Endodontic Surgery Dr. Rafik Al Kowafi BDS, MSc, German board of - - PDF document

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Endodontic Surgery

• Dr. Rafik Al Kowafi BDS, MSc, German board of Oral and

Maxillofacial Surgery ( Berlin- Germany), Doctoral degree by LBMS

Deffinition

• Endodontic surgery is the management or

prevention of periradicular pathosis by a surgical approach.

• In general, this includes:
• 1. Periapical surgery.
• 2. Hemisection/root amputation.
• 3. Intentional replantation.
• 4. Corrective surgery.
• 5. Abscess drainage.

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Periapical surgery (Apicoectomy)

• Apicectomy is the surgical removal of the

apical portion of a tooth and its associated pathological periapical tissues.

• The aim of apicectomy is to eradicate

persistent infection in the periapical tissues, and the purpose of retrograde filling is to gain complete seal and to obstruct the exit

• f bacteria and irritants, which remained in

the root canal.

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Periapical surgery (Apicoectomy)

• Indications:
• 1. Failed conventional endodontic.

Reasons of failure include:

– Inadequately filed canals. – Coronal leakage. – Root fracture. – Missed canals. – Restoration failure. – Fractured instrument. – Perforations.

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Periapical surgery (Apicoectomy)

• 2. Conventional endodontic is impracticable.

Reasons:

i. Anatomical:

a) Calcified root canal. b) Impassable pulp stone. c) Marked curvature of a root canal. d) Incomplete apical development.

ii. Pathological:

a) Inability to disinfect the root canal. b) Inability to control persistent inflammatory changes in the periodontal tissues. c) Root resorption. d) Persistent pathological changes at the apex of the root (e.g cyst).

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Periapical surgery (Apicoectomy)

• III. Operator-induced (Iatrogenic).

a) Surgically accessible perforation of the root. b) Irretrievable root filling materials, “e.g. Sealer paste may be expressed into the apical tissues, or gutta percha extruded through the apex may cause compression

• f the inferior alveolar neurovascular bundle”.

c) Presence of post in root canal which cannot be removed to perform retreatment. d) Fractured reamer or file that cannot be retrieved by non-surgical endodontics. e) Non-negotiable ledging

• iv. Traumatic:

– Horizontal fracture of the apical third of a root, with pulp necrosis

• 3. Need for surgical drainage.
• 4. Biobsy

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A, Anatomic problem of a severe root curvature for which h surgery is indicated. B, Apical resection and root end retrograde mineral. C, Four months postoperatively shows regeneration or bone.

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Irretrievable posts and apical

• pathosis. Root end resection and

filling with amalgam to seal in irritants.

A, Irretrievable separated instruments in mesial- buccal canal. A separated instrument only requires surgical intervention if the tooth becomes symptomatic. B, Following resection of root with fractured instrument and placement of amalgam seal.

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A, Overfill of injected obturating material has resulted in pain and paresthesia as a result of damage to inferior alveolar nerve. B, Corrected by retreatment, then apicectomy, curettage, and a root end amalgam fill. Repair of perforation. A, Furcation perforation results in extrusion or material (arrow) and

• pathosis. B, After flap reflection and exposure,

the defect is repaired

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Periapical surgery (Apicoectomy)

• Contraindications:
• A. Local contraindications:

1. Possibility of retreatment. 2. Unidentified cause of treatment failure. 3. Teeth with poor prognosis. 4. Poor access to the periapical tissues. 5. Anatomical structures may compromise flap design e.g. a short sulcus depth or prominent frenal or muscle attachments. 6. Poor crown/root ratio. 7. Close proximity to: Inferior alveolar nerve, mental nerve and maxillary sinus. 8. Coexisting periodontal disease such as horizontal or vertical bone loss.

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Periapical surgery (Apicoectomy)

• B. Systemic contraindications:
• 1. Severe uncontrolled metabolic diseases.
• 2. Uncontrolled leukemias and lymphomas.
• 3. Severe uncontrolled cardiac diseases.
• 4. Severe uncontrolled hypertension.
• 5. Severe bleeding diathesis

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Treatment planning for apicoectomy

• 1. History.
• 2. Clinical examination.
• 3. Radiological examination.
• 4. Case selection.
• 5. Referral of patients.
• 6. Pre operative medications.
• 7. Instrumentation.
• 8. Surgical procedure.

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History

• The

patient may complain

• f

pain, swelling, unpleasant taste “as pus discharge”, tenderness or mobility of the tooth on biting.

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Clinical assessment

• A. Extraoral examination

– A thorough examination should be undertaken, in particular noting:

• 1. Regional lymph nodes.
• 2. Swelling.
• 3. Mouth opening.

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Clinical assessment

• B. Intraoral examination

1. General status of the mouth 2. Presence of local infection, swelling and sinus tracts 3. Presence, quantity and quality of restorations, caries and cracks 4. Quality of any cast restorations (marginal adaption, aesthetics, history of decementation) 5. Periodontal status, including the presence of isolated increased probing depths 6. Occlusal relationship – is the tooth a functioning unit or is there potential for function? 7. Sensibility and percussive testing of the suspected tooth, adjacent teeth.

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Radiological assessment

• Periapical X-ray.

– At least 3mm of the tissues beyond the apex of the roots should be radiographically assessed. – If a large periradicular lesion is suspected further radiographs such as OPG, occlusal views or CBCT may be required. – If a sinus tract is present then a radiograph should be taken with a gutta-percha cone in place to delineate the tract. – During radiographic assessment, the root morphology, periapical pathology, adjacent structures(nerves, maxillary sinus), quality of the RCT and the location of the # instrument if present, all should be evaluated.

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Case Selection

• For GDP surgery should initially be restricted to maxillary

incisors or canines.

• Other teeth pose clinical problems that diminish the

chance of success as narrow or curved roots in mandibular incisors or restricted access to the palatal root of maxillary molars and premolars. Also it may be difficult to seal a lateral root perforation because of restricted access.

• As experience is gained, it becomes possible to undertake

more demanding surgery.

• Dr. Rafik AL Kowafi

Referral of Patients

• Patient should be referred for specialist care:

– If the dental surgeon feels that he or she has inadequate experience to undertake the surgery. – If there is any doubt about the patient’s medical history. – If there are anatomical or pathological features that may complicate surgery.

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Pre Operative Medications

• The drugs prescribed will vary according to the individual

preferences and specific needs of the patient.

• Some of whom may have coexisting medical disease.
• Anxiolytics “e.g. Diazepam” may be prescribed to reduce

patient anxiety.

• Antibiotics (if needed).
• An antimicrobial mouth rinse such as Chlorhexidine Gloconate

0.2% is recommended to cleanse the mouth before surgery.

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Instrumentation

• Adequate lighting source.
• Microhead handpiece and

burs or ultrasonic preparation tips.

• Apical retrograde micro-

mirror and micro-explorers.

• Local anesthetic syringe and

cartridges.

• Scalpel handle and blade
• No. 15.
• Needle holder and scissor
• Mirror.
• Surgical handpiece with

surgical burs.

• Bone file

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Instrumentation

• Surgical curettes with

different sizes.

• Periosteal elevator.
• Cotton pliers.
• Small hemostat.
• Suction tips (small, large).
• Suture material.
• Flap retractor
• Irrigating syringe.
• Miniaturized amalgam

applicator for retrograde fillings.

• Narrow amalgam

condensers.

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Instrumentation

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Periapical surgery (Apicoectomy)

• Periapical surgery includes the following:

1. Local anesthesia. 2. Incision and flap design. 3. Flap reflection and retraction. 4. Bone removal and exploration of the root surface for fractures or other pathologic conditions. 5. Curettage of the apical tissues. 6. Resection of the root apex. 7. Retrograde cavity preparation. 8. Placement of the retrograde filling material. 9. Wound debridement.

• 10. Radiographic verification
• 11. Flap replacement and suturing.

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Incision and flap design

• Type of flaps:

a) Triangular (one vertical releasing incision). b) Rectangular (two vertical releasing incisions). c) Trapezoidal (broad-based rectangular). d) Envelope or horizontal (no vertical releasing incision). e) Semilunar flap. f) Submarginal scalloped (Luebke-Ochsenbein).

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Incision and flap design

a) Triangular Flap:

• Most commonly used flap design.
• The triangular flap is formed by a

horizontal, intrasulcular incision and

• ne vertical releasing incision.
• Advantages:

1. Good wound healing. 2. Good visibility and access to defects. 3. Ease of flap reapproximation. 4. Minimal disruption of vascular supply. 5. Easy to suture.

• Disadvantages:

1. More difficult to incise and reflect. 2. Somewhat limited surgical access. 3. Difficult to expose the root apexes of long teeth (e.g, maxillary canines). 4. Possiblity of slight gingival recession.

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Incision and flap design

b,c) Rectangular and trapezoidal flaps:

• Provides excellent access for most cases.
• Rectangular design today is preferable over the

trapezoidal flap which creates a longer component in the non-keratinized tissue that heals more slowly and with more discomfort. As the vertical release tends to broaden out apically, the incision crosses more bony prominences over the roots of teeth and across the muscle frenum, further delaying the healing

• process. The dental papilla just adjacent to the

released flap actually ends up having a compromised blood supply and the potential for recession.

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Incision and flap design

• Advantages:

1. Enhanced surgical access. 2. Excellent visibility. 3. Good to view bone dehiscenses & fenestrations. 4. Minimal disruption of vascular supply.

• Disadvantages:

1. More difficult to incise & reflect. 2. Possible gingival recession. 3. More difficult wound closure than triangular flap.

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Incision and flap design

d) Envelope flap:

– Intrasulcular horizontal incision without vertical release. – Not used for apical surgery. – Used for root resects, root amputation, hemisections, repair of cervical perforations or resorptive defects.

• Advantages

1. Easy to performe. 2. Good for periodontal surgery. 3. Can be converted to rectangular flap if needed.

• Disadvantages

1. Limited access. 2. Not for apical surgery. 3. No releasing incisions (may cause flap tearing).

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Incision and flap design

e) Semilunar flap:

• This is a slightly curved half-moon horizontal

incision in the alveolar mucosa.

• Indication for long teeth e.g. maxillary canine.
• Advantages :

1. Easy reflection and quick access to the periradicular structures 2. Easy to suture. 3. No exposure of crestal bone. 4. No involvement of marginal and interdental gingiva.

• Disdvantages :

1. Poor access. 2. Excessive hemorrhage. 3. Delayed healing, and scarring 4. Limited use in mandible. 5. Unable to extend the flap. 6. The design can carry the flap over the inflamed surgical site or bony cavity.

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Incision and flap design

(f) Submarginal flap:

• Scalloped horizontal incision in attached

gingiva with two vertical releasing incisions.

• Must be adequate attached gingiva (3-5mm).
• Advantages:

1. Does not involve marginal or interdental gingiva. 2. Easy flap reapproximation and suturing. 3. Minimizes gingival recession. 4. No exposure of crestal bone.

• Disadvantages:

1. Possible flap shrinkage and scarring. 2. Disruption of blood supply to the gingival margin. 3. Excessive hemorrhage. 4. Limited use in mandible. 5. Unable to extend The flap if needed.

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Flap reflection and retraction

• Reflection

is with a sharp periosteal elevator beginning in the vertical incisions and then raising the horizontal component.

• To

reflect the periosteum, the elevator must firmly contact bone while the tissue is raised.

• Reflection is to an apical level

adequate for access to the surgical site, although still allowing a retractor to have contact with

• bone. Enough width and vertical

release

• f

the flap must be included to prevent the flap from being stretched, which can lead to tearing and slower healing.

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Localization and exposure of apex

• When the periapical lesion has perforated the buccal bone,

localization and exposure of the root tip is easy, after removing the pathological tissues with a curette.

• If the buccal bone covering the lesion has not been

completely destroyed, but is very thin, then its surface is detected with an explorer or dental curette.

• When the buccal bone remains completely intact, then the

root tip may be located with a radiograph. After taking a radiograph, the length of the root is determined with a sterilized endodontic file or metal endodontic ruler.

• The length measured is then transferred to the surgical

field, determining the exact position of the root tip.

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Bone removal

• Frequently, the cortical bone
• verlying the apex has been

resorbed, exposing a soft tissue lesion. If the opening is small, it is enlarged using a large surgical round bur, until the root and the lesion are visible.

• there should be copious saline

irrigation with a syringe or through the handpiece.

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Curettage of the apical tissues

• By using a suitably sized sharp

curette, most

• f

the granulomatous, inflamed tissue surrounding the apex should be removed to gain access and visibility of the apex, to obtain a biopsy for histologic examination (when indicated), and to minimize hemorrhage.

• Tissue

removal should not jeopardize the blood supply to adjacent teeth.

• If hemorrhage from soft or hard

tissue is excessive to the extent that visibility is compromised, homeostatic agents

• r
• ther

control techniques should be used.

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Root End Resection

• Root

end resection is indicated as it removes the region that most likely had the poorest

• bturation

because of the presence of accessory canals at the apex, which may have not been initially cleaned and debrided, thereby leaving a source

• f

continued infection.

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Root End Resection

• The apex is resected (2–3mm of the total root

length) with a narrow fissure bur and beveled at a 45º angle to the long axis of the tooth .

• For the best possible visualization of the root tip,

the beveled surface must be facing the dental surgeon.

• After this procedure, the cavity is inspected and

all pathological tissue is removed by curettage, especially in the area behind the apex of the root.

• If the entire root canal is not completely filled

with filling material or if the seal is inadequate, then retrograde filling is necessary.

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Root End Preparation and Restoration

• A retrograde filling seals the canal system,

preventing further leakage. The depth of the preparation must be at least 1 mm deeper than the length of the bevel to seal the apex adequately.

• In the past, root end preparation was done

by slow speed, specially designed

• microhandpieces. The rotary instruments

are too complicated to follow the root canal system,

• ccasionally

leading to misaligned preparations.

• Ultrasonic

instruments

• ffer

the advantages of control and ease of use; they also permit less apical root removal in certain situations .

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Root End-Filling Materials

• Ideal material

1. Seals the canal. 2. Well-tolerated (no inflammatory response). 3. Non-toxic & inhibit microbe growth. 4. Moisture-resistant. 5. Non-absorbable within root. 6. Dimensionally stable. 7. Not corrode or be electrochemical active. 8. Not stain tooth or tissues. 9. Adhere or bond to the root without undercuts.

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Root End-Filling Materials

• Types of Root End-Filling Materials:

1. MTA (Mineral Trioxide Aggregate) “One of the best materials used today” 2. Zinc Oxide Eugenol, IRM (Intermediate Restorative Material) and Super EBA (Ethoxy Benzoic Acid). 3. Polyvinyl resin (Diaket). 4. Amalgam. 5. Glass Ionomer Cement. 6. Composite resins (e.g. Retroplast). 7. Gutta-percha.

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Root End-Filling Materials

• Amalgam:

– It is the most used retro-filling material from past seven decades. – Amalgam is easy to manipulate and radio opaque. It is non- soluble in tissue fluids and marginal adaptation as well as sealing improves as amalgam ages due to formation of corrosion products. – High copper zinc free amalgam is preferred. Use

• f

Amalgambond, a 4-META bonding agent with amalgam significantly reduces the microleakage of amalgam retrofillings. – Amalgam has few limitations which include: 1. Initial marginal leakage. 2. Mercury toxicity. 3. Staining of hard and soft tissues (Amalgam tattoo). 4. Need for retentive undercut preparation. 5. Technique sensitivity.

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Root End-Filling Materials

• MTA (Mineral Trioxide Aggregate):

– This cement contains tricalcium silicate, tricalcium aluminate, tricalcium oxide, silicate oxide and other mineral oxides. – Mineral trioxide aggregate (MTA) has shown favourable biologic and physical properties and ease of handling; it has become a widely used material. – MTA has been shown to be conducive to bone growth over the apical region. MTA is a hydrophilic material, similar to portland cement. – MTA has a working time of about 10 minutes, although it takes 2 to 3 hours to reach final set, which is not an issue because the root apex is not a load-bearing region.

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Root End-Filling Materials

• Advantagesof MTA:

1. Better marginal adaptation than amalgam, IRM, or Super-EBA. 2. Less cytotoxic than amalgam, IRM, or Super-EBA. 3. With MTA, new cementum was

• bserved being deposited on

the surface of the material. 4. Hydrophilic. 5. Radiopaque.

• Disadvantages:

1. Longer setting time. 2. Expensive.

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Root End-Filling Materials

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MTA Application

Root End-Filling Materials

• Gutta percha:

– Orthograde gutta-percha root canal obturation that is associated with apical surgery is burnished after apicoectomy with either cold or hot burnisher. – Its adaptation to root dentin walls can also be accomplished with the use of solvents, excavators, scalpels and burs. – Due to it’s porous nature, it absorbs moisture from surrounding periapical tissue and expands initially, which is followed by contraction at a later stage. This may result in poor marginal adaptation and increased micro leakage.

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Root End-Filling Materials

• Zinc Oxide Eugenol (ZOE), Reinforced ZOE Cements

and Super EBA:

– Newer modifications of ZOE compounds, such as IRM and Super EBA provide a better apical seal. IRM is zinc oxide eugenol cement reinforced by addition

• f

20% polymethacylate by weight to the powder. – Super EBA is zinc oxide eugenol cement modified with ethoxybenzoic acid to alter the setting time and increase the strength of the mixture. Super EBA has much better physical properties than ZOE. It showed high compressive strength, high tensile strength, neutral pH, and low

• solubility. Even in moist conditions Super EBA adheres to

tooth structure.

• Studies have revealed that MTA and Super EBA are

superior to other retro-grade filling materials.

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IRM and Super EBA

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Wound debridement and irrigation

• The surgical site is flushed with copious

amounts of sterile saline to remove soft and hard tissue debris, hemorrhage, blood clots, and excess root end-filling material.

• With MTA, the irrigation is done before the

MTA is placed to avoid washing the filler out

• f the apical preparation.

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Radiographic Verification

• Before suturing, a radiograph is made to verify

that the surgical objectives are satisfactory.

• If corrections are needed, these are made

before suturing.

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Flap Replacement and Suturing

• Just before closure, the cervical region of the exposed

teeth is gently scaled to remove any debris, preexisting calculus, and granulation tissue

• This brief intervention speeds the reattachment and

reduces greatly the chance for recession.

• The flap is returned to its original position and is held

with moderate digital pressure and moistened gauze. This expresses hemorrhage from under the flap and gives initial adaptation and more accurate suturing.

• After suturing, the flap should again by compressed

digitally with moistened gauze for several minutes to express more hemorrhage. This limits postoperative swelling and promotes more rapid healing.

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Post operative Care

• Instructions inform the patient of what to expect (e.g., swelling,

discomfort, possible discoloration, and some oozing of blood) and the ways in which these sequelae can be prevented, managed, or both. 1. The surgical site should not be disturbed. 2. Pressure should be maintained (cold packs over the surgical area until bedtime might help). 3. Oral hygiene procedures are indicated everywhere except the surgical site; careful brushing and floosing may begin after 24 hours. 4. Proper nutrition and fluid intake are important but should not traumatize the area. 5. A chlorhexidine rinse, twice daily, reduces bacterial count at the surgical

• site. This minimizes inflammation and enhances soft tissue healing.

6. Analgesics are recommended, although pain is frequently minimal. 7. The patient is instructed to call if excessive bleeding, swelling, pain is experienced. 8. Sutures ordinarily are removed in 7 days.

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Follow Up

• At one month: all swelling and tenderness due to

the surgery subsided.

• 6 months after surgery: a reasonable period for

signs of recurrent infection to appear.

• If the apicected tooth is to

be crowned, it is preferable to wait at least 6 months after surgery to ensure satisfactory healing.

• Dr. Rafik AL Kowafi

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Assessing the outcome of surgical endodontics

• History.
• Clinical Examination.
• Radiographic Examination.
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History

• Free of symptoms as pain, swelling, discharge
• f pus “appear as unpleasant taste”, and

tenderness or mobility of tooth on mastication.

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Clinical Examination

• the apicected tooth should be:

– In functional occlusion, – No evidence of a sinus or pus discharge, – Periodontal pocket depths within acceptable limits.

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Radiographic Examination

• Short time after surgery or even before wound

closure radiograph is important as a baseline to assess subsequent healing.

• No advantage in taking further radiographs within 6

months of surgery.

• Complete regeneration of periapical bone and an

intact lamina dura after surgical endodontics.

• A persistent apical radiolucency (periapical scar) after

surgery dose not necessarily indicate an unsuccessful

• utcome.
• Dr. Rafik AL Kowafi

Apicoectomy with Trapezoidal Flap

Extensive periapical lesion at maxillary right lateral incisor. Indication for apicoectomy

Arrow points to possible location of lesion

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29 Incision for creation of trapezoidal flap. a Diagrammatic

• illustration. b Clinical photograph

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Removal of labial bone covering apical third of root. a Diagrammatic illustration. b Clinical photograph

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30 Removal of periapical lesion with hemostat and curette. a Diagrammatic illustration. b Clinical photograph

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a, b. Resection of apex with fissure bur and beveling at a 45°

• angle. The resection faces the surgeon and is at a

distance of 2–3 mm from the root tip

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31 a, b. Preparation of cavity at root tip of tooth using microhead

• handpiece. a Diagrammatic illustration. b Clinical

photograph

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Placement of filling material in cavity of apex using miniaturized amalgam applicator and condensing of amalgam with narrow amalgam condenser.

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32 Operation site and placement of sutures.

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Hemisection/root amputation.

• A, Fistula on midbuccal

portion of the mesiobuccal root of a molar. B, Full- thickness sulcular incision reveals an unsuspected vertical root fracture.

• C, Resection of the

mesiobuccal root can be accomplished because a sulcular incision was used, as opposed to a semilunar type.

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Intentional replantation

• is the intentional removal of a

tooth and replantion into the socket following endodontic surgery.

• 50 % Success at best.
• Indication:

1. lateral perforation that can not be treated surgically. 2. Anatomy make surgery risky e.g: mental foramen , maxillary sinus

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Intentional replantation

• Remember:
• 1. Do orthograde fill if

possible.

• 2. Do not touch the root.
• 3. Work fast “ less than 30
• min. “
• 4. Stabilize if necessary.
• 5. Reduce occlusion before

extraction.

• 6. Extraction should be non-

traumatic.

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Corrective surgery

• Corrective surgery is the management of defects that have
• ccurred by a biologic response (i.e., resorption) or

iatrogenic (i.e., perforations) error. These defects may be anywhere on the root, from cervical margin to apex.

• Generally, the procedure involves exposing, preparing, and

then sealing the defect.

• Indications:

1. Procedural errors (e.g., perforations). 2. Resorptive defects.

• Contraindication:

1. Anatomic considerations (proximity to the vital structures). 2. Inaccessible defect. 3. Repair would create periodontal defect.

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Corrective surgery

• Post perforation repair:

A, Lesion developing lateral to off-centered post suggests perforation that (B) is identified (arrow) on flap reflection. C, Post is reduced to within root and cavity filled with amalgam (D).

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Abscess drainage

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Abscess drainage

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Abscess drainage

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Complication of surgical endodontics

• 1. Recurrent apical infection.
• 2. Perforation of the lining of the maxillary sinus
• r nasal cavity.
• 3. Hemorrhage.
• 4. Pain during curettage.
• 5. Surgical emphysema.
• 6. Damage to adjacent teeth.
• 7. Parasthesia (damage to the mental n. or IAN)
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Complication of surgical endodontics

• 8. Failure to resects the root completely.
• 9. Excessive mobility of the tooth.

10.Unsatisfactory placement of the retrograde filling. 11.Recession of the gingival margin. 12.Splattering of amalgam at the operation site, due to inadequate apical isolation and improper manipulations for removal of excess filling material 13.Staining of mucosa due to amalgam that remained at the surgical field (amalgam tattoo).

30 march 2016 LIMU

• Dr. Rafik AL Kowafi

73

Complication of surgical endodontics

Amalgam splatter at operation site, as a result

• f improper manipulations for removal of

excess material Staining of mucosa due to amalgam that remained at surgical field after apicoectomy (amalgam tattoo)

30 march 2016 LIMU 74

• Dr. Rafik AL Kowafi

38

Complication of surgical endodontics

Wound dehiscence, as a result of improper design of semilunar incision

Malpositioned retrograde obturation material, due to insufficient preparation of apical cavity

30 march 2016 LIMU 75

• Dr. Rafik AL Kowafi