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Endodontics > Periradicular Surgery > Flashcards

Periradicular Surgery Flashcards

1
Q

What are the steps of management of failure?

A
  • Monitor
  • Attempt orthograde
    retreatment
  • Periradicular surgery
  • Extract
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2
Q

What are most periapical pathologies?

A

granuloma

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3
Q

What is periradicular surgery?

A

Surgical shortening of the root apex +/- retrograde sealing

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4
Q

What are the indications for surgery?

A
  • Failure of previous endodontic treatment
    If retreatment is not possible or will not correct the problem
  • Anatomical deviations
    Prevent complete cleaning and obturation
    Tortuous, curved roots, pulp stones, calcifications
  • Procedural errors
    Ledges, blocks, perforations, breakages,
    underfill, overfill
  • Exploratory surgery
    Identification of root fractures
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5
Q

What are the contraindications of surgery?

A
  • Anatomical factors
    Proximity to neurovascular bundles
  • Inadequate periodontal support
  • Non-restorable tooth
  • Medical factors
    Leukaemia, neutropenia, recent heart or cancer surgery
    Postpone if recent MI or radiation treatment
  • Skill and ability of surgeon Referral of complex cases
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6
Q

What is microsurgery?

A

Surgery using operating microscopes and miniaturized precision instruments to perform intricate procedures on very small structures

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7
Q

What is the triad of endodontic microsurgery?

A

magnification
instruments
illumination

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8
Q

What do soft tissue elevators do?

A

– Designed to allow elevation of soft tissue from cortical bone with minimal trauma
– Thin sharp edges allows soft tissue to be elevated cleanly and completely

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9
Q

What are ultrasonic units made of and what are the vibrations?

A

– Vibrations 30 – 40 kHz
– Excitation of quartz or ceramic piezoelectric crystals

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10
Q

When should haemostatic control be achieved?

A

*Adequate haemostasis is absolutely essential
* Bone crypt must be examined at high magnification
* Haemostatic control
– Pre-operative
– Intra-operative
– Post-operative

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11
Q

What is included in the pre-operative phase?

A

LA and haemostasis

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12
Q

What LA is used?

A

2% lidocaine with vasoconstrictor 1:50 000 epinephrine

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13
Q

What are topical haemostatic agents used intra-operatively?

A

– Epinephrine pellets
* Most effective and economic

– Ferric sulphate
* Agglutination of blood proteins – forms a plug
* Cytotoxic, tissue necrosis
* Adverse effects on osseous healing

– Calcium sulphate
* Mechanically blocks open vessels
* Aids in bone regeneration

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14
Q

How can haemostasis be maintained after flap has been sutured?

A

– Finger pressure on a wet sterile gauze

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15
Q

What is a sulcular full thickness flap design?

A

– Horizontal and vertical incisions
– Vertical incisions follow line of tissue fibres and blood vessels

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16
Q

What is a mucogingival flap design?

A

– Crowned anterior teeth
– Scalloped incision in middle of attached gingiva at 45°
– Vertical relieving incisions

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17
Q

How should incisions be done?

A
  • Interproximal papillae cut with mini blade following contour of tooth neck
  • Vertical incisions must start at line angle and follow fibre line straight up
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18
Q

How is flap elevation done?

A
  • Place elevator beneath gingivae at line angle
  • Reflect apically with a slow, firm motion to prevent tearing
  • Reflect periosteum completely to prevent bleeding
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19
Q

How is flap retraction done and why is it important?

A
  • Stable and non-traumatic retraction
  • Serrated tips give better anchorage
  • Poor retraction is key factor in post-op swelling and transient paraesthesia
20
Q

What is osteotomy?

A

Removal of cortical plate to expose root end

21
Q

What should you look for to plan osteotomy?

A

– Assess length and curvature of roots using preoperative radiograph
– Look at proximity to adjacent teeth, mental foramen, mandibular nerve and sinus space

22
Q

Why is smaller osteotomy better?

A
  • A conservative osteotomy allows faster healing
  • Larger osteotomy increases chances of fibrous healing
  • Microscope use allows osteotomy dimensions to be minimised
    – Root is a darker yellow colour
    – Methylene blue demonstrates periodontal ligament
23
Q

What are the clinical possibilities?

A
  • Intact cortical plate with no radiographic lesion
  • Intact cortical plate with a periapical lesion
  • Fenestration through cortical plate leading to apex
24
Q

Tips for osteotomy?

A
  • Keep it as small as practicable
  • Curettes are used to remove granulation tissue
  • Lingual/palatal aspect may only be cleaned after root resection
25
Q

What is root end resection?

A

3mm is resected perpendicular to long axis of tooth – Removes majority of lateral canals and ramifications

26
Q

How is ultrasonic root end prep carried out?

A
  • Carried out under low magnification
  • Ultrasonic tip is positioned at apex
  • Use copious coolant to a depth of 3mm
  • Inspect with a micro-mirror at high magnification
    – Remnants of gutta-percha
    – Recondense gutta-percha
27
Q

How can you clean and dry apical prep?

A
  • Absorbent paper points
  • Stropko device
    – Pressure reduced to 10 psi to avoid air embolism
28
Q

What should you inspect in the resected root surface?

A
  • Isthmi
  • C shaped canals
  • Canal fins
  • Apical micro-fractures
  • Poorly adapted gutta-percha
29
Q

What is the frequency of an isthmus in mesial roots of mandibular first molars?

A

70%

30
Q

What is the clinical significance of the isthmus?

A
  • Untreated isthmi are one of the main causes of surgical failure
  • Identification is extremely important using microscope and micromirrors
  • Ultrasonic preparation with KiS-1tip
31
Q

What should root end filling do?

A

This should seal the apex so that bacteria or their products cannot enter or leave the canal

32
Q

What are properties of root end filling materials?

A

– Well tolerated by apical tissues
– Bactericidal or bacteriostatic
– Adhere to tooth
– Dimensionally stable
– Easy to handle
– Do not stain
– Noncorrosive
– Do not dissolve
– Promote cementogenesis
– Radiopaque

33
Q

Why should you not use amalgam for root end filling?

A

Poor clinical performance
– Sets slowly
– Biocompatibility
– Leakage
– Corrosion and staining

34
Q

What makes up MTA?

A

Powder consisting of fine hydrophilic particles
– Tricalcium silicate
– Tricalcium aluminate
– Tricalcium oxide
– Silicate oxide
– Bismuth oxide

35
Q

What are the advantages of MTA?

A
  • Long setting time
  • Superior sealing ability
  • Moisture tolerant
  • Radiopaque
  • Excellent biocompatibility
  • Regeneration of cementum
36
Q

How should MTA be used?

A
  • Protect bone crypt
  • Mix powder with sterile water to putty
    consistency
  • Carry to root end with a MTA gun or Dovgan carrier
  • Use micropluggers/burnishers to lightly condense material
  • Wipe off excess with a small moist cotton pellet
37
Q

What are regenerative procedures used in periodontal surgery?

A

guided tissue regeneration

38
Q

How should you reposition and suture the flap?

A
  • Ensure correct position
  • Apply a damp gauze with fingerpressure
  • Place first suture at free end of flap
  • Use interrupted sutures
    – Ideally monofilament (e.g. Polypropylene or PTFE)
  • Remove sutures after 72 hours
39
Q

When is bruising worse?

A
  • Worse 3-4 days after procedure
  • Often occurs distant from surgical site
40
Q

What is paraesthesia and how can it occur?

A
  • Abnormal sensation or numbness caused by impingement, handling, laceration or severance of a nerve
  • Often transient caused by swelling as a result of inflammation
  • Normal sensation returns in 4 weeks
41
Q

What are other complications of surgery?

A
  • Serious infection
    – Rarely occurs
    – Treated with antibiotics
  • Lacerations
    – Prevent by application of Vaseline to lips
    – Avoid careless elevation of flap
  • Maxillary sinus perforation
    – Suturing of flap sufficient
42
Q

What are the classifications of healing?

A

– Healed
– Incomplete healing (Scar) – Uncertain healing
– Failed

43
Q

When should follow up occur after endodontic surgery?

A

Follow-up one year initially and then up to four years

44
Q

What are prognostic factors that may affect result?

A
  • Age
  • Tooth Position
  • Root-end filling material
  • Presence of co-existing periodontal disease
  • Apical seal
  • Coronal seal
  • Crypt size
45
Q

What is always preferable to root end surgery?

A

retreatment

Endodontics (11 decks)

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