Periapical surgery

Endodontic SurgeryEndodontic Surgery

Endodontic Surgical ProceduresEndodontic Surgical Procedures

Incision and drainageIncision and drainage Periapical curettagePeriapical curettage ApicoectomyApicoectomy Retrograde endodontic treatmentRetrograde endodontic treatment Perforation repairPerforation repair Root resectionRoot resection Hemisection (± root removal)Hemisection (± root removal) Exploratory surgeryExploratory surgery Intentional replantationIntentional replantation

Possible Indications for Possible Indications for Periapical SurgeryPeriapical Surgery

When a biopsy of the periapical lesion is requiredWhen a biopsy of the periapical lesion is required



Foreign body reaction with extruded materialForeign body reaction with extruded material




Perforation repair Perforation repair (that can not be done conservatively)(that can not be done conservatively)





If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canal Very long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration





If non-surgical treatment is not feasible - such as:If non-surgical treatment is not feasible - such as: Very long or wide post; Post not in line with canal Very long or wide post; Post not in line with canal Canal blocked by broken file, calcifications, etcCanal blocked by broken file, calcifications, etc Tooth is not likely to be suitable for further restorationTooth is not likely to be suitable for further restoration

Patient factorsPatient factors Medical / dental condition, time, costs, recent crown, etc.Medical / dental condition, time, costs, recent crown, etc.

Periapical Surgery Periapical Surgery

Considerations Considerations Psychological aspectsPsychological aspects

Patients are reluctant to have any form of surgeryPatients are reluctant to have any form of surgery




Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate Grung Grung et alet al - 28% higher success if non-surgical - 28% higher success if non-surgical

re-treatment was done prior to surgery re-treatment was done prior to surgery




Non-surgical endodontics has a higher success rateNon-surgical endodontics has a higher success rate Grung Grung et alet al - 28% higher success if non-surgical - 28% higher success if non-surgical

re-treatment was done prior to surgery re-treatment was done prior to surgery

Surgery is a “one visit” techniqueSurgery is a “one visit” technique Can not disinfect the canal with irrigants and/or medicamentsCan not disinfect the canal with irrigants and/or medicaments


Considerations Considerations There is no IDEAL retrograde filling materialThere is no IDEAL retrograde filling material

Many have been tried & most do not “seal” canals wellMany have been tried & most do not “seal” canals well




Surgery “entombs” bacteria rather than killing or Surgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal




Surgery “entombs” bacteria rather than killing or Surgery “entombs” bacteria rather than killing or removing themremoving them And only “treats” the apical 2 - 4 mm of the canalAnd only “treats” the apical 2 - 4 mm of the canal

Surgery does not remove the pathway of entry along Surgery does not remove the pathway of entry along which the bacteria have entered & infected the toothwhich the bacteria have entered & infected the tooth This is usually caries, a defective restoration, or a crackThis is usually caries, a defective restoration, or a crack


Considerations Considerations Over-extended root filling materialsOver-extended root filling materials

Will not always cause a foreign body reactionWill not always cause a foreign body reaction

Hence, always watch and reassess over timeHence, always watch and reassess over time


Considerations Considerations Over-extended root filling materialsOver-extended root filling materials

Will not always cause a foreign body reactionWill not always cause a foreign body reaction

Hence, always watch and reassess over timeHence, always watch and reassess over time

Large, well-defined radiolucenciesLarge, well-defined radiolucencies Are not always cysts as often thought by many dentistsAre not always cysts as often thought by many dentists

Can be any form of periapical pathosisCan be any form of periapical pathosis

Size and borders indicate time & speed of developmentSize and borders indicate time & speed of development


Considerations Considerations Potential post-operative sequelaePotential post-operative sequelae

Swelling and bruisingSwelling and bruising

Infection Infection

Pain / discomfortPain / discomfort

Anaesthesia / ParaesthesiaAnaesthesia / Paraesthesia

Tissue discolourationTissue discolouration

ScarringScarring

Gingival recessionGingival recession

Loss of interdental papillaLoss of interdental papilla

Altered aestheticsAltered aesthetics


““It must be recognised that few true It must be recognised that few true indications exist for the endodontic indications exist for the endodontic

surgical approach” surgical approach”

Gutman JL. Gutman JL. Surgical EndodonticsSurgical Endodontics 1991: 50 1991: 50

Endodontic Surgery - StagesEndodontic Surgery - Stages

a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan

b)b) Local AnaesthesiaLocal Anaesthesia

c)c) Periosteal FlapPeriosteal Flap

d)d) CurettageCurettage

e)e) ApicoectomyApicoectomy

f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling

g)g) Wound Closure - suturesWound Closure - sutures

h)h) Post-operative InstructionsPost-operative Instructions

i)i) Follow-up & ReviewFollow-up & Review


But first – some general principlesBut first – some general principles

Flap DesignsFlap Designs

Semi-LunarSemi-Lunar

Gingival crestGingival crest TriangularTriangular TrapezoidalTrapezoidal GingivalGingival

Luebke-OschenbeinLuebke-Oschenbein

Semi-Lunar FlapSemi-Lunar Flap

In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva


In the mucobuccal fold and attached gingivaIn the mucobuccal fold and attached gingiva

Poor accessPoor access Incision often over the lesionIncision often over the lesion Difficult moisture control Difficult moisture control (haemorrhage)(haemorrhage) Difficult to repositionDifficult to reposition Uncomfortable during healingUncomfortable during healing Leaves scarsLeaves scars

Gingival FlapGingival Flap

Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision

No access to apexNo access to apex May be useful for coronal May be useful for coronal

third perforations third perforations Used for palatal flapsUsed for palatal flaps

But difficult !But difficult !


Gingival crest incisionGingival crest incision Extended horizontal incisionExtended horizontal incision No vertical incisionNo vertical incision

Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision

Triangular FlapTriangular Flap

Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus One vertical incisionOne vertical incision

““First choice” flap for endodontic surgeryFirst choice” flap for endodontic surgery Good accessGood access Good visionGood vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition


Recall - 6 Months


Recall - 3 Months


Recall - 6 Months

Horizontal incision in the gingival sulcusHorizontal incision in the gingival sulcus Two vertical incisionsTwo vertical incisions

Trapezoidal FlapTrapezoidal Flap


““Second choice” for endodontic surgerySecond choice” for endodontic surgery



““Second choice” for endodontic surgerySecond choice” for endodontic surgery

Begin as a triangular flap and then do 2Begin as a triangular flap and then do 2ndnd vertical incision if extra access required vertical incision if extra access required

Good access & visionGood access & vision Good moisture controlGood moisture control Heals without scarsHeals without scars Easy to repositionEasy to reposition


Trapezoidal FlapTrapezoidal FlapRecall - 6 Months

Luebke-Oschenbein FlapLuebke-Oschenbein Flap

Scalloped horizontal incision in attached gingivaScalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival margin3 - 5 mm short of the gingival margin Follows contours of the gingival marginFollows contours of the gingival margin



Vertical incisionsVertical incisions 1 or 21 or 2

Depends on howDepends on how much access much access is required is required



Vertical incisionsVertical incisions 1 or 21 or 2

Depends on howDepends on how much access much access is required is required

Little, if any, scarringLittle, if any, scarring


Use for anterior teeth with crownsUse for anterior teeth with crowns To avoid gingival recessionTo avoid gingival recession

Luebke-Oschenbein FlapLuebke-Oschenbein FlapRecall - 6 Months

No. 15 - for periosteal flapsNo. 15 - for periosteal flaps

No. 11 - for incision and drainageNo. 11 - for incision and drainage Stabbing actionStabbing action

Scalpel BladesScalpel Blades

Scalpel BladesScalpel Blades

General Principles for Periosteal General Principles for Periosteal FlapsFlaps

Apical BevelApical Bevel

Micro-MirrorsMicro-Mirrors

Curettage Curettage TechniquesTechniques

Curettage TechniquesCurettage Techniques

Retrograde Filling Retrograde Filling MaterialsMaterials

Materials– Past and PresentMaterials– Past and Present

AmalgamAmalgam CavitCavit IRMIRM Super-EBASuper-EBA Composite resinsComposite resins Gutta perchaGutta percha Glass ionomersGlass ionomers MTA (ProRoot)MTA (ProRoot)

CorrosionCorrosion Galvanism (with posts)Galvanism (with posts) Tattoo on mucosaTattoo on mucosa ExpansionExpansion Dimensional changesDimensional changes Marginal breakdownMarginal breakdown Excess not absorbableExcess not absorbable Mercury releaseMercury release

Difficult to condenseDifficult to condense Condensation scatterCondensation scatter Cavity largeCavity large Undercuts neededUndercuts needed Poor adaptation to wallsPoor adaptation to walls No anti-bacterial actionNo anti-bacterial action Difficult to remove for Difficult to remove for

re-treatment re-treatment

Amalgam

Disadvantages & Problems

Amalgam

Poor tissue compatibilityPoor tissue compatibility Due to continuous release of eugenol Due to continuous release of eugenol Fibrosis of adjacent tissueFibrosis of adjacent tissue

SolubleSoluble

Large cavity requiredLarge cavity required

Difficult to handle materialDifficult to handle material Esp. Super-EBAEsp. Super-EBA

IRM + Super-EBA

Disadvantages & Problems

Low tissue toxicityLow tissue toxicity Bone appositionBone apposition

Good sealing abilityGood sealing ability Chemical bond to dentineChemical bond to dentine RadiopaqueRadiopaque Easy to mix & placeEasy to mix & place Colour contrast to toothColour contrast to tooth Short setting timeShort setting time

Moisture controlMoisture control HaemorrhageHaemorrhage

Relatively large Relatively large cavity required cavity required

Glass Ionomer

Advantages Disadvantages

Gutta Percha + Sealer

Low tissue toxicityLow tissue toxicity

Good sealing abilityGood sealing ability

RadiopaqueRadiopaque

Colour contrast to toothColour contrast to tooth

Conservative cavity onlyConservative cavity only

Anti-bacterial (sealer)Anti-bacterial (sealer)

Advantages

Easy to mix & placeEasy to mix & place

Good physical propertiesGood physical properties

Satisfies requirements of Satisfies requirements of

root filling materials root filling materials

Proven and acceptable Proven and acceptable material for RCF’s for material for RCF’s for over 120 years over 120 years

ReferenceReference FavourableFavourable Uncertain UnfavourableUncertain Unfavourable

Nordenram Nordenram et alet al 1970 1970 56 %56 % 36 %36 % 8 % 8 %

Harty Harty et alet al 1970 1970 9090 - - 1010

Rud Rud et alet al 1972 1972 8383 1414 3 3

Malmström Malmström et alet al 1982 1982 7474 1717 9 9

Forsell Forsell et al et al 1988 1988 6868 2121 1111

Amagasa Amagasa et alet al 1989 1989 9595 - - 5 5

Grung Grung et alet al 1990 1990 8585 1414 1 1

Friedman Friedman et alet al 1991 1991 7070 3030 - -

Rapp Rapp et alet al 1991 1991 5656 3333 1111

Abbott 1999Abbott 1999 92.392.3 4.24.2 3.53.5

Treatment Outcome StudiesTreatment Outcome Studies

All re-treats after retro. amalgam

Endodontic SurgeryEndodontic Surgery- - with GP + AH26with GP + AH26

Endodontic Surgery - StagesEndodontic Surgery - Stages

a)a) Consultation, Diagnosis, Treatment PlanConsultation, Diagnosis, Treatment Plan

b)b) Local AnaesthesiaLocal Anaesthesia

c)c) Periosteal FlapPeriosteal Flap

d)d) CurettageCurettage

e)e) ApicoectomyApicoectomy

f)f) Retrograde Endodontic TreatmentRetrograde Endodontic Treatment Apical Bevel, Canal Preparation, Root FillingApical Bevel, Canal Preparation, Root Filling

g)g) Wound Closure - suturesWound Closure - sutures

h)h) Post-operative InstructionsPost-operative Instructions

i)i) Follow-up & ReviewFollow-up & Review

ConsultationConsultation

Local AnaesthesiaLocal Anaesthesia

InstrumentsInstruments

Incision + Periosteal FlapIncision + Periosteal Flap

Bone Removal & CurettageBone Removal & Curettage

Retrograde Canal PreparationRetrograde Canal Preparation

Haemorrhage ControlHaemorrhage Control

Paper PointsPaper Points

Sealer - AH 26Sealer - AH 26

Gutta PerchaGutta Percha

Sealer - PlacementSealer - Placement

Retrograde Root FillingRetrograde Root Filling

SuturingSuturing

Post-Operative InstructionsPost-Operative Instructions

ALSO:ALSO:

1.1. Post-op RadiographPost-op Radiograph

2.2. Suture RemovalSuture Removal

4-5 days4-5 days

3.3. ReviewsReviews 3-4 months3-4 months 12 months12 months 3 years3 years

Pre-op

Mid-surgery

Review - 3 months

Review - 12 months

Review - 3 years

Post-op

Review - 8 years

Periapical surgery

Health & Medicine

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