Endodontic surgery

1. Endodontic Surgery

Endodontc Surgery
Dr. Yousra Nashaat
O6U
Dr Yousra Nashaat
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2. EndodonEnEEtic Surgery

By
Dr. Yousra Nashaat
Assoc. Prof of Endodontcs
October 6 University
O6U
Dr Yousra Nashaat
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3. II. Apical surgery (periradicular) 60-80% of endodontic surgery.

Defnition:
• Surgical management in the apical
part of the roots of the teeth.
Aim:
• Deals with the defect or excision of
the tssue related to the apical part of
the roots of the teeth.
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Dr Yousra Nashaat
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4. Any apical surgery includes

Pre-surgical workup :
1- The surgeon must
explain to the patent the
procedures & all available
alternatve treatments .
2- Patent should be
informed by any changes
in the daily actvites(drug
regimen ).
3- (Medical history, blood
pressure). Should be
recorded to predict if any
complicatons.
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Disinfection of the
operating theatre
1- Scrubbing all areas
where surgical
instruments will be
placed & any area
touched by the operator
during the surgery .
2- Instruments must be
kept covered with a
sterile towel .
3- A complete sterile set
of Surgical
armamentarium should
be available
Dr Yousra Nashaat
Patient preparation
1- Patent must wear a
sterile gown
2- Towels with antseptc
soluton are used to
scrub the exposed area
of the face & around the
lip & mouth.
3- Patent must rinse
with a mouth wash, to
decrease the number of
micro organisms.
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5. A complete sterile set of Surgical armamentarium

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Dr Yousra Nashaat
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6. Surgeon preparation

Disinfectng soap ( Betadine) with a brush will
be used to scrub from the elbow down .
After scrubbing, the
hands are washed , air
dried with sterile towel.
Surgeon washes his face & puts on a mask & cap.
Sterile gloves are then worn.
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Dr Yousra Nashaat
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7. Anesthesia & pain control (Local anesthesia )

Anesthesia & pain control
(Local anesthesia )
Block
anesthesia
Prolonged deeper
anesthesia
Infltration
injection
+
Hemostasis
Better visibility of the surgical
feld.
i- Desired level of anesthesia.
ii- Desired level of Vasoconstrictor
bleeding at the operation site
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Dr Yousra Nashaat
the
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8. Surgical Procedure I- Incision

• A cut made with a sharp blade through the tssue.
Vertcal
• Firm incision with no. 15 blade.
• Incision must be :
I. Made through the mucosa, connectve tssue & the
periosteum.
II. Blade edge should touch the bone & not removed untl
Horizontal
the cut is complete .
III. Pen grasp for beter control.
• Types of Incisions according to directon to the teeth
Vertical
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Horizontal
Dr Yousra Nashaat
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9. II- Flap design Exposure of surgical site

Aim
1) Refecton of the soft tssue overlying the
surgery site in order to give the best visibility.
2) To maintain healthy fap tssue to cover the
surgical site
decrease pain and allow
optmum healing.
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Dr Yousra Nashaat
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10. Principles and Guidelines for Flap Design

1- Wide faa base for adequate blood supply 3-Width of the fap must include at least one
Healing
tooth on either side of the surgical sites.
2-Incisions should be over healthy solid bone. 4- Never incise through the inter-dental aaailla
Avoid incision over the bony defects/
either include or exclude the interdental papilla.
periapical lesion
5-Avoid horizontal and severely angled
vertcal incision.
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Dr Yousra Nashaat
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11. Principles and Guidelines for Flap Design

6- Full thickness faa should be raised to
maintain the integrity of the periostum and
promote bone healing.
7. Vertcal incisions should be
made aarallel or slightly oblique to
long axis of the teeth and placed in
the bony concavites between the
bony eminencies.
8-Vertcal incision must extend to allow the
bone retractor to rest on solid bone.
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Dr Yousra Nashaat
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12. Types of flaps of Surgical flap 1. Full mucoperiosteal flaps

Types of faps of Surgical fap
1. Full mucoperiosteal faps
A. Triangular (one vertical releasing incision+ horizontal incision)
Advantages:
1. Easy to repositon
2.Minimal number of sutures
required.
2. Suitable for treatng short roots.
3. Blood supply to fap is maximal.
B. Rectangular (two vertical releasing
incisions
+ horizontal incision).
Advantages:
1. Increased surgical access to the
root apex.
2. Convenient for treatng more
than one teeth and large lesions.
3. Facilitate periodontal curetage.
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Dr Yousra Nashaat
• Disadvantages:
1. Limited surgical access
(single vertcal incision).
2. Limited surgical access to
expose the root apexes of
long teeth (maxillary canine).
3. More difcult retracton.
4. Difcult Suturing between
teeth.
• Disadvantages:
1. Difcult in reapproximaton
2. Difcult in post-surgical
stabilizaton than
triangular fap result in
high potental for fap
dislodgment.
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13. Types of flaps of Surgical flap 1. Full mucoperiosteal flaps

Types of faps of Surgical fap
1. Full mucoperiosteal faps
C. Trapezoidal (Broad-based rectangular).
Vertcal incisions making an obtuse angle
with horizontal incision
D. Horizontal/Gingival/Envelope (Intrasulcular incision no vertical
releasing incision).
Indicated in repair of cervical defects :
1. Root perforaton.
2. Root resorpton.
3. Root caries.
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Dr Yousra Nashaat
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14. Types of flaps of Surgical flap 2-Limited mucoperiosteal flaps

Types of faps of Surgical fap
2-Limited mucoperiosteal faps
A-Submarginal curved (Semilunar fap):
Advantage:
1-Simple to incise & refect.
2-Gives direct access to root apex.
3-Patent able to maintain good oral
hygiene.
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It is formed by a curved incision in the
alveolar mucosa and the atached gingiva.
The incision begins in the alveolar mucosa
extending into the atached gingival and
then curved back into the alveolar mucosa.
Disadvantage:
1. Minimal visibility.
2. Poor surgical access.
3. Placing the line of incision over the bony
defect(wound cannot be closed over the sound
bone).
4. Excessive force for retracton
tearing at
the corner.
5. Tension impaired healing
6. NoNashaat
reference points for replacing the faps. 14
Dr Yousra

15. Types of flaps of Surgical flap 2-Limited mucoperiosteal flaps

Types of faps of Surgical fap
2-Limited mucoperiosteal faps
B- Luebke-Ochsenbein (Submarginal scalloped
rectangular)
• Modifcaton of rectangular fap.
• Horizontal incision is scalloped and follows
the contour of the marginal gingiva.
Advantages:
1. Decrease the gingival recession Esthetcs.
2. Good accessibility and excellent visibility to
surgical site.
3. Simple to incise and refect.
Disadvantages:
1. Vertcal BV and collagen fbers are severed, resultng in
more bleeding
2.Possibility of fap shrinkage, delayed
healing, and scar formaton.
2. Crossing any bony eminence by incision line
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Dr Yousra
Nashaat healing.
result
in delayed
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16. Flap reflection

Flap refection
It is the process of separatng the soft tssues
(gingiva, mucosa and periosteum) from the
surface of the alveolar bone.
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Dr Yousra Nashaat
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17. Flap reflection

Flap refection
Mucoaeriosteal faas
Submarginal faas
• It begins in the vertcal
incision few mm apical to
the juncton of the
horizontal and vertcal
incision.
• Starts in horizontal since
the horizontal incision is
placed in the atached
gingiva.
2
1
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Dr Yousra Nashaat
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18. Flap retraction

It is the process of holding in positon the refected soft tssues.
Aim:
• Provides both visual and operatve access to the periradicular and radicular
tssues.
Instruments:
• Endodontc tssue retractors (Arnes/ Seldon /Minnesota retractor.
Proaer retracton deaends on:
• 1. Adequate extension of the fap incisions.
• 2. Proper refecton of the mucoperiostum.
Princiales of tssue retracton
• 1. Retractor should rest on sound bone with light aressure
• 2. Small groove by round bur can be cut in the bone to stabilize the retractor
• 3. Crushing tssue should be avoided
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Dr Yousra Nashaat
• 4. Sterile physiological saline is used to maintain tssue hydraton .
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19. Hard tissue management (Locating the apex)

1. Aaex locaton: (Always search for bony defect)
• Periapical lesion results in loss of buccal or labial cortcal
plate.
• Probing with a small sharp periodontal curete
Thin fragile undermined cortcal plate.
The aaex can be located by:
• a) Measurement by well angled radiograph
• b) Sterile ruler alongside the long of the tooth to mark root
apex.
• c) A small defect is created on the surface of the cortcal plate.
• d) Radiopaque marker( small piece of lead foil / small piece of
GP is placed in the bony defect and a direct radiograph is
exposed.
• e) Measurement of last fle used for canal enlargement.
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Dr Yousra Nashaat
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20. Hard tissue management (Locating the apex)

2. Osseous entry:
• Bone is removed using round surgical
burs and sufcient coolant at high
speed to reduce vibraton and heat
generaton.
• Imaact Air 45° or Air king hand aiece
Advantage : Air is exhausted to the rear
of the turbine rather than toward the
surgical site
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Emphysema
Dr Yousra Nashaat
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21. Surgical curettage

Excision or inoculaton of pathological tssue related to the apical part of the root, using a sharp
curete of suitable size.
Indicatons:
1. Gain access and visibility of the apex.
2. Remove the infamed tssue.
3. Obtain biopsy.
4. Reduces hemorrhage.
Technique: (Beter removed in one aiece)
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Dr Yousra Nashaat
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22. Surgical curettage

Curved bone curete is placed between the soft tssue
mass and the lateral wall of the bony crypt with the
concave surface of curete facing the bone.
Once the soft tssue is freed, the
bone curete should be turned
with the concave porton toward
the soft tssue and tssue is
scooped out of the cavity
• Frequent irrigaton ( saline )and proper sucton
• Proper visualizaton :Bony cavity and the apex of
treated tooth.
• Tissues should be immediately placed in a botle
containing 10% bufered formalin soluton for
transportaton to the pathology laboratory.
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Dr Yousra Nashaat
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23. Root end management 1- Root resection /Apicectomy

Defnition: Resecton of the apical part of the root & removal with the atached
pathological tssue.
Objectives
Instruments for root resection
1. To gain access to pathologic
tssue behind apex.
2. Removal of anatomic variatons.
3. Removal of operator errors.
4. To gain access to the canal for
examinaton and restoraton.
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1. Tapered fssure bur at high speed under
sterile saline.
2. Lasers ( ER-YAG , CO2 laser).
Advantages of laser:
• 1. Seal dentnal tubules.
• 2. Bacterial contaminaton.
• 3. Postoperatve pain.
• 4. Homeostasis and visualizaton
• 5.Sterilizaton of the contaminated root
apex.
• 6. Risk of contaminaton of the
surgical site.
Dr Yousra Nashaat
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24. Root end management 1- Root resection /Apicectomy

Extent of resecton:
• Removal of 3mm of the root end to expose the canal
and eliminate accessory canals.
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Dr Yousra Nashaat
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25. Root end management 1- Root resection /Apicectomy

45°
Angle of root resecton:
• Historically: angle of root-end resectons is 45° from the long axis of the root
facing toward the buccal aspect of the root.
• Recently : (Microscope and Ultrasonic)
• Resecton can be done perpendicular to long axis of the root 0° - 10°
0-10°
Advantages of 0° degree over 45°:
• 1) Maintain maximum root length.
• 2) Fewer dentnal tubules exposed thereby reducing leakage.
• 3) Reduced osteotomy size (less damage to buccal cortcal plate).
• 4) Beter healing.
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Dr Yousra Nashaat
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26. Root end management 2- Root end preparation

Requirements:
1. The apical 3mm of the root canal must be freshly
cleaned and shaped.
2. Parallel preparaton to long axis.
3. Adequate retenton form must be created.
4. All isthmus tssue when present must be removed.
5. Remaining dentn walls must not be weakened.
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Dr Yousra Nashaat
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27. Root end management 2- Root end preparation

Cavity designs:
1) Class l type :
• Small cavity is prepared parallel to long axis of the root
using the miniature hand piece with round or inverted
cone bur at a depth of 2-3 mm in the centre of the root.
2) Vertial Slot prepraton ( Matsura prepraton):
• Vertcal cut is made 5-7mm with aarallel fssure bur
from the buccal surface to the depth of the lingual wall
of the canal.
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Dr Yousra Nashaat
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28. Root end management 2- Root end preparation

3) Tunnel preparaton:
Drilling a hole extending from labial surface of
the root peripendicular to long axis of the root
canal reaching root canal.
Undercut is made at the end of the tunnel, then
fll root end.
Root apex is resected to level of the flling.
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Dr Yousra Nashaat
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29. Root end management 2- Root end preparation

4) Ultrasonii preparaton:
• Specially designed ultrasonic root end preparaton tps are
used.
Advantages of ultrasonic ta over bur:
1. Less need for root beveling
2. Placing the preparaton within the confnement of the root.
3. Conserve root structure
4. Reduce possibility of root perforaton.
5. Deeper preparaton
6. Parallel walls for beter retenton of root end flling material.
7. Clean cavity free from debris & smear layer.
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8. Precise isthmus preparaton.
Dr Yousra Nashaat
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30. Root end management 2- Root end preparation

• 0° degree bevel expose less of dentnal tubules to oral
environment.
• Beveling results in opening of dentnal tubules on resected
tooth surface.
Technique:
• 1) Stain root end with methylene blue.
• 2) Explorer is used to make tracking groove 0.5-1mm in
depth when there are 2 canals in 1 root.
• 3) Ultrasonic tp under water is used in light touch.
• 4) Ideal retro preparaton depth is 3mm.
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Dr Yousra Nashaat
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31. 3- Root end filling

3- Root end flling
Aim
• To establish a seal between the root canal space and the periapical tssues.
Ideal requirements of retrograde flling material: (It should)
1. Biocompatble.
2. Adher to the tooth structure ( well sealing ability).
3. Dimensionally stable.
4. Insoluble in tssue fuids.
5. Easily introduced.
6. Unafected by moisture during applicaton or after setng.
7. Radio-opaque.
8. Does not stain tooth or periradicular tssue (tatoo).
9. Noncorrosive.
10. Bacteriocidal or bacteriostatc.
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Dr Yousra Nashaat
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32. 3- Root end filling Root end filling materials

3- Root end flling
Root end flling materials
Material
Advantages
1) Amalgam (Zinc free). 1. Easy to manipulate
2. Available
3. Well tolerated by soft tssues
4. Radiopaque
5. Initally provides tght apical
seal
Disadvantages
1. Slow setng
2. Dimensionally unstable
3. It shows leakage
4. Stains overlying soft tssues,
resultng in
formaton of tatoo.
5. More cytotoxic than IRM,
super EBA or MTA.
2) Zinc Oxide Eugenol
Cements
1. Unmodifed ZOE cements
are weak and have a long
setng tme.
2. High solubility.
3. On contact with moisture
releases free eugenol, which is
irritant to tssues.
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Dr Yousra Nashaat
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33. 3- Root end filling Root end filling materials

3- Root end flling
Root end flling materials
Material
Advantages
IRM :
ZOE cement reinforced
by additon of 20%
polymethacrylate by
weight to ZnO powder.
2. Less absorbable.
3. Milder reacton than
unmodifed ZOE .
4. Mild to zero infammatory
efect after 30 days.
5. Higher success rate
compared to amalgam.
Super EBA
ZOE + ethoxy benzoic
acid
(EBA) to alter the setng
tme and
strength
Powder contains:
• 60 % zinc oxide
• 34 % silicone dioxide
6%natural resin.
1. Neutral pH
2. Low solubility
3. Radiopaque
4. Yield compressive and
tensional
5. Less leakage than amalgam
7. Non resorbable
8.Good adaptaton to canal
walls compared with amalgam
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Dr Yousra Nashaat
Disadvantages
1. Difcult to manipulate
short setng tme
2. Afected by humidity.
3. Tends to adhere to all
surfaces(Difcult to
place)
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34. 3- Root end filling Root end filling materials

3- Root end flling
Root end flling materials
Material
Advantages
Mineral trioxide aggregate.
1) Least toxic.
2) Biocompatble.
3) Hydrophilic.
4) High PH may induce hard
tssue formaton.
5) High sealing ability.
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Dr Yousra Nashaat
Disadvantages
1) Longest setng tme.
2) Difcult in manipulaton.
3) Expensive.
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35. 3- Root end filling Technique

3- Root end flling
Technique
• Put bone wax in the cavity during condensaton to atain a
clean surgical wound , free from retroflling material
remenants.
USE
Retro-mirrors
Retro-carrier
Retro-plugger
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Retro-flling material is burnished.
Dr Yousra Nashaat
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36.

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Dr Yousra Nashaat
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