Peri-Radicular Surgery

Question 1

When is surgical endo undertaken?

Answer 1

Emergency procedure 
Peri-radicular surgery
Corrective surgery
Surgical re-tx 
Regenerative procedure

Question 2

Aim of surgical endo?

Answer 2

Elimination apical periodontitis, retain the tooth where this can’t be achieved by non-surgical means

Question 3

When is surgical endo indicated?

Answer 3

Persistant disease when non-surgical or re-rct can’t be undertaken
correction of iatrogenic error not amenable to non-surgical approach
attempted all forms non surgical tx

Question 4

What are contraindications to peri-radicular surgery?

Answer 4

Medical condition - general contraiondication alveolar surgery (bleeding/MRONJ)
Poor surgical access
Non-restorable
Tooth inadequate periodontal support
Non-surgical tx favoured

Question 5

Diff in prognosis of traditional surgery vs modern surgery?

Answer 5

Tradition root end surgery = 59%

Modern micro-surgery = 94%

Question 6

What are the surgical objectives?

Answer 6

Remove diseased peri-radicular tissue
Debride canal system
Seal end root cavity
Allow healing/ regeneration PDL

Question 7

What are prerequisites for Edno surgery?

Answer 7

Informed consent 
Skilled operator
Detailed knowledge anatomy
MH checked
Light and magnification
Material/ equipment

Question 8

What is the sequence for endo surgery?

Answer 8

1. Pre-medication - NSAID/ corsodyl to reduce microbial load
2. LA
3. Flap reflection
4. Osteotomy
5. Currettage of lesion
6. Ultrasonic prep root-end cavity
7. Hamostasis - moisture control bony crypt
8. Filling cavity
9. Suture
10. POI

Question 9

What is the attached gingiva?

Answer 9

Band of keratinised tissue extending base of gingival sulcus down to mucogingival junction

Question 10

What is mucogingival junction?

Answer 10

Junction between attached and sulucular mucosa

Question 11

What incisions can be used in peri-radicular surgery?

Answer 11

Semi lunar
Intra sulcular
Submarginal
Papilla base

Question 12

What is a semi lunar incision?

Answer 12

Horizontal slash in sulcular epithelium

Question 13

What is risk with semi lunar incision?

Answer 13

Bleeding tendency
Diff to reflect and access
Risk lying over cavity - incision needs to be over solid bone for healing

Question 14

What is a intra-sulcular incision?

Answer 14

2 sides and triangular
Incision extended around gingival sulcus of tooth and extend onto adjacent tooth
Doesn’t disturb papilla and leave gingiva around tooth

Question 15

What is benefit of relieving incision when doing intra-sulcular?

Answer 15

Helps retract flap adequately giving good access

Question 16

When is submarginal incision used?

Answer 16

If pt has restorative work - crowns/ veneers

Question 17

Why are submarginal incisions beneficial is those with restorative work?

Answer 17

If reflect flap on teeth potential for recession - margins of restorative work

Question 18

Benefit of submarginal incision?

Answer 18

Minimise chance of recession

Question 19

What is needed for submarginal incision?

Answer 19

Adequate width of keratinised tissue, 5mm+

Question 20

What is papilla base incision?

Answer 20

Combination intra-sulcular - instead following sulcus around papilla goes across papilla

Question 21

Why does papilla base incision seem risky?

Answer 21

Breaks rule of having broad based incision which leaves tissue with adequate blood supply - only use of pt w/o perio

Question 22

Why is osteotomy required?

Answer 22

Gain access to lesion and apex

Question 23

Why can’t use normal air rotor for osteotomy?

Answer 23

Blows air and water - risk of emphysema

Question 24

How is root end cavity prepared?

Answer 24

Prepared using ultrasonic handpiece
Allows GP to be removed to clear cavity of existing material
Cut circumference of apex of tooth

Question 25

What is used for moisture control?

Answer 25

Racellet pellet - impregnated w/ adrenaline = haemostats

Question 26

What are diff materials used for filling?

Answer 26

Ethoxy benzoic acid cement
IRM
Bioceramic materials e/g MTA/ biodentine
GIC/ composite

Question 27

Why is EBC acid no longer used?

Answer 27

fiddly handle - no longer widely available

Question 28

Benefits of IRM?

Answer 28

Bactericidial and strong enough to be definitive

Question 29

What post op care instructions are given?

Answer 29

• Post-op instruction
• Ice-packs
• NSAIDs
• Antibiotics only indicated if extensive suppuration and contamination of surgical field
• OHI – Corsodyl mouth rinse (avoid brushing in surgical field)
• Review/ suture-removal 48-96 hours post-op