Endodontic Surgery

ENDODONTIC SURGERY
INTRODUCTION
Indicated in less than 5% of all the cases.
Root resection or root amputation , is the most common form

of periapical surgery.
Other procedures are periapical curettage, radisectomy,

replantation, transplantation, implantation, trephination,
incision & drainage.
OBJECTIVE
To ensure the placement of proper seal between the

periodontium and the root canal foramina.
CLASSIFICATION (GROSSMAN)
1. Root resection or apical curettage following an orthograde

filling.
2. Orthograde filling during root resection or periapical curettage.
3. Root resection and retrograde filling.
4. Root resection and retrograde filling following an orthograde
filling.
INDICATIONS (Ingle)
1. Need for surgical drainage.

2. Failed non surgical endodontic treatment.
a) irretrievable root canal filling material.
b) irretrievable intraradicular post.
3. Calcific metamorphosis of the pulp space.
4. Procedural errors
a)Instrument fragmentation
b) Non- negotiable ledging.
c) Root perforation
d) Symptomatic overfilling.
5. Anatomic variations
a) Root dilaceration
b) Apical root
fenestration
6. Biopsy
7. Corrective surgery.
a) Root resorptive defects
b) Root caries
c) Root resection.
d) Hemisection
e) Bicuspidation
8. Replacement surgery.
Replacement surgery
a) Intentional replantation
(extraction/replantation ) b) post – traumatic.
Implant surgery.
a) Endodontic
b) osseointegrated
CONTRAINDICATIONS
1. Patient’s medical status.

2. Anatomic considerations.
3. Dentists skill and
experience.
Thorough medical history essential.
Review medical status with patient’s personal physician.
Anatomic considerations of importance to endodontic

surgery
involve
1. Nasal floor
2. Maxillary sinus
3. Mandibular canal and its neurovascular bundle
4. Mental foramen and its neurovascular bundle
5. Anatomic limitations to adequate visual and mechanical
access.
Professionals should understand their limitations.
CLASSIFICATION OF ENDODONTIC SURGICAL
PROCEDURES
1. Surgical drainage
a) Incision and drainage
b) cortical trephination (fistulative
surgery)
2. Periradicular surgery
a) Curettage
b) Biopsy
c) Root end resection
d) Root end preparation and filling
3. Corrective surgery
a) Perforation repair
i) Mechanical
(Iatrogenic) ii)
b) Root resection
c) Hemisection
4. Replacement surgery (extraction / replantation)
5. Implant surgery
a) Endodontic implants
b) Root- form osseointegrated implants.
INCISION AND DRAINAGE
For fluctuant soft tissue swellings.

Incision should be made through focal point of swelling to
relieve pressure, eliminate exudate and stimulate healing.
Placement of drain
To maintain the patency of the opening
CORTICAL TREPHINATION
It is a procedure involving the perforation of the cortical plate

to accomplish the release of pressure from the accumulation of
exudate within the alveolar bone.
Apical trephination
ANASTHESIA AND HEMOSTASIS
 Objectives:
To obtain profound and prolonged anesthesia.
To obtain good hemostasis.
Lidocaine (xylocaine) , the anesthetic of choice.

Selection of vasoconstrictor agent.
Will have an effect on both duration of anesthesia and the

quality of hemorrhage control.
Epinephrine is the most widely used anesthetic agent in dental

anesthetics.
Injection sites and Technique.
Nerve block anesthesia involves injection in close proximity

of the nerve trunk. (L.A. containing 1:100000 or 1: 200000)
Infiltration anesthesia at the site of surgery.(1:50000)
Rate of injection directly affects the degree of hemostasis.

Reactive hyperemia or the Rebound phenomenon
Occurs due to localized tissue hypoxia and acidosis caused

by prolonged vasoconstriction.
FLAP DESIGNS
Principles and guidelines for Flap design

• Avoid horizontal and severely angled vertical incisions.
• Avoid incisions over radicular eminences.
• Incisions should be placed and flap repositioned on solid bone.
• Avoid incisions across major muscle attachments.
• Tissue retractor should rest on solid bone.
• Extent of the horizontal incision should be adequate to provide
visual and operative access with minimal soft tissue trauma.
• The junction of the horizontal sulcular and vertical incisions should
either include or exclude the involved interdental papilla.
• The flap should include the complete mucoperiosteum.
ARMAMENTARIUM
CLASSIFICATION OF SURGICAL FLAPS.
1. Full mucoperiosteal flaps

a) Triangular (one vertical releasing incision)
b) Rectangular (two vertical releasing incision )
c) Trapezoidal (broad based rectangular)
d) Horizontal (no vertical releasing
incision)
2. Limited mucoperiosteal flaps

a) Submarginal curved (semilunar)
b) Submarginal scalloped rectangular (Luebke - Ochsenbe
Triangular Flap
Advantages
Good wound healing
Ease of flap reapproximation.
Disadvantages
Limited surgical access.
Recommended for Maxillary incisors

and posterior teeth. Only
recommended flap design for
mandibular posterior teeth.
Rectangular
flap
Advantages
Increased surgical access to the root apex.
Disadvantages
Difficulty in reapproximation of flap margin
and wound closure.
Recommended for mandibular anterior

Teeth, multiple teeth, teeth with long roots
like maxillary canines.
Trapezoidal
Flap
Contraindicated in periradicular
surgery.
Horizontal flap
Limited application in periradicular surgery because of

limited access it provides.
Major applications in endodontic surgery are limited to repair

of cervical defects (root perforations, resorption, caries, etc )
and hemisections and root amputations.
Submarginal scalloped rectangular flap (Luebke- Ochsenbein)
Advantages
Esthetic considerations, since it
does not involve the marginal or
interdental gingiva and the crestal
bone is not exposed.
Disadvantages
More bleeding and greater potential
for flap shrinkage, delayed healing
and scar formation.
Stepwise procedures
Flap retraction
Hard tissue procedures
Periradicular curettage
Bone curettes are used.

Concave surface facing the bone to free the margins
Then turned towards soft tissue to facilitate removal in one piece.
Root end resection
Factors to be considered when determining the appropriate

extent of root end resection in periradicular surgery.
•Visual and operative access to the operative site.
•Anatomy of the root.
•No. of canals and their position.
•Need to place a root-end filling surrounded by solid dentin
•Presence and location of procedural errors.
•Presence and extent of periodontal defects.
•Level of remaining crestal bone.
Root end preparation
The purpose of root end resection is to create a cavity

to
receive a root-end filling.
Isthmus or anastomosis when it occurs become a
significant factor in the design and placement of the
root-end preparation.
Topical haemostatic agents
E.g.. Bone wax, Racellets, Ferric Sulfate, Calcium Sulfate,

Surgicel etc.
Root end filling materials
An ideal root-end filling material should be:

•Able to prevent leakage of bacteria and their by products in
to
the periradicular tissues.
•Non-toxic.
•Non carcinogenic
•Biocompatible
•Insoluble in tissue fluids.
•Dimensionally stable.
•Unaffected by moisture during setting
•Easy to use
•Radiopaque.
E.g. –Gutta-percha, Amalgam, Cavit, IRM, Super EBA,
Glass ionomers, Composite resins. Zinc Phosphate cements,
ZOE cements, MTA.
Soft tissue repositioning and Suturing
The flap replaced to its original position with the incision

lines approximated as closely as possible.
Apply gentle but firm pressure with surgical gauze moistened
with sterile saline for 2 to 3 mins.
Suture materials
Synthetic fibers (nylon, polyester, polyglactin, and polyglycolic acid)
Silk, Gut, Collagen.
Suture Techniques
1. Single interrupted suture

2. Interrupted loop suture (Interdental)
3. Vertical mattress suture
4. Single sling suture
Post surgical care.
Instructions to the
patient
Monitor the Healing.

Outline for answering Apicoectomy
Explain what it is
Indications & contraindications.
Flap designs (classification )
Preparation of the patient.
Soft tissue procedures
Hard tissue procedures.

Endodontic Surgery

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Endodontic Surgery

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ENDODONTIC SURGERY

Indicated in less than 5% of all the cases.

Root resection or root amputation , is the most common form

Other procedures are periapical curettage, radisectomy,

To ensure the placement of proper seal between the

1. Root resection or apical curettage following an orthograde

1. Need for surgical drainage.

1. Patient’s medical status.

Anatomic considerations of importance to endodontic

For fluctuant soft tissue swellings.

It is a procedure involving the perforation of the cortical plate

Lidocaine (xylocaine) , the anesthetic of choice.

Will have an effect on both duration of anesthesia and the

Epinephrine is the most widely used anesthetic agent in dental

Nerve block anesthesia involves injection in close proximity

Infiltration anesthesia at the site of surgery.(1:50000)

Rate of injection directly affects the degree of hemostasis.

Occurs due to localized tissue hypoxia and acidosis caused

Principles and guidelines for Flap design

1. Full mucoperiosteal flaps

2. Limited mucoperiosteal flaps

Recommended for Maxillary incisors

Recommended for mandibular anterior

Limited application in periradicular surgery because of

Major applications in endodontic surgery are limited to repair

Bone curettes are used.

Factors to be considered when determining the appropriate

The purpose of root end resection is to create a cavity

E.g.. Bone wax, Racellets, Ferric Sulfate, Calcium Sulfate,

An ideal root-end filling material should be:

The flap replaced to its original position with the incision

1. Single interrupted suture

Monitor the Healing.

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