INTRODUCTION

It is generally accepted that non-surgical endodontics therapy

periapical inflammation or infection and allows teeth to be restored that
previously might have been extracted. However failures does occur in a
small percentage of cases. When confronted with such cases the clinician
should be prepared to initiate alternative procedures including surgery to
enhance the rate of success.
The scope of endodontic surgery has expanded beyond
apicocectomy to include crettage, radisectomy, replantation
transplantation, implantation, trephination, incision and drainage.
Apicoectomy literally means !esection of the root apex" but for many
years it has been in#udiciously used to describe many types of endodontic
surgical procedures. At present the more acceptable term when referring to
surgical procedures performed around the root periradicular surgery.
$hivian suggested using the terminology non-surgical or conventional
verses surgical to describe the two endodontic procedures.
HISTORY ACCORDING TO INGLE
%ndodontic surgery has first recorded &'(( years ago when Aeticus,
a )ree* physician dentist excised an acute apical abscess with a
small scalpel.
&
+ater the procedure was refined and populari,ed by Hullihen in
&-./.
0arrar 1&--23, !hein 1&-/23 and ).4. 5lac* 1&--63 described root
amputation techni7ues and in &/&/ )arvin demonstrated
retrofillings radiographically.
PATHWAYS BE CONSIDERED WHEN REVALUATING AN
ENDODONTICALLY TREATED TOOTH
Classification
%ndodontic surgery encompasses surgical procedures performed to
remove the causative agents to radicular and periradicular disease and to
restore these tissue to functional health. It can be classified as follows8
1. Surgical drainage
a. Incision.
b. Trephination
2. Radicular surgery
a. Apical surgery
i. $urrettage and biopsy.
ii. Apicoectomy.
iii. !etrofilling.
9
b. $orrective surgery
i. :erforative repair ;echanical
!esorptive
ii. :eriodontal repair )T!
!esection
3. Replacement surgery
a. !eplant surgery Intentional
:ost traumatic
b. %ndosteal implant surgery %ndodontic
<sseointegrated
.
INDICATIONS AND CONTRA INDICATIONS
$lean well obturated canals are the biological basis of endodontic
success mar*ed improvements in the non surgical techni7ues have
improved the success rate, however if cleaning of the canal terminus root
canal access is impossible, 1a surgical approach should be considered3
whenever a root canal cant be filled properly with an orthograde filling
endodontic surgery should be considered.
A classical characteri,ation of specific indication and
contraindication has developed by +eub*e, )lic*, and Ingle. 5ased on the
classifications.
Indications of endodontic s!"e!# $G!oss%an&
&. Any condition or obstruction that prevents direct access to the apical
third of the canal such as8
a. Anatomic = calcifications, curvatures, bifurcations dens in
dente and pulpstones.
b. Iatrogenic = ledging bloc*age from debris, bro*en
instruments old root canal fillings and cemented posts.
9. :eriradicular disease associated with a foreign body, overfilled
canals, bro*en instruments protruding into apical tissue and loose
retrograde fillings.
2
.. Apical perforations8 any perforation that can"t be sealed properly by
a filling within the canal.
2. Incomplete apexogenesis with blunderbus or other apices that do not
respond to apical closure procedure.
'. Hori,ontally fractured root tip with periradicular disease.
6. 0ailure to heal following non surgical endodontic treatment.
>. :ersistant and recurring exaggeration during non-surgical treatment
or persistant, unexplainable pain after completion of non surgical
treatment.
-. Treatment of any tooth with a suspicious lesion that re7uires a
diagnostic biopsy.
/. %xcessively large and intruding periapical lesion.
&(. ?estruction of apical constricture of root canal due to uncontrolled
instrumentation.
Cont!a Indications fo! endodontic s!"e!#
&. Indiscriminate surgery.
9. :oor systemic health.
.. :sychological impact.
2. +ocal anatomical considerations.
'
Indiscriminate surgery : %ndodontic surgeries should not be a cover up for
every endodontic case or a cover up for the s*ill in non surgical endo
techni7ue.
@urgeries are not simply indicated because a periadicular lesion is
present at the time of treatment, is because a large lesion is present or
because the clinician believes a lesion may become cystic.
Poor systemic health : A complete medical history is mandatory. If a
7uestion exists about the patients health, medical consultation must be
sought with the patients physician. $ontraindications include blood
dyscrasias is neurological problems, terminal illeness, diabetes, heart
diseases, pregnancy in first and third trimestor.
Psychological Impact : :atients facing endodontic surgery may be terrified
by the suggestion of surgery to see* masochistic addiction to polysurgery
who is see*ing the experience. :atients should be allowed to verbali,e their
thought and fear are they have been informed of the operation.
Local Anatomical considerations : @hort root length precludes apical root
resection if the grown root ratio should becomes so disproportionate as to
limit the useful future of the tooth.
Poor bony support : An advanced periodontal disease may well dissuade
one from endodontic surgery. <n the other hand in these cases apical repair
6
can be expected to develop within the 9 years following successful
endodontic treatment.
ANATO'IC CONSIDERATIONS
Maxilla Anterior Facial Region
- The lateral incisors are seldom close to the nasal
floor than the central incisors.
- The maxillary incisors and canines are often covered
with little or no labial cortical plate.
- The maxillary sinus is in close proximities to the
root apices. At times apices of the maxillary premolar and
molars may penetrate the sinus floor and establish a
communication between the periodontal ligament and
mucoperiosteal lining of the sinus.
- Although the maxillary sinus membrane perforation
usually doesn"t cause postoperative problems, care must be ta*en
to prevent root tips, bone or other foreign bodies being
inadvertently pushed into the sinus.
- A prominent ,ygomatic process may impede
surgical access to the root of a maxillary molar teeth.
>
- A palatal root of the first or second molar that is
closely aligned with the greater palatine foramen. The position
and course of the palatine bundle must be carefully determined
when placing a palatal approach to the palatal root. To avoid
vessels, palatal access is gained by reflecting a flap created by
ma*ing a vertical incision between the premolars and a short
distal releasing incision of the tuberosity.
Mandible:
- :roximity of the mental foramen to the apices of
mandibular premolars and on occasion to the first molar.
- Thic* external obli7ue ridge in the second and third
mandibular molar region.
- The mandibular canal doesn"t interface with surgical
access except when a shallow mandibular process is associated
with long roots.
The mean vertical distance from the mesial root apex of first
mandibular molar to the superior border of the neurovascular bundle is
about '..mm.
The buccolingual position of the canal can be determined by
comparing a I<:A exposed at right exposed at right angle to the long axis
of the tooth with a second radiograph exposed at a vertical angulation of
-
9'A and the central beam directed superiorly, if in the second film the
mandibular canal waves inferiorly in relation to the roots apices, the canal
is lingual in the apices, if it moves upwards on the roots it is buccal, is the
apices minimal movement of canal indicates that it is in close proximity to
the apices.
PRE(OPERATIVE CONSULTATION WITH THE PATIENT
The surgical procedure should be described in detail, as should all
potential postoperative problems such as discomfort, swelling, bleeding,
brushing, maxillary anterior penetration and rare possibility of parasthesia.
- A hand drawn illustration is often useful.
- Alternative to surgery such as no treatment, tooth
extraction and referral should also put forward.
- :atient should be as*ed to sign that attest to them
understanding and treatment procedure, ris* and fees.
PRE(OPERATIVE PREPARATION AND PRE'EDICATION
O) THE PATIENT
Antise*tic %ot+,as+ - According to +oe, B:@ &/>(, chlorhexidine
gluconate reduces the levels of fracture in the oral cavity and plays a
important role in healing following endodontic surgery.
/
:atient is instructed to rinse with the solution for & min twice daily
for ' days. This regimen should begin the day before surgery.
Administration of non-steroidal anti-inflammatory drugs before the
surgical procedure helps to reduce postoperative pain and swelling.
Ibuprofen enacts its effects by inhibiting the en,yme cycle-oxygenase and
preventing the formation of inflammatory mediators. Its analgesic and anti-
inflammatory properties result from inhibition of peripheral prostaglandin
synthesis. A loading dose of 6((mg 9 hours before surgery, and 2((mg
every 2 hours postoperatively is advised.
@hort acting barbiturates, such as pentobarbital and secobarbital are
fre7uently used for sedation. $ommonly administered orally, '(, &'(mg C
.( min prior to the surgical treatment.
Tran7uili,ers effectively reduce apprehension and act as muscle
relaxants.
?ia,epam, 'mg ta*en orally .( minutes prior to treatment.
Darcotics can be effective premedication.
AR'A'ENTARIU'
The suggested surgical set up for periapical surgery8
&. Anesthesia = lidocaine H$+ 9E, epinephrine &,-(,(((
9. @terile cotton gau,e.
&(
.. :eriosteal elevator 1molt 2 curette, the friedy3.
2. @traight handpiece burs 9, 2, 6, -, .. F hand chisel, sterile saline,
handpiece, 1st and $A3 and microhead contra angle.
'. @urgical curettage.
6. Apical amalgam carrier, plastic instrument, amalgam plugger and
condenser.
>. Deedle holder or hemostat, sil* suture and scissors.
-. @urgical tray cotton pliers, explores, mirror etc.
0iberoptic light source could be used, which is attach to surgical aspirators
or retractors.
;agnification of operative site using visors and loupes. @urgical
telescopes and microscopes also provide crisp undistorted images of
operating site.
High tor7ue surgical drills are preferred to systems that rely on
compressed air as these motor engine driven system prevents the
phenomenon of cermicofacial subcutaneous air emphysema.
Haemostasis can be achieved by use of Du gauge geefoam, bone wax or
other physical barriers.
&&
$otton, cotton wool or gau,e saturated with adrenaline are least desirable
materials as the residual cotton fibres left in the crypt provo*e a latent
foreign body reaction.
Astringents such as &'.'E ferric sulphate burnished into a area of bleeding
promoes homeostasis by rapidly.
ANESTHESIA
GA solution of 9E lignocaine and &H-(,((( adrenaline is an effective
local Anesthetic in mirror oral surgeryI.
Bccal Infilt!ation
The specific target sites of infiltration in#ections are the
approximated levels of the root apices. Attempts to in#ect deeper tissue
may prove counter productive, because of the li*elihood of in#ecting into
s*eletal muscle.
Palatal infilt!ation
An increment of (..ml is sufficient.
'andi.le
$onduction anesthetia, in which anesthetic solution is deposited
near the mandibular foramen is used for mandibular periapical surgery.
&9
)LAP DESIGN
Requirements of an ideal flap:
&. Base is t+e ,idest *oint of t+e fla* 8 The need for the width at the
base is to afford sufficient circulation to the raised portion of the
flap so that the edges do not become ischemic and later slough.
9. A/oidin" incision o/e! a .od# defect.
.. Inclde t+e fll e0tent of t+e lesion.
2. A/oid s+a!* co!ne!s 8 Tips of sharp corners have a tendency to
become ischemic before collateral circulation across the sutured
tissues becomes established.
'. A/oid incisions ac!oss a .on# *!o%inence 8 Jsually found in the
maxillary cuspid region, since the mucosa covering the eminence is
thinner than that covering the interdental bone, less circulation is
available to provide nutrition to the edges of a flap placed on
eminence. Also, unesthetic scar formation develops.
6. Ga!din" a"ainst *ossi.le de+iscence 8 ;axillary molars and
bicuspids.
>. A/oid t+e %co"in"i/al 1nction 8 The #unction of the attached
gingiva and the alveolar mucosa had extremely friable tissues.
Incisions plced here ta*e much longer time to heal.
&.
-. )la* s+old "ene!all# e0tend one o! t,o teet+ late!all# 8 To
allow for relaxed retraction and prevent stretching and tearing of
tissue.
/. $are during retraction should be ta*en after the flap is opened the
tissue retracted from the underlying bone must be held away from
the surgical site.
&(. A fll t+ic2ness %co*e!iosteal fla* 8 should be raised to maintain
the integrity of the periosteum.
T+e .asic fla* desi"ns sed in endodontic s!"e!#
34 Gin"i/al )la*
Indications - $ervical resorptive defects.
$ervical area perforations.
:eriodontal procedures.
Ad/anta"es - Do vertical incision.
%ase of repositioning.
Disad/anta"es - +imited access and visibility.
?ifficult to reflect and retract.
:redisposed to stretching and tearing.
)ingival attachment violated.
54 Se%ina! )la* - %sthetic crowns present
Trephination.
!educes incision and reflection time.
;aintains integrity of gingival attachment.
%liminates potential crystal bone loss.
&2
Disad/anta"es - +imited access and visibility.
Tendency to increase hemorrhage.
$rosses root eminences.
;ay not include entire lesion.
:redisposed to stretching and tearing.
!epositioning is difficult.
Healing is associated with scarring.
64 T!ian"la! )la* -
Indications - ;idroot perforation repair.
:eriapical surgery.
- :osterior areas.
- @hort roots.
Ad/anta"es - %asily modified
- @mall relaxing
incisions.
- Additional vertical
incision.
- %xtension of hori,ontal
component.
%asily repositioned.
;aintains integrity of blood vessels.
Disad/anta"es - +imited access and visibility to longer roots.
Tension is created on retraction.
4ertical incision penetrates alveolar mucosa.
)ingival attachment severed.
&'
74 Oc+esen.ein
le.2e fla*
Indications - :rosthetic crown present
:eriapical surgery.
- Anterior region.
- +onger roots.
Wide band of attached gingiva.
Ad/anta"es - %ase of incision and reflection.
%nhanced visibility and access
%ase of repositioning.
;aintains integrity of gingival attachment.
- :revents gingival
recession.
- Avoids dehiscence.
- :revents crestal bone
loss.
Disad/anta"es - Hori,ontal component disrupts blood supply.
4ertical component crosses mucogingival
#unction and enter muscle tissue.
?ifficult to alter if si,e of lesion mis#udged.
84 Rectan"la! fla*
Indications - :eriapical surgery.
- ;ultiple teeth.
- +arge lesion.
- +ong roots.
+ateral root repairs.
Ad/anta"es -
:rovides maximum access and visibility.
!educes retraction tension.
0acilitates repositioning.
&6
Disad/anta"es - !educed blood supply to the flap.
Increased incision and reflection time.
)ingival attachment violated.
- )ingival recession.
- $rystal bone loss.
- ;ay uncover
dehiscence.
@uturing more difficult.
94 Palatal )la*s - The need to reflect the lateral tissues of the
maxilla may be needed in certain cases. As in
any flap all rules for flap design are applicable
however, the rich vascular supply of the
palatal area provides for excellent healing in
most instances.
- :alatal flap is prepared
with a scalloped incision around the
gingival margins.
- !elaxing incisions are
generally placed between the first cuspid
and bicuspid to prevent severing of the
anastomose of incisive and palatine
vessels.
?istal incision is placed distal to second molar
on the maxillary tuberosity to prevent severing
the greater palatine vessels.
- The free end of the flap could be tied the
teeth on the opposite side of the arch with
&>
a suture material.
:4 T!a*e;oidal )la* -
Indications - :eriapical surgery
- ;ultiple teeth.
- +arge lesions.
- +ong or short roots.
Ad/anta"es - :rovides maximum access and visibility.
!educes retraction tension.
0acilitates repositioning.
5lood supply to flap is maintained.
Disad/anta"es - Increased incision and reflection time.
)ingival attachment violated.
- )ingival recession.
- $restal bone loss.
- ;ay uncover dehiscence.
@uturing is more difficult.
SURGICAL TECHNI<UE
Ve!tical incision $Relie/in"= Rela0in"& -
Incision should be continuous, linear and well defined.
Avoid repeated incisions.
?o not ma*e an incision on bony prominence.
Int!aslcla! incision-
Incision follows the contours of the labial surface of the teeth.
&-
Reflection
!eflection is initiated with a sharp curves end of a Do. 2 molt
curette or the Hu friedly curette.
The elevators are used to reflect both the mucous and periosteum.
The elevator always on the bone and never on the flap.
A thin gau,e may be used for reflection to prevent tearing on the
flap.
Ret!action
!etraction is placed the bone firmly above the bony defect. The
reflected tissue should lie freely against the retraction and not be pushed or
pulled against lip or chee*.
Ha!d tisse %ana"e%ent
The average thic*ness of the bone overlying the mesial root of the
mandibular first molar is 2.9mm.
To penetrate the thic* cortical bone a rotating Do. 6 extra length
surgical bur mounted in a high speed impact hand piece should be
introduced slowly. This hand piece has an angled head that facilities easy
entry and visibility and doesn"t blow air or oil into the surgical site.
$opious irrigation with a sterile saline accompany all attempts to remove
bone, Gaccording to 0isher and )ross, $avelle and WedgewoodI,
&/
irreversible bone necrosis is reali,ed when temperature exceeds '6A$. 1A
small window is cut and a sterile bro*en off head of a bar is placed in the
depression, 1sterile ruler3 1window preparation3.
Pe!i!adicla! c!etta"e-
<nce apex has been located curette is performed with a sharp 1;olt
23 C )oldman 0ox- . curette. 0irst the bac* side of a curette is used to
loosen the fibrous capsule from the wall. Then the loosened inflammatory
tissue is scooped out of the cavity with a curette.
It is suggested that the soft tissue of the lesion surrounding the root
should be curetted in toto. However this is not always possible or practical,
especially if the lesion involves the maxillary antrum viability of the
ad#acent teeth is #eopardy, or the mandibular vessels.
<ccassionally, the root and apex are difficult to locali,e even after
removing the cortical bone. The root can be distinguished from its
surrounding by its color, morphologic features, and hardness. !oot
structure is harder that the soft cancellous bone with a defined anatomic
outline and a different color when viewed in a washed and debrided
operative field, $ambru,,i and associate described use of methylene blue
to identify and isolate root apex.
The decision to resect the apical tip depends on the 7uality of the
seal between the root canal and the surrounding periodontium. If the seal is
9(
satisfactory, periapical curettage and removal of the pathologic tissue and
the extruded filling material will suffice.
The old concept that cementum must be curetted away is not based
on scientific fact. A biopsy of soft tissue curettements is recommended as a
safeguard.
Jse of instruments that crush tissue, such as hemostats or needle
holders is discouraged. Instruments that pucture and grasp such as the allis
forceps are more favourable for the removal of si,eable specimens. The
tissue is placed in a specimen bottle of &(E formalin and sent to the
laboratory for diagnosis.
In case of excess gutta-percha overfilling. It can be removed with a
fast rotating Do. 6 or - bur. The ): should be then burnished and
compressed bac* into the canal space with a ball burnisher.
Root end Resection-
!oot end resection refers to the removal of the apical portion of the
root best accomplished by obli7uely resecting the most apical portion of
the involved root with a large round bur si,e >(9 or K 6 or K -.
Reasons for RER
- This segment is *nown for anatomical variations
such as accessory canals, deltas and severe curve it is also the
9&
area in which operator errors such as ,ips, ledges and perforation
are li*ely to occur.
- @ome apices close to the maxillary sinus, nasal
cavity and mental neurovascular bundle may re7uire !%! to
provide wor*ing room for apical curettment or place retrofilling.
5y resecting the apex a buffer area of bone can fill in so the apex
is not in immediate proximity to the anatom entity.
@elden has described the endoantral syndrome caused by irritation
of an apex to the sinus even though the tooth was endodontically treated
and needed !%:.
;atsura, $ummings has suggested that an apical resection of 9 to .
mm to expose the canal and eliminate accessory canals /(A resection care
must be ensure that the resection is carried completely through the root
from buccal to lingual.
Root end *!e*a!ation
!etropreparation is best done with a small round bur micro contra
angle handpiece. The canal can be located with a sharp explorer or morse
scaler.
The depth of penetration should be 9 to .mm and in center of the
root. +ateral over preparation may result in a wea*ening of the apical root
99
structure and development of crac*s upon condensation or dimensional
change of Ag amalgam.
A slot preparation is suggested by ;atsura where access is limited.
The canal is located and prepared to a vertical length of . to ' mm with a K
>(( bur and straight handpiece. !etention is placed with a inverted cone
bur.
Ult!asonic Ret!o*!e*a!ation
The pioneers in the field of ultrasonic cavity preparation under
enhanced visibility using a surgical operating microscope are 5uchanan,
$arr, !ubinstein, !euben and others.
:reparation is done with ultrasonic unit and special tips that are only
L mm in diameter and .mm in length 1about &C&(
th
the si,e of conventional
H:3. The !%: time is & to 9 minutes.
Ret!ofillin" 'ate!ials
The most commonly used retrofilling materials are I!;, @uper
%5A cement. Amalgam, Metac @ilver glass ionomer cement.
)la* Clos!e
0ollowing retrofilling procedure, the bone wax or ferric sulfate is
removed and the surgical site is thoroughly debrided with irrigating
solution to remove any loose particle of filling material bone or root
9.
structure. 5efore suture a radiograph should be ta*en to verify the removal
of filling particles. !ein#ection of local anesthesia could help to control
bleeding and extend comfort to the patient.
Re*ositionin" of t+e fla*
The flap is closed by gently placing the most apical portion of the
flap first. The flap is smoothed to place with a 9 x 9 gauge sponge so that
the natural and incisional reference points are matched.
Harrison has recommended 9 to . minutes of compression to
develop a thin fibrin clot under the flap.
SUTURING
The function of the suture is to secure the flap in its original or
desired position.
- @utures that are tightly placed compromise
circulation, increases chances of sutures to tear open
once the tissues swell.
@uturing needles traumatic 1eyelessCswaged3 needles which are
advantageous because of their reverse cutting edge.
- The needle should penetrate 9 to .mm from wound
margin.
- @uture materials are divided as8
92
&3 Absorbable 1digested by body en,ymes3.
93 Don-absorbable 1walled off3.
%.g., Absorbable @urgical gut 1traps food3.
Don absorbable @il* 1ethicon3.
The flap is gently replaced and smoothened into position with a 9 x
9 gauge sponge until the incisional reference points match. The first suture
should pass through the most dependent unattached tissue and the proceed
through the attached tissue and be tied. A puncture too close to the incision
can result in tearing of the tissue. A surgerons *not is most effective and
least li*ely to slip.
@ling suspensory or circumferential suturing is an effective
techni7ue for maximum tissue adaptation. 5ecause the lingual anchor is
lingual surface of the tooth. There is no tearing of the wea*er lingual tissue
as the suture thread settle obstrusively against linguo-gingival surface of
the crown.
Interrupted sutures may also be placed.
9'
POSTOPERATIVE SE<UELAE
The following postoperative se7uelae can occur after endodontic
surgery8
! "#elling
Although swelling does not occur in all the cases, it is sufficiently
common to warrant every effort to prevent it, such as by *eeping trauma to
a minimum during operation.
- %ffective method of reducing swelling is the
application of cold compress over the surgical area
for 9( minutes every hour post operative.
- %n,yme preparations and corticosteroids are used.
$! Pain
%! Ecchymosis
The discoloration of s*in due to extravasation and brea*down of
blood in that are can travel along fascial planes and may appear near
angle of the #aw, under the eye, nec* and even chest. These blac* and
blue mar*s usually disappear within 9 wee*s.
&! Parasthesia
96
Transient parasthesia sometimes lasts for a few days after root
resection in any part of the #aw. It is very rare in the maxilla.
'! "titch Abscess
:ossible causes are local laceration of tissue during suturing,
accumulation of food debris or irritation of suture material itself.
(! )emorrhage
@econdary hemorrhage is 7uite usual following root resection. If
hemorrhage occurs time to time a cold compress is placed over the
site.
*! Perforation
:erforation of the antrum may occur postoperative in a maxillary
teeth from cuspid to molar. It is not a serious se7uale unless foreign
bodies are introduced. a suitable flap is coated and sutured properly
followed by an antibiotic coverage.
+! Iatrogenic
When rarefaction of area is extrusive and intrusive it is always
possible to disrupt blood and nerve supply to the ad#acent tooth. To
prevent this complication endodontic therapy should be initiated
prior to surgical.
POSTOPERATIVE 'ANAGE'ENT O) THE PATIENT
9>
:referably the instructions should written and explained to the
patient.
Ice *ac2 and *!ess!e
- :atient should be instructed to apply an ice pac* over the surgical
site and firmly, but gently press the pac* on the facial tissues.
- The pressure and reduction in temperature slows the flow of blood
promotes coagulation in severed vessels and ultimately decreases
post operative bleeding and swelling.
- $old reduces sensitivity of peripheral nerves endings and acts as an
analgesic.
A**lication of %oist +eat
Application of moist heat on the surgical site is acceptable after &-
to 92 hours. Heat promotes the flood flows and enhances and inflammatory
response that is essential for wound healing during the first and second post
operative days.
A/oidance of acti/it#
It should be instructed to retrain from strenuous activity for the
remainder of the day on which the surgery was performed. To prevent
tearing of the sutures patient is instructed.
&. Dot raise the lip and loo* at the operated area.
9-
9. ?o not brush in the opened area use mouthwashes.
9/
Diet
An ade7uate balanced diet, preferable soft foods such as eggs,
mashed potatoes, fruit #uices, soap, malted mil*.
O!al +#"iene
$hlorhexidine mouthwash thrice daily for a wee* after the surgery.
Pain %ana"e%ent
An analgesic maintenance dose of 2((mg every - hourly for first .
operative days.
Dacrotic through controversial can be prescribed hydrocodone
1>.'mg3 with >'( mg paracetamol every 2 to 6 hours.
INCISION AND DRAINAGE
It is a standard procedure to drain an abscess. There are two
problems that accompany this procedure firstly, optimal to intervene and
secondly obtaining ade7uate local analgesia.
Ideally, the immediate area to be incised, the pointed area should
feel soft and fluctuant under the examiner"s fingertips. There should be a
fluid thrill that is when pressure is applied the feeling should be transmitted
through the fluid. The apex of the swelling may appear whitish or
yellowish. This is the ideal time to incise and drain.
.(
+earning the correct moment of surgical intervention is gained by
experience.
@ome time a lesion may be in the indurated stage. In such cases the
patient is prescribed antibiotics and hot saline rinses half hourly to bring
the abscess to a head. 5ut there is no thumb rule in the matter of incising
and draining while the lesion is still in indurated stage.
The second problem, that is of obtaining local analgesia exists
because8
&. It is difficult to establish profound analgesia for an inflamed and
abscessed area.
9. reluctance to in#ect into the area is because initially it is very painful
due to increase in fluid pressure by in#ecting into the region, but it
also unwise to ris* the spread of infection by the pressure of
in#ection.
The following guidelines for administering anesthesia should be
followed8
- Topical anesthesia should be applied liberally followed by
conduction analgesia peripheral to the site of infection.
- 5loc* anesthesia followed by conduction anesthesia is best.
.&
- A intramucosal wheal infiltration around the perimeter of the lesion
is given.
A!%a%enta!i%-
9N x 9N gauge sponges.
Three cotton swabs.
<ne scalpel with Do. && blade.
<ne small curved haemostat.
<ne needle holder
<ne half curved cutting needle with ((( sil* thread.
<ne suture scissors.
<ne aspirator tip.
@election of rubber dam T" drain.
- )auge is placed to catch the flow.
- @wab the area with disinfectant.
- Test the depth of anesthesia and perform a sweeping vertical
incision with a Do. && scalpel through the most pointed area to the
bone and irrigate copiously with anaesthetic solution.
- Aspiate immediately.
.9
- <pen the incised area widely by following out the tract with a
haemostat. @pread the handles of haemostat to separate the bea*s.
- :lace a T drain with the bar of the drain inside the incision.
- @uture the drain in place if necessary.
TREPHINATION
This surgical form is used to secure drainage and alleviate pain
when exudates in the cancellous bone is dammed up behind the cortical
plate.
The tremendous pressure leads to excruciating pain of an
intraosseous acute apical periodontitis or apical abscess. This intraosseous
pressure can be released and the area decompressed through trephination,
which provides a pathway to empty pus and other acid exudates.
After a good local anesthesia is obtained, a mini vertical incision
provides ade7uate access and landmar* visuali,ation.
- The focal area of lesion is pinpointed by examination and wor*ing
through the soft tissue cortical plate of bone is grossly removed with
a Do. - bur to identify the root apex.
- The bone is then penetrated at the apex with a Do.2 bur.
Trephination speeds relief and healing but may not be accompanied
by a great flow of exudates or pus.
..
HE'ISECTION
Hemisection refers to sectioning of the crown a molar tooth, with
either the removal of half of the crown and its supporting root structure or
the retention of both halves, to be used after reshaping and splinting as two
premolars.
Indications fo! +e%isection-
&. When periodontal involvement of one root is severe.
9. When loss of bone is extensive in furcation area.
.. When caries involves much of the root.
Cont!aindication fo! +e%isection-
&. When loss of bone involves more than one root, and the remaining
root would have inade7uate support.
9. When bridge span is long, and the abutment tooth would rend
inade7uate support.
.. When roots are fused.
P!oced!e
- The roots to be retained undergo endodontic therapy and the pulp
chamber is filled with amalgam.
.2
- Do filling material is placed into the root to be removed, for that
entire half of the tooth will be extracted.
- A sharp cowhorn explorer or periodontal probe is used to identify
the buccal and lingual furcations.
- 5y first placing the tip of a high speed tapered tissue bur in the
furcation, the operator can effectively section the molar with
accuracy.
- An elevator should be wedged between the two halves and slightly
rotated to determine if the separation is complete.
- The pathologic half is then extracted with forceps or eased out with
an elevator. The soc*et area is lightly curetted and pac*ed with bone
wax C gel foam.
This is followed by copious irrigation.
RADISECTO'Y
"ynonyms : !oot amputation
!adisectomy denotes the removal of one or more roots of molar.
This procedure is often done for periodontal reasons.
Indications fo! Radisecto%#
&. When endodontic treatment of one root is technically impossible or
when such treatment has failed.
.'
9. When untreatable furcation involvement is present and removal of
root will facilitate oral hygiene in that area.
.. When extensive loss of bone has occurred around one root of an
upper molar.
2. When a fractured root of an upper molar is present.
'. When a root has been perforated and root be treated endodontically.
6. When a root has been destroyed by extensive decay.
Cont!aindications-
&. When loss of bone involves more than one root and the remaining
root would have inade7uate support.
9. When roots are fused.
A!%a%enta!i%-
- @urgical length or long shan* fissure bur si,es >((, >(&, ''> and
''-.
- +ong tapered fissure diamond stones = to smoothen retained tooth
segment.
- %levators straight, apical elevators.
- 0orceps upper C lower forceps, universal forceps.
.6
%ndodontic therapy is completed prior to the surgical procedure8
- A flap need to be raised if root amputation performed on
periodontially involved teeth.
- A flap has to reflected if the teeth is periodontially involved.
T+e!e a!e t,o %et+od .# !oot a%*tations can .e *e!fo!%ed -
! ,ertical cut method
- Jtili,ers a long shan*, tapered fissure carbide bur in
airrotor to section through the entire crown and root
to the furca in gaining separation.
Ad/anta"es of /e!tical ct %et+od-
&. ?irect visuali,ation of bur penetration to ensure that preparation will
be in the correct position.
9. !emoval of that portion of the crown that is over the root to prevent
undesirable postoperative occlusal forces.
.. :osition of each cut, based on the anatomy of the furca, to allow the
root to cleave along desirable angles.
2. %xcellent visuali,ation of furca after amputation.
.>
$! )ori-ontal cut preparation
Hori,ontal cut is made through the tooth without the crown being
altered in the preparation.
$utting the tooth in this manner leaves a deep trough between the
crown and the alveolar mucosa which is obvious trap for food and debris.
Any occlusal forces over the amputated root will tend to put severe
stress from a undesirable direction on the remaining roots.
A%*tation P!oced!es on 'andi.la! 'ola!s
- Also *nown as bicuspidi,ation.
P!oced!e
A gentle curve is made in a si,e 2( silver cone and inserted it
through furca from the buccal to lingual.
The rest of the procedure is as in vertical procedure is as in vertical
cut method for maxillary molars.
.-
SU''ARY AND CONCLUSION
All endodontic procedures should ensure the placement of a proper
seal between the periodontium and the root canal foramina. When this seal
can"t be achieved satisfactorily by wor*ing through the canal system, a
surgical procedure presents visual and manipulative control of the area and
placement of the seal through the surgical site.
When failure occurs in non-surgical endodontic therapy the clinician
should be prepared to initiate alternative procedure including surgery to
enhance the rate of success.
./
CONTENTS
Introduction
History
$lassification
Indication and $ontraindication
Anatomic $onsiderations
:reoperative $onsultation with the patient
:reoperative preparation and :remedication of the patient
Armamentarium
0lap ?esign
@urgical techni7ue
@uturing
:ostoperative se7uelae
:ostoperative management of the patient
@ummary O $onclusion
2(