ENDODONTIC SURGERY

SEMINAR BYDr. N.Upendra Natha Reddy

Postgraduate Student

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CONTENTS Page No

INTRODUCTION/HISTORY 1

CLASSIFICATION 6

INDICATIONS 7

CONTRA-INDICATIONS 9

PRE-OPERATIVE ASSESSMENT/ PRE-MEDICATION 9

SURGICAL KIT 12

FLAP DESIGNS 15

TECHNIQUES OF ENDODONTIC SURGERY 28

INCISION AND DRAINAGE 28

TREPHINATION 31

APICAL CURETTAGE AND BIOPSY 36

APICOECTOMY 38

ROOT END CAVITY PREPARATION 47

ROOT END CAVITY OBTURATION 56

ROOT END FILLING MATERIALS 59

CORRECTIVE SURGERY 63

REPLACEMENT SURGERY 71

IMPLANT SURGERY 73

SUTURING 77

POST-OPERATIVE INSTRUCTIONS 82

POST-OPERATIVE SEQUELAE 83

SUCCESS AND FAILURE 87

REFERENCES 96

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INTRODUCTION

According to the strictest definition of the word surgery, most

endodontic treatment falls into the category of a surgical procedure, since

removal of tissues, such as vital pulp, necrotic debris, or dentin, is

involved. However, as commonly used, the term endodontic surgery

refers to the removal of tissues other than the contents of the root canal

space to retain a tooth with pulpal and/or peri-apical involvement.

HISTORY

Endodontic surgery was first recorded 1500 years ago when

Aetius.S., Greek physician-dentist, excised an acute apical abscess with a

small scalpel. Later the procedure was redefined and popularized,

although one may question whether Hullihen’s contribution in 1839 was a

refinement over Aetius. “Make an incision through the gum, along the

entire length of the fang”, stated Hullihen, “then apply a roasted fig or

bruised raisins to the gum”. Farrar (1884), Rhein (1897), and G.V.Black

(1886) described root amputation techniques, and in 1919, Garvin

demonstrated retrofillings radio graphically.

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Currently, endodontic surgery falls into more than one domain.

Many general practitioners and most oral surgeons routinely perform

various types of endodontic surgery. Endodontists should be able to

perform peri-apical surgery on any root in the dental arch, including

mandibular molars. Periodontists may become involved in the endodontic

surgery, peri-apical or amputational, when a tooth requiring periodontal

surgery has a peri-apical problem of pulpal origin in addition.

Currently endodontic surgery is a predictable and integral part of

comprehensive endodontic services. Schilder, as president of the

American Association of Endodontists, editorialized that endodontic

surgery has advanced and currently plays a major role in

“retreatodontics”. However, the surgical approach to endodontics can be

badly misused. For some, periradicular surgery automatically follows root

canal obturation and at times is performed in lieu of filling the root canal.

Others refuse to perform or recommend endodontic surgical procedures.

Both groups lack an appreciation of comprehensive dental care. There are

two major areas of endodontic surgery at this time: peri-apical and

amputational. The two have certain basic similarities but have

considerable differences as well.

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For many years the term conservative treatment has been used as a

synonym for non-surgical treatment. Chivian correctly protested that

using conservative to mean “without surgery” would indicate that

surgery is radical treatment. Since peri-apical surgery usually saves a

tooth that could not be retained by other methods, it too is conservative.

Weine also agrees that peri-apical surgery should not be considered

radical therapy, in contrast, tooth retention by any method is

conservative.

For years, many dentists unaccountably have separated

endodontists into two divisions: conservative and surgical. This

classification inappropriately implies that surgery is a radical approach.

Surgical treatment should be considered an extension of therapy, a means

of preserving teeth that otherwise would have to be extracted, and is

therefore no less conservative than what we consider to be routine, non-

surgical root canal treatment.

The definition of conservative, “tending to preserve existing

conditions”, supports this position. How did the erroneous perception of

surgery as a radical and last -resort treatment originate? Apparently this

idea began in 1884, when Farrar described “radical and heroic treatment

of alveolar abscess”. In outlining a plan of treatment, Farrar used the term

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radical. In a perusal of the endodontic literature of the past 100 years, the

term conservative is used to describe non-surgical treatment. This archaic

terminology is still found in current textbooks and journal articles.

However, because a surgical endodontic approach is often the only

method of salvaging otherwise hopeless teeth, it is indeed conservative.

Other important factors that have enhanced the success and

increased the applications of surgery are research and education. Through

experimental investigations, surgical approaches and outcomes are better

understood. Advanced endodontic programs have increasingly

emphasized surgical training in response to the need for this treatment

approach.

Endodontic surgery encompasses surgical procedures performed to

remove the causative agents of radicular and peri-radicular disease and

restore these tissues to functional health.

With the recent advent of magnification and illumination, coupled

with ultra-sonic root end canal preparations and sealing with new retro-

grade filling materials, the success of surgical endodontic treatment will

provide the answer to solving myriad problems that were once considered

hopeless. The expanded scope of surgical endodontics includes apical

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curettage, apicoectomy, root end filling, root resections, hemisections,

replantation, transplantation, and guided tissue regeneration, with more

advances on the horizon. This gives the clinician a wide range of choices

in this conservative approach.

Root canal treatment is a relatively successful procedure if

diagnosis and technical aspects are carefully performed. Most pulpal and

peri-apical disease is best managed nonsurgically. There is a common

belief that if root canal treatment fails, surgery is indicated for correction.

This is not necessarily true, as most failures are best corrected by

retreatment. There are however, situations in which surgery is necessary

to retain a tooth that would otherwise be extracted.

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CLASSIFICATION OF ENDODONTIC SURGERY

It can be classified as follows:

1. Surgical drainage

Incision

Trephination (fistulative surgery)

2. Radicular surgery

A. Apical surgery.

Curettage and biopsy (peri-radicular surgery).

Apicoectomy.

Retro filling.

B. Corrective surgery.

1. Perforative repair.

Mechanical.

Resorptive.

2. Periodontal repair.

Guided tissue regeneration.

Resection.

3. Replacement surgery.

A. Replant surgery

Intentional

Post traumatic.

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B. Endosteal implants surgery.

Endodontic

Osseo-integrated (endosseous)

INDICATIONS FOR ENDODONTIC SURGERY

1. Surgical Drainage

A. Necessity for drainage

1. Elimination of toxins

2. Alleviation of pain

2. Apical surgery

A. Irretrievable root canal fillings

1. Obviously inadequate filling

2. Apparently adequate filling

B. Calcified canals

C. Procedural errors

1. Instrument fragmentation.

2. Nonnegotiable ledging.

3. Over instrumentation and apical fracture.

4. Symptomatic overfilling.

D. Presence of dowels

E. Anatomic variations

F. Apical cyst

G. Biopsy

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H. False indications.

1. Presence of an incompletely formed apex, making hermetic

sealing of the apex impossible.

2. Marked overfilling.

3. Persistent pain.

4. Failure of previous treatment.

5. Extensive destruction of peri-apical tissue and bone

involving one third or more of the root apex.

6. Root apex that appears to be involved in a cystic condition.

7. Presence of crater shaped erosion of the root apex,

indicating destruction of apical cementum and dentin.

8. Inability to gain negative culture.

9. Internal resorption.

10.Extreme apical curvature.

11.Fracture of root apex with pulpal death.

3. Corrective surgery

A. Root anomalies

B. Perforating carious and resorptive defects

C. Periodontal-endodontal defects

Guided tissue regeneration.

Root resection, hemi section, bisection.

Correction, radicular gingival groove.

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4. Replacement surgery

A. Replant surgery

Intentional.

Post-traumatic.

B. Implant surgery

Endodontic.

Endosseous.

CONTRA-INDICATIONS TO ENDODONTIC SURGERY

1. Indiscriminate surgery.

2. Poor systemic health.

3. Psychological impact.

4. Local anatomic factors

Short root length.

Poor bony support.

Site of surgery.

PRE-OPERATIVE ASSESSMENT

The quality of endodontic surgery, and in many respects the final

successful out is dependent on proper patient assessment, diagnosis and

treatment planning. It is during this process that the facts surrounding the

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case in question must be obtained and integrated into a meaningful

diagnosis and treatment plan. Contraindications involving the patient’s

psychological or systemic makeup can be identified as well as patient

acceptance of, and cooperation with, the anticipated surgical procedure.

Often this will include procedures to minimize stress with patients who

are particularly susceptible to pain and anxiety. Oral soft- and hard tissue

conditions, including patient compliance with oral hygiene practices, can

be ascertained and reinforced.

Local patient factors focus on the nature of the previous root canal

treatment, if any, and the ultimate management of both soft and hard

tissues during surgical entry and wound closure. These include the

potential need to remove previous dental restorations, which are failing,

and to attempt non-surgical pretreatment as part of overall management.

The removal of leaking crowns, restorations with deep decayed margins,

poorly adapted inter proximal restorations and root fillings of silver

comes or pastes is common. Favoring results have been obtained when

root canal systems are retreated prior to surgical management.

Radiographic examinations are also essential, using prior

radiographs if available, along with additional films exposed at the

consultation visit. When posterior teeth are involved it is common to

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take several radiographs from different angles, identifying the number,

curvature and angle of the roots requiring surgery. Likewise, anatomical

structures, which may impair surgical or visual manipulation of the

surgical site, are identified, such as the mental foramen, zygomatic

process, anterior nasal spine and external oblique ridge.

Crucial to the success of the surgical procedure will be

communication with the patient concerning the need for surgery, the

prognosis, the use of preoperative medication or mouth rinses, the actual

procedures to be performed, the potential for postoperative discomfort,

the use of postoperative palliative procedures, the need for suture

placement and removal, follow-up care and long-term assessment. It is

recommended that the following pretreatment regimens be considered.

1. A periodontal examination should be performed prior to surgery

and, if necessary, scaling and/or root planing performed. The

patient’s oral hygiene practices should be assessed and reinforced.

2. Patients can be placed on chlorhexidine rinses 1 day before

surgery, to continue for 2-3 days afterwards.

3. Patients can begin taking a non-steroidal anti-inflammatory

medication 1 day before surgery, or at the latest one dose 1 h

beforehand.

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4. Patient should be advised to refrain from smoking.

5. If sedative pre-medication is to be used the patient must bring an

accompanying person, who will be responsible for escorting home

and compliance with postoperative instructions.

General Medical Conditions

Hypertension Coronary artherosclerotic disease

Stable angina Myocardial infarction

Infective endocarditis Chronic obstructive pulmonary disease

Asthma Cerebrovascular accident

Epilepsy Diabetes

Adrenal insufficiency Steroid therapy

Organ transplant Impaired hepatic or renal function

SURGICAL KIT

Basic instruments for surgical intervention have changed little in

the past century. Many manufacturers have attempted to duplicate or

enhance these instruments, but few major changes exist. The clinician

must be familiar with the different types of instruments, and how and

why they are beneficial in the performance of endodontic surgery. It is

well accepted that there is more than one way to achieve high quality in

the delivery of surgery. Therefore, instruments must be chosen which

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best allow the surgeon to perform as well as possible. Instruments must

be sharp, undamaged and permit total control of the surgical site. Back-

up instrument support for indispensable items must also be considered.

Pre-surgical assessment

Mirror and curved explorer

Straight and curved periodontal probes

Soft-tissue incision, elevation and reflection

Sharp scalpels – numbers 15, 15c, 11 and 12

Broad-based periosteal elevator

Broad-based periosteal retractor

Tissue forceps

Surgical aspirator

Irrigating syringes and needles

Peri-radicular curettage

Straight and angled bone curettes

Small endodontic spoon curette

Periodontal curettes

Fine, curved mosquito forceps

Small, curved surgical scissors

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Bone removal and root-end resection

Surgical length round and tapered fissure burs

Straight hand piece

Contra-angled hand piece/slow and high

Root-end preparation/placement of root-end filling/finish of resected

root end

Miniature contra-angle or ultrasonic unit; sonic hand piece

Burs-very small inverted cone or round; angled ultrasonic or sonic

tips

Root-end filling material

Haemostatic agent (avoid bone wax)

Miniature material carriers and condensers

Small ball burnished

Paper points or fine aspirator tip

Citric acid 10-50% and sterile cotton pellets

Small, fine explorer

Suturing and soft-tissue closure

Surgical scissors

Hemostat or fine needle holders

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Various suture types and sizes (3-0 to 5-0)

Sterile gauze for soft-tissue compression

Miscellaneous (or readily available)

Adequate aspiration equipment

Additional light source

Magnification

Root canal filling materials

Anaesthetic syringes and anaesthetic.

FLAPS- FUNCTION AND DESIGN

FUNCTIONS OF A FLAP

The most important function of a flap is to raise the soft tissue

overlying the surgical site to give the best possible view to the operator

and sufficient exposure of the area to be operated on. Since the free and

attached gingiva and the underlying mucosa have considerable

vascularity attempting to work through them would lead to increased

blood loss and obstructed view.

Endodontic surgery has had a great advantage over gingivectomy

gingivoplasty and push back procedures – methods of periodontal surgery

that were in vogue for some time until recently. These types of surgery

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left raw, bleeding tissues in addition to uncovered bone in some cases.

They were characterized by considerable postoperative pain and required

surgical pack placement. In endodontic surgery the overlying tissue was

stripped back and could be replaced after the procedure to give the best

possible covering to the surgical site. Therefore the second important

function of a flap is to provide healthy tissue that will cover the area of

surgery, decrease pain by eliminating bone exposure, and aid in obtaining

optimal healing.

It is no wonder that sophisticated periodontal surgery has

incorporated the use of flaps, and most operations now involve that type

of approach. The split thickness flap, apically repositioned flap, sliding

flap and others have been found invaluable in the treatment of periodontal

disease. Any of the new improvements in endodontic flap design and

methods of flap retraction have been gleaned from the experience of

Periodontists. Whenever endodontic surgery is to be performed an

extremely careful periodontal evaluation must be ascertain the most

desirable flap. Additionally when the site is opened for endodontic

surgery, the operator should concomitantly perform any periodontal

surgery necessary in the area. In many cases the exposure afforded by

flap retraction for endodontic surgery exposes periodontal defects that

would otherwise remain undetected.

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Requirements of an ideal flap

Making sure base is widest point of flap

Avoiding incision over a bony defect

Including the full extent of the lesion

Avoiding sharp coroners

Avoiding incision across a bony eminence

Guarding against possible dehiscence

Placing a horizontal incision in the gingival sulcus or keeping it

away from the gingival margin

Avoiding incisions in the mucogingival junction

Avoiding improper treatment of periosteum

Taking care during reaction.

TYPES OF FLAPS

Semi lunar flap,

Full vertical flaps

Double vertical incisions

Modified envelope flaps

Palatal flaps

Ochsenbein Luebke flaps.

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1. Semilunar flap (Refer Fig.1)

The semilunar flap has been used for many years in endodontic

surgery. The chief advantage of this flap is its simplicity, requiring

merely a straight, horizontal incision firmly through the soft tissues to the

underlying bone. Because the incision is placed away from the gingival

margin, the semilunar flap does not cause the uncovering of gingiva from

the gingival margin of crown restorations or disturb the healing of

gingiva after periodontal surgery. It is referred to as semilunar because

the horizontal incision is slightly modified to have a dip toward the

incisal aspect in the center of the flap, giving resemblance to a half-moon.

The disadvantages of this flap have caused it to be replaced by

types of vertical incisions. Among these disadvantages are the following.

Considerable lateral extension is required to expose sufficient area at

the surgical site.

If sufficient lateral extension is not provided, the incision may tear at

the edges during retraction and create areas that heal poorly and with

considerable scar formation.

If minimal attached gingiva is present, the flap may encroach on the

sulcus depth of the teeth to the flapped.

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Since the edges to be sutured are held apart during surgery, the healing

is not as rapid as healing with other flaps and may result in

considerable scar formation.

If the lesion is larger than anticipated, the incision may end up being

over the surgical defect.

When the cuspid or adjacent tooth is involved in the surgery, the

cuspid eminence is violated by the incision.

This flap usually originates in or is placed in the mucogingival

junction, often leading to retarded healing and scar formation.

Indications for use of the semilunar incision are situations in

which the contour and shape of the marginal gingiva must be preserved,

as in patients with complete jacket crowns in the area or for use after

periodontal surgery.

This type of flap is contraindicated where deep periodontal

pockets are present, where minimal attached gingiva is present, when a

very large lesion is anticipated, and when other types of flaps are deemed

to be more desirable.

It is especially important that the gingival sulcus of all teeth

involved in a semilunar flap be explored with a periodontal probe before

the incision is made. The horizontal incision must be made a minimum

of 2mm from the greatest sulcus depth.

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2.Vertical flaps (Refer Fig.1)

Although referred to as vertical flaps because of the vertical

incisions made to aid in the raising of the tissues, these flaps are always

made in conjunction with a horizontal incision. The horizontal incision is

usually placed in the gingival sulcus. Cutting the epithelial attachment

around the necks of the teeth and across the interdental papillae develops

this portion of the incision. When pushed back by a periosteal elevator,

the gingival edge of the flap has a scalloped border. When periodontal

surgery is to be performed in addition to the endodontic surgery a reverse

bevel may be used to remove the diseased gingival tissue around the

necks of the teeth and to return more healthy tissue to that area during

closure.

If one vertical incision is used, the flap is referred to as a single

vertical whereas the term double vertical implies the use of two vertical

incisions. The vertical incisions greatly aid in the retraction of the tissue

overlying the defect and have been recommended for use by periodontics.

If the Ochsenbein Luebke incision is considered to be a vertical type,

which it truly is, vertical flaps have taken over almost completely as the

most desirable type in endodontic surgery.

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The chief advantages of vertical flaps are that are optimal healing

usually occurs, since no edges of the flap are manipulated during surgery,

and the visualization of the surgical site is excellent because of the

maximal uncovering of the area. In addition, any necessary minor

periodontal surgery may be performed at the same time. The

disadvantages are that the gingival areas of many teeth are uncovered,

the possibility of opening a dehiscence is present, careful flap design

must be adhered to in order to avert having the base too small, and sharp

corners may be present at the junction with the horizontal portion of the

incision.

The only contraindication for the use of vertical flaps are the

cases in which the shrinkage that may occur during gingival healing

might lead to the uncovering of gingival margins of crowns of cases in

which gingival tissues are still healing after periodontal surgery. If the

possibility of a dehiscence is present, the gingival portion of the flap may

be prepared to be a split thickness flap leaving the periosteum covering

undisturbed. Since vertical flaps are much more complicated o prepare

and reflect than semilunar flaps, only those familiar with periodontal and

surgical techniques should utilize them during the initial attempts at

endodontic surgery. As greater experience and confidence are gained,

improved results may accrue with the use of the vertical flaps.

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In the typical flap double vertical incision are used when anterior

teeth are treated. The incisions are placed to the farthest edge of each

tooth adjacent to the tooth to be treated. If the defect is expected to be

very large or if the terminal end of the incision would normally

approximate an attachment to be avoided, the vertical incisions may be

placed two teeth over from the surgical site. In the posterior areas,

generally only one vertical incision is used, located mesially to the tooth

one or two teeth anterior to the one to be treated.

In mandibular molars a scalloped incision is developed around the

necks of the adjacent teeth, extending anteriorly to the first bicuspid or

cuspid in which a short, single vertical incision is placed to relax the flap

and aid in visualization of the area of defect.

Some vertical flaps suggested for use are designed with an

extremely wide base compared to the edge of the flap. This is to ensure

that there will be sufficient blood circulating to all portions of the flap,

which may be a problem if a vertical flap is not correctly designed. The

base extends the width of two adjacent teeth, with two vertical incisions

coming down at an oblique diagonal angle to the mesial and distal edges

of only the tooth with the defect. Although this method does minimize

the area of bone uncovered during the surgery, it may prove to be too

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restrictive if the bone defect is larger than anticipated. This type of flap is

often referred to as an envelope flap since it resembles the back of an

envelope.

3. Palatal flaps (Refer Fig.1)

The use of a flap to retract the palatal tissues of the maxilla may be

needed in certain cases. These include reverse filling, perforation repair,

apicoectomy or root amputation of the palatal root of a maxillary bicuspid

or molar, and perforation or resorption repair of the palatal surface of

anterior teeth. As in any flap, all rules for flap design must be satisfied

for best results. However, the rich vascular supply of the palatal area

provides for excellent healing in most instances.

The typical palatal flap is prepared with a scalloped incision

around the gingival margins. Normally at least two teeth to the mesial

and to the distal aspects of the tooth that is to be operated on must be

included in the flap retraction for desirable visualization. Relaxing

incisions are best placed between the first bicuspid and cuspid to

diminished the change for severance of the palatal blood vessels and

resultant hemorrhage problems. The blood vessels from the incisive

canal and greater palatine foramen anatomize in this area are not as large

as they are farther anteriorly or posteriorly.

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The bone topography in the posterior area of the palate is inclined

to be pebblier than the labial or buccal surface of either the maxilla or

mandible. This makes periosteum elevation more difficult as the elevator

strikes humps or peduncles of bone during retraction. The scalpel may be

used to partially dissect the tissue for a modified split thickness flap in

these cases. Even with the mucosa retracted, examination of the surgical

site with a palatal flap is difficult. Even with assistance it is very

complex to retract the flap, use a mouth mirror for visualization of the

area, and use a hand piece or hand instrument for preparation, curettage

or filling. Therefore it is wise to obtain retraction by placing a suture at

the edge of the flap and tying it tightly to the teeth on the opposite side of

the arch. This tissue on the opposite side need not be penetrated, but the

suture material is merely tied around the gingival margin of the bicuspid

or molar. When the surgery is completed, the suture is cut and routine

replacement afforded to the flap.

4. Ochsenbein Luebke flap (Refer Fig.1)

Developed by a Periodontist and an Endodontist, this flap has been

designed to combine the advantages of the vertical flaps with those of the

semilunar flaps. Since the horizontal portion of this flap is placed a

minimum of 2mm from the depth of the gingival sulcus, those gingival

tissues covering jacket crowns or healing after periodontal surgery are

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unaffected. The site of surgery has excellent exposure and yet less tissue

is reflected, since the flap does not extend to the marginal gingiva. The

exact width of the flap may have greater variability, since the flap does

not have to terminate at a particular edge of any tooth. The edges of the

flap are not manipulated during the surgery; therefore the blood supply to

the area of suture margins remains excellent. Suturing is easier than

when the horizontal incision lies in the gingival sulcus. There is no

chance of opening a dehiscence.

The main disadvantage of this flap is that extreme care must be

exercised so no sharp points occur at the junction of the vertical and

horizontal incisions. There are only a few contraindications to this type

of flap. If minor periodontal surgery is to be performed around the

gingival sulcus, the double or single vertical incision is to be placed

across a prominent eminence, vertical incisions avert the problem. If

minimal attached gingiva is present, the horizontal incision may approach

the mucogingival junction.

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Fig. 1. Flap designs

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Triangular tissue flap design with single vertical releasing incision. The vertical releasing incision can be performed in different ways. Either (A) the incision leaves the interdental papilla intact or (B; insert) the incision includes the interdental papilla. In either case the incision line should meet the tooth at 90.

Rectangular tissue flap design with double vertical releasing incisions. As with the triangular flap design, variations can be used with the vertical incisions (A and B); a description has been included.

Trapezoidal tissue flap design. Note vertical releasing incisions are angled towards the base of the flap.

Horizontal tissue flap design. No vertical releasing incisions are used initially but they can be added later to enhance surgical access if necessary.

Semilunar tissue flap design. Note that the scope of this flap limits extension if necessary.

Luebke – Ochsenbein (Submarginal) tissue flap design. This flap may have one or two vertical releasing incisions, or may be limited to a horizontal incision, only if sufficient surgical and visual access can be obtained.

Fig. 2. Flap designs

TECHNIQUES OF ENDODONTIC SURGERY

I. Surgical Drainage

Surgical drainage usually involves emergency procedures and

acute lesions. Both require patience in diagnosis and kindness in

treatment.

Incision And Drainage (Refer fig.3)

Incision And Drainage (I & D) is the standard method to drain

apical abscesses. Although the technique is relatively easy, two problems

always accompany an I & D. First, is the problem of timing—the optimal

time to intervene. Second is the problem of obtaining adequate local

analgesia.

Learning the correct moment for surgical intervention is gained by

experience. Ideally, the immediate area to be incised, the “pointed” area

should feel soft and fluctuant under the examiner’s fingertips. The apex

of the swelling may appear whitish or yellowish. This is the ideal time at

which to anesthetize, incise and drain.

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Obtaining local analgesia is difficult because:

1. It is difficult to establish profound analgesia for an inflamed and

abscessed area.

2.There is some reluctance to inject into the area. Not only is it initially

very painful to increase the fluid pressure by injecting into the region, but

it is also unwise to risk spreading the infection by the pressure of the

injection.

Order of operation after anesthesia is as follows:

A. Arrange the instruments.

B. Place the gauge sponges to catch the flow.

C. Swab the area with disinfectant.

D. Test the dept of anesthesia with the end of the swab stick.

E. Perform a sweeping vertical incision with a No:11 scalpel through

the pointed area down to the bone and irrigate copiously with

anesthetic solution.

F. Have assistant aspirate immediately.

G. Open the incised area widely by following out the tract with a

hemostat. Spread the handles of the hemostat to separate the beaks.

More irrigation with anesthetic solution washes out the toxic

elements and reduces remaining sensitivity.

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H. Place a “T” drain with the bar of the “T” inside the incision.

Placement of a drain is optional because the initial epithelial and

connective tissue bridging break down under moderate pressure.

I. Suture the drain in position if necessary.

Figure -3

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Fig. 3. Incision and drainage of acute apical abscess. A. Good level of anesthesia is established. B. Sweeping incision made. C. Scalpel carried through to bone. D. curved hemostat used. E. Positioning of “T-drain”. F. If drain not in place it may be sutured.

TREPHINATION (Refer fig.4)

This surgical form is used to secure drainage and alleviate pain

when exudate in the cancellous bone is dammed up behind the cortical

plate. The tremendous pressure leads to the excruciating pain of an

intraosseous acute apical periodontitis or apical abscess. The intraosseous

pressure can be released and the area decompressed through trephination,

which provides a pathway to empty pus and other acid exudates.

A mini vertical incision provides adequate access and landmark

visualization.

The focal area of the lesion is pin pointed by examination. Working

through the retraction of the soft tissue, the overlying cortical plate of

bone is grossly removed with No: 8 bur to identify the involved root

apex.

The bone is then penetrated at the apex with a No:4 bur. In certain

cases entrance can be made through the cortical plate with a file

because of the resorptive activity of the periradicular lesion.

One must be careful to avoid structures, such as inferior alveolar

nerve, mental foramen or the roots of non-affected teeth in that area. A

lead shot, a broken bur head, or a pellet of gold foil in the incision is an

excellent way to pinpoint by radiograph the proper location for entrance.

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Figure –4

II. Radicular Surgery

Radicular surgery involves root structures and may be divided into

apical surgery and corrective surgery. Apical surgery is a procedure

designed to modify and curette the apex and peri-radicular tissues. Most

cases require filling of the root end following a 3 mm () apical

resection. Corrective surgery involves the repair of the perforated root

structure per se.

Four basic steps are common to apical and corrective surgery,

whether one stops at curettage or proceeds to perform an apicoectomy, a

retro filling, a root repair, or a resection.

Adequate flap design

Exposure of surgical site

Curettage of inflammatory tissue

Closure of the flap

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Fig. 4. Surgical trephination of intact labial cortical plate.

TECHNIQUES

1. The two-step or filling first method

2. Post-resection filling technique

A. Two –step or Filling-First Technique

Two cases require canal filling prior to periapical surgery

1. Failing case with a canal filling that may be removed.

2. A case where the need for surgery had become apparent during the

course of routine therapy before the filling appointment.

Retreatment: A heavy condensation technique will give important

additional information helpful during the surgery. Such disclosures

include:

Position of apical foramen

Existence of significant lateral canals

Resorptive defects

Bifurcated canals

The proper time for this filling is either immediately before the

surgery or during the surgical exposure.

35

B. Post-resection filling technique

Currently as a result of the reports of Dorn and Gartner and

Frank et al, one no longer employs amalgam as a material for canal

reverse filling.

Indications for Reverse Filling

1. Teeth with clinical and/or radiographic symptoms and no

negotiable canal.

2. Presence of a well fitting post and core that might cause root

fracture during removal.

3. Presence of a sectioned silver point.

4. Presence of an irretrievable broken instrument or filling material

with lack of apical seal.

Any of these situations may occur without clinical or radiographic

evidence of damage being present

Disadvantages

1. The time spent with the tissue reflected and bone uncovered is

greater than with the two-step technique, since both canal filling

and curettage are performed after the flap is opened.

36

2. Since the degree of pain and edema is usually proportional to the

time the flap is retracted, this method would appear to cause

greater post-operative problems.

3. The presence of blood from the per-apical tissues can interfere

with the condensation of the cones.

4. The final filling is usually less dense, as there is no solid dentinal

matrix to pack against.

5. The additional information derived form viewing the radiograph of

the canal filling is not available.

6. Since no rubber dam is placed, it is possible for the patients to taste

any of the canal irrigants.

7. The possibility of swallowing or aspirating a file or reamer is

present.

Advantages

1. Time for total procedure is lessened because no immediate

disinfection is performed, no application of rubber dam is

necessary, and no master gutta-percha cones need to be verified

radiographically.

2. It is easier to locate a difficult –to- find apex, since a large

instrument may be placed through the canal and into the peri-apical

tissue as a landmark.

37

3. If an instrument or filling material is broken off in the apical

portion of the canal or partially into the per-apical tissues, the

fragment may be surgically removed before canal filling.

Removal of diseased soft tissue (peri-radicular curettage) and Biopsy

This procedure can often be performed before or in conjunction

with root-end resection. The purpose is to remove the bulk of the soft

tissues, which may be present at various root canal orifices on the root

surface. This adverse tissue response has been described as reactive or

protective. Therefore, omitting to remove every remnant of soft tissue

will not lead to failure, as the tissue elements in the periphery of these

lesions are often productive in nature and contain fibroblasts, vascular

buds, new collagen and bone matrix. In those cases in which the soft-

tissue mass is exposed upon flap reflection or initial bone removal upon

flap reflection, curettage can proceed prior to root-end resection. In other

cases resection is necessary to gain access to most of the tissue.

Straight and angled surgical bone curettes are necessary, along

with angled periodontal curettes. At times it may be necessary to inject

0.5 ml of anesthetic solution to control haemorrhage and ensure patient

comfort if the lesion is extensive. Initially the bone curettes are used to

peel the soft tissue from the lateral borders of the bony crypt. This is

accomplished with the concave surface of the curette facing the bony

38

wall, applying pressure only against the bone. Care must be taken to

avoid penetration of the soft tissue, which may share the tissue, server the

vascular network, and increase local haemorrhage. Once the tissue is

freed along the lateral margins, the bone curettes can be turned and used

in scraping fashion along the deep walls of the crypt. This will detach the

soft tissue from its lingual or palatal base. Once loosened, tissue forceps

are used to grasp gently the tissue, which is teased from its position with

a bone curette. The tissue sample is placed directly into a bottle of 10%

neutral buffered formalin for biopsy. In those cases, which require root-

end resection prior to curettage, one must make sure that the root

structure is sufficiently exposed to minimize shredding of the soft tissues

during resection.

In the presence of large lesions, care must be exercised during

curettage of the lateral surfaces of the bony crypt to avoid exposure of

adjacent roots and their pulpal vasculature. Pre-surgical radiographs

should reveal this possibility, and tissue in these areas may need to be left

in position. Caution must also be exercised when close to the maxillary

antrum, mental foramen or mandibular canal to prevent damage to vital

structures. When soft tissue is adherent either lingually to the root or in

the furcation region, periodontal curettes are essential for thorough

removal.

39

Whilst retention of root structure is necessary for tooth stability

and strength, rarely should peri-radicular surgery be limited to just

curettage. Therefore root-end resection is usually needed.

APICOECTOMY (Refer fig.5)

The term root-end resection refers specifically to the removal of

the apical portion of the root. There are many indications for resection of

the root end during peri-radicular surgery, each designed to eliminate

aetiological factors and to enhance the sealing of the root canal at the

resected root surface. These indications vary from case to case, but

support the stated purpose.

Syngcuk Kim used the HESS model of root anatomy to find out

the incidence of lateral canals and apical ramifications when resection

was performed at 1, 2 and 3 mm. The incidence of lateral canals was

found to be 52, 78 and 98% respectively.

Until early 1990’s bevel angle of 45 was taught in all schools of

dentistry with the following reasons for its use.

1. Gain visual and operating access for root tip resection,

2. Ease of placing retrofilling materials,

3. Ease of inspection.

40

In recent years 45 bevel angle was found to have no biological

basis. Resection at 90 was found to eliminate 98% of the apical

ramifications and 93% of lateral canals. Hence root resection must be

done perpendicular to long axis of the root whenever possible. However,

a 10 bevel is allowed where perpendicular bevel may not be possible.

Massimo Gagliani et al (1998) evaluated the apical root resection

angle and cavity made by ultrasonic retrotips and its influence on apical

seal, They found that 90 angle showed less dye leakage for dentin than 45

angle and that a 3mm or more apical cavity produces a safe and effective

seal.

The ideal root end preparation according to Peter Gillheany and

associates should be:

Parallel to the long axis of the root,

3 mm deep and centered.

The optimum depth of the retrograde cavity should be 3mm,

because as the depth increased the leakage decreased. This was attributed

to the occlusion of the apical tubules by the retrofilling material (Massino

Gaglianiet al 1998).

41

The root end can be resected and beveled tin one of two ways.

Once the root end has been exposed, the bur (narrow or constringe) is

positioned at the desired angle and the root is shaved, beginning from the

apex, cutting caronally. The bur is moved from mesial to distal at the

desired angle, shaving the root smooth and root outline. The approach

allows for continual observation of the root end during cutting.

The second technique of resection is to predetermine the amount or

root end to be resected. This approach, however, may remove more root

structure than is necessary. The bur and hand-piece are positioned at the

chosen angle and cutting through the root from mesial to distal resects the

apex. Once the apex is removed, the root face is gently shaved with the

bur is smooth the surface and ensure complete resection and visibility of

the root face. This technique works well when an apical biopsy is desired

or to gain access to significant amounts of soft tissue located lingual to

the root.

Figure – 5

42

Fig. 5. Two ways of performing apicoectomy

The appearance of the root face following root-end resection will

vary, based upon the type of bur used, the external root anatomy, the

anatomy of the canal system exposed at the particular angle of resection,

and the nature and density of the root canal filling material. Various

types of burs have been recommended for root-end resection, such as

round burs, straight fissure burs, diamond burs, and cross-cut fissure burs.

Each will leave a characteristic anatomical imprint on the root face from

rough-grooved and gouged to regularly grooved and smooth. To date, no

study has clearly defined the advantages of one type of bur over the other,

although for year’s clinical practice as favoured a smooth flat root

surface.

The extent too which the removal of the root end should occur will

be dictated by the following factors.

Access and visibility to the surgical site.

Position and anatomy of the root within the alveolar bone.

Anatomy of the cut root surface relative to the number of canals and

their configuration.

Need to place a root-end filling into sound root structure.

Presence and location of procedural error, e.g. perforation. Presence of

an intra-alveolar root fracture.

Presence of any periodontal defects.

43

Anatomical considerations, e.g. proximity of adjacent teeth, or level of

remaining crestal bone.

Presence of significant accessory canals; roots with such anatomical

aberrances would be likely to receive more extensive resection.

Only when 3 mm of the apex is resected are lateral canals reduced

by 93%. Additional resection reduced the percentage insignificantly. A

root resection of 3 mm at a 0-degree bevel angle removes the majority of

anatomic entities that are potential causes of failure. Any remaining

lateral canals are sealed during retrograde filling of the canal. Therefore

removing the apex beyond 3 mm is of marginal value and compromises a

sound crown / root ratio.

Regardless of the rationale for the extent of root-end removal, there

is no reason to resect to the root to the base of a large peri-radicular

lesion, as was previously advised. Likewise, resection to the point where

little (<1mm) or no crestal bone remains covering the buccal aspect of the

root may very well doom the tooth to failure. On the other hand, failure

to remove sufficient root structure to be able to inspect the resected root

surface and establish an apical seal may also contribute to failure. In this

case, root canals may be missed, or they may be so extensive that they

cannot be properly managed within the confined space.

44

The complete root face must be identified and examined

subsequent to resection. The examination is done with a fine, sharp

probe, e.g. DG 16, guided around the periphery of the root and the root

canal. The external root anatomy will determine the ultimate shape of the

cut root end, ad oval, round, dumbbell shaped, kidney shaped, or teardrop

shaped. Outlines will vary depending on the tooth, angle of the bevel and

position of the cut on the root. Once cut, however, the entire surface

must be visible. If visibility or access is impaired, or the root possesses

an unusual cross-sectional outline, 1% methylene blue dye can place on

the root surface to help identify the periodontal ligament that surrounds

the root. A small cotton pellet containing dye is wiped over the root face

for 5-10s. Subsequently the area is flushed with sterile water or saline.

The dye will stain the periodontal ligament dark blue, highlighting the

root outline. A potential drawback to the technique may be deposition of

cotton fibres on the resected surface or on bone. Residual remnants of

cotton fibres have been shown to induce a foreign-body reaction in

healing tissues.

The shape of the exposed canal system will very depending on the

angle of the bevel and the canal anatomy at the level of the cut. Canal

45

systems will generally assume a more elongated and accentuated shape as

the angle of the bevel is increased buccally. Often, canal systems will be

irregular and extend further than anticipated.

Also visible on most resected root ends is the presence of the root

canal filling material. Variations in quality of the filling will be seen in

both type of filling material, e.g. gutta percha, silver cones, pastes, and

the nature of the obturation technique, e.g. lateral condensation, vertical

condensation or thermoplastic filling. Likewise, the different burs

advocated for resection will create discrepancies in the surface of the

filling material and adaptation to the canal walls. For example Coarse

diamond burs will tend to rip and tear at the gutta-percha root canal

filling, spreading the gutta-percha over the edge of the canal aperture and

onto the resected root face. Invariably this will create gaps between the

originally adapted gutta-percha and the root canal wall. Similar findings

are noted with metal burs. In order to prevent this, surface finishing with

an ultra fine diamond is recommended.

Figure – 6

46Fig. 6. A. Cleaning and shaping of the root canal with file tips through the resected root end. B. Condensation of the gutta-percha filling with the tip through the root-end. C. Removal of excess filling material and finishing of the root surface with an ultrafine diamond bur.

The presence of additional foramina anatomizes between foramina,

fracture lines and the quality of the apical adaptation of the root canal

filling must be checked on the resected root surface. If methylene blue

has been used, it will also have a tendency to stain the periphery of the

canal system and highlight fracture lines. Nitromersol, a dental

disinfectant which strains reddish-brown, can also be used when

examining the root face or a fibreoptic light can be aimed at or behind the

root end to enhance visibility. If these methods do not work, it may be

necessary to remove additional root structure to identify the canal system

or, in the case of a fracture line, to enhance its direction and extent.

A major area of concern following root-end resection and dentinal

tubule exposure is the possibility that these tubules may serve as a direct

source of contamination from un-cleaned root canals into the peri-

radicular tissues, especially if there is coronal leakage. Root ends

resected from 45o to 60o have a many as 28000 tubules/mm2 at a point

47

immediately adjacent to the canal. At the dentinocemental junction, an

area which may communicate with the root canal even in the presence of

a root-end filling, an average of 13000 tubules/mm2 are found. Likewise,

due to angular changes in the tubules at the apex, there could be patent

communication with the main canal if the depth of the root-end

preparation the buccal aspect of the cavity is insufficient to compensate

for these anatomical variations. Root-end resections in older teeth have

shown less leakage than that seen in teeth from younger patients; this

corroborates the findings of sclerosis and reduced patency in apical

dentinal tubules. It has been suggested that, if the apical ramifications

commonly found in young teeth are dismissed as a rationale for root-end

resection, then resection would be inadvisable due to the patency of the

apical dentinal tubules.

Another concern following root-end resection is the presence of a

contaminated smear layer, containing tissue debris and possibly

microorganisms, over the resected root end. This may serve as a source

of irritation to the peri-radicular tissues, primarily preventing the intimate

layering of cementum against the resected tubules. Cutting usually

creates a thicker smear layer without water spray than with a heavy air-

water spray, or by using coarse diamond burs than tungsten carbide burs.

Therefore it is recommended that root-end resection be performed under

48

constant irrigation, which assists the partial removal of the dentinal smear

layer from the surface. Also, if diamond burs are used to resect the root,

medium grit is preferred, followed by a fine or ultra fine grit diamond. If

there is a gutta percha root canal filling, resection without irrigation

should be avoided as it may promote the lodging of dentine chips in the

gutta-percha, which would serve as a source of irrigation if contaminated.

These chips may not be removable during the elimination of the smear

layer with a dentinal cleanser.

ROOT END CAVITY PREPARATION (Refer fig.7)

Various instruments are being used for retro-preparation like

1. Conventional slow speed handpiece,

2. Hi-speed handpiece,

3. Ultrasonics and

4. Sonics.

Conventional slow-speed handpiece and burs are bulky to handle,

require excessive removal of bone and tooth structure and can

result in shallow misaligned cavities.

The ideal root end preparation suggested by Cohen should be

3mm deep and centered.

49

One of the advancements in endodontic surgery that allowed

greater efficiency was the adaptation of piezoelectric ultra-sonic for root

end preparations. Ultrasonic tips are available in various configurations

(Analytic Endo, Satelec / Amadent Co. and Spartan / Obtura Co.) to

accommodate virtually all access situations. Specially designed tips

produce smooth cutting with relatively little chatter when the tips are

activated against the dental walls of the apical preparations. These micro

tips are very a narrow in diameter (i.e., about one teeth the size of a

conventional micro head hand piece).

The first ultrasonic tips for endodontics and endodontic surgery

were the CT tips made of stainless steel (SS) and designed by Dr. Gary

Carr. They were first available in early 1990. The CT tips were the most

popular tips and have been widely used until recently. In 1990 KiS tips

were introduced; these provided improvements in many areas, including

cutting efficiency by coating the tip with zirconium nitride, more

convenient angles, and relocation or irrigation port. It shows a

comparison of the two tips: the CT tips are short more angled than the

KiS tip. The location of the ultrasonic irrigation port, which is on the tip

rather than on the shaft, delivers maximum irrigation volume directly into

50

the cutting site. KiS tips are also different from CT tips in terms of shaft

angle, tip angle and length.

In summary, the advantages of ultrasonic tips over micro-head burs are:

Better access, especially in difficult-to-reach areas (e.g., a lingual

apex)

More through debridement of tissue debris.

Conservative preparations tracing the long axis at a precise depth

of 3 mm.

Precise isthmus preparations with parallel canal wall for better

retention of filling materials.

Root End Preparation is accomplished under the microscope at low-to-

mid magnifications (4 16 ). First, a number of appropriate tips are

pre-selected, depending upon the location of each apex. Second, the

resected root surface, stained with methylene blue, must be critically

examined at high magnification (16 to 25 ) to see the microanatomy.

Third, at low magnification (4 to 6 x), the selected ultrasonic tip is

positioned parallel with the long axis of the root. To accomplish this the

surgeon must examine the position of entire tooth at low magnification

(4 ), including the crown and root eminence and compare this with the

position of the ultrasonic tip. Failure to make this comparison will risk

51

an off-angle root end preparation or perforation. Fourth, the ultrasonic tip

is activated and the apical canal is retro-prepared with copious water

coolant to a depth of 3 mm. If an ultrasonic tip is pressed too firmly it is

dampened to deactivation, thus a light sweeping motion using short

forward-and-backward and up-and-down strokes is all that is needed for

effective cutting action. Depending on the canal configuration, a typical

3 mm retro-preparation should take less than 1 minute with KiS tips.

Once the retro-preparation is completed, the cavity preparation is

inspected with a micro-mirror at high magnification of 16 to 25 . A

thorough inspection should include the interior canal walls for remnants

of gutta percha, especially on the difficult-to-reach facial wall, and

confirmation that the parallel walls are sharply defined and smooth.

FIG7

52

Fig.7. Root end cavity preparation

TYPES OF PREPARATION

Two types of preparations have been in routine use for some time;

the Class I and the slot, or Matsura, type. An additional preparation

also has been described and is referred to as the figure eight type of

reverse fill preparation.

Before any preparation is begun, the root to be reversing filled

must be beveled. Placing a filling in an un-beveled apex is similar to

placing a filling at the point of a pyramid. No flat table would be present

to pack against, and the filling material would merely fall down the sides

and not seal the tip. Using a fissure bur in the airotor or straight hand

piece and cutting the root tip from mesial to distal surface at

approximately a 45-degree obtain beveling on the tooth, allowing for

visualization of the entire root face. Teeth that have a palatal or lingual

inclination may require a greater angle of beveling for ease of preparation

and filing placement.

Beveling of the root tip may be accomplished without significant

reducing root length and thus retaining almost the same crown root ratio.

If the crown root ration is highly unfavorable, but the strategic

importance of the tooth warrants its retention, the slot preparation should

be made, which requires little, if any root length reduction.

53

After beveling, the outline of the root face will have one of two

configurations, either oval or figure eight. The most common shape will

be a slightly irregular oval, with the canal having a smaller oval shape in

the approximate center. The ideal reverse fill preparation for this shape is

similar to the typical Class I occlusal amalgam preparation of operative

dentistry, only in miniature. It is prepared by using a no33½ bur or

ultrasonic tip down into the canal for a minimum of 1mm but preferably

at least 2 to 3 mm. It is important to remember that the bevel of the root

face is at approximately 45 degrees and that if the preparation is made

with the bur perpendicular to the root face, there is a good chance for

perforation of the root lingually. Therefore the bur must come down

along the long axis of the tooth and remain within the confines of the

canal while the preparation is made. If insufficient room is available to

come down the long axis, greater beveling of the root face or removal of

periapical bone should be performed. If this is not desirable, the slot

preparation should be utilized.

The other root face configuration developed after beveling is the

figure eight shape with a long oval or slot canal in the center. This shape

may be found when two canals are present in one root of a tooth, such as

the mesio-buccal root of a maxillary first molar, maxillary and

mandibular bicuspids and mesial roots of mandibular molars and

54

mandibular anterior teeth. When these roots have one canal in one root,

the configuration of the root face after beveling will be oval.

The proper preparation for teeth having one root and two canals is

the figure eight preparation. A no.33½ bur or ultrasonic tip is used and

two round but touching preparations are made, with care taken to keep

the bur along the long axis of the root. This type of preparation should be

made in any one rooted tooth when it is suspected that two canals may be

present, even if only one canal was previously filled.

The third type of preparation is the slot type, also referred to as

the Mastura preparation, from the name of its early advocate. This should

be used where it is inconvenient to utilize the other types of preparations

that involve access along the long axis of the tooth. The slot preparation

is made with the bur used perpendicularly to the long axis of the tooth

and requires much less tooth and / or periapical bone removal. The most

common needs for the slot preparation are in those teeth where removal

of root structure will lead to an inadequate crown root ratio or removal of

periapical bone sufficient to gain access will infringe on adjacent vital

structures. Examples of the latter are maxillary bicuspids and molars near

the maxillary sinus, mandibular molars near the mandibular canal, and

maxillary anterior teeth near the nares. In addition, teeth with palatal or

55

lingual inclinations, such as maxillary lateral incisors and mandibular

anterior teeth, may be easier to prepare and fill by using the slot

preparation.

The preparation is made by using a no.700 bur in the straight hand

piece or airotor makes the preparation. Starting at the apex of the tooth,

the bur is brought toward the cervical margin approximately 2mm,

leaving a trough of tooth structure missing. Then a no.33½ of 35 burs or

ultrasonic tip is used to sharpen the corners of the preparation to afford

undercuts for the retention of the filling material. When a slot

preparation is used, much less root face beveling is required, since the

retention is obtained in the undercut areas near the base of the

preparation.

Micro-mirrors

One of the key instruments in microsurgery is the micro-mirror.

The reflective surface is made of either highly polished stainless steel or

sapphire. The mirrors are small enough to fit into an osteotomy

measuring no larger than 4 to 5 mm in diameter. Inspection of root ends

cannot perform thoroughly without the aid of micro-mirrors. The

anatomy of the root surface is reflected in the micro-mirror into the

viewing range of the microscope before and after the retro-preparation.

56

INSPECTION OF THE ROOT END PREPARATION

For depth of field purposes, the root end is best prepared that low-

to-mid magnification (8 to 12 ). However, the preparation must be

inspected at high magnification (16 to 25 ). Uncommonly, retro-

preparations can also be inspected by direct view. In addition to

examining the completed preparation for clean, sharply defined walls, it

should also be examined one last time for important anatomic structures

(e.g. accessory canals, micro-fracture) that may have escaped detection

during the initial inspection.

DEPTH OF THE ROOT END PREPARATION

The optimal depth of the root and preparation should be 3mm;

however, depths of 1,2 and 4 mm have also been studied. Using the Hess

model slides provided by Dr. N. Perrini, the incidence of lateral canals

and apical ramifications in the natural apex have been studied; over 95%

of these anatomic entities are found within the apical 3 mm. Although a

retro-preparation deeper than 3 mm does not provide any greater benefits,

a retro-preparation shorter than 3 mm may jeopardize the long-term

success of the apical seal. The management of the apical 6 mm; 3 mm

root resection perpendicular to the long axis of the root and retro-

preparation and retro-filling of 3 mm parallel the long axis of the root.

Each is essential to ensure an adequate seal of the root apex.

57

ROOT END CAVITY OBTURATION

To clean and obturate the root canal before root-end resection or to

do it at the time of surgery has been controversial for many years. Some

authors have found greater success when the canal is obturated in

conjunction with surgery, less often when a previous root canal filling

was left in place, and least often when the canal was filled immediately

prior to surgery. On the other hand a better prognosis has been identified

when the root is cleaned and filled prior to surgery. Favourable results

with root canal obturation either before or during surgery have been

demonstrated. In a recent evaluation of the surgical management of non-

surgical endodontic failures, cleaning, shaping and obturation of the root

canal prior to surgery resulted in the highest rate of success. In the cases

that could be managed this way the root end was not resected, and

surgical procedures were limited to curettage. Cases in which root-end

resection was performed and root-end filling placed resulted in a higher

number of failures. What is important is that the canal system is cleaned

and sealed as well as possible. In many respects this necessitates that old

root canal fillings should be redone as well as possible. Under these

circumstances many cases may be successful without the use of a root-

end filling.

58

In some cases in which a radiolucency exists and time is a factor,

or cases in which there are persistent exacerbations between visits or

failing root canal treatment which has been treated non-surgically in an

assumed optimal manner, canal re-preparation and refilling can be done

at the time of surgery. A tissue flap is reflected, the root apex exposed

and resected. The canal preparation is performed with the file tips

protruding through the resected root end. Small aspirators can bleached

next to the apical opening to present root canal irritant (0.5-2.5% sodium

hypochlorite) entering the bony cavity. After adequate preparation, the

canal is dried with paper points. Obturation should allow with gutta-

percha and sealer condensed from the coronal access apically. Any

condensation technique is acceptable; however, the master gutta percha

point should not be pulled through the apex, as point retraction may

occur. The excess gutta-percha can be removed with an ultra fine bur,

which usually creates a well-adapted root canal filling on the resected

surface. In these situations the placement of a root-end filling will

usually be unnecessary. This is common with gutta percha fillings,

especially those placed immediately before or at the time of surgery. An

ultra fine diamond bur can be run over the root surface with a sterile

water or saline spray. If the canal is properly obturated the result will be

a very smooth, well-adapted root canal filling. Paste fillings acceptable

because of frequent voids, the irritating nature of most pastes and the

59

potential for paste dissolution. Metal fillings (e.g. silver points) are also

unacceptable because of poor adaptation and the potential for corrosion.

When a root-end cavity is to be obturated it must be isolated to

ensure moisture control. This is usually done with a haemostatic

collagen-based agent, such as Hemofibrine or Hemocollagene, which can

remain in the osseous cavity or be removed prior to closure. Also used is

a solution of ferric sulphate, which must be removed from the bone cavity

prior to tissue closure.

Presently there are no commercially available materials, which will

provide a perfect seal, therefore the materials that are used must be

carefully prepared and placed to ensure the best possible adaptation to the

root cavity walls. Coupled with the attempt to seal the apical end off he

canal system, attention must also be directed to the coronal end. It is

illogical to place a filling material, which is imperfect at the root end of

the tooth and neglect the potential for coronal leakage around root canal

fillings, and coronal restorations with carious lesions, imperfect margins,

or through exposed dentinal tubules in the cervical area.

60

Figure 8

ROOT END FILLING MATERIALS

Materials used: Gutta-percha, Goldfoil, Amalgam, Poly

carboxylate cements, Zinc oxide eugenol paste, Diaket, Cavit,

Super-EBA Cement, Mineral trioxide aggregate, Bone cement etc.

One of the major requirements of an ideal retrofilling material is its

close adaptability to the cavity walls of the retro-preparation.

61

Fig. 8. Step by step procedure of apical surgery. A. Pen grasp of scalpel is used to make vertical incision. Vertical and horizontal incisions of scalloped flap have been made and flap is retracted.

C. Sharp curette is used to test density of cortical plate. D. If cortical plate is solid # 8 bur is used. E. Inflammatory tissue and bone are probed with sharp curette. F. Debridement of inflammatory tissue done, apex is beveled and lesion irrigated. G. Retro-preparation with ultrasonic tips.

H. Amalgam placed. I. Radiograph taken sutures placed.

However, when non-adhesive materials are used for apical sealing,

a microscopic space always exists between the restoration and the

tooth interface, which leads to microleakage (M Torabinejad

1995).

1962, Nicholls showed preference to zinc oxide eugenol cements,

but these cements showed increased solubility and tissue irritation

(Paul D Brent et 1999).

Super EBA was introduced by oynick and oynick in 1978 the

strength of mixture.

Studies (Frank J Vertucci et al 1986) showed that the tissue

response to super EBA in replanted teeth was less severe and less

extensive when compared to amalgam.

This was attributed to the antibacterial action of eugenol, which

may account for the success of endodontic surgery by killing the

bacteria (A Rainwater et al 2000).

Adhesion to dentin is an interesting property of glass ionomer

cement and therefore it has been advocated for use as a rootend

filling material.

Several studies (Kamran Safavi et al 1999) have shown superior

biocompatibility, fluoride release and marginal adaptation of glass

ionomer cements and hence it has been incorporated in this study.

62

Recently newer materials like Mineral Trioxide Aggregate and

Bone cement have been used for retrofilling.

Mineral Trioxide Aggregate has been proven to be biocompatible,

have good sealing ability, dimensionally stable, insensitive to

moisture and promote tissue regeneration.

Torabinejed et al 1995 reported that Mineral Trioxide Aggregate

leaked significantly less than all the other materials like Amalgam,

IRM and Super-Ethoxy Benzoic Acid.

MTA: Induces osteogenesis and cementogenesis.

Studies showing Amalgam causing more microleakage : Richard

M Moodnik et al (1975), James T. Kimura (1982), Satoshi Inoue et al

(1991), Rahmat A Barkhordar et al (1989). Others studies also

suggesting the same: John D Bramwell and M L Hicko (1986)

Studies suggesting MTA to be superior: Mahmoud Torabinejad et

al (1995) several studies, James D Kettering and M Torabinejad (1995),

Torabinejad and T R Pittford (1996)

Studies suggesting GIC to be superior: Noriyasu Hosoya et al

(1995) than amalgam and heated gutta-percha.

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Studies suggesting Super EBA to be superior: John T Biggs et al

(1995) better than amalgam

Frank Gerhards and Wilfried Wagner (1996): Harvard cement,

Diaket, Gold leaf, Ketac-Endo and, amalgam in human teeth. Ketac-Endo

showed significantly less leakage compared with amalgam. Harvard

cement and gold foil showed more leakage than amalgam and was no

significant difference between Diaket, Amalgam, Gold foil and Harvard

cement.

Postoperative radiographic assessment

As previously indicated, a postoperative radiograph should be

taken before closure of the surgical site. Mistakes can be rectified and

procedures altered more easily at this point. In some cases, especially

posterior teeth, several angled radiographs should be considered.

Radiographs taken with specific film-holding devices are preferred.

When review examination radiographs are taken with the same device,

healing can be assessed more accurately. Some points for the clinician to

consider are :

1. Is there scattered radiopaque material within the surgical site?

2. Are the correct root ends surgically obturated?

3. Do the root-end fillings appear adequate in depth and adaption?

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4. Are the fillings well condensed?

5. Is there un-resected root structure, or have the wrong roots been

inadvertently damaged?

6. Has root-end filling material been pushed into the maxillary sinus

or mandibular canal?

7. Is there a fracture visible that was not seen clinically?

CORRECTIVE SURGERY

Corrective surgery is categorized as surgery involving the

correction of defects in the body of the root other than the apex. When

the coronal and middle thirds of the root are involved, it is imperative to

physically observe, diagnose, and repair the defect. A full flap, such as

the single or double vertical design, must be utilized to gain adequate

vision and access. Reparative defects of the root and associated

procedures are classified as follows:

I. Perforation repair

A. Mechanical

B. Resorptive

II. Periodontal repair

A. Guided tissue regeneration

B. Resection

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PERFORATION REPAIR

Mechanical.

Perforations generally occur when the dentist is disoriented as to

the direction of the bur and its relationship to the anatomy of the pulp

chamber or root. High potential areas for perforations are the furcal floor

of molars and two-rooted maxillary premolars-roots that are narrow

mesiodistally and broad bucco lingually with curved canals.

“Stripping” of a canal is the overcutting of root structure resulting

in a longitudinal opening that can all too easily occur on the furcal

surface of mandibular molars or any narrow root. This lesion is often

caused by overwidening a canal orifice through aggressive use of Peeso

or Gates-Glidden drills. If the perforation that occurs at the present

appointment is small and the bleeding is well controlled, the root canal

filling can be condensed as the seal. Because large strippings are usually

surgically inaccessible, a hemisection where restoratively indicated may

save the case.

Midroot and apical third perforations should be immediately sealed

if possible, or calcium hydroxide should be used prior to sealing. If the

perforation is excessively large or long standing, a full vertical flap

should be reflected and the area repaired with Super EBA. If the location

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of the perforation is near the root apex, an apicoectomy is a more

effective and efficient way of handling the case.

Resorptive

Eventual repair of a defect on the root surface, from either internal

or external resorption, depends to a large part on whether there is

complete communication from the pulp to the oral cavity. If the lesion

has destroyed an area of the root into the periodontal structures, but has

not communicated with the oral cavity, it can generally be repaired by

placing calcium hydroxide into the cleaned and prepared root canal to

promote cementogenesis. One should expect new cementum and bone

repair to follow, and finally the internal and external defects may be

obturated by non-surgical root canal filling alone.

In the event cemetogenesis and new bone formation do not occur to

serve as a matrix for the internal filling of the canal and defect, or in the

event the lesion has broken through to communicate with the oral cavity

and will not respond to cementogenesis, corrective radicular surgery is in

order.

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Periodontal Repair

Guided Tissue Regeneration

In the past, extensive periodontal defects required extraction or

root amputation. Today, with techniques of guided tissue regeneration,

many teeth can be saved without root resection. This concept is based on

an inert barrier membrane, such as Goretex, providing the retention of

blood clot in a relatively undisturbed environment of the walled off

periodontal pocket. This allows the local undifferentiated cells of the

periodontal ligament and surrounding bone to form new bone that bridges

across the surgical wound with the potential of forming a new periodontal

attachment, thereby blocking the down growth of epithelial migration. In

the event this procedure proves ineffective, the root severely involved in

periodontal disease may have to be amputated.

Root Amputation

Root amputation procedures are a logical way to eliminate a

weak, diseased root to allow the stronger to survive, whereas if retained

together they would collectively fail. Selected root removal allows

improved access for home care and plaque control wit resultant bone

formation and reduced pocket depth.

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Indication for Root Amputation

1. Existence of periodontal bone loss to the extent that periodontal

therapy and patient maintenance do not sufficiently improve the

condition.

2. Destruction of a root through resorptive processes, caries, or

perforations.

3. Surgically inoperable roots that are calcified, contain broken

instruments, or are grossly curved.

4. The fracture of one root that does not involve another.

5. Conditions that guarantee that the surgery will be technically feasible

to perform and that give evidence for a reasonable prognosis.

Teeth that do not fit these criteria are contraindicated for root

amputations.

Contraindications for Root Amputation

1. Teeth not strategically located. These teeth are better served with a

bridge.

2. Lack of necessary osseous support for the remaining root or roots,

inadequate root structure, or a poor crown: root ratio.

3. Fused roots or roots in unfavorable proximity to each other.

4. Endodontically inoperable roots.

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5. Lack of patient motivation to effectively clean and maintain the

furcal areas and follow through with proper restorative procedures.

Two different approaches to resection are available.

One approach is to amputate horizontally or obliquely the involved

root at the point where it joins the crown, a process termed root

amputation. The other approach is to cut vertically the entire tooth in

half-from mesial to distal in maxillary molars and premolars, and from

buccal to lingual in mandibular molars-removing in either case the

pathologic root. This procedure is termed hemisection.

Bisection or “bicuspidization” refers to a division of the crown that

leaves the tow halves, yet forms a more favorable position for the

remaining segments that leaves them easier to clean and maintain. If the

remaining roots are too close to each other, minor orthodontic movement

may be necessary to property align them.

Amputation Technique for Mandibular Molars

Treatment planning is critical when evaluating mandibular molars

for root removal. If it is not a terminal tooth in the arch, and there are

sound adjacent abutment teeth, a fixed bridge may be just as satisfactory,

and possibly stronger and more economical. Some outstanding

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successes, however, are seen involving three unit bridges. Anatomically,

the mesial and distal roots are about the same length. The mesial root is

slightly wider bucco-lingually, more curved, and its cross-section appears

as a figure eight.

Hemisection is the most common method of removing a

pathologically involved mandibular molar root. A terminal second

mandibular molar is ideally suited for hemisection provided there are

opposing teeth. The remaining root and crown structure is then restored

as a premolar.

Technically, the preparation procedure is the same as that for the

maxillary molars. The roots to be retained undergo endodontic therapy,

and the pulp chamber is filled with amalgam. No filling material needs to

be placed into the root to be removed, for that entire half of the tooth will

be extracted.

A sharp cowhorn explorer or periodontal probe is used to identify

the buccal and lingual furcations. By first placing the tip of a high-speed

tapered fissure bur (No. 702 XL) in the furcation, the operator can

effectively section the molar with accuracy. Sufficient proximal furcal

floor should be left to establish a restorative finish line, as well as

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sufficient crown for retention. Again, the sectioning is done at the

expense of the part to be extracted. Care must be exercised not to gouge

the remaining stump.

An elevator should be wedged between the two halves and slightly

rotated to determine if the separation is complete. The pathologic half is

then extracted with forceps or eased out with an elevator. The socket area

is lightly curetted and packed with bone wax or gel foam while the

remaining hemisected half is trimmed and smoothed with a blunt tapered

diamond. The packing should be removed from the socket and followed

by copious irrigation and debris removal with a 2” x 2” gauze sponge.

Bisection or “bicuspidization” is successful in molars in which

periodontal disease has invaded the bifurcation. The type of cut is the

same as that used in hemisecting, except the location is centered to evenly

divide the crown at the center of the furcation. The furcal is then turned

into an interproximal space where the tissue is more manageable by the

patient.

Single root amputation in the mandibular arch may on occasion be

indicated where a splint or bridge is in place. For the most part, however,

an uneven exertion of occlusal forces tends to exert a force on the

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remaining root, thereby causing a fracture. Some cases are treated

successfully by single root amputation, and when economic factors

dictate, it is indicated.

REPLACEMENT SURGERY

Replant Surgery - Intentional Replantation

The primary reason for intentional replantation is based on the

inability to perform adequate non-surgical rot canal therapy on a tooth, as

well as on the inadvisability of performing endodontic surgery.

Some teeth requiring root canal therapy are absolutely inoperable

in situ. Mouths with such a small orifice that finger instrumentation of

pulpless molar teeth is impossible are candidates for extraction and

intentional replantation. Roots with obstructed canals resulting from

calcification, silver points, posts, or separated instruments, although

indicated for retrofillling, may need to be extracted and intentionally

replanted be cause of an oversized external oblique ridge that blocks safe

access.

Pulpless teeth have also been encountered with so many

perforations or lateral aberrations of the canal that repair in site is

impossible. If extraction appears to be the only alternative in these cases,

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one is right to pose the question “What have we to lose” reported survival

periods of up to 22 years for replanted teeth and have also made

recommendations for case selection.

Intentional replantation should be considered when it is the only

alternative to extraction.

Steps in Intentional Replantation

1. The tooth should be extracted as atraumatically as possible and

received in a sterile gauze sponge saturated with normal saline

solution. It should be held in the moist sponge throughout treatment,

and the roots and attached periodontal tissue should be frequently

irrigated with saline.

2. If the canals are not blocked, standard access is made to the pulp

chamber, and the canal or canals are prepared and filled; the coronal

access sealed in hand as carefully as in site. A slight (1-to2-mm

apicoectomy, prior to retrofilling, is done to reduce the hydrostatic

pressure buildup during replacement.

3. Roots containing blocked canals are retrofilled in the usual manner.

4. Preparations in teeth with perforation or resorptive defects are

similarly done. Root canal filling in these cases should be completed

before the repair of defects.

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5. Before replantation, the alveolus should be gently curetted and

irrigated with saline to remove the clot and “freshen” the socket, being

careful not to promote excessive bleeding or detach viable periodontal

ligament attachment to the alveolar bone.

6. The tooth is replanted and stabilized with a splint if necessary.

Posterior teeth normally are well retained and do not need splinting.

Anterior teeth may be splinted with a coronal acid-etch technique

using a direct bonding plastic.

IMPLANT SURGERY

Two types of endosteal implants fall under the purview of

endodontics-endodontic implants and ossointegrated implants, also called

endosseous implants.

Endodontic Implants

It makes great sense that, if a rigid implant can safely extend out

the apex of the tooth into sound bone, and by so doing stabilize a tooth

with weakened support, the patient is well served and perhaps has

avoided a fixed bridge. Such is the reasoning behind the endodontic

implant, many of which have proven quite successful.

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Placing endodontic implants is a technique-sensitive operation. A

perfectly round preparation must be reamed through the tooth apex and

into periradicular bone. Unfortunately, there were three errors to

commission by those caught up in the “glamour” of this new innovation.

The worst was a failure to prepare a perfectly round preparation so that

the extruding implant would perfectly seal the apex, much as a cork seals

a bottle. Trying to prepare a perfectly round preparation in an ovoid

canal caused tow problems, the most obvious being that the apical

opening remained ovoid. Microleakage eventually developed because the

apex was not properly “corked”.

The second problem was fractured roots. To “round out” the ovoid

apex, larger and larger preparations were made, thus materially

weakening the root. Then, when the tapered implant was forced into

place, it acted as a wedge and a vertical fracture developed.

The third cause of failure was overlooked second canals,

particularly in mandibular anterior teeth, and an error of omission was in

not correcting or controlling the periodontal condition that led to the

alveolar bone loss in the first place.

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Root Form Osseointegrated Implants

A new option has opened for replacing teeth lost because of a

hopeless prognosis. The osseointegerated root-form implant has now

achieved a success rate approaching that of conventional endodntics.

Branemark’s 1985 definition of osseointegration – “the direct structural

and functional connection between ordered, living, bone and the surface

of a load-carrying implant”-trumpeted the advent of successful

osseointegration, and the usage of implants skyrocketed.

Although Branemark”s paper of 1977, reporting on the first 10

years of implant research, dealt exclusively with mandibular anterior

implants in the edentulous arch, subsequent usage has expanded to fixed

and removable prosthesis abutments and single tooth replacement.

Although single tooth replacements are the most common indication in

the endodontic environment, there are often indications for two or more

replacements in an endodontic milieu. Endodontic graduate programs are

now teaching osseointegerated implants.

Indications

The patient who presents himself for endodontic treatment but has

a non-treatable tooth that is a candidate for removal and an implant

include:

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1. Vertical root fractures.

2. Horizontal root fractures in the coronal 1/3 to ½ of the root.

3. Non-reparable resorption, either external or an extra-canal

invasive resorption.

4. Non-treatable endodontic failures.

5. Non-treatable endo-perio lesions.

6. Non-treatable retained primary teeth.

7. Gross post-perforations.

8. Non-restorable teeth.

Contraindications for Placement of Implants

1. Lack of special training by the surgeon.

2. Uncontrolled or brittle diabetes mellitus.

3. Patient psychiatric factors.

4. Postmenopausal women on thyroid medication and without

estrogen replacement therapy (according to a preliminary report).

There is an increased likelihood of failure (absence of integration

of the implant) if the following six requisites for success are not

observed:

1. The implant must be fabricated form an alloplastic biocompatible

material such as titanium alloy, or hydroxyapatite.

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2. The preparation of the bony socket must be done with a gentle

surgical technique. Electric handpieces that revolve at slow RPMs

are designed specifically for implant surgery.

3. The implant must closely fit the precise bony preparation

throughout its length.

4. The implant must be mechanically fixed to the bone, by either

threads or a roughened surface on the implant.

5. The implant must remain unloaded during the healing phase of 3 to

9 months, depending on which jaw received the implant and the

extent of bone grafting that was necessary.

6. The implant must be properly restored with an even distribution of

occlusal forces, both working and balancing. The restoration must

not overtax the system.

SUTURING

Adequate well-placed sutures will aid in the healing process.

Improper, insufficient, poorly placed sutures will diminish the rate of

healing and may lead to uncomfortable or unesthetic scar or keloid

formation. For placing sutures in the most desirable manner, the

following suggestions are made.

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1. Digitally press the flap before suturing.

After the surgery is completed, the flap is returned to its original

position and firm but not overly forceful digital pressure is applied for 3

full minutes. This allows the fibrin network to begin its formation so that

an adherence develops between the raised and underlying tissues.

2. Never be skimpy with sutures.

The function of a suture is to keep the edges of the flap in contact

during the period immediately after the surgery. In this way the tissues

attach across the lines of incision and optimal healing is gained. If the

tissues are not apposed, granulation tissue will grow in, which is most

undesirable. Also, the sutures prevent the underlying bone from being

exposed to the oral environment and thereby lessen postoperative pain.

In order for these objectives to be accomplished enough sutures

must be placed to keep the edges of the flap in apposition. It is almost

impossible to place too many sutures, and it is much better to err on the

side of too many than too few. If any question arises as to the need for

additional sutures after the surgeon observes t initially sutured flap, the

answer is to place more.

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3. Take deep bites with the needle into the tissue.

Placing the sutures close to the incision lines may cause problems.

is difficult to avoid placing the knots over the lines of incision, and when

the sutures are tightened one side or the other may pull through the tissue.

The answer is to take deep bites with the needle for enough from the lines

of incision.

4. Do not pull the stitches too tightly.

When deep bites are taken to place each suture, care must be

exercised in tying the knot so that the edges are brought just into contact

with each other and that no further tightening is allowed. There is room

to tighten more, but this will cause a bunching of the edges and may lead

to decreased blood circulation in the area.

5. Avoid placing the knots over the lines of incisions.

The knots of each stitch should be placed close to either of the

puncture sites in the tissue rather than in the center. Leaving the knot in

the center will place it right over the line of incision. The bulk of the

knot, when pushed by the lip or cheek, will cause additional irritation and

delay healing in the already inflamed areas.

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If possible, the most desirable position for the knot is over the

puncture site on the non-raised side of the incision, which is the most

normal segment. If, after the suture is tied, it is noticed that the knot is

over the line of incision, it can be moved easily. The knot is grasped by

the teeth of the miniature hemostat and gently pulled toward the un-

flapped segment.

6. Do not leave sutures in place for too long.

Individuals heal with different speeds, and it is impossible to

predict with any accuracy the rate in a particular case. However, leaving

sutures in place for too long always causes a local inflammation and may

lead to overgrowth of tissue., embedding the thread. Therefore 5 days

after the operation seems to be the average and thus ideal time to remove

sutures, with the maximum being 7 days postoperatively.

7. Be sure to schedule a suture removal appointment:

As ridiculous as it seems, in the exhilaration of a job well done, the

surgeon may forger to schedule an appointment for suture removal at 5 to

7 days after surgery. Many patients have had resorbable sutures used in

other surgical procedures and are not aware that the same type is not used

in dentistry. Some weeks later the patient may call to complain of

irritation in the area of the surgery, and an embedded suture is discovered,

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much to the chagrin of the surgeon. Similarly, the number of sutures

placed must always be recorded on the patient’s chart so the surgeon can

be certain that no stitches have been left behind.

8. Choose the type of suture material.

Many companies market packaged disposable presterilized suture

material. There are a myriad of varying choices in thickness and type of

material to replace the formerly used gut or silk material. Polyester fibers

are woven and treated with a chemical that prevents oral fluids, bacteria

and other contaminants from being absorbed by the thread. It appears

that this foreign matter that accumulates within the suture material causes

the local inflammatory response frequently noted. Suture material is also

produced in a monofilament but is more difficult to tie. Both new

materials, being so smooth, require the placing of three square knot ties to

prevent unraveling.

Knots are no longer needed to attach the thread to the metal, but a

traumatic needle is available so that a much smaller puncture hole is

made. Individual packages are kept ready for the surgical procedure.

When needed the material is removed from its outer wrapper and dropped

onto the surgical tray.

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9. Use a circumferential tie.

For use with vertical flaps, the circumferential tie, so named

because of its similarity to the circumferential periodontal ligament fibers

is a valuable. After the vertical incisions are sutured, thee

circumferential tie is used to bring the scalloped gingival margin to place.

Postoperative patient instructions

When the soft tissues are properly managed and surgical time is

minimized, healing is generally uneventful. Careful attention to

postoperative instructions, however is essential for patient comfort and

tissue healing during the next few days. Postoperative instructions should

be given verbally and supported in writing for the patient’s easy

reference.

1. Strenuous activity should be avoided, along with drinking alcohol and

smoking.

2. An adequate diet consisting of fruit juices, soups, soft foods and liquid

food supplements should be consumed. Avoid hard, sticky or chewy

foods.

3. Do not dug at or unnecessarily lift the facial tissues.

4. Oozing of blood from the surgical site is normal for the first 24h.

Slight and transient for the first 24 h. Slight and transient facial

swelling and bruising may be experienced.

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5. Post-surgical discomfort is minimal but the surgical site will be tender

and sore. The use of analgesics for 24-28 h will help to alleviate this

occurrence. Normally, continue with the analgesics given pre-

surgically.

6. For the first day place ice packs with form pressure directly on the

face over the surgical site for 20 min and remove for 20 min. Repeat

until retiring that evening.

7. The day following surgery and for the next 3-4 days, chlorhexidine

rinses are used twice daily. Alternatively warm salt-water rinses are

used every 1-2 h if possible (half a teaspoon of salt in a glass of

water).

8. Sutures will be removed in 48-72 h.

9. Brushing of the surgical site is not recommended until the sutures are

removed. Prior to that the surgical area can be cleaned using a large

cotton puff or ball saturated with warm salt solution.

10.Telephone numbers are provided for your convenience should

complications arise.

POSTOPERATIVE SEQUELAE

Surgical sequelae include pain, swelling, ecchymosis, laceration,

premature separation of sutures, infection, maxillary sinus perforation,

and transient paresthesia. Calling the patient at home the evening after

85

surgery and the next day is always deeply appreciated. To minimize

post-surgical sequelae, oral and written postoperative instructions must be

given to the patient and the person accompanying the patient. Because of

anxiety and nervousness, patients sometimes misunderstand or simply do

not remember the verbal instructions; for this reason written instructions

allay confusion or further anxiety.

Pain

Pain is usually not a serious problem. Long-acting anesthetic

agents, such as bupivacaine (i.e., Marcaine) or etidocaine (i.e., Duranest)

can be injected postoperatively into the surgical site to control pain for a

period of up to 8 hours. The reader is referred to Chapter 18 for the

preventive ibuprofen or acetaminophen regimen that almost always

ensures that any pain will be minimal and transient. Rarely are narcotic

analgesics required.

Hemorrhage

Postoperative hemorrhage is rare. To prevent it from occurring,

two 2X2 sterile gauge pads are folded in half and moistened with chilled

sterile water. This pack is placed over the sutured flap in the buccal fold

and pressed by the surgery with moderate pressure for several minutes.

The patient is provided an ice pack to press lightly against the cheek or

86

jaw for at least 30 minutes to constrict the cut micro-vasculature,

minimizes swelling and promotes initial coagulation.

Swelling

Swelling is common surgical sequelae and is a major concern for

the patient. Patients must be informed that the surgical site and face may

swell regardless of the home care. Also, patients must be assured that the

degree of swelling is not an indication of the success or failure of the

surgery or the severity of the case. Intermittent application of ice packs,

10 minutes on and 5 minutes off, for the 2 days almost always minimizes

swelling.

Ecchymosis

Ecchymosis is the discoloration of facial and oral soft tissues

because of the extravasation and subsequent breakdown of blood in the

interstitial subcutaneous tissues. This is basically an esthetic problem. It

is more prevalent in elderly patients with capillary fragility and patients

with fair skin. Frequently, ecchymosis occurs below the surgical site

because of gravity. For instance, the surgical site may be a maxillary

premolar, but the ecchymosis may be found in the neck area. The patient

should be assured that the ecchymosis has no bearing on the success or

severity of case.

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Paresthesia

When paresthesia occurs, it is when the mental nerve presents near

the second premolar and first molar. However, transient paresthesia may

occur even if the surgical site is far from the nerve. Inflammatory

swelling of the surgical site may cause temporary impingement on the

mandibular nerve causing transient paresthesia. If the nerve has not been

severed, normal sensation generally returns within a few weeks. In rare

instances, however, it may take a few months to regain normal sensation.

The patient should be assured of the probable return of sensation in the

affected side; however, on rare occasions paresthesia can be permanent.

Maxillary Sinus Perforation

Perforation of the Schneiderian membrane covering the sinuses

may occur. If perforation of the sinus occurs, utmost care should be taken

to prevent any material from entering the sinus.

The patient should be cautioned not to blow his or her nose and

should be instructed to elevate the head during the night. Prophylactic

antibiotic therapy with Augmentin 500mg every 6 hours along with

Sudafed for 1week should be prescribed. The patient should return for a

post-surgical checkup in 1 week.

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Postoperative examination and review

Re-examination of the patient, both clinically and radiographically,

is normally scheduled at 6 months and 1 year. In most cases osseous

repair is virtually complete at 1 year. Evidence of this as well as clinical

healing has been considered as a valid criterion for continued success.

Therefore, no additional follow-up may be necessary. Failure to observe

complete repair or delayed healing should complete repair or delayed

healing should warrant additional evaluation for as long as 4 years, until

repair is evident, or signs and symptoms indicate failure.

Radiographic interpretation is highly variable and can easily be

influenced by the quality and angulation of the film and processing

irregularities. Therefore, the clinician should use a film-holding device

for all follow-up radiographs. Likewise, familiarity with radiographic

classifications of healing (success-failure) is essential. This will enable

case outcomes to be based on a sound, logical and consistent decision

making process.

Success and failure – aetiology and evaluation

Whilst many studies have attempted to determine success-failure

rates for perpendicular surgery, none have been able to integrate fully all

parameters of evaluation with techniques performed, materials used,

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patient compliance and clinician expertise, variability and interpretative

skills. Attempts at multivariate analysis have provided some trends and

correlations, but even these findings may only be applicable to

specifically controlled cases.

Success (complete healing) with peri-radicular surgery has been

reported to range from 25% to 90% using mixed populations, less than

ideal percentages of review examinations and minimal evaluation

periods. Because of the significant variability in results, comparison of

studies is not possible. However, the identification of factors that have

contributed to the success or failure of peri-radicular surgery is essential,

and these should be integrated into all phases of case assessment and

treatment. Often the aetiology of failure may be difficult to identify and

may encompass the integration of multiple factors. For peri-radicular

surgery, most failures can be attributed to specific causes. At the same

time, when failure cannot be explained, speculation may lead to uncertain

aetiological factors and treatment. Table lists aetiological factors often

cited as valid or uncertain in the failure of peri-radicular surgery.

Evaluation of success or failure following root-end surgery is

limited to clinical and radiographic examinations. Clinical criteria for

success or failure are most commonly used and are integrated with the

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radiographic findings. Clinically patients are classified into one of three

categories at the time of review examinations. Patient assessment,

however, must be made after integrating both clinical and radiographic

parameters of evaluation. If the only goal of peri-radicular surgery is to

retain the tooth in adequate clinical function, then many cases can be

classified as successful. Many factors, however, such as case selection,

evaluator bias and patient factors, can skew levels of success or failure.

Likewise, many clinically symptom-free teeth may have histo-

pathological changes at the root apices along with minimal or extensive

radiographic changes. Even in the presence of an apparently normal

radiographic appearance, a clinically symptom-free tooth may exhibit

histo-pathological changes in the peri-radicular tissues. This is especially

true adjacent to resected root surfaces which are difficult to assess

radiographically.

Factors influencing success or failure of peri radicular surgery

Valid causes for surgical failure

Failure to debride the root canal space thoroughly

Failure to seal the root canal space three-dimensionally

Tissue irritation from toxic root canal or root-end fillings

Failure to manage root canal or root-end materials properly

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Superimposition of periodontal disease

Vertical root fracture

Recurrent cystic lesions

Improper management of the supporting periodontium

Uncertain causes for surgical failure

Infected dentinal tubules

Infected periradicular lesions

Failure to use antibiotics

Accessory or lateral canals

Loss of alveolar bone

Root resorption

Timing of root canal obturation (before or during surgery)

Type of root-end filling

Clinical success

No tenderness to percussion or palpation

Normal mobility and function

No sinusitis or par aesthesia

No sinus tract or periodontal pocket

No infection or swellings

Adjacent teeth respond normally to stimuli

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Minimal to no scarring or discoloration

No subjective discomfort

Clinical uncertainty

Sporadic vague symptoms

Pressure sensation or feeling of fullness

Low-grade discomfort on percussion, palpation or chewing

Discomfort with tongue pressure

Superimposed sinusitis focused on treated tooth

Clinical failure

Persistent subjective symptoms

Discomfort to percussion and/or palpation

Recurrent sinus tract or swelling

Evidence or irreparable tooth fracture

Excessive mobility or progressive periodontal breakdown

Inability to chew on the tooth.

Re-treatment of surgical procedures

Not all surgery is successful. With astute case analysis the

aetiological factors may be identified and further surgery performed.

When this is not the case, some patients undergo this is not the case,

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some patients undergo multiple operations only to have persistent signs

or symptoms of failure. Often these teeth will be extracted, or last-ditch

efforts will be made with intentional replanation.

Radiographic evaluation of success and failure

Radiographic success

Normal periodontal ligament width or slight increase

Normal lamina dura or elimination of radiolucency

Normal to fine meshed osseous trabeculae

No resorption evident

Radiographic uncertainty

Slight increase in periodontal ligament width

Slight increase in width of laminadura

Size of radiolucency static or slight evidence of repair

Radiolucency is circular or asymmetrical

Extension of the periodontal ligament into radiolucency

Evidence of resorption

Radiographic failure

Increased width of the periodontal ligament and lamina dura

Circular radiolucency with limited osseous trabeculae

Symmetrical radiolucency with funnel shaped borders

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Evidence of resorption

When a case has been identified as failing it is necessary to use all

tests and information available to determine the cause before further

surgery is undertaken. Table lists some of the more common

unsuspected, anatomical and technical causes for failure. Not all of these

causes are amenable to further surgery, and often a tooth may require

extraction and prosthetic replacement.

Very few studies have evaluated the results of peri radicular

surgery that was performed subsequent to previous surgical failure.

Success rates of surgeon have been 50% or less with little subsequent

alteration in healing after 1 year. Even poorer results have been reported

when the peri radicular lesion at the time of the first surgery was > 5 mm

in diameter.

Causes of surgical failure

Unsuspected Root fracture not readily visible

Post – hole perforation, especially on the buccal or lingual surface

Instrument perforation coronal to the resected root end

Persistent infection in the apically resected tubules

Corrosion of previously placed amalgam root end filling

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Anatomical

Fenestrations or dehiscence’s – loss of marginal bone

Aberrant root anatomy or canal space

Proximity of root of adjacent teeth

Proximity of maxillary sinus

Technical

Poor canal cleaning and obturation

Inadequate root end resection

Inadequate root end preparation and obturation

Toxicity of root end filling materials

Improper soft tissue management

The primary reason for failure following peri radicular surgery is

the presence of necrotic tissue debris in uncleaned and obturated canal

space. The primary cause for failure with non-surgical root canal

treatment has been identified as coronal leakage due to poor quality of the

coronal restoration. Therefore, it is essential to access, clean and obturate

as much of the canal space as possible and to seal thoroughly the coronal

aspects of the root canal system before resorting to surgical intervention.

If this is not adhered to, failure will inevitably.

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