Surgical Endodontics

Question 1

Name the 5 types of endodontic surgery?

Answer 1

• Apicectomy
• Root resection
• Surgical perforation repair
• Surgical management of root resorption
• Intentional reimplantation

Question 2

Name the 6 challenges for endodontics?

Answer 2

• Large area of bone loss will reduce likelihood of success
• Overextended GP will be challenging to remove
• Separated instruments in aspical 1/3 with associated AP
• Short obturation and position of GP suggests ledge
• Pattern of bone loss and proximity of GP suggests strip perforation
• Pattern of bone loss and proximity of restoration suggests perforation

Question 3

What is the definition of an apicetomy?

Answer 3

The removal of the root tip, curettage of
infective & granulation tissue as well as any
foreign bodies from the surrounding peri-
radicular tissues and placement of a
retrograde root end restoration

Question 4

Name the 5 post-treatment clinical/radiographic symptoms that suggest endodontic failure?

Answer 4

• presence of clinical signs and/or symptoms
• swelling, sinus, tenderness to pressure or
  percussion, pain of endodontic origin
• enlargement of existing peri-radicular
  radiolucent lesion
• development of new peri-radicular radiolucent
  lesion
• persistence of peri-radicular radiolucent
  lesion in a tooth that had root-canal treatment
  at least 4 years previously.

Question 5

What occurs of there are no signs or symptoms but with persistent periapical radiolucency?

Answer 5

Absence of signs and symptoms of periapical disease but a persistence of a periapical
radiographic radiolucency may indicate either healing by repair with fibrosis or persistent chronic
inflammation.
Time and/or acute exacerbation will identify persistent chronic inflammation.

Question 6

Prevalence of periapical radiolucency?

Answer 6

• 58% of root filled teeth had periapical
  radiolucency.
• 77% of teeth with post retained crowns
  had periapical radiolucency.
• 41% of patients has at least one non-root
  filled teeth with periapical disease.

Of the 28,881 endodontically treated
teeth, 36% had periapical radiolucencies.
* Of the 271,980 untreated teeth, 2% had
periapical radiolucencies.

Question 7

Name the 3 treatment options following diagnosis of endodontic failure?

Answer 7

• Orthograde re-root treatment (non-surgical).
• Surgical management via periradicular tissues.
• Extraction +/- prosthetic replacement unit.

Question 8

Describe the outcome differences between orthogreade re-root treatment vs apicectomy?

Answer 8

• Endodontic surgery offers more favourable
  initial success, but non-surgical retreatment
  offers a more favourable long-term outcome.

At 2 - 4 years significantly higher success rate
was found for endodontic surgery of 78%
compared with nonsurgical retreatment of 71%.
* At 4 - 6 years significantly higher success rate
with non-surgical retreatment of 83%
compared with 72% for endodontic surgery.

Question 9

What treatment is GS for post-treatment diagnosis of failed endodontic treatment?

Answer 9

In most cases of failed root treatment
non-surgical orthograde re-root
treatment is the treatment modality of
choice.
* Periradicular surgery must only be
considered in select circumstances

Question 10

Name the 6 indications for surgical endodontics?

Answer 10

1. Re-RCT can’t be completed due to persistent exudation despite repeated chemo-mechanical debridement.
2. RCT has been carried out to guideline standards but symptomatic or progressing periradicular disease is associated with an optimally root-filled tooth.
3. Symptomatic or progressing periradicular disease associated with a well root-filled tooth and in which root canal retreatment:
   » may be detrimental to the structural integrity of the tooth
   » would be destructive to a restoration or fixed prosthesis
   » would involve the removal of a post with a high risk of root
   fracture.
4. Symptomatic or progressive periradicular disease associated with a tooth in which iatrogenic or developmental anomalies prevent orthograde root canal treatment.
5. Biopsy of periradicular tissue is required.
6. Visualisation of the periradicular tissues and tooth root is required if perforation or root fracture is suspected.

Question 11

Name the 10 contraindications for surgical endodontics?

Answer 11

1. Primary disease has not been stabilised
2. Poor coronal seal
3. Unrestorable tooth
4. Combined periodontal–endodontic lesion
5. Prognosis of the tooth is limited by
   compromised bone support or crown: root ratio
6. Root fracture
7. Insufficient access to the root end and the
   associated lesion is difficult or risk of access
   greater than the potential advantages
8. Patient unable to tolerate or co-operate
9. Operator does not have the prerequisite skills,
   experience, equipment or materials.
10. Medically compromised.

Question 12

When is re-endodontics surgery as possible tx option?

Answer 12

Lower probability of periapical healing after a second surgical procedure.
Reason for failure of the first surgical procedure should
be determined
R vs B balanced

Question 13

Root perforation prognosis - What is good? What is bad?

Answer 13

Good: fresh, small and apical
Bad: old, large and crestal

Question 14

Describe a Class A endodontic microsurgical case?

Answer 14

absence of a periapical lesion, no mobility and normal
pocket depth, but unresolved symptoms after non-surgical
approaches have been exhausted.
Clinical symptoms are the only reason for the surgery

Question 15

Describe a Class B endodontic microsurgical case?

Answer 15

presence of a small periapical lesion together with
clinical symptoms.
The tooth has normal periodontal probing depth and no mobility.
The teeth in this class are ideal candidates for microsurgery

Question 16

Describe a Class C endodontic microsurgical case?

Answer 16

large periapical lesion progressing coronally but without
periodontal pocket and mobilit

Question 17

Describe a Class D endodontic microsurgical case?

Answer 17

similar to those in class C,but have deep periodontal
pockets

Question 18

Describe a Class E endodontic microsurgical case?

Answer 18

deep periapical lesion with an endodontic- periodontal
communication to the apex but no obvious fractur

Question 19

Describe a Class F endodontic microsurgical case?

Answer 19

represents a tooth with an apical lesion and complete
denudement of the buccal plate but no mobility

Question 20

Name the 7 principles for endodontic microsurgery?

Answer 20

• Aseptic technique
• Use of surgical microscope
• Minimally invasive technique resulting in
  faster healing
• Use of microsurgery instruments, blades
  & needles
• Minimal osteotomy
• Shallow / no bevel root resection with
  inspection
• Precise placement of biocompatible root
  end restoration

Question 21

What are the risks necessary to be explained for informaed consent for endodontic surgery?

Answer 21

• Post-operative pain, swelling, bleeding,
  bruising, infection
• Sutures
• Gingival recession
• Scarring
• Iatrogenic damage to adjacent teeth
• Possible treatment failure

Question 22

The main aim for endodontic sugery flap design?

Answer 22

The main considerations governing flap design are good
access and vision, while minimizing trauma to the soft tissues
during retraction.
* The design should ensure good blood supply to the flap,
avoid damage to the surrounding structures and facilitate
primary wound closure.

Question 23

Describe the considerations made when designing flap design for endo surgery?

Answer 23

A full thickness flap is required and this should be extended
one or two teeth either side of the lesion(s) to allow adequate
vision, atraumatic elevation and retraction.
* The incision type should be selected following consideration
of smile line, local anatomy (frenal attachments, crown
margins, bony eminences, width of attached gingivae),
periodontal probing depths, marginal bone levels and the
potential for recession following surgery.

Question 24

Name 4 types of flap design?

Answer 24

Rectangular full thickness flap - gingival recession
Submarginal flap - delayed healing but preserving marginal gingivae
Papilla Base flap - minimise gingival recession and preserves papillae
Flap reflection

Question 25

Name 5 ideals of good incisions?

Answer 25

* avoid crossing underlying bony defects * create the incision with a single firm continuous stroke * plan the start and finish points of the incision * avoid bony eminences with vertical relieving incisions. * Vertical (rather than oblique) relieving incisions, parallel to blood vessels to minimise bleeding & scar tissue formation

Question 26

What is the defintion of an Osteotomy?

Answer 26

A bony dehiscence will be present over the root apex where granulation tissue has herniated through the labial cortical plate. In these cases access to the root end is straightforward. If this is not the case, a cavity must be prepared in the bone to access the root end. The osteotomy should be sufficient to allow access to the full extent of the lesion. A minimum of two to three millimetres of healthy intact crestal bone should remain following cavity preparation to reduce the risk of recession and provide adequate periodontal support for the tooth

Question 27

What is the defintiion of Curretage?

Answer 27

Once access to the root end has been achieved, the granulation tissue within the bony crypt should be removed with curettes to allow accurate visualisation of the root apex. Removed tissue should be sent for histopathological examination

Question 28

What is the definition of root end resection?

Answer 28

As the residual infection is most likely to reside in the anatomical complexities in the apical 3 mm of the root, it is recommended that the apical 3 mm of the root-end be removed as a matter of routine The root should be resected perpendicular to its long axis. Such a resection angle reduces the number of dentinal tubules exposed, decreasing the communication pathways between the canal system and periradicular tissues. Bevelling of the root tip is not recommended

Question 29

What 5 things to inspect for in root end resections?

Answer 29

* Isthmuses * Fractures * Lateral canals * Retained instruments * Other irregularities

Question 30

What is the definition of root end preparation?

Answer 30

Following root end re-section the apical 3 mm of the root canal system should be prepared to facilitate an adequate apical seal. * The rationale for preparation and filling of the root-end is to debride the canal system and seal off any residual intracanal infection. * The ideal root-end cavity should be prepared along the axis of the root, have near parallel walls, and encompass the root-canal anatomy. * Ultrasonic instruments are preferred for root end cavity preparation because they are small, easy to manoeuvre and allow deeper preparation of the root end than a round bur

Question 31

What is the definition of root end restoration?

Answer 31

Rationale for placement of a root-end filling is to prevent reinfection of any residual intracanal microorganisms and/or their products into the peri- radicular tissues

Question 32

Name 9 properties for an ideal root-end filling material?

Answer 32

- Biocompatible * Antibacterial * Easy to place and remove * Radiopaque * Dimensionally stable * Non-staining * Adhere to the root canal wall * Insoluble * Induce regeneration of the peri-radicular tissues.

Question 33

Name 5 materials used in endodontic retrograde filling surgery?

Answer 33

Pro Root MTA - Mineral Trioxide Aggregate * Bioaggregate * Ceramicrete * Biodentine * RRM - Root Repair Material (paste + putty)

Question 34

What is the definition of bioactivce ceramics?

Answer 34

Includes bioresorbable materials like calcium phosphate bone substitute and non-bioresorbable such as the calcium silicate (hydraulic) cements. * Biocompatible – low /no host inflammatory response * Bioactive - able to create a hydroxyapatite layer when in contact with tissue fluid rich in calcium and phosphate. This occurs largely due to the calcium hydroxide that is formed as part of the setting reaction. This allows the material to be highly biocompatible, osteoinductive, osteoconductive, and contributes to its sealing ability. * Favours regeneration of bone, cementum and PDL

Question 35

NAme 7 advantages of tricalcium silicate bioceramics?

Answer 35

Hydraulic setting reactions mean that they are hydrophilic with excellent ability to seal in moist areas, uninhibited by blood * Little or no host response when touches vital tissues – similar to calcium hydroxide * Collagen fibres can integrate with the material * When used apically stimulates osteoblasts to release osteocalcin and interleukins that favour bone deposition * When used for pulp capping this stimulation of odontoblasts encourages the formation of tertiary dentine * Regeneration of cementum & PDL also possible * Useful in many endodontic situations incl. retrograde apical filling material, internal / external perforation repair, internal / external tooth resorption, pulp capping, apexification, apexogenesis, orthograde sealant with GP

Question 36

Describe what is used for endo surgery wound closure?

Answer 36

The flap should be repositioned and held in place under gentle compression for a few minutes with damp gauze. * Gentle compression of the flap for one-minute post closure ensures fibrin adhesion and may prevent haematoma development. * When suturing the tissues, it is important to ensure that the flap is not under tension. * Contemporary suture materials are 6/0 or 7/0 grade and monofilament polypropylene (eg Prolene®) or braided polyglactin (eg Vicryl Rapide®) Removed after fiveto seven days when the wound strength is sufficient

Question 37

What is the post-Op care and follow-up for Endo surgery?

Answer 37

OTC pain relief. * Avoidance of lip lifting / touching surgical site. * Soft diet with avoidance of pips & small grains. * Avoidance of brushing surgical site for 5-7 days. * 0.2% Chlorhexidine gluconate mouthwash. * Suture removal and gentle OHI / return to brushing 5-7 days. Gentle brushing continues for 3 weeks. * As a minimum review with radiograph at 1 year. * Follow for 4 years to determine success.

Question 38

Name 5 factors what have major impacts on surgical outcome?

Answer 38

presence and size of periapical lesion/crypt (larger crypt reduced success) * loss of cortical plate * quality of the pre-existing root-canal filling judged radiographically * placement of root-end filling * quality of the coronal restoration.