontic surgery is a facet of comprehensive root
canal treatment, which can manage problems that cannot be eliminated by non
surgical techniques.
HISTORY :
Pre 1900
Intentional Replantation
Abulcasis (11th Century)
Pare (1561)
Fauchard (1712)
Pfaff (1956)
Berdmore (1768)
Hunter (1778)
Incision and drainage were managed by persons other than dentists and
physicians.
The need to manage chronic sinus tracts by either opening them, cleaning
them out or burning them (Lorentz).
The use of lancet or sharp pointed knife to puncture swelling (Harris).
Surgical Trephination (Hullihen).
Application of carbolic crystals to the gums followed by resection to
alleviate pain (Bronson).
Surgical treatment for management of alveolar abscess (Rhein)
First root end resection (Smith)
1900-1939 (FOCAL INFECTION THEORY)
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All root tissues located within the diseased tissue around apex was
considered contaminated.
1940-1959
Single visit RCT followed by Surgical curettage (Jones)
Open window method for apical curettage (Weaver)
Use of root end preparations and root end fill with amalgam (Garvin,
Luks, Guerny)
Development of specific amalgam carrier for placement of material in
apical third (Messing).
1960-1990
This period in the history of surgical endodontics represents what we
know and practice today.
INDICATIONS OF ENDODONTIC SURGERY:
1) Any condition or obstruction that prevents direct access to the apical
third of the canal such as ;
a. Anatomic Calcifications, Curvatures, dens n dente, pulp stones.
b. Iatrogenic Ledging, broken instruments, old root canal fillings
2) Periradicular disease associated with a foreign body: over filled canals,
excessive cement in the periodontium.
3) Apical perforations
4) Incomplete apexogenesis with blunderbuss that does not respond to
apexification.
5) Horizontal fracture root tip with periradicular disease.
6) Failure to heal using non-surgical endodontic treatment.
7) Persistent and recurring exacerbations during non-surgical treatment or
persistent unexplainable pain.
8) Treatment of any tooth and a suspicious lesion requiring a diagnostic
biopsy.
9) Excessively large lesions.
10)Destruction of apical constricture of root canal due to uncontrolled
instrumentation.
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11)Fenestration / Dehiscence
12)Lack of time
CONTRAINDICATIONS :
General Considerations :
a) Medically compromised patients.
b) Emotionally unstable patient
c) Limitation in surgical skill and experience of the operator
LOCAL CONSIDERATIONS :
1) Localized acute inflammation Treatment is incision and drainage
2) Anatomic considerations.
Procedures that penetrate the mandibular
canal, maxillary sinus, mental foramen, floor of the nares should be

avoided whenever possible.
3) Inaccessible surgical sites inaccessible position and location of root
apices, especially in posterior teeth and need to gain access to the
surgical site through dense layer of bone may preclude a successful
result.
4) Teeth with poor prognosis Short rooted teeth, teeth with advanced
periodontal disease, vertically fracture teeth.
5) Surgery should not be considered cure-all to compensate for inadequate
technique that resulted in failure to heal.
Esthetic Considerations :
1) Scarring Any incision will leave a scar. The maxillary anterior gingiva is
the most visible gingiva of the mouth and is exposed in varying degrees when
laughing or talking. Since this segment has the greatest number of surgical
endodontic entries, the normal lip line, smile line should be presurgically
observed.
When the labial gingiva is a major part of the smile, hiding the
horizontal incision in gingival crevice is recommended as in reducing the
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length and number of vertical releasing incisions. Semilunar incision produces

the worst scar.
2) Amalgam Tattoo A problem that exists with the use of the best and most
frequently used reverse fill and root-repair material is the tattoo. However
when the material is confined to the root preparation, tattooing is minimized, if
not eliminated.
Many tattoos are associated with failing amalgam reverse fills,
suggesting that percolation enhances the tattooing. If a tattoo is caused by
reverse fill failure and re-entry for curettage an a new reverse fill are planned, a
flap may be designed to excise the tattoo.
Accessibility of Surgical Site :
1)
Limitation of mouth opening TMJ problems resulting from surgery,

trauma, congenital defects like microstomia. Chemical or electrical burns
etc.
2)
Shallow mucobuccal fold when the mucobuccal fold is shallow, the

surgeon must incise and elevate thicker soft tissues, this procedure
produces excessive capillary bleeding. If muscles represent in the fold
area, such as mentalis, associated with lower incisions, the soft tissues of
the lip or cheek may limit access and view.
3)
Short alveolar process In the case of incomplete development, or in

mature individuals with small jaws, the root apexes maybe much closer to
important intraosseous anatomic structures.
Eg. Floor of the nose,
maxillary sinus, mandibular canal and mental canal and foramen.

4)
Extremely long roots : In long rooted teeth, the primary problem is that,
their apexes are located in the widest portion of the alveolar process,
which is narrowest at the crest and increasing in width apically.
secondary problem is the greater likelihood of their proximity to

intraossoeus structures. A third consideration is the greater soft tissue
thickness involved in the incision and elevation when the apex of such a
tooth extends beyond the mucobuccal fold.
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5)
Bony tori or exostoses : The most common alveolar process, tori occurs
lingual to mandibular bicuspids often extending posteriorly to the molars.
There are bony exostosis which occurs on the buccal cortical plate of
maxillary molars and premolars. Their presence sometimes prohibits the
normal buccal approach to maxillary posterior unless the exostoses are
removed first.
6)
Flaring or wide alveolar process : Some individuals have wider alveolar

processes than others. Wide processes are more prevalent among men
than women, among large boned compared to small boned individuals.
The significance of this occurrence is the potential for greater bone
thickness over the apexes of teeth. Mandibular teeth are most affected by
flared processes.
Dental Appliances : Access to certain areas may be slightly limited to fixed
partial dentures and orthodontic appliances. Such prosthesis may possibly
affect flap design, some instrumentation during apical surgery and suturing.
Periodontal Considerations :
1) Periodontal pockets : It is important to know if periodontal pockets
exists when considering flap design for surgery.
Two choices are
available when pockets are present.

a) Avoid placing the incisions near the defects.
b) Include the defects in a therapeutic manner.
2) Tissue Dehiscence : Soft tissue clefting, seen most frequently over
mandibular incisors, affects flap design, when clefts are present, probing
should be carried out to determine if any attached gingiva remains apical
to the base of the cleft.
3) Lack of attached gingiva : If a flap is made apical to uncorrected
mucogingival defect, chances are good for primary or secondary
breakdown of the incision line.
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Prosthetic Considerations :
1) Crown margins : When surgery is planned for an area with a pre-existing
FPD or crown, several factors need to be considered. If the marginal
gingiva is healthy and margins of the prosthesis are subgingival,
avoiding a scalloped horizontal crevicular incision may prevent
problems. If the margins are already exposed or if the crown / bridge is
to be replaced, then a crevicular or inverse bevel incision is acceptable.
2) Crown-root ratio : When an apicocectomy is to be performed, the
surgeon must consider, if the root that will be left is of sufficient length
and diameter for the tooth to continue to stay in function and remain
stable, especially, when the tooth is used as an abutment.
Anatomic Considerations :
Neurovascular bundles : The nasopalatine nerve, greater palatine nerve, inferior
alveolar nerve, readily unites if severed, as the flap is easy to reposition and
immobilize.
The mental nerve has the poorest chance of regenerating, if severed as
the flap is very difficult to reposition over the foramen and also nearly
impossible to immobilize the flap because of cheek and lip movements.
Maxillary Sinus : If the sinus is inadvertently entered and symptoms of an
acute sinusitis develop, the patient should be referred to an ear, nose and throat
surgeon for treatment.
Floor of Nose : It is not uncommon for apical pathosis associated with
maxillary incisors to extend superiorly and thin or perforate the cortex of the
nasal fossa floor. Curettage of such lesions may lead to perforation of soft
tissue lining of the external nasal fossa.
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The potential for such a problem emphases the need for properly
angulated, interpretable pre-operative radiographs.
Frenums : The maxillary labial frenum is the most prominent frenum to be
encountered in endodontic surgery. In cases where the frenum is unaesthetic or
is suspected of occurrence of diastema, a concomitant frenectomy is
considered.
The other large frenum encountered is the mandibular lingual frenum,
but rarely are mandibular lingual flaps needed.
SYSTEMIC CONSIDERATIONS :
Medically compromised patients comprise an ever increasing percentage
of the population because of the rapid advances in medicine which have
dramatically increased the survival rates associated with most diseases.
Therefore it is essential to be aware of each patients systemic disorder and
associated drug therapy, so that proper patient management procedures can be
employed during dental treatment.
A thorough case history has to be taken which includes the medical
history and physical evaluation.
Physical evaluation involves an assessment of patients health status,
emotional stability. Evaluation of B.P., Pulse, Gait, Stature, Age, respiration,
and any other signs (swollen ankles, obesity, clubbed fingers) which may
indicate abnormalities.
When any doubt exist, a medical consultation is obtained.
Endodontic surgery routinely requires three categories of drugs : local
anesthesia, vasoconstrictors and analgesics. Antibiotics may be indicated in
patients susceptible to bacteremias.
The stress reduction protocol is considered for compromised patients
who are particularly susceptible to pain, anxiety, stress complex and require
endodontic surgery.
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a) Instill professional confidence.

b) Avoid or minimize pain
c) Administering preoperative sedation
d) Administer intraoperative sedation
e) Schedule surgery for mornings.
Mid morning surgery appointments are best because of the
patients functional reserves are at peak level.
f) Accomplish surgical procedure expeditiously
g) Avoid surprises
Pre-warn the patient of all procedures which will produce some
type of sensation.
h) Ensure post surgical pain, anxiety and stress control.
i) Schedule a post surgical evaluation appointment.
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS :
Systemic Hypertension :
Prescribe 5 mg diazepam, night before surgery.
Limit anaesthetic injections to three cartridges if possible.
Use 1:100000 or lower concentration for nerve black anaesthesia.
Use 1:50,000 epinephrine for hemostasis.
Coronary Arterosclerosis, Angina, Myocardial Infarction :
Prescribe Ibuprofen or codeine (alone) for analgesic therapy.
Ensure availability of nitroglycerine tablets at all appointments.
Confirm bleeding time and clotting time
Avoid aspirin, acetoaminophen
Avoid antisialogogues
Consider prophylactic antibiotic coverage.
Congestive Heart Failure - Infective Endocarditis :
-
Prophylactic antibiotic coverage

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Under Local Anaesthesia
- Amoxycillin 3 g orally 1 hour before

- Clindamycin 600 mg orally 1 hour before
Under General Anaesthesia Amoxycillin 1g IV + 0.5 g aminoxycillin orally 6

hours later.
- Vancomycin 1 g i.v. infusion for 1 hours.
PULMONARY SYSTEM :
Chronic Bronchitis and Emphysema :
Treat in an upright sitting or slightly reclining position.
Avoid supine position
Avoid narcotics / barbiturates
Avoid antihistamines and anticholinergics
If patient is on corticosteroids, alterations of dosage level
Asthma :
Acetoaminophen should be used for analgesic therapy.
Instruct patient to bring inhaler to each appointment.
Avoid exercise, infection and known allergens.
Neurologic System : Cerebrovascular Accident
Prescribe ibuprofen or codeine for analgesic therapy.
Prothrombin time should be less than 35 seconds.
Bleeding time should be les than 6 minutes.
Limit anaesthetic / vasoconstrictor injections to 6 ml.
Avoid aspirin and acetoaminophen in patients on coumarin.
Epilepsy:
Protect the patient from self injury by passive restraints.
Ensure patient has taken prescribed anticonvulsive drug.
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Determine bleeding time if patient is taking valproic acid.

Ensure staff is familiar with seizure control measures.
ENDOCRINE SYSTEM :
Diabetes Mellitus :
Prophylactic antibiotic coverage
Have source of glucose available
Schedule morning appointments
Instruct patient to inform immediately if early symptoms of insulin
shock are detected.
Strict diet after surgery
If patient is on oral hypoglycaemic drugs, avoid salicylates.
Adrenal Insufficiency :
If patient is taking less than 20 mg cortisol daily, steroid
supplementation not required.
If patient is taking 20-40 mg cortisol, double or triple maintenance dose
on morning of surgery, followed by normal maintenance dose in the
second pre-operative day.
If more than 40 mg cortisol, steroid supplement not required.
Prophylactic antibiotic coverage.
Hyperthyroidism :
Avoid all elective dental procedures
If emergency care is required
o Prescribe NSAID for pain.
o Prescribe antibiotics for infection.
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Avoid injection of vasopressor amines with local anaesthesia

Refer immediately for medical treatment
HEPATIC SYSTEM :
Use minimal effective dosage levels of local anaesthetics.
Obtain presurgical prothrombin time and bleeding time.
Use strict infection control
RENAL SYSTEM :
Prophylactic antibiotic therapy
Schedule surgery for morning after dialysis
Transplant patients are usually given steroids and cytotoxic drugs
PREGNANCY :
Contraindicated in first and third trimester.
During these periods, only emergency treatment is indicated to alleviate
pain of endodontic origin.
PHARMACOLOGICAL CONSIDERATIONS :
Analgesics :
Non-Narcotic Analgesics :
1) Salicylates
- Aspirin 650 mg every 4 hours.
It is administered just prior to surgical procedure so that it is at
maximum effectiveness as the local anaesthesia begins to wear off. Side effect
Reverse placebo effect.
Diffusal : 1000 mg initially followed at 8-12 hours interval with 500 mg.
2) Paraaminophenol Derivative :
- Acetoaminophen 650 mg every 4 hours for several days following surgery.
3) Proprionic acid derivatives
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- Ibuprofen 400-600 mg every 4-6 hours following surgery.

4) Naproxen
- 500 mg initially followed by 250 mg every 6-8 hours.
Narcotic Analgesics :
1) Codeine
2) Oxycodone
3) Hydrocodone 5-10 mg every 4 to 6 hours
4) Dihydrocodeine
5) Pentazozine
Antibiotics :
Penicillin V 1000 mg followed by 500 mg 6 hourly.
Erythromycin 1000 mg followed by 500 mg 6 hourly
Clindamycin 300 mg followed by 300 mg 6 hourly
Cephalosporins 500 mg followed by 500 mg 6 hourly
CLASSIFICATION OF SURGICAL ENDODONTICS :
According to Ingle :
1. Surgical Drainage
a) Incision and drainage
b) Cortical trephination
2. Periradicular surgery
a) Curettage
b) Biopsy
c) Root end resection
d) Root end preparation and filling
3. Corrective surgery
a) Perforation repair
i) Mechanical
ii) Resorptive
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b) Root resection
c) Hemisection
4. Replacement surgery
5. Implant surgery
i) Endodontic Implants
ii) Root form osseointegrated implants
According to Cohen :
1. Class A : Absence of periapical lesion
2. Class B : Presence of small periapical lesion with no periodontal pocket
3. Class C : Presence of large periapical lesion with no periodontal pocket
4. Class D : Presence of large periapical lesion with periodontal pocket
5. Class E : Presence of periapical lesion with an endodontic and
periodontal communication but no root treatment.
6. Class F : Tooth with an apical lesion and complete denudement of the
buccal plate.
According to Gutmann :
1) Periradicular surgery
a) Curettage
b) Root end resection
c) Root end preparation and filling
2) Fistulative surgery
a) Incision and drainage
b) Cortical trephination
c) Decompression
3) Corrective surgery
a) Perforative repair
i.
Resorptive and carious
ii.
Mechanical
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b) Periodontal management
c) Intentional replantation
Endodontic surgery consists of 7 basic steps.
1) Incision : In order to gain access to bone, soft tissue must be
incised. This is accomplished with sharp sterile scalpel (#15 B.P.
blade).
Cardinal Rule I :
The incision must be made with a firm, continuous stroke. Pen grasp is
the most preferred hand position.
Types of Incision :
-
Partial thickness
Full thickness
Partial Thickness : Cut is made through mucosa and submucosa and separates
superficial tissue form deep tissue.
Full thickness : Made through mucosa, connective tissue and periosteum until
bone is felt.
Cardinal Rule II :
-
An incision should not cross an underlying bony defect that existed prior
to surgery or produced by surgery.
Cardinal Rule III :

-
Vertical incisions should be made in the concavities between bony

eminences (tissue in thickness and more blood supply)
Cardinal Rule IV :
The termination of the vertical incision at the gingival crest must be at
the line angle of a tooth. This will provide firm, attached tissue for suturing,
will not split the papilla and will minimize the chances of causing a tissue cleft.
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Cardinal rule V :
The vertical incision should not extend into the mucobuccal fold. It an
result in severe bleeding. To avoid incising through the fold, the vertical
incision line should create an obtuse angle with the horizontal incision line.
Cardinal Rule VI :
The base of the flap must always be wider than the width of the free
edge. This will maximize the blood supply.
Cardinal VII :
The periosteum must be reflected as an integral part of the flap.
Cardinal Rule VIII :
Any tissue retractor must rest on bone and not impinge on soft tissues.
Cardinal Rule IX :
All suturing begins by insertion of needle through the unattached tissue
to the attached tissue.
FLAP DESIGN :
1) Semilunar flap : curved, horizontal incision, convex position towards to
gingival crest. Not recommended for surgical endodontic procedure as
it shrinks form blood loss and follows on obvious, unsightly collagen
scar.
2) Triangular flap / Single vertical flap :
-
Horizontal gingival crest incision formed by single vertical relaxing

incision.
It allows for visualization of complete length of root, option of

performing minor periodontal surgeries, and retains excellent blood
supply. Indicated in short roots.
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Disadvantage : Difficult to suture interproximally , gingival stripping can

occur, oral hygiene is a problem.
3) Trapezoidal / Double vertical flap.
Can be rectangular or trapezoidal in shape. It allows more complete
surgical access than single vertical flap.
Advantages : Retrofilling long roots, curettage of large periradicular
lesions, repairing lateral root defects.
Disadvantages : Chances of more haemorrhage and flap shrinkage.
NB : Rectangular flap indicated when there is bony fenestration.
4) Leuke Ochsenbein flap / scalloped flap modified double vertical flap
combining the excellent visual assess and tissue relaxation of double
vertical flap and also over coming the reparative defects in the
interdental papilla.
-
Indicated in areas of veneered crowns and esthetics.
Preferred in maxillary anteriors
Contraindications :
Deep periodontal pockets on the labial surface of teeth.
NB : the horizontal incision should be 3 mm from the free gingival
groove.
Disadvantages : Severe haemorrhage, Shrinkage.
Mini Vertical Flap :
-
Indicate d in Trephination and minor curettage. Consist of sheet oblique

incision to a proximal side of the apex of the involved tooth.
Advantages :
Simple, easy to suture, heals faster, less scoring, contraindication in
large lesion.
Gingival Flap : Extended horizontal incision along the gingival crest.
Advantages :
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Gingivectomy procedures
Gingival levels can be change d in any position
Disadvantages :
-
Difficult to retract
Tension on flap is excessive
Haemorrhage
Access and visualization
Oral hygiene
No relaxing incisions Leaving of tissue
2) Flap Reflection :
Periosteal elevator placed between periosteum and bone.
It should
begin in the vertical incision and then causing the horizontal component.
3) Flap Retraction :
Holding in position of reflected flap during surgery. The size and shape
of the retractor must be sufficiently longer to the size of the flap. Too small a
retractor allows the tissue to flap over whereas large retractor will traumatize
the surrounding tissue. The retractor must be positioned on solid bone and the
soft tissue is not pinched.
4) Osteotomy :
When bone is thin, cortical plate has been destroyed, the underlying
inflammation is seen. However when the bone is intact, a window is created
with a NO.6 or NO.8 carbide bur in a straight hand piece with copious sterile
saline irrigation. Large round bur is preferred d in wiping motion away form
bone over an apex.
5) Periradicular Curettage :
-
To eliminate the zone of irritation and contamination.
To take the specimen for histologic examination.
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Curettage done with sharp curettes :

Those scaler is an excellent instrument to sharply cantle the adhering
inflammatory tissue. (NB) control of heamorrhage.
6) Apicoectomy :
A large round bur is excellent for apical research. Round burs prevent
gauging and formation of sharp line angles.
Indication : Removes the untreated apical portion of root and enables the
operator to determine the cause of failure.
Provides a flat surface to prepare root end cavity and pack it with root
end filling material.
7) Flap closure :
The bone wax, ferric subsulphate is removed and surgical site is
thoroughly irrigated to remove any loose particles, bone, filling materials.
Thread Gauge :
Based on thickness of tissues to be sutured.
Most oral tissue
: 4 0 silk
Lip, tongue
: 5 0 silk
Palate
: 3 0 silk
Needles :
Straight to 3/8 curve, , even a full curve. Needle length is relative to
specific working area, which can vary form 3/8 to 5/8.
A suture needle should enter and exit both segments atleast 2 mm from
the incision.
Because bacteria collect on the surface of all suture material, it is
recommended that all sutures be cleaned and disinfected with a germicidal
mouthwash prior to their removal.
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Probably, the finest innovation in suturing has been the development of

the preswaged atraumatic needle.
Suturing Technique : Sutures may be tied by hand or by instruments. The
instruments used are straight haemostat, curved mosquito forceps and needle
holder.
The needle should be gripped atleast 2/3rd of the way back from the tip
to allow room for needle to rotate through both edges of tissue.
-
Sling suspensory, Continuous mattress, Blanket techniques
PERIRADICULAR SURGERY
PERIRADICULAR CURETTAGE (APICAL CURETTAGE, PERIAPICAL
CURETTAGE) :
Definition :
It is a surgical procedure to remove diseased tissue from the alveolar
bone in the apical or lateral region surrounding a pulp less tooth.
Indications :
-
To remove the infected tissues from the alveolar bone surrounding the
root.
To remove necrotic cementum
To gain access to the root for additional surgical procedures
To remove excessive, overextended root canal filling materials
To assist in rapid healing and repair of periradicular tissues.
To remove septic lesions as convenience to the patient.
To remove a long standing, persistent lesion especially when a cyst is

suspected.
To eliminate a persistent sinus tract
To remove external resorptive processes
To release confined inflammatory exudates
To manage wide open apex with necrotic pulp and apical lesions
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To obtain a specimen for biopsy
Periradicular Curettage Versus Root End Resection :

Over the years, various authors have advocated periradicular curettage
as definitive treatment for a periradicular lesion, without subsequent root-end
resection to maintain the root length for stability. However, no studies are
available which address loss of tooth stability due to root-end resection.
ROOT END RESECTION ( ROOT END AMPUTATION, APICOECTOMY)

Definition : The ablation of the apical portion of the root and attached soft
tissue.
Indications : Removal of pathologic processes.
They include resorptive processes, fracture root tips, contaminated root
apices.
-
Removal of anatomic variations. They include accessory canals, apical

canal bifurcations, apical deltas, severe curves, lateral canals and
calcifications.
Removal of iatrogenic errors. They include broken instruments, ledges,

perforations etc.
Removal of soft tissue lesions
Access to the canal system. In cases where major canal systems are
blocked e.g. postcore restorations.
When non-surgical pretreatment is impractical.
Creation of an apical seal.
Evaluation for aberrant canals and root fracture.
Reduction of fenestrated root apices.
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This situation is common in maxillary premolars and molars. In order to

eliminate the inflammation in the periosteum and provide an osseous lowering
for the roots, apical segment is removed or sculpted.
Cleaning and Drying the Apical Preparation :
The Stropko air/water syringe tip permits the controlled introduction of
air, water, or saline into the apical preparation, so it can be rinsed and dried
easily and effectively. The option of two Stropko irrigators and dryers, one for
rinsing only and the second for drying only, eliminates this minor problem and
adds versatility and precision to the surgical armamentarium.
The irrigator and drier replaces the standard three-way tip on most air
and water syringes and accepts most Luer-Loc needle attachments.
For
example, the Stropko air/water syringe tip is compatible with the following ;
Ultradent tips, Monojet endodontic irrigating needles.
A common finding of resected root surfaces of posterior teeth is an
isthmus, which is a narrow connection between two root canals usually
containing pulp tissue. It can be either complete or incomplete. At 3 mm from
the apex, isthmuses are often found to merge two canals in one root. Thus the
isthmus is a part of the canal system and not a separate entity; accordingly, it
must be cleaned, shaped, and resealed.
Ultrasonic tip preparation is the only way to carve an isthmus. This
requires a careful and delicate approach, because the isthmus is located in the
thinner portion of the root, which can easily be perforated or stripped. The
ultrasonic tip with a diameter of less than 0.2 mm is the best tip to treat the
isthmus without causing procedural mishaps.
Ultrasonic Apical Preparation :
First ultrasonic tips for endodontics and endodontic surgery were the CT
tips made of stainless steel and designed by Dr.Gary Carr.
The advantages of ultrasonic tips over microhead burs are ;
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Better access, especially in difficult-to-reach areas (e.g. a lingual apex).

More thorough debridement of tissue debris
Conservative preparations tracing the long axis at a precise depth of 3
mm.
Precise isthmus preparations with parallel canal walls for better
retention of filling materials.
Bevel angle of the root tip was 0 to 10 o when compared with burs
which was 45o.
ROOT END PREPARATION (RETROGRADE FILL, RETROFILL,
REVERSE FILL).
Definition : A method of sealing the apical extend of the root canal system
through cavity preparation in the resected root end and placement of a
restorative material.
SURGICAL ACCESS: HARD TISSUE MANAGEMENT :
Once the endodontic surgical flap is reflected and retracted, surgical
access is made through the cortical bone to the roots of h teeth. This is one of
the primary objectives of periradicular surgery. A knowledgeable approach to
the proper management of osseous tissue will prevent tissue damage and
enhance osseous healing, while at the same time effect a surgical access
conducive for visibility and the management of the roots.
The control of environmental and technical factors, such as heat
generation, pressure placed on the cutting instrument, type of cutting
instrument, speed of cutting, air and water coolants, flushing, manner of
cutting, depth of cutting, and time of cutting, is necessary to ensure a normal,
uneventful course of healing and to reduce postoperative sequelae.
Speed of Cutting :
Early studies in orthopedics focused on slow speeds of bone drilling to
reduce heat levels generated and subsequent aseptic necrosis of bone.
34
Recommendations were in the range of 500 rpm. Initial studies on the removal
of bone for dental purposes focused on speeds in the range of 8,000 rpm,
claiming that, in dentistry the majority of bone is removed with slow speed
rotary instruments.
Histologically, the cutting of bone with or without a
coolant or with a mixture of blood and saliva or water produced very

comparable tissue changes at this speed.
Type of Bur :
The shape of the bur and its cutting edges play a significant role in
ultimate osseous healing.
Studies comparing the use of fissure bus with
diamond burs and round burs favor the use of round burs to remove bone. This
was verified in the positive osseous tissue response seen on moderate to high
speed usage with #2 round burs, #4 round burs, #6 round burs, and #8 round
burs. Cutting with round burs produced less inflammation, smoother cut edges,
and earlier, more rapid healing of experimental surgical sites.
Cutting osseous structure with a diamond stone was the most inefficient,
with defects healing at an extremely slow rate.
Use of Coolant :
A major factor which contributes to frictional heat in adjacent bone
during cutting stems form the clogging of the bur flutes with bone chips and
coagulated tissue, especially when deep cuts are made.
This leads to an
increased torque and specific energy release with increasing bone cavity depth.
The chips and tissue which clog the flutes of the bur exert a pressure against
the internal surface of the cavity, reducing the burs efficacy, which enhances
friction generated increased temperatures.
The use of coolant, especially with high speed rotary instruments, can
cause a backsplash effect and potentially contaminate a sterile field and the
35
operator. Various approaches have been suggested to offset these problems by

minimizing the bacterial populations in the patients mouth prior to treatment,
in water lines, in handpiece and in dental units. It is imperative that the
endodontic surgeon employ the necessary procedures to control bacterial
populations prior to surgery. Based on these studies, it is recommended that ;
1. All patients rinse thoroughly with a mouth wash for 1 minute
prior to initiating the surgical procedures.
2. All handpiece be appropriately sterilized before use and/or
flushed with atleast 100 ml of water or hypochlorite solution;
3. All water lines leading to the handpiece should be flushed prior to
use with atleast 1 liter of water or hypochlorite solution and;
4. Devices which prevent water retraction and aspiration of
contaminated fluids (check valves) should be placed in all dental
units.
Pressure and Time During Cutting Procedures :
High speed cutting (250,000 to 300,000 rpm) required a minimal
amount of hand pressure to effect a cut. This reduced time factor, along with
light pressure, can be achieved by employing the technique of a brush stroke
cut or the superficial shaving method of Tetsch.
Technique of Bone removal :
1. Good anesthesia and hemostasis must always be obtained. If
additional hemostasis is necessary, injection directly into cortical
bone of an anesthetic solution with a vasoconstrictor (1:50,000)
may be indicated.
2. Handpieces must be sterile with coolant lines flushed.
In
addition, water liens to the handpiece must be back flushed to

reduce contamination. Check valves should be placed to prevent
water retraction.
36
3. Use high speed handpiece which have multiple apertures for

coolant, and ensure the direction of the spray is towards the
cutting edges of the bur.
4. Use sharp, sterile round burs to cut bone.
5. Light amounts of pressure are used when cutting bone.
6. Cut bone in a shaving or brush stroke manner, avoiding long
contact of the bur with the osseous surface.
7. Use good aspiration, properly positioned to evacuate the coolant
and debris form the cutting area rather than removing the coolant
before it an contact the cutting edges of the bur.
8. Avoid deep penetration (3-5 mm) with the bur head during
cutting. Deep penetration enhances frictional heat generation,
especially in confined cutting areas.
9. Always position the handpiece, bur, and aspirator tip to facilitate
full vision of the operative field.
10. Periodic irrigation of the surgical site with sterile saline or sterile
water during osseous entry will help to remove debris form the
site, enhance visibility, and dilute any bacterial contaminants
present.
Principles of Surgical Access to Root Structure :
Once the tissue flap is properly retracted, the surface of the bone is
examined for texture, contour, and integrity. Often fenestrations or dehiscences
may be present on the root(s) anticipated for surgery. Also root eminences in
the cortical plate will be visible long with areas of thin cortical bone through
which the yellowish color of the root is often visible.
These anatomic
landmarks help to visualize the relationship of the roots to the crown and the
angel of the roots in the alveolar process.
No Periradicular lesion Intact Cortical Bone :
Surgical endodontics may be indicated when there is no apparent
radiolucent lesion around the root.
A common situation occurs when an

37
endodontic instrument separates in the canal, the canal has not been cleaned
and shaped, the patient is experiencing discomfort, and all attempt to
nonsurgically remove the segment have failed. However, the mere fact that no
periradicular changes are evident radiographically does not dismiss the fact that
a soft tissue lesion may be present. Centrally placed lesions in the alveolar
process will often go undetected because they have not encroached upon the
internal wall at the junction of the cancelous and cortical bone. Considerations
should be given to exposing radiographic films form both a mesial and distal
angulation, in addition to a straight on view. Common situations include
lesions at the apices of the buccal root of the maxillary first premolar or mesial
buccal root of the maxillary first molar which are superimposed directly over
the palatal roots in straight on radiographs.
Tooth length and position of the apex can be estimated by measuring an
accurate radiograph and transposing this length along the tooth and bone with
the use of a premeasured sterile file or millimeter ruler. The bone in the region
of the root apex can be forcibly probed with the sharp tip of a DG-16
endodontic explorer, #23 or #5 explorer, Stewart probe, or sharp straight curette
to determine if a small defect may be present.
When an accurate location of the root apex has been determined, the
bone is carefully cut away in a shaving motion, with light pressure and copious
irrigation. During the removal of bone, the root surface can be distinguished
form the surrounding osseous tissue in four ways. The root structure generally
has a yellowish color, it does not bled when probed, its texture is smooth and
hard as opposed to granular or porous, and it is surrounded by the periodontal
ligament.
Periradicular lesion Intact Cortical Bone :
When a periradicular lesion is present, it is often possible to penetrate
the cortical plate with the sharp endodontic explorer or probe, or the sharp tip
of a periosteal elevator or small straight curette. IN many cases the cortical
38
plate will be very thin and can be peeled off, exposing the soft tissue lesion.
The undermined bone can be removed along the borders with a rongeuer
forceps, hemostat, or sharp bone curette. Ultimately a round bur may have to
be used to clearly define the extent of the lesion and expose its osseous borders.
In cases where initial penetration of the cortical bone with a probe does
not expose the soft tissue lesion, the bone is shaved off the surface. Once the
position of the lesion is identified, the bony cortex around the borders of the
lesion is carefully removed in a laterally cutting fashion, as opposed to
penetrating into the soft tissue with the bur. If the lesion extends laterally
towards adjacent roots, removal of bone should terminate before removing the
cortical plate which covers roots not involved in the surgical procedure.
Generally, an opening in the cortical plate, a few millimeters on either side of
the root, will be sufficient.
Periradicular Lesion Fenestrated Cortical Bone :

When fenestrations of cortical bone exist, whether due to thin bone, a
perforating sinus tract, or perforating lesion, removal of the remaining cortical
plate over the root apex. The brooders of the bony window being established
are extended slowly, without disturbing the underlying soft tissue. If the soft
tissue is hemorrhagic and vision in the surgical area is being obscured, injection
of the soft tissue mass with an anesthetic solution containing vasoconstrictor
(1:50,000) is indicated to control hemorrhage at the surgical site.
During the removal of osseous tissue around the borders of the lesion, a
shelf of bone is left, if possible, apical to the lesion on which to place the
periosteal tissue retractor. Failure to do this may require a greater soft tissue
reflection than anticipated or desired, or may result in constant impingement on
the soft tissue flap with the retracting instrument.
39
Once the root or soft tissue lesion is properly exposed for surgical access
and visibility, curettement, root end resection, and the establishment of an
apical seal can be accomplished.
Instrumentation and Technique :
Once the osseous tissue overlying a periradicular lesion has been
surgically removed, the soft tissue located around or adjacent to the root is
curetted. Generally, both straight and angled sharp bone curettes are necessary
along with multiple, variously angled periodontal curettes. Proper use of the
curette will often facilitate the removal of soft tissue mass in one piece.
Prior to curettage, the soft tissue mass may be injected with an
anesthetic solution containing a vasoconstrictor (1:50,000). This will ensure
comfort during the curettage and control haemorrhage in the surgical site.
Efficient and rapid root end resection is accomplished with a high speed
handpiece ( 45o or 90o angled head).
Use of low speed fissure bur showed the smoothest root surface and the
least disruption of gutta percha.
The technique of root end resection employs a lingual to labial bevel,
angled to the coronal aspect of the tooth. Suggested angles for root bevels
ranges from 30o to 45o.
Factors Influencing Degree of Removal of Root Tips :
1. Accessibility and visibility
2. Position and anatomy of root to the alveolar bone
3. Presence of any periodontal defects, root fracture,
perforations.
Root End Cavity Preparations :
Indicated when the apical seal is inadequate.
A small enlargement of the canal opening is made with a small round
bur in a straight hand piece. The depth of preparation should be 2-3 mm.
40
An ultrasonic instruments offers advantages over round burs :

-
Control and ease of use
Permits less apical root beveling
Uniform depth of preparation
Follow the direction of canal
Clean the surface better the bur
Root End Filling Materials :

Seal the apical portion of root canal.
Haemorrhage has o controlled prior to filling the cavity.
1/50000 epinephrine, bone wax.
Retrofilling Materials :
Zinc free amalgam, high cu amalgam, IRM, EBA, GIC, Cavit, Silastics,
Composite resins, Varnishes, Dentin bonding agents, MTA, CO2, Nd YAG,
Calcium phosphate cement.
FISTULATIVE SURGERY
Fistulative surgery involves procedures to establish by surgical means a
communication between the oral cavity and submucoperiosteal or periradicular
intraosseous areas of pathosis of endodontic origin. These procedures include
incision and drainage, cortical trephination, decompression.
Incision and drainage and cortical trephination are emergency
procedures designed only to relieve acute pain so that definitive endodontic
therapy can be completed after acute symptoms are solved.
Patients requiring surgical emergency treatment can be categorized in
patients with moderate to severe pain and
a) Intraoral swelling only
b) Intraoral and extra oral swelling
c) No intraoral or extra oral swelling
41
In category I patients, respond immediately to incision and drainage.

In category II patients, because of extra oral swelling, antibiotic therapy
as well as analgesic therapy should be initiated immediately. Drainage is
essential in these cases.
In Category III patients, the involved tooth should be accessed, chemo
mechanically debrided and apically trephinated.
If drainage cannot be
established, the emergency treatment of choice is cortical trephination.

The preparation of the resected root to improve the seal of the root canal
system is a multiphasic procedure consisting of haemorrhage control, root
isolation and preparation of the root end to receive a restorative material.
Blood hemostasis is initially achieved through proper anaesthetic
techniques prior to tissue incision and flap reflection, local haemostasis is by
injection into the soft tissue lesion. If haemorrhage still exits, attempts can be
made to inject directly into the bony cavity or flush the area with anaesthetic
solution.
Incision and drainage and cortical trephination are extremely effective in
alleviating most acute conditions caused by periradicular tissue inflammation
and infection. However, they are not adequate in treating cases presenting with
signs and symptoms of overwhelming infections which may rapidly progress to
life threatening condition.
INCISION AND DRAINAGE :
It involves an incision in the inferior border of an intraoral swelling,
followed by probing into the swollen tissues with a mosquito hemostat, curette
to release exudates trapped in the tissue compartment.
Analgesic therapy should be initiated before the procedure to allow the
drug to reach peak serum level at the earliest possible time.
42
In patients with large, fluctuant intraoral swelling, another type of pain

phenomenon can occur which may alarm both patients and practitioners.
As this blades passes into the target area, there is sudden outpouring of
purulent exudates, moments later, the patient experiences excruciating pain, far
more severe, than the pain that led the patient to seek treatment. This lasts for
5-7 minutes and results from severe change in tissue pressure gradients causing
excitory stimulation of sensory nerves.
The incision should be horizontal, not vertical and made along the
dependent base of the swelling, so that the release of exudates is gravity
assisted.
Probing into the incisional wound to release exudates entrapped in tissue
compartments completes the incisions and drainage procedure (No.11, 12, 15
scalpel blade).
CORTICAL TREPHINATION :
Patient who complains of pain with no swelling, the treatment of choice
is apical trephination but they are limited in certain cases (post and core,
fractured instruments, ledging).
Cortical trephination is the only option.
Trephination is a surgical technique used to all eviate acute pain caused by

accumulation of purulent material when drainage through root canal is
impossible.
The cortical trephination procedure involves an incision through
mucoperiosteal tissues, exposure of the surface of cortical bone, penetration of
the cortex with a rotary (round bur) instrument and creating a pathway through
cancellous bone to the vicinity of involved periradicular tissues.
Cortical trephination is always initiated from a buccal approach, never
lingual or palatal. Thus palatal roots of maxillary molars are rarely amenable
to this emergency procedure. Trephination only relieves the symptoms, it is not
43
always a definitive treatment. If it does not relieve symptoms, then antibiotic

coverage is required.
DECOMPRESSION :
This procedure is designed to reduce the size of the lesion so that
surgical intervention is not necessary, or if necessary will be limited to
immediate periradicular tissues of the involved teeth. The procedure disrupts
the integrity of the lesion wall, eliminates the internal osmotic pressure
differential and results in healing by osseous regeneration. Other terms used to
describe decompression include marsupialization, Partsch operation etc.
Indications :
A periapical lesion involving one or more non vital teeth.
A lesion greater than 200 mm2 in size.
Lesion seen radiographically as a circumscribed, ell defined lesion
bounded by thin radiopaque line.
Lesion that produces a straw colored fluid upon aspiration.
Decompression Technique :
After clinical and radiographic examination, the site of penetration
through the mucoperiosteum and cortical plate is selected. The route must
allow penetration of a cannula into the deepest extend of the lesion and should
be between the roots of adjacent teeth (in interdental bone). The selected site
should be as coronal as possible. After initiating at analgesic therapy and
obtaining sound local anesthesia, a small vertical incision is made in the
mucoperiosteal tissues to allow separation with a periosteal elevator and
exposure of cortical bone. Using a rotary instrument (6 or 8 round bur) in high
speed handpiece with a water coolant, the cortical bone is removed. After
aspiration, the cavity is thoroughly irrigated with normal saline.
44
It is necessary to insert a cannula to maintain the patency of the surgical

opening otherwise, it will close. Metal tubes, acrylic tubes, rubber dam and
other materials have been used.
Creating flange on the cannula to prevent its displacement into the
cavity lesion by warming the cannula over the flare. The patient is instructed
on proper irrigation technique. A 10 ml disposable Luer-Lok syringe irrigating
needle is prescribed.
The patient is asked to return after 48 hours for suture removal,
irrigation of the lesion and adjustment of the cannula for tissue comfort. Recall
after 3 months.
(NB : Ideally endo therapy should be completed after tube placement. It
prevents occurrence of root treatment flare up).
Procedure :
An incision is made in a No.11 blade directed into center of the lesion.
A vertical incision is made through the periosteum to bone and usually
penetrates into the defect on occasion the underlying bone may require
perforation with a round bur before the tube can be placed. Initial drainage
usually occurs at this time. The beveled end of the tube is inserted using a
slight rotary motion until a resistance is felt at the posterior wall of the defect.
Any adjustment is done at the beveled end. The other end is made into a button
by gently touching with warm spatula.
CORRECTIVE SURGERY
Involves the correction of defects in the body of the root other than the
apex.
Corrective surgical procedures may be necessary as a result of
procedural accidents, resorption (internal or external) root caries, root fracture
and periodontal disease.
45
Corrective surgery may involve periradicular surgery, root resection

(removal of an entire root from multirooted teeth leaving clinical crown intact),
hemisection or intentional replantation.
Reparative defects of the root and associated procedures are classified
as;
1) Perforation repair
a) Mechanical
b) Resorptive / caries
2) Periodontal repair
a) Guided Tissue Regeneration
b) Root Resection / Hemisection
c) Surgical Correction of radicular lingual groove
Perforation Repair :
Mechanical : Are procedural accident that can occur during root canal or post
space preparation common sites are pulp chamber floor of molars and distal
aspect of mesial root of mandibular molars and distal aspect of mesial root of
mandibular molars and mesiobuccal roots of maxillary molars.
Perforations can be caused by two errors :
1) Creating a ledge in the canal wall during initial instrumentation and
perforating through the side of the root at the point of canal obstruction
or root curvature.
2) Using too large or too long an instrument and either perforating directly
through the apical foramen or creating a hole in the lateral surface of the
root by over instrumentation (canal stipping).
Cervical Canal Perforations :
The cervical portion of the canal is most often perforated during the
process of locating and widening the canal orifice or inappropriate use of
Gates-Glidden burs.
46
Diagnosis : Sudden appearance of blood. Correction includes both internal and

external. Small perforations may be sealed from inside the tooth. If the
perforation is large, it may be necessary to seal first from the inside and then
surgically expose the external aspect of the tooth and repair the damaged tooth
structure. MTA has been used with excellent results.
Mid Root Perforations :

They occur mostly in curved canals during instrumentation. It can be
recognized as sudden appearance of bleeding. Access to midroot perforation is
most often difficult and repair is not predictable.
Two step method is used wherein the root canal are first obturated and
then the defect is repaired surgically. MTA has been used.
Prevention :
In lower first molars at 1.5 mm below the bifurcation, they found the
dentin of the root to be 1.5 1.3 mm thick from the canal to the cementum.
The mesiobuccal canal is in most danger of being striped.
Anticurvature filing - maintaining mesial pressure on enlarging
instruments to avoid delicate danger zone of distal wall where root is very thin.
Stripping can be prevented by exercising caution : Careful use of rotary
instruments inside the root canal.
Apical Perforations :
Cause : The instrument not negotiating a curved canal, or not establishing
accurate working length and over instrumentation. It is as a result of ledging,
apical transportation, apical zipping.
47
The term apical zip is defined as an elliptical shape that may be formed
in the apical foramen during preparation of a curved canal and subsequently
transports the apical foramen to the outer wall.
Sites are mesiobuccal and palatal roots of maxillary molars and mesial
roots of mandibular molars.
Diagnosis : Patient may complains of pain during treatment and bleeding is
seen.
Treatment : If apical zip is created, there will be two foramen : One natural and
other is iatrogenic. In this case, obturation of both these foramin and main
body of the canal requires the vertical compacting techniques with heat
softened gutta percha, often surgery is necessary if a lesion is present apically.
If the perforation is caused by over instrumentation, treatment includes
re-establishing tooth length short of original length and then enlarging the canal
with larger instruments to that length.
Creating an apical barrier is another technique that can be used to
prevent over extensions during root canal filling, materials used to develop
such barriers include dentin chips, calcium hydroxide powder, proplast, MTA.
Post Space Perforation :
A well done root canal procedure can be destroyed in a few seconds by a
misdirected post space preparation.
Treatment :
The use of resin composite bonded to adjacent root dentin with a
bonding agent.
Preparing the space at the time the root canal is obturated reduces the
risk of perforating. It is safer to do so with a hot instrument or a file than with
a round bur or an end cutting bur. Gates Glidden and Peeso drills are not likely
to be at risk in causing perforations.
Resorption (External / Internal) :
48
Repair of a defect on root surface depends on whether there is a

communication between resorptive defect and the oral cavity / pulp space.
When there is communication between resorptive defect and oral cavity,
surgical procedure is required.
When the defect communicates with pulp
space, there is excessive bleeding present.

Treatment :
Before repairing the defect, gutta percha point may be placed in root
canal to prevent the repair material from obstructing the root canal. The gutta
percha point acts as an internal matrix. The pulp space can either be obturated
at the same appointment or at a later date.
If the resorptive defect has extended into the gingival sulcus, then
mucoperiosteal flap should be raised and defect is established and repaired and
flap is repositioned and stabilized with sutures. IF resorptive defects are on
lingual / palatal surface accessibility is difficult.
Treatment intentional
replantation or extraction should be considered.

Periodontal Repair : Guided Tissue Regeneration
In the past, extensive periodontal defects required extraction or root
amputation.
Today with techniques of guided bone regeneration and
demineralized freeze-dried bone allografts, many teeth that were previously

untreatable can be saved.
Can be resorbable and non resorbable type.
Resorbable type : Collagen membrane, polylactic acid, polyglycolic
acid.
Non resorbable type : Latex, Expanded polytetrafluoroethane.
ROOT AMPUTATION :
Root amputation are procedures to eliminate a weak, diseased root to
allow the stronger root to survive, whenever if retained together would
49
collectively fail. Selected root removal allows improved access of home care
and plaque control with resultant bone formation and reduced pocket depth.
Indications :
1) Existence of periodontal bone loss to extend that periodontal therapy
and patient maintenance do not sufficiently improve the condition.
2) Destruction of a root through resorptive process, caries or mechanical
perforations.
3) Surgically inoperable roots that are calcified, contain broken
instruments.
4) Fracture of one root that does not involve the other.
Contraindications :
1) Lack of necessary osseous support for remaining root.
2) Fused roots or roots in unfavorable proximity to each other.
3) Remaining roots not favourable endodontically
4) Lack of patient motivation
5) Poor crown : root ratio
AMPUTATION TECHNIQUE FOR MAXILLARY MOLARS :
Maxillary molars typically have mesiobuccal roots that are broad
buccolingually, narrow mesiodistally and extend 2/3 of the distance to lingual
root.
Distobuccal roots are more conical in shape.
Palatal canal imparts
stability.
Amputation is performed with 701 XL bur because of its length.
Especially in mesiobuccal roots.
Preshaping crown with a bur so that large crown structure is removed
over the root to be extracted.
To resect the root involving abutment, it is horizontally resected at
oblique angle.
Osseous recontouring is done.
Finally reshaping of crown is done with diamond stones.
50
Morphologic Factors :
The length, width and contour of roots are important factors in
determining where the resective cut is made and strength of remaining tooth
structure.
Two different approaches to resection are available. One approach is to
amputate horizontally or obliquely the involved root at the point where it joins
the crown, a process called root amputation.
The other approach is to cut vertically the entire tooth in half from
mesial to distal of crown in maxillary molars, and form buccal to lingual of
crown in mandibular molars removing in either case the pathologic root.
This procedure is called hemisection.
INDICATIONS FOR HEMISECTION :
1. Furcal invasion by inflammatory periodontal disease not
amenable to correction by root planning, oral hygiene procedures.
2. A carious lesion involving one root of a multirooted tooth.
3. Fracture of a single root of multirooted tooth.
4. Perforation of a root during endo treatment.
5. Partial calcification of root canal not amenable to conventional
endodontic treatment
6. Severe dilacerations
CONTRAINDICATION :
1. Extensive bone loss
2. Pronounced pre-operative mobility
3. Fusion of roots at or near the apices
4. Inoperable canals
5. Ineffective oral hygiene
51
6. Furcal involvements where the furcation is far apical to CEJ that gaining
surgical access is difficult with loss of osseous support.
HEMISECTION :
The radiograph is examined to determine that the fusion of the roots is
not present. Endodontic treatment is completed on the root to be retained. The
chamber and root to be resected is condensed with amalgam. The area is
anaesthetized and the coronal segment of the tooth is sectioned with a fissure
bur. The bur is placed in the bifurcation and moved in the buccal and lingual
direction until the entire crown is severed. The bur is then move dint eh apical
direction to severe the furca.
When the crown and furca are severed, a
periosteal elevator is used to release the periodontal attachment and luxate the
root. Extraction forceps are used to grasp and luxate the section to be removed.
Smoothen the sharp, furca with a blunt tapered diamond. A radiograph is taken
to determine all of the overhanging furca is removed. The buccal and lingual
plates are compressed with finger pressure. Sutures are not usually required.
Tooth is restored with a crown.
Bisection / Bicuspidization Refers to a division of the crown that
leaves the two halves and their respective roots. They are designed to form a
favourable position for the remaining segments that leaves them easier to clean
and maintain a good oral hygiene.
Procedure :
-
Endodontic treatment should be carried on the root to be retained.
The occlusion should be adjusted to eliminate the trauma of lateral

excursion
After endodontic treatment, post endodontic restoration has to be placed.

SOFT TISSUE MANAGEMENT
CONTROL OF HAEMORRHAGE
LOCAL AND SYSTEMIC
52
LOCAL CONTROL :
A) Topical
a) - Adrenaline - Nor-adrenaline
b) Absorbable Agents
Cellulose Oxidized Cellulose (Oxycel)
Oxidized regenerated cellulose
Absorbable gelatin sponge
Human fibrin foam
Calcium alginate
c) Thromboplastin agents
Thrombin Human and Bovine
Russel Viper Venom Powder and solvent
d) Chemical agents
Tannic Acid (2-5%)
Tin ferric chloride (15%)
Zinc chloride (6-10%)
Alum (5%)
H2O2 (Dilute)
e) Socket plugs
Ethicon bone wax
Horpleys wax
White head varnish
Bismuth iodophor paste
ZnO and Eugenol on cotton wool
f) Electrocautery When tissues are touched with cautery, it causes
precipitation of protein elements in the end of the wound
resulting in sealing of the vessel.
g) Cold compressors Ice application
h) Mechanical measures
53
Pressure (Use of wet gauze)

Splints
i) Ligation and Sutures
Atraumatic needles and silk
Absorbable suture
Bone punch Occlude the orifice of bone canal for intraosseous bleeding.
SYSTEMIC CONTROL :
1. Adrenochrome monosemicarbozone dehydrate (available in Tab / Inj)
2. Prenarin (conjugated estrogen) 20-40 mg.
3. Vitamin K 5 mg tab. TDs, 2 mg/iv
4. Vitamin C + rutin
5. Calcium Gluconate
6. Ehtamsylate
7. Styptobion tab / IM
8. Fresh frozen plasma (20-30o C storage)
9. Freezed dried human AHG
10. Epsilon Amino Caproic Acid
11. Cyelocapron
Classification of Topical Hemostatic Agents :
1) Mechanical agents (Non Resorbable)
a) Bone wax
2) Chemical agents
a) Vasoconstrictors : Epinephrine
b) Ferric sulphate
3) Biologic agents
Thrombin
4) Absorbable hemostatic agents
a) Mechanical agents
i) Calcium sulphate
54
b) Intrinsic action agents

i) Gelfoam
ii) Absorbable collagen : collatape
iii) Microfibrillar collagen hemostats : Avitene
c) Extrinsic action agents
i) Surgical
Bone Wax :
Composition : Beewax + Softening agent + Conditioning agent.
Mechanism of action : when placed under pressure, lugs the vascular openings.
Drawback : Presence of persistent inflammation vasoconstrictors.
Epinephrine is commonly used. Cotton pellets containing racemic epinephrine
(1.9 mg).
Ferric Sulphate (Monsels Solution) :
Mechanism of Action : Agglutination of blood proteins and acidic pH of the
solution.
Advantages : Easy to apply, does not require pressure.
Disadvantages : Known to be cytotoxic and cause necrosis and tattooing.
Thrombin :
Mechanism of Action : Initiate the extrinsic and intrinsic clotting pathways.
(NB) It is designed for topical application only.
Disadvantages :
-
Difficulty in handling
Cost factor
Calcium Sulphate :
Consist of powder and liquid component which is mixed into a thick
putty like consistency and placed in bony walls.
Mechanism of Action : It plugs the vascular channel of action.
55
Advantages :
-
It resorbs in 2-4 weeks
It is porous which allows fluid exchange and does not allow flap
necrosis.
In expensive.
Gelfoam and Spongostan : Hard, gelatin based sponge that are water insoluble
and resorbable.
Mechanism of Action : They promote the disintegration of clot causing
subsequent release of thromboplastin.
Collagen :
Mechanism of Action :
1) Stimulation of platelet adhesion, aggregation and release reaction
2) Activation of Factor VIII
3) Mechanical tamponode action
4) Release of serotonin
Applied directly to heeding site while using pressure.
Haemostasis
achieved in 2-5 minutes.

Microfibrillar Collagen Hemostat :
Avitene and Instat are 2 popular forms.
It is derived form purified bovine dermal collagen, shredded into fibrils
and converted into an insoluble partial hydrochloric acid salt.
Mechanism of Action : It functions through topical hemostasis, providing
collagen framework for platelet adhesion, which initiates platelet plug
formation.
Disadvantages :
-
Difficult to apply to wet surface
Inactivated by autoclaving
56
Their contamination may enhance infection
Expensive
Surgical : Prepared by oxidation of regenerated cellulose, spun into threads and

woven into a gauze that is sterilized with formaldehyde.
Mechanism : Act as a barrier to blood and then as an artificial coagulum as
plug.
Suturing : To secure the flap in its original position should not pull or stretch
the tissue and should not compromise circulation.
Suture kit : Thread, needles, scissors, haemostat, cotton tips.
Suture Materials :
a) Silk
Non resorbable
Twisted or braided
Increased strength
Easy to handle
Least expensive
-
Disadvantage : Oral hygiene

b) Catgut suture : Collagen made form submucous layer of small
intestine of sheep.
Resorbable.
Disadvantages : Takes atleast 24 days to resorb, so oral hygiene is a

problem.
c) Monofilament (Polyester).
Advantages : Strength
Disadvantages : Can tear the tissue like wire cuts cheese.
Complications :
57
Haemotoma formation
Ecchymosis
Stichabscess
Removal of suture done after 7 days.

1) Incision : In order to gain access to bone soft tissue must be incised (No.15
BP Blade).
2) Elevation : A most fracture 9 periosteal elevator is used to reflect or elevate
tissue.
A total exposure of the lesion is the most important objective in
elevation.
3) Retraction : to hold the soft tissue away form the surgical area without
impinging upon the circularly system of the flap.
4) Ostectomy: Removal of the overlying bone at the root apex of the offending
teeth.
For greatest efficiency in cutting bone, carbide should be used with a
heavy water spray to cool or cleanse the bone and bur.
For endodontic surgery, assorted round burs ranging from size #2 to #8
and the round ended tapered fissure burs sizes #402 and #458 efficiently
accomplish most entries into bone.
The bony window should be large enough to permit access to all
dimensions of the lesion and facilitate total nucleation.
5) Curettage : The purpose of removing the pathologic tissue is to eliminate the
zone of irritation and contamination and take the specimen for histologic
examination.
The Allis forceps is an excellent instrument to remove the tissue without
damaging it. Three efficient curettes - #4, #50C, #11.
6) Apicectomy:
58
7) Closure : Before re-attaching the reflected tissue, it is advisable to examine

the surgical site radiographically. Haemorrhage has to be controlled before
patient is dismissed. Various techniques has been employed.
- Reinject L.A. solutions containing 1:50,000 epinephrine and suture the flap.
- Pack the bony cavity wit iodoform gauze and apply pressure for 5-10 minutes.
- Pack the bony cavity with bone wax for 5-10 minutes, remove the wax and
suture the flap.
Pack the bony cavity with artificial clotting agents.
The most commonly used preparations are Gelfoam and surgical.
Gelfoam is a specially treated sterile porous gelatin sponge. It is inert
and when packed in bone and it is absorbed in 4-6 weeks. Overfilling is
avoided as the material expand an contact with blood. Prophylactic antibiotic
session is recommended to reduce the potential for postoperative sensitivity.
Surgical, a modified carboxymethyl cellulose, an oxidized, regenerated
cellulose and is also effective in controlling bleeding from bony cavities. Once
in contact with blood, the cellulose develops and products which can cause an
artificial clot. This material is not absorbed and its low pH has been suspected
to be cause of postoperative pain.
Suturing : A standardized suture kit should contain thread, needles, scissors and
a hemostat or needle holder, cotton tips.
Suture Materials : 3 types
-
Catgut suture : Collagen made form submucous layer of small intestine

of sheep.
Advantages : Absorbability i.e. suture removal is not necessary.
Disadvantages : It takes atleast 24 days to resorb, so oral hygiene is a

problem.
Monofilament (Polyester) (Plastic)

Advantages : Strength
59
Disadvantages : Can tear the tissue like a wire cuts cheese. The cut ends are
sharp and can lacerate the lips and cheeks.
POST-OPERATIVE INSTRUCTIONS
1. It is normal for blood to seep from site of a surgical procedure for
several hours after the operation. Moth rinses are avoided, as they
stimulate bleeding. Cleanse the mouth with teaspoon of table salt and
glass of hot water. Try to locate the bleeding spot and apply pressure
with a piece of gauze. If this fails to stop, call the surgeons office.
2. Swelling may be seen which may last form few hours to several days.
Following surgery, an icepack should be applied to swollen area, at 10
minutes interval for first 6-8 hours and heating pad should be applied for
30-60 minutes 4 times a day on second, third and fourth days.
3. Pain may be present following surgery using ice pack and taking two
aspirin tablets every 3-4 hours will help reduce this pain.
4. Careful brushing is desired and promotes healing.
5. Post-operative infection may be seen. Hot saline rinses are taken.
6. Patient may experience loss of appetite as the teeth may be tender and
certain foods may be difficult to chew. Treatment high protein diet as
well as multivitamin capsule.
7. If one or more stitches loosens and hangs free, it should be trimmed with
scissors.
REPLACEMENT SURGERY
INTENTIONAL REPLANTATION
Replantation is defined as the replacing of a tooth in its socket following
deliberate or traumatic avulsion.
The only true indication for intentional replantation is when there is
absolutely no other treatment available to maintain a strategic tooth.
60
The major contraindications include unrestorable, fracture or non

strategic teeth, presence of periodontal disease, irregular root structure and lack
of patient compliance.
Technique :
-
Ensure proper removal of all debris and irritating substances form the
tooth.
Root canals should be cleaned, shaped and obturated to the extent

possible.
It is advisable to fill the endodontic access opening with an amalgam to

strengthen the crown, so it can withstand the forces of extraction.
Patient premedication with antibiotics and anti-inflammatory agents.
After anesthesia, the tooth to be extracted is isolated and surrounding

area is cleaned with an antiseptic solution. Elevators should be carefully
used to loosen the tooth, minimizing injuries to the investing tissues and
root surface.
Extraction forceps should make minimal contact with
tooth structure.
-
The tooth is gently lifted form its socket and base of socket is carefully
curetted to remove any foreign debris. Under no circumstances, should
the walls of socket be curetted.
Socket can then be covered with a sterile gauze.
Examine the tooth for fracture, extra roots or foramina or any unusual
configurations such as C-shaped roots.
When the tooth is ready to be replaced in its socket, the walls should be
gently flashed with saline to remove the blood clot.
The tooth is
carefully and slowly placed into its socket allowing for a slow escape of
blood which has build up in the socket. Slight pressure is applied to the
buccal and lingual cortical plates to ensure adaptation.
-
The occlusion is re-checked and a splint is placed if necessary. Splints

are removed within 5-7 days.
61
Analgesics are used as necessary, with NSAIDs being the drug of

choice.
INDICATIONS :
1.
Inadequate interocclusal space is perform non surgical endodontic

treatment.
2.
Canal obstruction
3.
Surgical approach not possible
4.
Non-surgical and surgical treatment have failed
5.
Visual access is inadequate to perform root end resection.
6.
Root defects (resorption, perforation).
Factors Affecting the Outcome :

1) Keeping the out of socket time as short as possible.
2) Keeping the periodontal ligament cells on root surface moist with saliva.
3) Minimizing damage to cementum and periodontal ligament cells.
Contraindications :
1. Periodontal involvement with excessive mobility of tooth.
2. Buccal or lingual palate that is destroyed or missing.
3. Septal bone at bifurcation and trifurcation that is destroyed or missing.
4. Extraction may cause fracture of crown.
IMPLANT SURGERY
Can be divided into root form osseointegrated implants and endodontic
implants.
ROOT FORM OSSEOINTEGRATED IMPLANTS :
Osseointegration is defined as the direct structural and functional
connection between ordered, lining bone and surface of load carrying implant.
Biomechanical as well as bacterial factors have long been recognized to
play a substantial role in osseointegration maintenance.
62
Immediate Implant Placement :

Implant placement is done immediately following tooth extraction.
Advantages :
-
Incorporation of two procedures into one appointment.
The expediency of total treatment time.
Minimization of osseous collapse as well as resorption and maintenance

of soft tissue architecture.
Indications for Root Form Osseointegrated Implants :

1. Vertical root fracture
2. Horizontal root fracture in coronal 1/3 to of the root.
3. Non-repairable resorption
4. Non-Treatable endo-perio lesions
5. Non treatable endodontic failures
6. Non-treatable retained primary teeth
7. Gross post perforations
8. Non-restorable teeth
Contraindications :
1. Lack of special training by surgeon
2. Uncontrolled diabetes mellitus
3. Psychiatric factors
4. Post menopausal women on thyroid medication and without estrogen
replacement therapy
Procedure :
The tooth should be extracted with as little trauma as possible. It is
important to retain the cortical bone buccal and lingual to the extraction socket.
63
The implant apex should be stabilized in atleast 3 to 4 mm of bone and

implant head should be positioned to confirm to either central fossa, in
posterior teeth or cingulum in anterior teeth, for screw retained prosthesis.
Bone graft materials.
Soft tissue closure and supportive therapy.
ENDOSSEOUS IMPLANTS :
Partially enclosed and submerged within the bone. They are in varying
designs and composition.
Shapes : Blades, spirals, screws, hollow cylinders, cones or cylinders with
porous surfaces.
Endosseous implants with polymeric inserts, which acts s shock
absorber.
Coated with ceramic such as hydroxyapatite or Ti-plasma stage to
enhance their interaction to biological environment.
Indications :
To replace a removable prosthesis with fixed prosthesis in posterior
edentulous area of mandible. To lend support to middle of a long span bridge.
To support either a usually complete denture or fixed prosthesis in a totally
edentulous mandible.
Types :
a)
Subperiosteal implants : Is a framework specially fabricated to fit on top

of supporting areas in mandible or maxilla under mucoperiosteum with
perimucousal extension for support and attachment of a prosthesis.
b)
Transosteal implants are inserted through an extraoral incision below

the chin with series of projection that penetrate the mandible from its
inferior border and connected by a bone plate that rest on inferior border
of mandible.
c)
Endosteal implants Surgically placed within alveolar and basal bone,

they are further divided into root form and blade form implants.
64
Requirements of an Implant :
1. The implant must be fabricated from an alloplastic biocompatible
material such as titanium, titanium alloy or hydroxyapatite.
2. The preparation of bony socket must be done with a gentle surgical
technique.
Electric handpiece revolve at slow RPMs are designed
specifically for implant surgery.

3. The implant must closely fit the precise bony preparation throughout its
length.
4. The implant must be mechanically fixed to bone by either threads or a
roughened surface on the implant.
5. The implant must remain unloaded during healing phase of 3 to 9
months.
6. The implant must be properly restored with an even distribution of
occlusal forces.
Factors Affecting the Placement :
-
Severity of initial infection
Location of root relative to the alveolus
Residual bone buccolingually and coronally apically
Vascularity of residual bone
Density of residual bone
Quality of cancellous marrow spaces
Availability of bony walls to contain the bone graft material
Volume of bone regeneration necessary
Soft tissue available for closure
Experience of the operator

ENDODONTIC IMPLANTS
Definition :
Is a metallic extension of the root with the object of increasing the rootto-crown ratio, to give the tooth better stability in the arch.
65
Indications :
1. Transverse root fracture
2. Internal resorption involving apex
3. Pathologic resorption involving apex
4. Periodontally weak tooth
5. When there is less root length compared to crown
Contraindications :
1. Recently erupted tooth
2. Impacted teeth
3. Cyst/tumors of maxilla and mandible
4. Complete lingual spiny ridge
5. Carcinoma of oral tissues
6. Drug addictions
7. On going radiation therapy
8. Extensive neuralgic diseases
9. Pregnancy
10. Alcoholism
11. Blood diseases
Procedure
The equipment needed for endodontic implantation is the same as for
endodontic treatment, with the addition of a series of extra-long reamers, 40
mm, in sequential sizes and implants of corresponding size.
First, anesthetize the tooth and involved area with a local anesthetic.
Next, with the rubber dam in place, aseptically complete the usual treatment of
access preparation, enlargement, and irrigation of the root canal. The access
preparation should differ from the usual in that it must be larger and wider in
the clinical crown, to accommodate the placement of a rigid implant that
requires straight-line insertion into the canal. In addition, the root canal must
66
be enlarged to at least the size of a No.60 instrument. In a tooth with multiple

canals or an apical root curvature, the canals should be filled and sealed with
gutta percha and cement in the usual manner.
Unfilled canals or a partially unfilled canal in a curved root tip, as
occurs with penetration of the osseous layer form the root canal in a straight
line preparation, will result in failure and formation of subsequent periapical
rarefaction.
A marker is then set on the 40 mm reamers at a level equivalent to the
length of the tooth plus the number of millimeters the implant will extend
beyond the root apex. The first 40 mm reamer used to perforate the root apex
should be several sizes smaller than the last sized instrument used to complete
the preparation of the root canal. The last 40 mm reamer used should be at
least equivalent in size to the last endodontic instrument used in the root canal
alone and the bone is reamed to the desired length. Irrigate the root canal with
anesthetic solution or sterile saline solution rather than sodium hypochlorite,
which can irritate the periapical tissue. Irrigation of the canals debrides as well
as controls hemorrhage within a few minutes.
Dry the canal with sterile
absorbent points.
Select an implant of equivalent size to the last instrument used, score it
lightly to indicate the desired length, that is, form the occlusal tip through the
root canal to the exact length cut into the cancellous bone, and insert it into the
root and bone. The implant must fit tightly and must penetrate the bone to the
prepared length.
If necessary, enlarge the root canal a little more to
accommodate the implant, but the implant must fit at the apical foramen. Dry
the root canal again. Shorten the implant at its apical tip by 1 mm, to ensure
that will seat snuggly and will not bind in the cut osseous bed. Insert a plugger
into the access opening until it binds, and measure the exact length it can be
inserted unimpeded into the canal. This plugger will be used to seat the
implant during cementation; because the butt end of a Vitallium or chrome
67
cobalt implant must be cut off prior to insertion into the tooth because of the
hardness of the metal.
Using a diamond or carborundum disc, cut the butt end of the fitted
implant and remove a length equivalent to that measurement obtained by
inserting the plugger blade into the root anal. Insert cement into the dried canal
(Grossman suggests a polycarboxylate cement; Frank suggests AH 26 cement),
and try to avoid cement extrusion beyond the canal. Using a hemostat to hold
the sterilized implant, insert the implant slowly not the canal and bone. Seat
the implant by pressing the plugger blade firmly against the butt end of the
implant until it binds completely in the canal. When a post type crown is to be
made, seat the implant to the level corresponding to the midroot and leave
sufficient space to cement a post-core crown afterward.
TRANSPLANTATION
It is not as successful as intentional replantation because of the
immunologic factors. Autotransplantation is a transplantation of a tooth in the
same individual. It is a method of choice. Allotransplantation is from one
person to another is still considered as experimental procedure.
VALID CAUSES FOR SURGICAL FAILURE :

1) Failure to debride the root canal space thoroughly.
2) Failure to seal the root canal space three dimensionally.
3) Tissue irritation from toxic root canal fillings or root end fillings.
4) Failure to manage root canal or root end filling materials properly.
5) Superimposition of periodontal disease
6) Vertical fractures
7) Recurrent cystic lesion
8) Improper management of the supporting periodontium.
QUESTIONABLE CAUSES FOR SURGICAL FAILURE.
68
1) Infected dentinal tubules and surgical site.

2) Antibiotics
3) Accessory and lateral canals
4) Loss of alveolar bone : The loss of alveolar bone, especially the buccal
cortical plate, has been shown to render a poor postoperative prognosis
following periradicular surgery.
5) Root resorption
6) Timing of root canal obturation : Always put in the root filling first,
because if you cut off the root tip first it will be difficult to make a
successful root filling; but if you fill the root canal first and then cut off
the root tip you will heave a clean, oval surface. On the other hand, a
better prognosis has been identified by many authors when the root is
filled prior to surgery. Studies conducted using ultrasonics for canal
debridement during surgical treatment have shown a greater reduction in
bacterial populations.
Anatomic Factors :
1) Fenestration Dehiscence
2) Aberrant root anatomy or canal space
3) Root proximity in the alveolar bone
4) Maxillary sinus
5) Focal myositis
6) Loss of osseous structure
Technical Factors :
1) Quality of canal cleaning and obturation
2) Quality of root end resection.
a) Root apices which are not completely resected, exhibiting a
smooth flat root face, may serve as a source of irritation to the
surrounding periradicular tissues.
69
b) Roots or root systems not completely resected from buccal to

lingual may hide obscure roots canals, canal extensions,
anastomoses, or coronal canal exiting.
c) Extensive resections without regard for adjacent teeth may cause
needless pulp devitalization or damage to adjacent root structure
resulting in possible resorptive defects.
3) Quality of root end cavity preparation.
a) Failure to include an isthmus or portion of a canal extension in
the preparation.
b) Failure to achieve a minimum or ideal depth of cavity preparation
based upon the particular anatomic situation.
c) Lack of retention in the root end preparation
d) A palatal, lingual or lateral perforation of the root.
e) Choosing an improper cavity preparation design for a particular
root anatomy without considering all the anatomic factors, e.g. a
long axis prepared in a deeply platally placed root of a maxillary
first premolar, or a slot preparation when the buccal crystal bone
is already compromised and
f) Inadvertent preparations of a cavity in bone which resembles root
structure.
Quality of the Root End Filling Materials and Techniques :

1) Poor adaptation and condensation.
2) The biologic breakdown of root end filling materials
3) Excess material left in the surgical site, either as overhangs,
overcontours, or scattered debris, has also been implicated in case
failure.
4) Cytotoxic root filling materials which have been expressed beyond the
apex or which are left or placed s the root end filling material can cause
70
damage to the surrounding vital structures (antrum, alveolar nerve) and

periradicular surgery will invariably not be able to correct the damage
because of the irreversible tissue destruction.
Improper Soft Tissue Management :
Failures in periradicular surgery can also be attributed to improper flap
design, tissue reflection, retraction and repositioning, and suturing.
71
CONCLUSION
Improvement in conventional therapy in last 5-10 years has dramatically
reduced the number of cases requiring surgery. This fact must be attributed to
better endodontic instruments and materials, increased knowledge of canal
anatomy, refinement of operative skills and added understanding of basic
medical sciences.
Yet even with the improvement, there still exist a need for surgical
procedures to manage problems that cannot be eliminated by non-surgical
technique.
72

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ENDODONTIC

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

DR. DILU DAVIS

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Dept. of Conservative Dentistry and Endodontics

Procedures that penetrate the mandibular

canal, maxillary sinus, mental foramen, floor of the nares should be

length and number of vertical releasing incisions. Semilunar incision produces

Limitation of mouth opening TMJ problems resulting from surgery,

Shallow mucobuccal fold when the mucobuccal fold is shallow, the

Short alveolar process In the case of incomplete development, or in

Eg. Floor of the nose,

maxillary sinus, mandibular canal and mental canal and foramen.

secondary problem is the greater likelihood of their proximity to

Flaring or wide alveolar process : Some individuals have wider alveolar

Two choices are

available when pockets are present.

a) Instill professional confidence.

Prophylactic antibiotic coverage

Under Local Anaesthesia

- Amoxycillin 3 g orally 1 hour before

Under General Anaesthesia Amoxycillin 1g IV + 0.5 g aminoxycillin orally 6

Determine bleeding time if patient is taking valproic acid.

Avoid injection of vasopressor amines with local anaesthesia

- Ibuprofen 400-600 mg every 4-6 hours following surgery.

Resorptive and carious

Cardinal Rule III :

Vertical incisions should be made in the concavities between bony

Horizontal gingival crest incision formed by single vertical relaxing

It allows for visualization of complete length of root, option of

Disadvantage : Difficult to suture interproximally , gingival stripping can

Indicated in areas of veneered crowns and esthetics.

Preferred in maxillary anteriors

Indicate d in Trephination and minor curettage. Consist of sheet oblique

Gingival levels can be change d in any position

Tension on flap is excessive

Access and visualization

No relaxing incisions Leaving of tissue

To eliminate the zone of irritation and contamination.

To take the specimen for histologic examination.

Curettage done with sharp curettes :

Probably, the finest innovation in suturing has been the development of

Sling suspensory, Continuous mattress, Blanket techniques

To remove necrotic cementum

To gain access to the root for additional surgical procedures

To remove excessive, overextended root canal filling materials

To assist in rapid healing and repair of periradicular tissues.

To remove septic lesions as convenience to the patient.

To remove a long standing, persistent lesion especially when a cyst is

To eliminate a persistent sinus tract

To remove external resorptive processes

To release confined inflammatory exudates

To obtain a specimen for biopsy

Periradicular Curettage Versus Root End Resection :

ROOT END RESECTION ( ROOT END AMPUTATION, APICOECTOMY)

Removal of anatomic variations. They include accessory canals, apical