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PRINCIPLES OF
ENDODONTIC SURGERY
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DEFINITION:
Endodontic surgery is the management or prevention of
periradicular pathosis by a surgical approach.
It includes:
Abscess drainage
Periapical surgery
Corrective surgery
Root removal
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RATIONALE:
To remove the causative agents of periradicular pathology.
To restore the periodontium to a state of biologic and
functional health.
OBJECTIVE:
To ensure the placement of a proper seal between the
periodontium and the root canal foramina.
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PERIAPICAL SURGERY
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1. Anatomic po!"#m$ p#%#ntin& comp"#t# '#!i'#m#nt(
o!t)ation
a. Calcified bloc!ed" canals
b. #evere root curvatures
c. Constricted canals
*. R#$toati%# con$i'#ation$ t+at compomi$# t#atm#nt
a. Presence of a crown
b. A tooth that has been restored with post and core
,. -oionta" oot /act)# 0it+ apica" n#co$i$
I$%ICATI&$#
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'. Irretrievable material preventing canal treatment or
retreatment
(. Procedural errors during treatment overobturation"
. La p#iapica" "#$ion$ t+at 'o not #$o"%# 0it+ oot
cana" t#atm#nt
). *ollowing completion of endodontics+ if symptoms are
associated with the tooth chronic fistula and drainage+ pain
and sudden onset of a vestibular space infection".
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Contraindications or cautions" for periapical
surgery
,. -nidentified cause of root canal treatment failure
. /hen conventional root canal treatment is possible
0. /hen retreatment of a treatment failure is possible
'. #imultaneous root canal treatment and apical surgery
(. Anatomic structures e.g.+ ad1acent nerves and vessels" are in
close pro2imity
3. #tructures interfere with access and visibility
). Poor crown4root ratio
5. #ystemic complications e.g.+ bleeding disorders"
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STEPS IN PERIRADICULAR SURGERY
A. Anesthesia
6. Incision and flap reflection
C. Periapical e2posure
%. Periapical curettage
E. Root7end resection
*. Root end preparation
8. Root7end restoration
9. *lap repositioning and suturing
I. Post surgical care
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I2 FLAP DESIGN
A properly designed and carefully reflected flap
results in good access and uncomplicated
healing
The incisions most commonly used are:
a. #ubmarginal curved semilunar"
b. #ubmarginal +and
c. *ull mucoperiosteal sulcular"
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a. #emilunar incision
#lightly curved half7moon horiontal incisionin the alveolar mucosa
Advantage:
Easy access and ;uic! access to the
periradicular structures
8ingival attachment is not disturbed %isadvantage:
*ull root surface not seen
Root resection difficult
#low healing
E2cessive hemorrhage #carring
-#nc#3 contain'icat#' /o mo$t
#n'o'ontic $)
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b. #ubmarginal incision
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Advantages:
Esthetics less incidence of gingival recession"
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C. *ull mucoperiosteal flaps#ulcular incisions"
,. Triangular flap
I$%ICATI&$#: >a2illary incisors and posterior teeth.
&nly recommended flap for mandibular posterior teeth.
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A%?A$TA8E#:
@ 8ood wound healing
@ Ease of flap re7appro2imation with minimumnumber of sutures
%I#A%?A$TA8E#:
@
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. Rectangular flap
I$%ICATI&$#: Anterior teeth
>ultiple teeth
Teeth with long roots li!e ma2illary canines
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A%?A$TA8E#:
@ Increased surgical access to root ape2
@ Reduces retraction tension
@ *acilitates repositioning
%I#A%?A$TA8E#:
a.%ifficulty in re7appro2imation of flap margins
b.8ingival attachment violated
recession+ crestal bone loss and dehiscence.
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0. Trapeoidal
#imilar to rectangular e2cept the vertical incisions intersect
the horiontal incision at an obtuse angle so as to create abroad based flap with the vestibular part wider than the
sulcular portion
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F"ap #/"#ction *lap reflection is the process of separating the soft tissues
gingiva+ mucosa+ and periosteum" from the surface of the
alveolar bone.
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II2 P#iapica" #5po$)#
A soft tissue lesion is seen
fre;uently+ after flap reflection
If the opening is small+ it is
enlarged using a large surgical
round bur+ until appro2imately half
the root and the lesion are visible
Radiographs are used in
combination with clinical findings
to locate root ape2
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III2 P#ia'ic)"a C)#tta
A surgical procedure to remove
diseased tissue from alveolar bone
in the peri radicular area or lateral
region surrounding a pulpless
RCT" tooth
A suitably sied sharp curette is
used for enucleation of the lesion
-sually+ remnants of tissue remain+which is not a problem
9emorrhage control to be achieved
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IV2 Root #n' #$#ction
Indicated because it removes
the region that most li!ely had
the poorest obturation
70 mm of the root is resected
6evel of resection
B7,B degrees
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V 2 Root #n' p#paation an'
#$toationPurpose:
To create a cavity to receive a root7end
filling.
The filling seals the canal system+ so
that no bacteria or bacterial by
products can enter or leave the canal
Instruments -sed:
#mall round or inverted cone bur
-ltra sonic tips
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RETROGRADE ROOT END RESTORATIVE 6ATERIALS
Amalgam
Glass ionomer cement
Zinc oxide eugenol cement
Intermediate restorative material (IRM) Super ethoxybenzoic acid (!A)
Gutta percha
Mineral trioxide aggregates (MTA)
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INSPECTION AT VARYING 6AGNIFICATIONS
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PRINCIPLES INVOLVING RETRO PREPARATION AND RESTORATION
@0mm: root resection+ B7,Bobevel
@0mm of retrograde restoration
Provides 3mm of seal from original ape2 thus sealing all
accessory and lateral canals
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VI2 SOFT TISSUE REPOSITIONING AND
CO6PRESSION The elevated mucoperiosteum is gently replaced to its original
position with the incision lines appro2imated as closely as
possible.
Ti$$)# comp#$$ion:
-sing a surgical gaue moistened with sterile saline+ gently apply
firm pressure to the flapped tissue for to 0 minutes ( minutes
for palatal tissue" before suturing.
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VII 2 SUTURING
P)po$#:
To appro2imate the incised
tissue and stabilie the flapped
mucoperiosteum until
reattachment occurs.
#ling suture is demonstrated in
the picture.
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