Periradicular Surgery: A Concise Guide

Introduction
 Over the past decade, periradicular surgery has
continued to evolve into a precise, biologically based
adjunct to nonsurgical root canal therapy.
 Although nonsurgical endodontic treatment gives
good results in most cases, surgery may be indicated
for teeth with persistent periradicular pathoses that
have not responded to nonsurgical approaches.

History
 Over 1,500 years ago - Aetius, a Greek physician performed first recorded
endodontic surgical procedure - incision and drainage of an acute endodontic
abscess
 5000 BC – Sushruta – performed excision of palatal growth
 9th century – Abulcasis – performed surgical removal of epulis and Cautery
procedure
 1728 - Pierre Fauchard - Replantation and Transplantation techniques
 1845 - Hullihen - ‘Hullihen’s surgery’ or ‘Rhizodontrophy’ or Trephination
procedure

History
 1871 – Smith - First root end resection
 1880 – Brophy - Root end filling
 1881 - Claude Martin - Father of root end resection
 1884 – Farrar - Root amputation
 Surgical operating microscopes –
- 1980’s - Endodontic microsurgery
 1990s – Dr. Gary Carr surgical ultrasonic tips first designed – Carr
tips
 1999 – Spartan/Obtura - Kim Surgical tips – Kis tips

Definition
 A surgical procedure related to problem of the pulp less or
periodontallly involved tooth, requiring root amputation and
endodontic therapy.
(John I Ingle)
 Removal of tissues other than the contents of the root canal space
to retain a tooth with pulpal and/or periapical involvement.
(Franklin Weine)

Rationale
 To remove the causative agents of periradicular pathology.
 To restore the periodontium to a state of biologic and functional
health.

Objectives
 To ensure the placement of a proper seal between the
periodontium and the root canal foramina.

Indications
Glick and Ingle
1. Need for surgical drainage
 Incision and drainage
 Trephination
2. Failed nonsurgical endodontic treatment
 Irretrievable root canal filling,material
 Irretrievable intraradicular post
3. Calcific metamorphosis of the pulp space
4. Procedural errors
 Instrument fragmentation
 Non-negotiable ledging
 Root perforation
 Symptomatic overfilling
5. Anatomic variations
 Root dilaceration
 Apical root fenestration

6. Biopsy
7. Corrective surgery
 Root resorptive defects
 Root caries
 Root resection
 Hemi section
 Bicuspidization
8. Replacement surgery
 Replacement surgery
 Intentional replantation (extraction/replantation)
 Post-traumatic
 Implant surgery
 Endodontic
 Osseo integrated

Relative Contraindications
1. Patient’s medical status
 Major system disorder – Cardiovascular, Respiratory, Digestive,
Hepatic, Renal, Immune, Skeleton-muscular
2. Anatomical considerations
 Nasal floor
 Maxillary sinus
 Proximity to neurovascular bundles of mandibular canal and
mental foramen
 limitations to adequate visual and mechanical access
3. Practitioner’s skill and experience

CLASSIFICATION (by Kim et al)
Based on sequence of use:
 Examination instruments
 Incision blades
 Elevation instruments
 Tissue retraction instruments
 Curettage instruments
 Osteotomy instruments
 Inspection instruments
 Retro fill carriers
 Retro fill Pluggers
 Miscellaneous instruments
 Suturing instruments
 Suction tips
 Irrigation instruments
 Ultrasonic instruments
 Surgical operating microscope

Examination Instruments
 Dental mirror
 Periodontal probe
 Endodontic explorer
 Micro explorer
Tip of microexplorer used to –
• Search for leak in root-end
filling
• Distinguish canal or craze
line from microfracture line

Incision blades
Bard Parker Blades:
 Microblade
 No. 15c
 No. 15
 No. 12
 No. 11
15C blade in use
Microblades

Elevation Instruments
Traditional Microsurgical
Enlarged tips of soft
tissue elevators
Molt’s curette (above)
Periosteal elevator No. 9 (below)

Tissue Retraction Instruments
 Arens tissue retractor
 Selden retractor
 University of Minnesota retractor
Cats paw retractor

Curettage Instruments
•Minicurettes
•Mini jacquette 34/35
•Columbia 13- 14
•Miniendodontic curettes
•Minimolten curettes Enlarged tips of
minijacquettes and mini-
endodontic curettes

Osteotomy Instruments
Straight Handpiece
Microhead Handpiece
Impact air 45o handpiece with H161 Lindemann bone cutting bur
– instrument of choice for osteotomy

 No. 4 round bur
 No. 6 round bur
 No. 8 round bur
 No. 57 fissure bur
 Multipurpose bur
 Endo-Z bur

Inspection Instruments
Micro mirrors
Round and modified rectangular
Flexible neck
Stainless steel (top and bottom)
Scratch-free sapphire mirror surface
(centre two)

Surgical Operating Microscope
Magnification Range = 2X - 32X
MAGNIFICATION RANGE
Low: 3 - 8 X
Medium: 10 – 16 X
High: 20 – 30 X
The surgical operating microscope was used first time in neurosurgery and ophthalmology in
1960
and Endodontic microsurgeries in 1980s

Advantages
 High magnification
 Surgical technique can be performed precisely
and accurately
 Surgical technique can be easily evaluated
 Fewer radiographs needed
 Video recordings possible
 Reduces occupational stress

Classification of Endodontic surgery
 Fisulative surgery
 Incision and drainage
 Cortical trephination
 Decompression procedures
 Periradicular surgery
 Curettage
 Root-end resection
 Root-end preparation
 Root-end filling
 Corrective surgery
 Perforation repair
 Mechanical (iatrogenic)
 Resorptive
 Periodontal management
 Root resection
 Tooth resection
 Intentional replantation

Surgical Drainage :
Surgical drainage is indicated when purulent and/or
hemorrhagic exudates forms within the soft tissue
and the alveolar bone; a result of a symptomatic
Periradicular abscess.
 Surgical drainage maybe accomplished by ;
 Incision and drainage (I and D)
 cortical Trephination

Incision And Drainage
Procedure
 Local anesthetic - Mepivacaine (low pKa)
 Horizontal incision with No.11 or 12 BP blade at the base of the
fluctuant area
 Frank et al - rubber dam drain to maintain the patency of the surgical
opening.
 McDonald and Hovland - incision alone
 Gutmann and Harrison- use of drain is
Indicated in moderate to severe cellulitis and other
positive signs of an aggressive infective process.

Materials used
 Iodoform gauze
 Rubber dam material -“H” or “Christmas tree” shape.
 Penrose drain
Penrose drain Serrated drain

 No 6 or 8 round bur
 Buccal approach
 The objective is to create a
pathway through the
cancellous bone to the vicinity
of the involved periradicular
tissues.
Trephination
Cortical trephination is a procedure involving the perforation of the
cortical plate to accomplish the release of pressure from the
accumulation of exudate within the alveolar bone.

Treatment planning for periradicular surgery
1. Presurgical patient management
2. Need for profound local anesthesia and hemostasis
3. Management of soft tissue
4. Management of hard tissues
5. Surgical access, both visual and operative
6. Access to root structure
7. Periradicular curettage
8. Root-end resection
9. Root end preparation
10. Root-end restoration
11. Soft-tissue repositioning and suturing
12. Postsurgical care

PRESURGICAL PATIENT MANAGEMENT
Patients medical status
 Proper history taking is first key for success of any
surgical procedure.
 Patient should be evaluated for major system disorders
(cardiovascular, renal, hepatic, digestive, immune and
skeletal muscle) which may contraindicate or alter
approach to surgery.
 Also premedication for patient in normal or in
presence of any of the above medical conditions
should be given priority and consulted with physician.

Patient preparation
 Patient preparation starts with patient communication
regarding reason for surgery, risks involved, also factors
which improve prognosis for successful outcome of surgical
procedure.
 There may be necessity of premedication (sedatives or
hypnotics, systemic antibiotics) for patient in order to
improve accessibility also postsurgical healing.
 Presurgical mouth rinse with chlorhexidine gluconate
(Peridex) may improve surgical environment by decreasing
tissue surface bacterial contamination.
 Mouth rinse should be started a day before
surgery, immediately before surgery, and up to 4 to 5 days
post surgically. This reduces bacterial contamination of
surgical site and improve wound healing.

Anaesthesia
 Local anaesthetic with vasoconstrictor
 Objectives:
 obtain profound and prolonged anaesthesia
 provide good hemostasis both during and after the surgical
procedure
 Selection based on:
 Medical status of the patient
 Desired duration of anaesthesia

TYPES OF LOCAL ANALGESIA
 Topical analgesia (surface analgesia)
 Sub mucosal infiltration
 Sub periosteal infiltration
 Nerve block analgesia
 Intra ligamentary analgesia.
 Intra osseous analgesia.
2
1
3
6
5
4

TOPICAL ANALGESIA (SURFACE ANALGESIA)
 An anaesthetic is applied in a gel form to the intact
mucous membrane.
 It passes through the epidermis and makes the nerve
endings analgesic prior to administration of a deeper
or infiltration analgesic .
 Use-The surface analgesia prevents the pain of the
needle.

Technique:
 The mucosa is dried using sterile cotton.
 A small quantity of local anesthetic paste or ointment is
placed on a sterile cotton roll.
 This is placed on the mucosa
at the proposed site for 2 min.
 Care is taken to prevent its
spread elsewhere. Excess is
wiped away.

 The solution is deposited around the nerve filaments
in the sub mucosa.
 In supraperiosteal technique, the tip of the needle
is placed beneath the sub mucosa in the elastic
tissue.
 The solution does not penetrate the bone.
SUBMUCOSAL INFILTRATION

 It should be regarded as a preliminary for depositing
sub periosteal LA allowing the placement of the
anaesthetic comfortably.
 It is not useful in simple conservative procedures also .
 Use-on nervous adults or children where the pressure
caused by injecting subperiosteally is too
uncomfortable for the patient.

Technique: Maxillary
Maxillary Central Incisor
 The mucosa is pulled taut and the needle (preferably a
short one) is inserted about 8 mm from the gingival margin
or about 21 mm from the incisal edge such that the hub of
the needle is just apical to the incisal edge.
 The needle is pushed with a deliberate forward motion.
 About 1 ml solution is deposited.

Maxillary Lateral Incisor
 Shorter root should be considered.
 Due to palatine position of the apices, often
nasopalatine block is required.
Maxillary Canine
 The root is very long 25 mm. Canine eminence to
serve as guide.

Maxillary First Premolar
 The needle is placed distal to the canine eminence.
About 22mm from the buccal cusp.
Maxillary Second Premolar
 The canine eminence and the base of the zygomatic
process are used as guide. About 21mm from the
buccal cusp.
 A palatal infiltration is often required for first and
rarely second

Maxillary First /Second/Third Molar
 Buccal infiltration with a short needle. The presence of
zygomatic process makes it necessary for two
infiltrations-one mesial to for mesio buccal root
(about 23 mm from the MB cusp) and one distal for
the disto buccal root (about 21 mm from the DB cusp)
 The palatal root requires another infiltration about 3-
4mmbeing inserted in into the mucosa about 8 mm
from the gingiva.

Mandibular Central Incisor, Lateral Incisor, Canine
 The tip of needle is approximately 18 mm from the
incisal edge. The needle is placed deep into the
sulcus. 0.75-1 ml solution is deposited.
 A variation is simple infiltration to the interdental
papilla.
Technique: Mandibular

Mandibular First /Second Premolar
 The tip of the needle is close to the root apices in
the buccal sulcus .The needle is placed
subperiosteally. About 0.5-1ml solution is
deposited.

Mandibular First /Second/Third Molar
The tip of the needle is placed in the sulcus
adjacent to the apices of the teeth involved. The
broad shelf of bone means that it takes a longer
time for the penetration of the solution.

SUBPERIOSTEAL INFILTRATION
 To ensure adequate anaesthesia it is necessary to insert
the needle in the periosteum.
 The tip of the hypodermic needle is inserted under the
periosteum. A lot of pressure must be applied to the
plunger to deposit the solution.
 This can be very uncomfortable and to the patient.
painful.
 Use- Is necessary for conservative procedures.

NERVE BLOCK ANALGESIA
 The tip of the hypodermic syringe is inserted near an
anatomically discrete nerve bundle and LA is
deposited around it. Larger quantity of solution is
required. The size of the nerve bundle demands more
time for penetration of the solution to the centre
 The analgesia is profound and extends over the areas
served by the nerve bundle.

Technique: Maxillary
 Posterior Superior alveolar nerve block
 First (DB and palatal root) /Second /Third Molar
which are supplied by the branches of maxillary nerve
through the posterior superior alveolar nerve
 The needle is inserted distal to the last molar, upwards
and medial at about 45°.
 1.5 ml of solution on the distobuccal aspect of the
maxilla.
 Complication: vessels of the pterygoid venous plexus
are ruptured resulting in haematoma.

Posterior superior alveolar nerve block

Middle Superior alveolar nerve block
 The mesio buccal root of the first molar along with the
premolars and the mucosa is supplied by Middle
Superior alveolar nerve.
 1ml of solution is deposited deep in the sulcus
between the second premolar root an d the mesio
buccal root of first molar.

Middle Superior alveolar
nerve block

Anterior Superior alveolar nerve block
 This nerve supplies the upper canine, lateral
 incisor and the central incisor.1-1.5 ml of
 solution to be deposited
 deep in the sulcus
 below the level
 of the infraorbital
 foramen.

Infraorbital nerve block
 Analgesia of the anterior part particularly useful when
infection precludes the use of infiltration techniques.
The solution is deposited at the entrance of the
infraorbital foramen blocking both the ASA and MSA.
 A swelling of the tissues is felt when the solution is
deposited

 The infraorbital ridge
is palpated and the
notch is identified.
The tip of the needle
is inserted deep in
the sulcus above the
apex of the second
premolar and
advanced till it is 1.5-
2 cm deep.

Palatine nerve block
 Analgesia of the palate as far as canine on one side can
be achieved by depositing approx 0.5-0.75 ml of
solution over the greater palatine nerves as they
emerge from the greater palatine foramen. This is
distal to the second molar at the junction of the hard
palate and the alveolar process.
 The needle is inserted about 0.5 cm.

Nasopalatine nerve block
 The tip is inserted through the nasopalatine papilla
until it rests within the entrance to the incisal canal. If
the bone is contacted the needle is withdrawn 0.5-1
mm. about 0.1-0.2 of solution is deposited.

Technique: Mandibular
Inferior alveolar nerve block
 It is the single most important technique in dental
practice. Combined with the lingual nerve and the
long buccal it provides anaesthesia of hard and soft
tissues of one side of the mandible from third molar to
incisor

Considerations
 A few mm above the occlusal plane in the horizontal
section it lies against the medial surface of the ramus
in the pterygoid space.
 Anteriorly- Pterygoid raphe ( buccinators and superior
pharyngeal constrictor)
 Posteriorly –parotid gland.
 Laterally –medial surface of the ramus.
 Medially –medial pterygoid muscle.

When the patient opens his mouth wide it is possible to
identify the prominent ridge of pterygo mandibular
raphe.

 The thumb is used to retract the cheek and also
delineate the apex of the buccal pad of fat. As the
thumb is moved backward the external oblique ridge is
palpated. The tip of the thumb is moved medially to lie
in the retro molar fossa.

 It is then withdrawn
slightly and aspirated.
 1.5 ml of solution is
deposited
 The needle is then inserted about 0.5 cm and 0.1-0.2 ml
solution is deposited to anesthetize the lingual nerve.
 The needle is then further advanced for 1.5-2 cm until
its tip lightly touches the bone.

Lingual nerve block.
 It ascends diagonally back through the space until it
joins the mandibular nerve superior to the mandibular
foramen. A shallow depression above the foramen is
the site where the solution is to be deposited.
 It is achieved by injecting 0.1-0.2 ml of solution at
the level of the alveolar crest distal to the second/third
molar. It can be done either when the needle is
inserted or withdrawn.

Long buccal nerve block
 For the analgesia of the mucosa and the gingiva.
 The needle is inserted distal and buccal to the third
molar approx. 1 cm from the distobuccal aspect.0.5 ml
solution is deposited.

Mental nerve block
 Solution deposited at the level of mental foramen
enters reaches the inferior alveolar nerve to
anesthetize the premolars, canine and incisors of that
side.
 1.5-2 ml solution is deposited deep in the sulcus.

INTRALIGEMENTARY ANALGESIA
 The tip of 30 gauge needle is
inserted into the coronal
part of the periodontal
ligament and solution is
injected under high
pressure.
 Use- This provides
anaesthesia to a single tooth.

 Shapes of the syringes are modified to achieve high
pressure.
 The 30 gauge needle is inserted through the gingival
sulcus into the periodontal ligament. The needle is
angled about 30° to the long axis of the tooth.
 The needle is pushed approx. 2 mm into the
periodontal ligament parallel to the root surface.
 Continuous and firm pressure is applied for 20-30 sec.
An strong resistance is felt. About 0.05-0.1 ml solution
is deposited.
 This is done at all four corners of the tooth .Max of
0.4-0.8 ml of solution is injected .The needle is then
held for 5-10 sec to dissipate the pressure before needle
is withdrawn.

INTRA OSSEOUS ANALGESIA
 A small hole is drilled through the mucosa and the
bony cortex to allow the insertion of a needle directly
into the bony medulla enabling profound analgesia
around a group of teeth.
 There is a high risk of the solution to be taken up in
the blood stream.
 Use- only when other techniques have failed.

 A sterile 1 or 2 round bur assisted by copious supply of
water is used to drill through the mucosa .the cortical
bone and medullary bone. The needle is inserted into
the bony medulla and 1-2 ml of solution is deposited at
the apex of the tooth.
 Dis: Local anesthesia is deposited very near vascular
area and the levels of LA increase dramatically.

LOCAL COMPLICATIONS
Failure to obtain analgesia
 Usually due to faulty technique.
 Presence of infection
 Best to repeat the procedure.
 Particular attention to the anatomical landmarks.
 LA should be given in a remote area.
 Nerve block anaesthesia is important.

Pain during injection
 Poor technique
 Good technique as well as gentle and slow injection
should be followed.
 Warming the anaesthetic syringe just before injecting
reduces discomfort.
 Rarely a sharp electric shock is felt along the nerve.
This indicates nerve sheath being pierced.
 Needle should be withdrawn.

Haematoma formation
 In areas of great vasculature ,blood vessels may be
punctured. This results in bleeding in the tissues with
a haematoma being developed.
 The patient should be reassured that the haematoma
will dissipate over a week or 10 days like a bruise.
 Antibiotic therapy should be started as there are
chances of infection.

Intra vascular injection
 This can be prevented by using a aspirating syringe
Trismus
 Muscle spasm which makes it difficult to open mouth.
 Results when an injection into the medial pterygoid
causes a tearing of the muscle fibers and a
haematoma. Onset is more than 24 hours later.

Blanching
 Which occurs at the site of injection :
 Due to combined defect of the hydrostatic pressure of
the local anaesthetic and the vasoconstrictor.
 Which occurs at a remote site :
Either due to an inadvertent intravascular injection
or interference with the autonomic nerve supply of
the blood vessels affected by the local anaesthetic.

 Blanching covers
a variable area of
the face and lasts
from 30 seconds
to 30 minutes
after it
disappears
without any
trace .No
treatment is
required.

Paralysis
 Unilateral paralysis of the facial muscles is an
uncommon complication and when it does happen it
is due to inferior alveolar nerve.
 It occurs because the tip of the needle is positioned
too far back in relation to the mandible and enters the
parotid gland where it makes the branches of facial
nerve analgesic.

 The complication is
alarming to the
patient. Dental
treatment should be
abandoned. The
patient should be
reassured.
 The patient should
be advised to protect
the conjunctiva and
avoid scratching of
eyelid

Prolonged impairment of the sensation
 This is caused by direct damage from the needle or due
to small haematoma.
 The patient should be monitored at regular intervals
and the paraesthesia should be mapped by tests.
 Recovery should be complete within 3 months.

Lip Trauma
 Usually occurs in children who had an inferior nerve
block. As sensation start to return but while the lip is
still numb and rubbery children are inclined to bite
their lip to test its feeling unaware that this can cause
severe trauma.
 Untreated a bite can develop
a fibrin slough.

 Prevention being better than cure. The parents should
be advised to discourage the child.
 The wound should be kept moist by smearing a thin
layer of sterile Vaseline over it every few hours. The
traumatic ulcer usually heals without

Visual disturbances
 Due to vascular spasm or intra-arterial injection.
Normal vision usually returns after 30 minutes. The
patient should be reassured but not discharged until
vision returns.

SYSTEMIC COMPLICATIONS
Vasovagal attack
 The most frequently encountered complication.
 Emotional disturbance leading up to the
administration of LA predisposes to a faint. The
patient tends to tense himself up to cope with the
injection. Immediately afterwards the strain of his
exertions seems to overwhelm him-with the massive
vagal discharge plus the arteriolar dilatation leading to
a reduction in the blood returning to the heart, which
in turn results in a gross reduction in cardiac output .

 The consequence is a sudden loss of
consciousness, the patient collapses within a few
seconds. The patient becomes pale, suffers nausea and
dizziness and out in a cold sweat. His skin feels cold
and clammy and further he will lose consciousness
and pupils dilate. Pulse becomes weak and thready
and may in a short while appear t be absent.
 The patient should be placed in a supine position and
a head low position. this encourages the return of
blood to the heart which in turn will stimulate cardiac
output.

 The airway should be checked ,the jaws should be drawn
forward.
 Any tight clothing should be loosened.
 Patients usually respond in 2-3 minutes. A few remain
confused over some time
 An apparent simple faint represents a severe disturbance
of the cardiovascular and the central nervous systems and
should not be taken lightly. Unless it is essential to
complete the dental treatment on the same day ,the
patient should be appointed on next day.

Systemic toxicity
 Despite the fact that LA solution are injected in a very
vascular area toxic reactions are rare. When they do
occur there may be convulsions, respiratory
depression, or even circulatory collapse .These
symptoms pas relatively early. Indeed they may be of
such short duration that they may not be observed.

Drug interactions
 This is a potential problem when the patient is taking
systemic medications. The LA containing
noradrenaline can potentiate the blood pressure
response in patients receiving tricyclic
antidepressants.

Allergy
 A patient may report to the dentist stating that he is
allergic to LA. This should be confirmed by a
subcutaneous injection If there is an erythema the
cause should be determined , methyl paraben
(preservative ) is the cause.

Idiosyncracy
 This is a systemic complication that results in an
individualized reaction in the patient. Psychogenic
factors play an important role. Toxic symptoms are
seen even when the dose is below maximum. May lead
to serious reaction.

Homeostasis
 Adequate homeostasis is a pre requisite for endodontic surgery
1. Mechanical agents: Bone wax
2. Chemical agents
a. Vasoconstrictors
b. Ferric sulfate
3. Biologic agents : Thrombin
4. Resorbable hemostatic agents
i. Calcium sulfate
ii. Gel foam
iii. Absorbable collagen
iv. Microfibrillar collagen hemostats
v. Surgicel
(Kim & Rethnam: DCNA; 41; 1997)

Management of soft tissue
PRINCIPLES OF FLAP DESIGN
1. Making sure base of the flap should be wider than
the free end.
2. Avoiding the incision over a bony defect
3. Including the full extent of the lesion.
4. Avoiding sharp corners
5. Avoiding incision across a bony eminence

6. Avoiding incision in the mucogingival junction.
7. Taking care during retraction.
8. Incision should be made with firm, continuous firm
stroke perpendicular to the cortical bone plate.
9. The sutured flap margin should rest on solid cortical
bone plate.

Classification
 Full thickness (Mucoperiosteal) - Epithelium + Connective tissue +
Periosteum
Partial thickness (Split) - Epithelium + Connective tissue
 According to Gutmann & Harrison
Full mucoperiosteal Limited mucoperiosteal
Full mucoperiosteal flap – no attached
Gingiva around neck of crown
Limited mucoperiosteal showing -
Remaining attached gingiva

 Full mucoperiosteal flap
 Triangular
 Rectangular
 Trapezoidal
 Horizontal/Envelope
 Papilla base
 Limited mucoperiosteal
 Sub marginal curved/Semilunar
 Sub marginal scalloped rectangular/Luebke Ochsenbein

Advantages of Full Mucoperiosteal Flaps
1. Rapid wound healing
2. Good surgical access
3. Minimal disruption of blood supply
4. Minimal untoward post-surgical sequelae
5. Optimal apical orientation and
6. Primary intentional healing.
Disadvantages
1. Loss of soft tissue attachment
2. Loss of crestal bone height
3. Post surgical flap dislodgement

Advantages of limited mucoperiosteal flap
1. Marginal and interdental gingiva not involved
2. Unaltered soft tissue attachment level
3. Crestal bone is not exposed
4. Adequate surgical access and
5. Good would healing potential
Disadvantages
1. Disruption of blood supply to unflapped tissues
2. Flap shrinkage
3. Difficult flap re-approximation
4. Delayed secondary wound healing.
5. Limited apical orientation

TRIANGULAR FLAP
INDICATIONS:
 Mid root perforation repair
 Periapical surgery in posterior areas with short roots
ADVANTAGES:
○ Good wound healing
○ Minimal disruption of vascular supply to flapped tissue
○ Ease of flap re-approximation with minimum number of
sutures
DISADVANTAGES:
○ Limited surgical access
○ Difficult to expose the root apices of long teeth like maxillary and
mandibular canines
○ Tension is created on retraction

RECTANGULAR FLAP
INDICATIONS:
 Mandibular anteriors
 Multiple teeth
 Teeth with long roots like maxillary canines
ADVANTAGES:
 Increased surgical access to root apex
 Reduces retraction tension
DISADVANTAGES:
 Difficulty in re-approximation of flap margins
 Post surgical stabilization is difficult
 Gingival attachment violated, gingival recession, crestal bone loss
may occur

TRAPEZOIDAL FLAP
 Similar to rectangular except the 2 vertical incisions intersect the
horizontal incision at an obtuse angle → to create a broad based flap
with the vestibular part wider than the sulcular portion
 Disadvantages:
 Angled incision – severs more vital structures
 More bleeding
 Disruption of vascular supply to non-flapped tissues
 Shrinkage of flapped tissues

HORIZONTAL FLAP
 Horizontal intrasulcular incision with no vertical releasing incision
 Limited applications - Limited access
 Repair of cervical defects (root perforations, resorption, caries)
 Hemi sections and Root amputation
 ADVANTAGES:
 Ease of repositioning as no vertical incision
 DISADVANTAGES:
 Limited access and visibility
 Difficult to reflect and retract
 Predisposed to stretching and tearing

SUBMARGINAL CURVED/SEMILUNAR FLAP
INDICATION
1. Esthetic crowns present
2. Trephination
ADVANTAGES
 Reduces incision and
reflection time
 Maintain integrity of
gingival attachment
 Eliminates potential
crestal bone loss
DISADVANTAGES
 Limited access and visibility
 Tendency for increase
hemorrhage
 Crosses root eminences
 May not include entire lesion
 Predisposed to stretching and
tearing
 Repositioning is difficult
 Healing is associated with scar

SUBMARGINAL SCALLOPED RECTANGULAR/
LUEBKE OCHSENBEIN FLAP
 Modification of rectangular flap
 Horizontal incision is placed in buccal/labial attached
gingiva & is scalloped - follows the contour of marginal
gingiva
 INDICATIONS
 Prosthetic crowns
 Periradicular surgery of anterior region
 longer roots

ADVANTAGES
 Ease in incision and
reflection
 Enhanced visibility and
access
 Ease in repositioning
 Maintains integrity of
attachment
 Prevent gingival recession
 Avoid dehiscence
 Prevent crestal bone loss
DISADVANTAGE
 Horizontal component
disrupts blood supply
 Vertical components crosses
mucogingival junction and
may enter muscle tissue
 Difficult to alter if size of
lesion misjudged

INCISION
 Incisions for the majority of mucoperiosteal flaps for
periradicular surgery can be accomplished by ;
No.11, NO.12, No.15, No.15C, micro surgical blade.

FLAP REFLECTION
 Flap reflection is the process of separating the soft tissue (Gingiva
Mucosa and Periosteum) from the surface of the alveolar bone.
 This process should begin in the vertical incision a few millimeter
apical to the junction of the horizontal and vertical incisions.
Periosteal elevator for flap reflection are ;
 No.1 and No.2 (Thompson Dental Manufacturing Co)
 No.2 (Union Bronch)
 No.9 (Union Bronch Co)

FLAP RETRACTION
 Process of holding in position the reflected soft tissues
 Provides visual and operative access
 Tissue retractor must always rest on solid cortical bone with firm
light pressure

HARD TISSUE MANAGEMENT
Osteotomy
 Following reflection and retraction of the mucoperiosteal
flap, surgical access must be made through the cortical bone to the
roots of the teeth.
 Methods to locate the root apex
 Methylene blue dye
 Visual and tactile method(Barnes)
1. Root structure generally has a yellowish color
2. Roots does not bleed when probed
3. Root texture in smooth and hard as opposed to the granular and
porous nature of bone
4. The root is surrounded by the PDL

OPTIMAL OSTEOTOMY SIZE
 Traditional endodontic surgery - approximately 10 mm in
diameter.
 Should be just large enough to manipulate ultrasonic tips freely
within the bone crypt.
 Since the length of an ultrasonic tip is 3 mm, the ideal diameter
of an osteotomy is about 4mm.

Periradicular curettage
 A surgical procedure to remove diseased or reactive tissue
from alveolar bone in the periradicular area or lateral region
surrounding a pulp less tooth (AAE 1994)
 Purpose:
• To remove pathological periradicular tissues for visibility
and accessibility for treatment of apical root canal system
• To remove foreign material present in periradicular
tissues

 To accomplish removal of entire mass, the largest bone curette,
consistent with the size of the lesion, is placed between the soft
tissue mass and lateral wall of the bony crypt with concave surface of
curette facing the bone.
 Once soft tissue has been freed along the periphery of the lesion, the
bone curette should be turned with concave portion towards the soft
tissue and used in scraping fashion to free tissue from deep walls of
bony crypt.

Root End Resection
Indications
 Eliminating
 Anatomical variations
 Ledges
 Canal obstructions
 Resorptive defects
 Perforation defects
 Separated instruments
 Visualize seal created by orthograde treatment and need for root-
end seal
 Gain access to pathological tissue trapped along lingual surface of
root

 Ingle et al recommended the root end resection is best accomplished by
the No.702 tapered fissure bur or No.6 or No.8 round bur in a low speed
straight hand piece.
Lasers
 Komori and associates evaluated the use of the Er:YAG laser for root-end
resections:
 Er:YAG laser - smooth, clean, resected root surfaces free of any signs
of thermal damage.
INSTRUMENTS

 Moritz and associates
 CO2 laser treatment optimally prepares the resected root-end
surface to receive a root-end filling
 seals the dentinal tubules
 eliminates niches for bacterial growth
 sterilizes the root surface
 Advantages of the laser use:
 Absence of discomfort and vibrations
 Less chance for contamination of the surgical site
 Reduced risk of trauma to adjacent tissue

Rationale for laser use in endodontic periradicular surgery includes
(Miserendino et al)
(1) improved homeostasis and concurrent visualization of the
operative field
(2) potential sterilization of the contaminated root apex
(3) potential reduction in permeability of root-surface dentin
(4) reduction of post-operative pain
(5) reduced risk of contamination of the surgical site through
elimination of the use of aerosol-producing air turbine hand
pieces.

BEVEL ANGLE
 Historically – 30-45o: to gain visual and operating access to the root tip for
resection, placement of retro filling materials, and inspection.
 Present - 90o Maximum= 10o degree bevel
Advantages:
•Exposes fewer dentinal tubules, thus preventing
excess leakage and contamination.

ROOT END PREPARATION
Purpose:
• To create a cavity to receive a root-end filling.
Objective: It must be placed parallel to the long axis of the root.
Instruments Used:
 Small round or inverted cone burs
 Ultrasonic tips

IDEAL ROOT END PREPARATION
 The apical 3 mm of the root canal must be freshly cleaned and
shaped.
 The preparation must be parallel to and coincident with the
anatomic outline of the pulp space.
 Adequate retention form must be created.
 All isthmus tissue, when present, must be removed.
 Remaining dentin walls must not be weakened.

Traditional root-end cavity preparation technique
 Miniature contra-angle or straight hand piece
 Small round or inverted cone bur.
 Class I cavity preparation along the long axis of the root within the
confines of the root canal.
 Recommended depth - 2 to 3 mm being the most commonly
advocated. (Gutmann and Harrison)
 Disadvantage: Apical perforation due to difficulty in aligning the bur

 Recently, specially designed ultrasonic root end preparation
instruments have been developed.
 Ultrasonic tips developed by De Gary Carr- Available with plain and
diamond coated tips.
 Kis Microsurgical Ultrasonic Instruments – The tips are coated with
zirconium nitrite for faster dentin cutting with less ultrasonic
energy

Advantages of Ultrasonic tips over micro head burs
 Need for beveling eliminated
 Tip stays centered in root and follows canal space
 ↓ chances of lingual or lateral root perforations
 Conserving greater thickness of root canal wall
 Better access to surgical areas, especially difficult to reach areas such as
lingual apices
 Deeper root-end preparation achieved

 Less dentinal tubules exposed
 Cleaner cavity than bur – smoother, less debris and smear layer
 Ultra precise isthmus preparations.
 Parallel canal walls preparation for better retention of filling
materials.
Drawbacks:
Creation of micro cracks due to vibrations produced

RETROGRADE RESTORATIVE MATERIALS AND TECHNIQUES
Purpose:
To seal the apex so that no bacteria or bacterial by products can enter or
leave from the canal
Properties of ideal retrograde restorative materials :
 Well tolerated by periapical tissues
 Bactericidal or bacteriostatic
 Adhere to the tooth
 Dimensionally stable
 Readily available and easy to handle

 Not stain teeth or periradicular tissue
 Non corrosive
 Resistant to dissolution
 Electrochemically inactive
 Promote Cementogenesis
 Radiopaque

Root End filing materials :
 Gutta percha
 Amalgam
 Cavit
 IRM
 Super EBA
 Glass Ionomer
 Composite resins
 Carboxylate cements
 Zinc phosphate cements
 Zinc oxide eugenol cements
 Mineral trioxide aggregation (MTA)

The prognosis ultimately depends on factors such as:
 An accurate bevel
 Adequate access
 Homeostasis
 Accurate retrograde preparation
 Accurate retrograde restoration
 Existent periodontal disease
 Occlusal trauma
 Missed vertical fractures
 Quality of the orthograde filling
 Individuals host response.

SOFT TISSUE REPOSITIONING AND COMPRESSION
 The elevated muco periosteum gently replaced to its original position
with the incision lines approximated as closely as possible.
 Type of flap design will affect the ease of repositioning.
 Tissue compression: Using a surgical gauze moistened with sterile
saline, gently apply firm pressure to the flapped tissue for 2 to 3
minutes (5 minutes for palatal tissue) before suturing.
 Enhances intravascular clotting in the severed blood vessels

SUTURING
Purpose: To approximate the incised tissue and stabilize the flapped muco
periosteum until reattachment occurs.
CLASSIFICATION OF SUTURE MATERIALS
 Based on material:
Synthetic fibers Natural
Nylon Collagen
Polyester Gut
Polyglactin Silk
Polyglycolic acid
 Absorbency:
Absorbable Non absorbable
Polyester Silk
Polyglactin Nylon
Polyglycolic acid
Collagen
Gut

 Size:
USP size: 3-0, 4-0, 5-0, 6-0.
The higher the first number, the smaller the diameter of the
suture material.
 Structure: Monofilament and Multi filament
Twisted and Braided

Silk Sutures: Non absorbable, multi filamentous, and braided.
High capillary effect
Enhances movement of fluids and
microorganisms between fibers
Plaque accumulation on the fibers
Severe oral tissue reactions
Prevented by postoperative rinse with chlorhexidine
Advantage: Ease of manipulation

Gut: Collagen is the basic component of plain gut suture material
 derived from sheep or bovine intestines.
 The collagen is treated with diluted formaldehyde to increase its
strength
 Shaped into the appropriate monofilament size.
 Gut sutures are absorbable in 10 days
Chromic gut: plain gut treated with chromium trioxide.
 delayed absorption rate
 Gut suture material is available in sterile packets containing isopropyl
alcohol.

Polyglycolic Acid (PGA): made from fibers of polymerized glycolic acid -
absorbable. The rate of absorption is about 16 to 20 days.
 Multi-filament, braided and handling characteristics similar to silk.
 First synthetic absorbable suture and it is manufactured as Dexon.
Polyglactin (PG): Developed by Craig and coworkers In 1975
 Copolymer of lactic acid and glycolic acid
 Called polyglactin 910 (90 parts glycolic acid and 10 parts lactic acid).
 Sutures of polyglactin are absorbable, braided and multi filament.
 Commercially available as Vicryl

NEEDLES
 Needle with reverse cutting edge (the cutting edge is on the outside of the
curve) is preferable.
 Available in arcs of 1/4, 3/8, 1/2 and 5/8 of a circle, with the most useful
being the 3/8 and 1/2 circle.

SINGLE INTERRUPTED SUTURE
SUTURING TECHNIQUES

INTERRUPTED LOOP (INTERDENTAL) SUTURE

POST OPERATIVE INSTRUCTIONS AND CARE
 Do not lift up lip or pull back the cheek to look at where the surgery was
done.
 A little bleeding from surgical is normal. This should only last for a few
hours.
 A little swelling and bruising face may be evident which may last for a few
days.
 Do not drink alcohol or use tobacco (smoke or chew) for the next 3 days.
 Have a good, soft diet and drink lots of liquids for the first few days after
surgery.

 Place an ice bag (cold) on face where the surgery was done. Leave it
on for 20 minutes and take it off for 20 minutes. Continue this for 6
to 8 hours.
 Take the prescribed medicines as recommended.
 Rinse the mouth with 1 tablespoon of the chlorhexidine mouthwash
twice daily for 5 days.
 Suture removal after 5-7 days by the dental personnel only.
 Maintain post operative follow up recall visits
 If any problems exists inform and visit your dentist immediately.

BARRIER MEMBRANE TECHNIQUES IN ENDODONTIC SURGERY
 Regeneration: is the replacement of destroyed tissue with new tissue
formed by the cells of the same origin. This new tissue reacts in a
similar manner against pathologic stimuli as the original tissues.
 Repair: is the restoration of the destroyed tissue by disease with new
tissue consisting of cells different from the original cells. These cells
react differently from the original cells against pathologic stimuli.

Materials used:
 GTR membrane
 Calcium sulphate
 Periosteal graft
 Platelet rich plasma
 Tri calcium phosphate
Objective: To enhance the quality and quantity of bone regeneration
in the peripheral region and to accelerate bone growth in
circumscribed bone cavities after endodontic surgery.

GTR Membrane
Indication
 Through and through periapical lesion.
 Large periapical lesion
 Endo-perio lesion
Periapical lesion communicating with the alveolar crest
Furcation involvement as a result of perforation
Root perforation with bone loss to alveolar crest

Advantages:
○ Barrier function in case of lack of periosteum.
○ Greater concentration of osteogenic cells in the healing area
○ High success rate.
Disadvantages:
○ Cost
○ Possibility of infection
○ Need for a second surgery (non resorbable materials only)
○ Need for a space-maintaining device in large defects
○ Problems in the application of the barrier.
○ Operator skill (e.g. , high surgical skill required when a palatal flap is
raised)

CALCIUM SULFATE
Indications :
 Post apicoectomy bone defects
 Through and through lesions
 Periapical lesions with furcation involvement
 Post surgical endo-perio communications.
Advantages:
 Inexpensive
 No inflammatory reaction
 Absence of post operative complications.
 Possibility of using the materials even in a septic environment
 Ability to achieve secondary closure of soft tissue on the exposed material.
 Stabilization of blood clot.
 Adhesion to root surface.
 Biocompatible
 Complete absorption.

Actions: 1. Periosteum
Osteo progenitor cells
Osteogenesis
2.Barrier for epithelial infiltration
Indications: multifaceted endodontic- periodontic problems
Advantages:
○ Highly vascular
○ Easily harvested
○ Configuration adjusted to shape of recipient site
Disadvantages:
○ Profuse bleeding
○ Difficulty in obtaining the split thickness graft
PERIOSTEAL GRAFT AS BARRIER MATERIAL: (Kwan et al 1998)

Platelet rich plasma – Rich source of growth factors
Properties and Advantages:
•Decreased intra operative and post operative bleeding
•Rapid soft tissue healing
•Rapid vascularization
•Decreased post operative pain
•Osteo conductive
•Hemostatic properties
•Safe
•Affordable
(Demiral et al JOE , 30 (11) , 2004)
PLATELET RICH PLASMA + TRI CALCIUM PHOSPHATE

Corrective surgery
 Corrective surgery is categorized as surgery involving the correction of
defects in the body of the root other than the apex.
 Corrective surgical procedure may be necessary as a result of
procedural accidents, resorption (internal or external), root caries, root
fracture, periodontal disease.
Corrective surgery may involve
 Root resection.
 Hemi section.
 Intentional replantation.

ROOT AMPUTATION
Root amputation procedures are a logical way to eliminate a
weak, diseased root to allow the stronger root(s) to survive when, if
retained together, they would collectively fail.

 Distance between pulp chamber floor and coronal aspect of the root
separation= 3mm (Minimum)
 2 mm allow for establishment of supra crestal attachment apparatus
and 1 mm for placement of crown margins

INDICATIONS FOR ROOT AMPUTATION:
(Rosenberg et al)
 Existence of periodontal bone loss to the extent that periodontal
therapy and patient maintenance do not sufficiently improve the
condition.
 Destruction of a root through resorptive processes, caries, or
mechanical perforations.
 Surgically inoperable roots that are calcified, contain separated
instruments, or are grossly curved.
 The fracture of one root that does not involve the other.
 Conditions that indicate the surgery will be technically feasible to
perform and the prognosis is reasonable.

CONTRAINDICATIONS FOR ROOT AMPUTATIONS:
 Lack of necessary osseous support for the remaining root or roots.
 Fused roots or roots in unfavorable proximity to each other.
 Remaining root or roots endodontically inoperable.
 Lack of patient motivation to properly perform home-care procedures.

HEMISECTION
 Hemi section is defined as separation of a multi rooted tooth and
the removal of a root and the associated portion of the clinical
crown.
Sutures placedResected root
Deep periodontal pocket Flap raised

BISECTION OR “BICUSPIDIZATION”
Refers to a division of a crown that leave the two halves and
the respective roots.
 BS should be considered in mandibular molars in which
periodontal disease has invaded the bifurcation and repair
of internal furcation perforation has been unsuccessful.
 The furcation is then turned into an interproximal space
where the tissue is more manageable by the patient

INTENTIONAL REPLANTATION
 Defined as the act of deliberately removing a tooth and following
examination, diagnosis, endodontic manipulation and repair
returning the tooth into its original socket.
INDICATIONS
 Difficult access
 Anatomic limitations
 Perforation in areas not accessible surgically.
 Failed apical surgery
 Apical surgery creating defect
 Accidental avulsion( unintentional replantation)

Contraindication
 Pre-existing moderate to severe periodontal disease
 Curved and flared roots
 Non restorable tooth
 Missing interseptal bone
3 factors that directly affect the outcome of intentional
replantation.
 Extra oral time
 Keeping PDL cells viable
 Minimizing damage to the cementum and pdl ligament cells
during elevation and extraction

Endodontic microsurgery
 DEFINITION
 A surgical procedure on exceptionally small and complex structures
with an operation microscope.
(Kim et al)
 The microscope has changed surgical endodontics from a “blind”
technique to one that is visually dominated.
 It enables the surgeon to assess pathological changes more precisely
and to remove pathological lesions with far greater precision, thus
minimizing tissue damage during surgery.

Indications
 Failure of previous nonsurgical endodontic treatment
 Failure of previous endodontic surgery
 Anatomic deviation
 Procedural errors
Contraindication
 Periodontal health of the tooth
 Patient health consideration
 Surgeons skill and ability
Hard tissue management
 Osteotomy: H161 lindermann bone cutter----- 8x to 16x
 Periradicular curettage: Columbia no 13 and no14 ---10x to 16x
 Apical resection: lindermann bur -----4xto 8x

Comparison of traditional v/s microsurgery
Kim and Rubenstein, 2001
PROCEDURE TRADITIONAL MICRO-SURGERY
Identification of
apex
Difficult Precise
Osteotomy Large (=>10
mm)
Small (<5mm)
Root surface
inspection
None Always
Bevel angle Large (45o) Small (<10o)
Isthmus
identification
Nearly impossible Easy
Retro
preparation
Approximate Precise
Root end filling Imprecise Precise

SURGICAL SEQUELAE
Pain:
- Minimal and of short duration, if the tissue management is adequate
- Long acting Local anesthetics
- Analgesics and Anti inflammatory drugs
Swelling:
Causes:
○ Post surgical edema
○ Hematoma
○ Infection
Management:
Inform patient
Reassure patient
Cold pack application

MANAGEMENT:
Cold pack application
Pressure packs: 2X 2 inch gauge or wet tea bag held with moderate pressure
for 10- 15 minutes.
If severe return to the dental clinic - Resuturing and use of hemostatics
(Tannic acid: hemostatic)
•Improper elevation and Retraction
•Incision into muscle attachment
•Inadequate suturing
•Trauma due to brushing, mastication
Bleeding

Common in elderly patients with fragile capillaries
Causes:
•Bruising
•Soft tissue compression
Depends on: site
degree of trauma
complexion
Ecchymosis
Discoloration of the facial or oral soft tissues caused
by extravasation and subsequent breakdown in the
subcutaneous tissue

CONCLUSION
Endodontic surgery is dynamic and it is
imperative that scientific investigation
continue, concepts ,techniques and materials
used in endodontic surgery must be continually
evaluated and modified and more emphasis
must be placed on the assessment of long-term
outcome

REFERENCE
 Pathways of the Pulp by Stephen Cohen, Richard C. Burns,7th,8th Edition
 Endodontics by John I. Ingle, Leif Bakland 5th Edition
 Microsurgery in Endodontics: Syngkuc Kim
 Surgical Endodontics: Guttman and Harrison: Mosby:1994.
 Contemporary surgical endodontics: Stockdale: 2 Edition
 Contemporary oral and maxillo facial surgery:Peterson: 5th Edition.
 Colour Atlas of surgical endodontics: Barnes
 Colour atlas of endodontic surgery: Loushine
 Microscopes in endodontics: DCNA: Syngkuc Kim, July; 41 (3)1997.
 Ultrasound real time imaging in the differential diagnosis of periapical lesions: Cotti
et al. IEJ; 36; 2003.

Periradicular Surgery: A Concise Guide

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (10)

Similaire à Periradicular Surgery: A Concise Guide

Similaire à Periradicular Surgery: A Concise Guide (20)

Dernier

Dernier (20)

Periradicular Surgery: A Concise Guide