Endodontic surgery

By Dr.Derrick

1. Endodontic Surgery BDS IV Makerere University

2. It is possible that a non surgical root canal procedure wont be able enough to save your tooth and your endodontist will recommend surgery. There is no need for a patient to get worried about surgery because advanced technologies like digital imaging and operating microscopes allow the procedure to be performed quickly comfortable and successfully.

3. Objectives and rationale Curettage - for of the pathologically affected periradicular tissue which cannot be accessed in an orthograde approach e.g. granuloma, true cysts, and foreign body reactions. Resection – of root apices that cant be removed non surgically. Inspection - mostly in failing clinical cases to find out the cause

4. I ndications Failure of non surgical endodontic treatment In periradicular disease affecting root filled tooth in the following cases obliterated root canals Teeth with full crown restorations Presence of a post whose removal may cause root fracture Biopsy of the periradicular tissue is needed. Failure of previous surgery Anatomical problems like severe root curvature

5. Horizontal apical root fracture Periodontal considerations leading to hemisection or radisection Contraindications Patient factors , including the presence of severe systemic disease and psychological considerations. Dental factors including : • unusual bony or root configurations • lack of surgical access • possible involvement of neurovascular structures • poor supporting tissue such as in severe uncontrolled periodontal disease 3. The skill, training , facilities available, and experience of the operator, should also be considered.

6. Steps of endodontic surgery Case diagnosis Preoperative surgical notes- CHX mouth rinses and NSAIDS to reduce postope pain Anaesthesia/hemostasis Management of soft and hard tissues Surgical access or osteotomy Access to root structure Root-end preparation Periradicular curettage Root-end filling Soft-tissue repositioning and suturing Postsurgical care

7. Instruments used Examination and inspection- micromirrors, perio probe Incision elevation curettage- handle and blade, molts curette, periosteal elevators Retraction Osteotomy and root resection-impact air 45 degree hand piece, lindemann burs Preparing root end -microsurgical ultrasonic instruments and MTA root end filling instrument Irrigation - stropko irrigator and micro suction Hemostasis Suturing- suture handle and sutures

8. Soft tissue management Surgical flap design is variable and depends on a number of factors, including: • access to and size of the periradicular lesion • aesthetics • adjacent anatomical structures. The raised flap must be protected from damage and desiccation during surgery and retractors should rest on sound bone.

9. Rules for placing incisions Performed meticulously in such a manner that facilitates healing by primary intention. A complete and sharp incision deep into the bone at one stroke. Many incision lines make suturing difficult. The vertical releasing incisions are placed on interdental bone. Care should be taken of the incised flap under moist and retracted conditions with tissue retractor. Interdental papilla has to be protected and preserved in both anterior esthetic zones and posterior regions.

10. Hard tissue management Osteotomy Involves the removal of cortical plate to expose the root. An assessment of the length of the root and its axis should be made to ensure that bone is removed accurately. Further bone removal should be carried out with a bur in a reverse-air handpiece, cooled by copious sterile saline or sterile water.

11. Periradicular curettage Removal of soft tissue from the periradicular region This is to allow adequate visualization of the root apex. Curettes are used Pathological material should, if possible, be sent for histopathological examination

12. The size of the osteotomy should be minimal enough to hasten healing while being large enough to microscopically access, examine, explore, and instrument the root apex. An ideal and adequate osteotomy (4 mm in diameter).

13. Root-end resection Carried out as close to 90 degrees to the long axis of the tooth as possible to reduce the number of exposed dentinal tubules to ensure access to all the apical anatomy. The apical 3 mm of the root tip is resected perpendicular to the long axis of the root. Carried out with great care with the help of a bur in an Impact air 45° handpiece.

14. It is believed that about 93% of the lateral canals and 98% of apical ramifications are removed when 3 mm of root apex is resected

15. Root-end preparation The preparation should be 3mm deep, in the long axis of the tooth, incorporate the whole pulp space morphology best carried out with an ultrasonically powered tip The tips should be used at low power and with a light touch to reduce the risk of root cracking. should be carried out with sterile saline or water as a coolant. The root walls should be examined to ensure that they are free of debris and previous root canal fillings

16. Root-end filling The root-end preparation should be isolated from fluids, including blood. A suitable haemostatic agent should be placed in the bony crypt and the root end cavity dried The root-end filling material should be compacted into the cavity with a small plugger to ensure a dense fill. MTA Radiographic verification of the quality of the root end filling is appropriate before wound closure.

17. Closure of the surgical site The soft tissue flap is re-apposed with sutures. Optimum healing being achieved with primary closure. After suturing, the tissues should be compressed with damp gauze for 3–5 minutes. Sutures are removed 48–96 hours post-operatively providing the wound is stable. Synthetic monofilament sutures are therefore the preferred.

18. Post operative care Clean the oral cavity Place gauge over the surgical area Allow patient to rest for some time Ice bags should be placed ant interval of 5 minutes, they help reduce post operative swelling and inflammation Anti septic rinsing should be done for there days after surgery every after a meal Warm mouth rinse a day after surgery to improve circulation in the surgical area thus healing Antibiotics are not mandatory Grossman et al But anti-inflammatory drugs and analgesics are prescribed

19. Post operative complications Post op pain Haemorrhage Post operative swelling Infection

20. Radisection and Hemisection Radisectomy denotes the removal of one or more roots of a molar. Hemisection refers to sectioning of the crown of a molar tooth, with either the removal of half the crown and its supporting root structure or the retention of both halves, to be used after reshaping and splinting as two premolars.

21. Why hemisection or radisection At times, a multirooted tooth has an untreatable periodontal lesion on one or more of its roots, but the remaining root or roots are well supported and treatable To retain a portion of this strategic tooth and avoid extraction of the entire tooth, hemisection or radisectomy can be performed

22. Indications of radisection Extensive bone loss around one root of an upper molar Fractured root of a molar Root has been perforated and cannot be treated endodontically Contraindications. When loss of bone involves more than one root, and the remaining roots would have inadequate support When the involved tooth is an abutment tooth for a long span bridge When the roots are fused

23. hemisection The indications: When periodontal involvement of one root is severe When loss of bone is extensive in the furcation area When caries involves much of one of the roots Note Endodontic treatment should precede root removal. The coronal seal placed in the pulp chamber over the root to be removed should have set before hemisection or radisectomy to avoid “core material scatter” in the adjacent tissues

24. Intentional Replantation Intentional replantation is the purposeful removal of a tooth and its almost immediate replacement, with the objective of obturating the canals apically while the tooth is out of the socket.

25. Indications Difficulty of access for surgical endodontics especially in lower second and third molars When the apex of the involved tooth is in close proximity to key anatomical structures such as the mental nerve

26. The procedure involves careful extraction of the tooth under adequate asepsis and anaesthesia. Care should be exercised in ensuring that the periodontal ligament is not injured and is frequently washed with HBSS solution during the extraoral procedural time. The root resection and retro filling is done with ultrasonic tips and MTA. The tooth is then reinserted into the socket and the buccal and lingual cortical plates are manually compressed. A semirigid temporary splint is then placed to stabilize the tooth. Regular follow-up of such cases is important to ascertain the status of such teeth