Surgical Endodontics Flashcards
Name the 5 types of endodontic surgery?
- Apicectomy
- Root resection
- Surgical perforation repair
- Surgical management of root resorption
- Intentional reimplantation
Name the 6 challenges for endodontics?
- 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
What is the definition of an apicetomy?
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
Name the 5 post-treatment clinical/radiographic symptoms that suggest endodontic failure?
- 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.
What occurs of there are no signs or symptoms but with persistent periapical radiolucency?
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.
Prevalence of periapical radiolucency?
- 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.
Name the 3 treatment options following diagnosis of endodontic failure?
- Orthograde re-root treatment (non-surgical).
- Surgical management via periradicular tissues.
- Extraction +/- prosthetic replacement unit.
Describe the outcome differences between orthogreade re-root treatment vs apicectomy?
- 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.
What treatment is GS for post-treatment diagnosis of failed endodontic treatment?
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
Name the 6 indications for surgical endodontics?
- Re-RCT can’t be completed due to persistent exudation despite repeated chemo-mechanical debridement.
- RCT has been carried out to guideline standards but symptomatic or progressing periradicular disease is associated with an optimally root-filled tooth.
- 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. - Symptomatic or progressive periradicular disease associated with a tooth in which iatrogenic or developmental anomalies prevent orthograde root canal treatment.
- Biopsy of periradicular tissue is required.
- Visualisation of the periradicular tissues and tooth root is required if perforation or root fracture is suspected.
Name the 10 contraindications for surgical endodontics?
- Primary disease has not been stabilised
- Poor coronal seal
- Unrestorable tooth
- Combined periodontal–endodontic lesion
- Prognosis of the tooth is limited by
compromised bone support or crown: root ratio - Root fracture
- Insufficient access to the root end and the
associated lesion is difficult or risk of access
greater than the potential advantages - Patient unable to tolerate or co-operate
- Operator does not have the prerequisite skills,
experience, equipment or materials. - Medically compromised.
When is re-endodontics surgery as possible tx option?
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
Root perforation prognosis - What is good? What is bad?
Good: fresh, small and apical
Bad: old, large and crestal
Describe a Class A endodontic microsurgical case?
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
Describe a Class B endodontic microsurgical case?
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
Describe a Class C endodontic microsurgical case?
large periapical lesion progressing coronally but without
periodontal pocket and mobilit
Describe a Class D endodontic microsurgical case?
similar to those in class C,but have deep periodontal
pockets
Describe a Class E endodontic microsurgical case?
deep periapical lesion with an endodontic- periodontal
communication to the apex but no obvious fractur
Describe a Class F endodontic microsurgical case?
represents a tooth with an apical lesion and complete
denudement of the buccal plate but no mobility
Name the 7 principles for endodontic microsurgery?
- 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
What are the risks necessary to be explained for informaed consent for endodontic surgery?
- Post-operative pain, swelling, bleeding,
bruising, infection - Sutures
- Gingival recession
- Scarring
- Iatrogenic damage to adjacent teeth
- Possible treatment failure
The main aim for endodontic sugery flap design?
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.
Describe the considerations made when designing flap design for endo surgery?
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.
Name 4 types of flap design?
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
Name 5 ideals of good incisions?
- 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
What is the defintion of an Osteotomy?
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
What is the defintiion of Curretage?
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
What is the definition of root end resection?
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
What 5 things to inspect for in root end resections?
- Isthmuses
- Fractures
- Lateral canals
- Retained instruments
- Other irregularities
What is the definition of root end preparation?
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
What is the definition of root end restoration?
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
Name 9 properties for an ideal root-end filling material?
- 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.
Name 5 materials used in endodontic retrograde filling surgery?
Pro Root MTA - Mineral Trioxide
Aggregate
* Bioaggregate
* Ceramicrete
* Biodentine
* RRM - Root Repair Material (paste +
putty)
What is the definition of bioactivce ceramics?
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
NAme 7 advantages of tricalcium silicate bioceramics?
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
Describe what is used for endo surgery wound closure?
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
What is the post-Op care and follow-up for Endo surgery?
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.
Name 5 factors what have major impacts on surgical outcome?
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.
