Surgical Endodontics Flashcards
Define endodontic surgery and its objectives?
“removal of tissues other than the contents of root canal to retain a tooth with pulpal or periapical involvement.
Objectives
- Removal of diseased periapical tissue like granuloma, cyst, overfilled material, etc.
- Root inspection for knowing etiology of endodontic failure, fracture, accessory canals, etc.
- To provide fluid tight seal at apical end by retrograde preparation and obturation
- To eliminate apical ramifications by root resections so as to completely remove the cause of failure for endodontic treatment.
What are indications of endodontic Surgery?
- Need for surgical drainage
- Failed nonsurgical treatment:
a. Irretrievable root canal filling material
b. Irretrievable intraradicular post
c. Continuous postoperative discomfort
d. Recurring exacerbations of nonsurgical endodontic treatment - Calcific metamorphosis of the pulp space
- Horizontal fracture at the root tip with associated periapical disease
- Procedural errors:
a. Instrument separation
b. Non-negotiable ledging
c. Root perforation
d. Severe apical transportations
e. Symptomatic over filling. - Anatomic variations
a. Root dilacerations
b. Apical root fenestrations
c. Non-negotiable root curvatures - Biopsy
- Corrective surgery
a. Root resorptive defects
b. Root caries
c. Root resection
d. Hemisection
e. Bicuspidization - Replacement surgery
a. Intentional replantation
b. Post-traumatic replantation - Implant surgery
a. Endodontic implants
b. Osseo integrated implants. - Exploratory surgery
What are contra indications of endodontic surgery
- Periodontal health of the tooth
- Patients health considerations
- Anatomic considerations such as in mandibular second molar area:
- Roots are inclined lingually
- Root apices are much closer to mandibular canal
- Presence of too thick buccal plate
- Restricted access to the root tip
. Shortrootlengthinwhichremovalofrootapexfurther compromises the prognosis
- Proximity to nasal floor and maxillary sinus
- Nonrestorable teeth
o Vertically fractured teeth
o Nonstrategic teeth.
Classification of endodontic surgery?
- Surgical drainage
- Incision and drainage (I and D)
- Cortical trephination (fistula surgery)
- Periradicular surgery
- Curettage
- Biopsy
- Root-end resection
- Root-end preparation filling
- Corrective surgery
- Perforation repair
i. Mechanical(iatrogenic)
• Resorptive (internal and external)
i. Root resection
ii. Hemisection
3. Replacement surgery
4. Implant surgery
- Endodonticimplants
- Root-form osseointegrated implants.
Classification of Endodontic Microsurgical Cases
ClassA: Absenceofperiradicularlesionbut persistent symptoms after nonsurgical treatments.
Class B: Presence of small periapical lesion and no periodontal pockets.
Class C: Presence of large periapical lesion progressing coronally but no periodontal pockets. Class D: Any of Class B or C lesion with periodontal pocket.
Class E: Periapical lesion with endodontic and periodontal communication but no root fracture. Class F: Tooth with periapical lesion and complete denudation of buccal plate
Talk about surgical drainage?
Surgical drainage is indicated when purulent and/or hemorrhagic exudates forms within the soft tissue or the alveolar bone as a result of symptomatic periradicular abscess Steps
- Give local anesthesia
- Give incision to the most dependent part of swelling with scalpel blade, No. 11 or No. 12. Place horizontal incision at dependent base of the fluctuant area for effective drainage to occur .
Classification of flaps? Why must they be vertical?
- Full mucoperiosteal flaps –– Triangular o Rectangular o Trapezoidal o Horizontal
- Limited mucoperiosteal flaps o Submarginal curved (semilunar) o Submarginal scalloped rectangular .
Avoid horizontal and severely angled vertical incisions, because Gingival blood supply occurs from supra periosteal vessels and these follow vertical course parallel to long axis of teeth .
Write a bout triangular flaps, indication and contra, advantages and disadvantages
Triangular Flap o It is a full thickness most commonly used flap in endodontics
- Indications o Maxillary incisor region o Maxillary and mandibular posterior teeth o It is the only recommended flap design for posterior mandible region.
- Contraindications o Teeth with long roots (maxillary canine) o Mandibular anteriors because of lingual inclination of their roots.
- Advantages o Enhanced rapid wound healing o Ease of wound closure.
- Disadvantage o Limited surgical access.
Write a bout rectangular flaps, indication and contra, advantages and disadvantages
Rectangular Flap
• It is extension of triangular flap. Here two vertical releasing incisions and horizontal intrasulcular incision is given
Indications
- Mandibular anteriors
- Maxillary canines
- Multiple teeth.
This flap is not recommended for mandibular posterior teeth.
Advantages
- Enhanced surgical access
- Easier apical orientation
- Excellent wound healing potential.
Disadvantages
- Wound closure as flap reapproximation and postsurgical stabilization are more difficult than triangular flap.
- Potential for flap dislodgement is greater.
Write a bout envelope flaps, indication and contra, advantages and disadvantages
Envelope Flap
• It is formed by a single horizontal intrasulcular incision and is usually recommended for corrective endodontic surgery.
Indications
- For repair of perforation defects
- For root resections
- In cases of hemisections.
Advantages
- Improved wound healing
- Easiness of wound closure and postsurgical stabilization.
Disadvantages
- Extremely limited surgical access
- Essentiallyimpracticalforperiradicularsurgery,butsome use it for palatal surgery.
What’s peri radicular curettage? Indications and technique?
Periradicular Curettage
• It is a surgical procedure to remove diseased tissue from the alveolar bone in the apical or lateral region surrounding a pulpless tooth .
Indications
- For removing the infected tissue from the bone surrounding the root
- For removing overextended fillings
- For removing necrotic cementum
- For removing a long standing persistent lesion especially when a cyst is suspected.
Surgical Technique
- Give local anesthesia, design flap and expose the surgical site.
- Use bone curette to remove the pathologic tissue surrounding the root.
- After removing the tissue from bony area, grasp the soft tissue with the help of tissue forceps and send it for histopathological examination.
What’s root end resection and its indications
- Inability to perform nonsurgical endodontic therapy due to anatomical, pathological and iatrogenic defects in root canal
- Persistent infections after conventional endodontic treatment
- Need for biopsy
- Need to evaluate the resected root surface for any additional canals or fracture
- For removal of iatrogenic errors like ledges, fractured instruments and perforation which are causing treatment failure
- Blockage of the root canal due to calcific metamorphosis or radicular restoration.
Factors to be Considered before Root-end Resection? Length, angle and maim objective
Instrumentation
- High-speed handpiece with surgical length fissure bur is preferred because round bur may result in gouging of root surface.
- Nowadays, use of Er:YAG laser for root-end resection is recommended as it produces clean and smooth root surface, decreases permeability of root surface, reduces postoperative pain and discomfort.
Extent of Resection According to Cohen et al., length of root tip resection depends upon frequency of lateral canals and apical ramifications at root end.
It was found that when apical 3 mm is resected, lateral canals are reduced by 93% and apical ramifications 98% .
Angle of Root-End Resection a bevel of 0–10° is recommended for resection because, It allows inclusion of lingual anatomy with less reduction
Root-End Preparation Main objective of root-end preparation is to create a cavity to receive root-end filling ,so as to seal off the root canal system from periradicular tissues.
What’s Traditional Root-End Cavity Preparation?
Five requirements suggested for a root-end preparation to fulfill:?
• straight handpiece with a small round or inverted cone bur is used to prepare a cavity at the root end within confines of the root canal
- Apical 3 mm of root canal must be cleaned and shaped
- Preparation must be parallel to anatomic outline of the pulp cavity
- Creation of an adequate retention form
- Removal of all isthmus tissue if present
- Remaining dentine walls should not be weakened
What is retrograde filling?
- Main aim of nonsurgical or surgical endodontics is three dimensional obturation of the root canal system.
- Therefore, after apical surgery, placement of a root-end filling material is an equally important step.
- To place a material in the retropreparation, it is mixed in the desired consistency, placed into the retropreparation and compacted with the help of burnisher.
- After it is set, excess is removed with carver or periodontal curette
- Finally, the root-end filling is finished with carbide finishing bur and a radiograph is taken to confirm the correct placement of the filling.
