Endodontic surgery

Indications
1-Need for surgical drainage. 2-faild nonsurgical endodontic a-irretrievable canal filling materials. b-irretrievable intra-radicular post. 3-calcification of root canals . 4-Procedural errors: instruments fracture. ledging and perforation. symptomatic overfilling.

5-Anatomic variations: Root dilacerations 6- biopsy. 7-corrective surgery root caries. root resection Hemi section Bicuspidization 8-Replacement surgery: -intentional replantation. - post traumatic surgery .

Contraindications;

1-The patient medical status. 2-anatomic considerations. 3-The dentist skill and experiences.

Classification of endodontic surgery 1- surgical drainage

a-incision and drainage .

b- cortical trephination

2-periradicular surgery
a- apical curettage b- biopsy c-root end resection d- retrograde cavity e- corrective surgery .

3-replacement surgery

4- implant surgery
a- endodontic implants

b- root-form osseointegrated implant .

Presurgical considerations
1- success of surgical treatment versus nonsurgical retreatment . 2- review of medical history and consultation with physician if required . 3-patient motivation . 4- Aesthetic consideration like scarring . 5- evaluation of anatomic factors by taking radiograph at different angles . 6-periodontal evaluation .

1-surgical drainage : a- surgical drainage

indicated when purulent and / or hemorrhagic exudates forms within the soft tissue or the alveolar bone as a result acute periapical abscess .

Diffuse swelling : surgical drainage & systemic antibiotics Hard indurated and diffuse swelling : allow it to localize and become soft & fluctuant before incision and drainage . - incision is given with scalpel blade NO.11 or 12 . Horizontal incision is placed at dependent base of the fluctuant area .

Cortical trephination : These procedure is made with patient suffering from mild to sever pain without intra-oral or extraoral swilling .
A- apical trephination : made by enlarging of the apical foramen to size 25 file to allow drainage into the canal space .

B-cortical trephination : involves incision in muco-periosteal fold and cortical perforation by rotary burs .

Functions of the flap

1-to give view and exposure of the surgical site 2-to provide healthy tissue that will cover the area of surgery , decrease pain by eliminating bone exposure and aid in obtaining optimal healing .

Flap design Principles and guidelines for flap design

1-avoid horizontal and severely angled vertical incisions to avoid excessive bleeding & retardation of the healing . 2-avoid cutting over Radicular eminences especially with canine and premolars . 3- incision should be placed and flaps re-positioned over areas sold bone : 5mm of bone should exist between the edge of a bony defect and incision line. 4-avoid incisions across major muscle attachment . 5- extent of vertical incision should be sufficient to allow the retractor to seat on solid bone , thereby leaving the root apex well exposed . b

6- extent of horizontal incision should be adequate to provide visual and operative access with minimal soft tissue trauma . 7- avoid incision in the muco-gingival junction . 8- the junction of the horizontal sulcular and vertical incisions should either include or exclude the involved interdental papilla . 9- in submarginal incision , minimum 2mm of attached gingiva around each tooth to be flapped . 10- the flap should include the complete mucoperiosteum &avoid improper treatment of periosteum .

Types of flap 1- Triangular flap : formed by 2 incisions : horizontal and

vertical . Vertical incision is placed towards the midline . Horizontal incision is submarginal curved incision placed along the crowns of the teeth in attached gingiva .

Indications :
1- maxillary incisors region . 2-maxillary & mandibular posterior teeth . 3-it the only recommended flap design for posterior mandibular region .

Contra-indicated in teeth with long roots and mandibular anterior teeth because of lingual inclination of these roots . Advantages : 1- ease of wound closure . 2- enhanced rapid wound healing .
Dis-advantages : 1-limted surgical access .

2-rectangular flap :
Formed by an intrasulcular horizontal & two vertical releasing incisions . Advantages 1-enhanced surgical access 2- easier apical orientation . Dis-advantages 1-wound closure and healing are difficult. 2-potential flap dislodgment is greater . Indications 1-mandibular anterior region 2- maxillary canine . 3- multiple teeth . Contra- indications: mandibular posterior region .

3- Trapezoidal flap ;
Formed by two releasing vertical incisions join a horizontal intera sulcular incision at obtuse angles . Disadvantages : 1-wound healing by scar . 2-poketing or clefting of soft tissue 3- compromise in blood vessels . 4- contraindicated in periradicular surgery .

1-semilunar flap :
Formed by single curved incision and it is not preferred in modern endodontic .
Dis-advantages : 1-limted surgical access 2- difficult wound closure . 3- poor apical orientation . 4- maximum disruption of blood supply .

2- submarginal scalloped rectangular flap

It is a modification of the rectangular flap . Formed by scalloped horizontal incision in the attached gingiva and two vertical incision made on each side of surgical site . Indications : 1- in presence of gingivitis and crowns . Advantages ;
1- marginal & inter- dental gingiva are not involved . 2-crestal bone is not exposed . 3- adequte surgical access . 4- good wound healing . Dis-advantages : 1- disruption of blood supply to unflapped tissue . 2- flap shrinkage . 3- healing with scar . 4- limited apical orientation 5- difficult flap re-approximation .

Tissue response to bone removal : bone in surgical site has

temporary decrease in blood supply because of local anaesthesia which causes bone to become more heat sensitive and less resistance to injury .

Bur type & speed : Cutting of bone with No. 6 or 8 produces less inflammation than diamond points . Low speed with irrigation produce less inflammation than high speed .

Periradicular surgery 1- periradicular curettage :

Is a surgical procedure to remove diseased tissue from the alveolar bone in the apical or lateral region surrounding a pulp- less tooth .
indications : 1-access to the root structure for additional surgery . 2- for removing of infected tissue . 3- for removal of over-extended filling . 4- for removing of necrotic cementum .

5- for removing a long standing persistent lesion .

6- to assist in rapid healing and repair of periradicular tissues

2- root end resection = apiccoectomy

Is the cutting of apical portion of the root and attached soft tissues . Indications : 1- inability to perform non surgical therapy . 2- persistent infection after conventional therapy . 3-need for biopsy . 4- to explore if any additional canals or fracture . 5- for removal of iatrogenic errors . Angle of Root end resection : Bevel 45 degree to labial improve visibility & accessibility but increase the leakage from open dentinal tubules . Now bevel 10 degree is recommended for decrease dentinal tubules exposure , maintains maximum root length , reduce osteotomy and decrease the apical leakage .

The shape of the root- end cavity : class 1, slot shape or socered shape and ultrasonic cavity . The ultrasonic cavity have several advantages : 1- smaller preparation size and better access .
2- no need for root end bevel . 3- a deeper preparation possible . 4- more parallel walls for better retention . 5- less debris & smear layer .

Retrograde filling :

Materials :
1- amalgam 2- super EBA 3- MTA 4- composite resin 5- Glass-Ionomer filling .

corrective surgery :
a- perforation repair . b-periodontal repair .