Endodontic surgery

Dr.V.RAMKUMAR CONSULTANT DENTAL&FACIOMAXILLARY SURGEON REG: NO 4118 –TAMILNADU- INDIA( ASIA)

INTRODUCTION

Endodontic surgery is defined as a surgical aid to treat endodontic problems.

Classification

1. Incision & drainage2. Peri-apical surgery

- Curettage- Retrograde filling- Apicoectomy

3. Postoperative evaluation –alternative methods.- Re-implantation- Endodontic implants

1. Incision & Drainage

It is carried out to drain the pus & toxins from the peri-apical region under antibiotic cover so that the patient is relieved of discomfort, pain & swelling.

The surgical avoids the spontaneous drainage and the resultant cutaneous fistula.

Success depends on the timing of the procedure.

Better under block anesthesia.

Peri-apical surgery It includes amputation, curettage & retrograde

filling. In practice all these 3 procedures are carried out

as part of Apicoectomy.

Indications: 1. Predisposing factors for the failure of conservative root canal therapy.

-Unfavourable curved root apex-Root resorption-Accessory root canals-Apical third root fracture-Cyst formation

Cont….

2. Failure following root canal therapy

- inadequate or overfilled root canal

-fragmentation of the instruments inside the root canal

-persistent postoperative discomfort

-lateral perforation at the apical third of the root

-persistent periapical radiolucency

Cont…..

3. Inaccessibility to ‘ conservative root canal therapy’

- Porcelain jacket crown or post crown

-Anatomical defects like dens in dente

-Calcified root canal

-Non-vital teeth used as abutments for bridges

-Broken RCT instruments in the root canal.

Contraindications

1. Anatomical considerations- Surgical inaccessibility eg, molars- Sharp root- Inadequate or poor bony support due to

advanced periodontal disease- Proximity of the root apex to anatomical

structures like mental foramen, inferior alveolar canal, nasal or antral floor.

Cont…

2. Systemic disorders

- First trimester of pregnancy

- Uncontrolled diabetes, heart disease,

hypertension, kidney , liver and

hemorrhagic disorders.

- Focal sepsis consideration

- Emotional and uncooperative patients.

Surgical technique 1. Anesthesia – LA –Block anesthesia.

2. Design of the flap : a. Semi lunar flap b. Triangular flap c. Trapezoidal flap d. Rectangular flap e. Modified labial flap f. Vertical incision

3. Reflection of mucoperiosteal flap

CONT…..4. Apical surgery

- Bone window - Identify root apex – root resection (bur) - Curettage – granulomatous sac

5. Retrograde filling

- Seal the apical foramen adequately after cleaning, preparation, disinfection of the root canal.- Zinc free amalgam – material of choice

6. Suturing

ROOT PREPARATION

ROOT PREPARATION

ROOT FILLING

Postoperative follow-up

1. Suture removed on 7th post op day

2. Review at regular intervals

3. Recall to evaluate the prognosis of the tooth after Apicoectomy

Prognosis depends on

Presence of preoperative symptoms Size of the preoperative periapical lesion Quality of the root canal filling Its timing relative to he surgery Presence of a retrograde filling Type of the retrograde filling Technique and skill of the surgeon Tooth involved

Reasons for failure

1. Incomplete apical seal

2. Damage to the root like lateral perforation

3. Post surgical migration of the epithelial attachments towards the root apex, damage to the periodontal, alveolar 7 gingival tissues

4. Wound breakdown

Reimplantation

It refers to the intentional removal of a tooth and its reinsertion into its socket after endodontic therapy and root section in vitro.

Indications:

- This is limited to posterior teeth where apicoectomy is not feasible or inaccessible

- It internal or external resorption has perforated the root apex

- Where the root canal in posterior tooth is sharply curved, it cannot be treated by conventional methods.

Procedure 1. LA – Atraumatic tooth removal, curettage of

the socket

2. Tooth is endodontically treated, root filled; root resections and retrograde filling are done by another operator. Care to prevent drying of the tooth.

3. Treated tooth is replaced into the socket. Tooth is immobilized with any appropriate method of wiring.

CONT….

4. Postoperatively, adequate relief must be provided for any possible traumatic occlusion of the tooth.

5. Splint is left insitu for a period of 8 weeks.

Endodontic implants It is a rigid structure which extends through the

root canal into the periapical osseous tissue, to lengthen the existing root anchorage and to provide stability of the tooth.

In contrast to other implants, endodontic implants are not exposed to the oral environment.

They act as stabilizers when the loss of periodontal support is more than 40%.

ENDODONTIC IMPLANT

Indications:

1. To reinforce the management of transverse root-fracture

2.To stabilize the overdenture abutment3. To stabilize during the autoimplantation4. In teeth with severe periodontal

disturbances and extensive bone loss, endodontic implant is used as an aid to pulp-periodontal therapy.

Thank you