Endodontic Surgery Dr. Rafik Al Kowafi BDS, MSc, German board of - PDF document

Endodontic Surgery Dr. Rafik Al Kowafi BDS, MSc, German board of Oral and Maxillofacial Surgery ( Berlin- Germany), Doctoral degree by LBMS Deffinition • Endodontic surgery is the management or prevention of periradicular pathosis by a surgical approach. • In general, this includes: 1. Periapical surgery. 2. Hemisection/root amputation. 3. Intentional replantation. 4. Corrective surgery. 5. Abscess drainage. 30 march 2016 LIMU Dr. Rafik AL Kowafi 2 1

Periapical surgery (Apicoectomy) • Apicectomy is the surgical removal of the apical portion of a tooth and its associated pathological periapical tissues. • The aim of apicectomy is to eradicate persistent infection in the periapical tissues, and the purpose of retrograde filling is to gain complete seal and to obstruct the exit of bacteria and irritants, which remained in the root canal. 30 march 2016 LIMU Dr. Rafik AL Kowafi 3 Periapical surgery (Apicoectomy) • Indications : 1. Failed conventional endodontic. Reasons of failure include: – Inadequately filed canals. – Coronal leakage. – Root fracture. – Missed canals. – Restoration failure. – Fractured instrument. – Perforations. 30 march 2016 LIMU Dr. Rafik AL Kowafi 4 2

Periapical surgery (Apicoectomy) 2. Conventional endodontic is impracticable. Reasons: i. Anatomical: a) Calcified root canal. b) Impassable pulp stone. c) Marked curvature of a root canal. d) Incomplete apical development. ii. Pathological: a) Inability to disinfect the root canal. b) Inability to control persistent inflammatory changes in the periodontal tissues. c) Root resorption. d) Persistent pathological changes at the apex of the root (e.g cyst). 30 march 2016 LIMU Dr. Rafik AL Kowafi 5 Periapical surgery (Apicoectomy) III. Operator-induced (Iatrogenic). a) Surgically accessible perforation of the root. b) Irretrievable root filling materials, “e.g. Sealer paste may be expressed into the apical tissues, or gutta percha extruded through the apex may cause compression of the inferior alveolar neurovascular bundle”. c) Presence of post in root canal which cannot be removed to perform retreatment. d) Fractured reamer or file that cannot be retrieved by non-surgical endodontics. e) Non-negotiable ledging iv. Traumatic: – Horizontal fracture of the apical third of a root, with pulp necrosis 3. Need for surgical drainage. 4. Biobsy 30 march 2016 LIMU Dr. Rafik AL Kowafi 6 3

A , Anatomic problem of a severe root curvature for which h surgery is indicated. B , Apical resection and root end retrograde mineral. C , Four months postoperatively shows regeneration or bone. 30 march 2016 LIMU Dr. Rafik AL Kowafi 7 A, Irretrievable separated instruments in mesial- buccal canal. A separated instrument only requires surgical intervention if the tooth becomes symptomatic. B, Following resection of root with fractured instrument and placement of Irretrievable posts and apical amalgam seal. pathosis. Root end resection and filling with amalgam to seal in irritants. 30 march 2016 LIMU Dr. Rafik AL Kowafi 8 4

Repair of perforation. A, Furcation perforation A, Overfill of injected obturating material has results in extrusion or material (arrow) and resulted in pain and paresthesia as a result of damage to inferior alveolar nerve. B, Corrected by pathosis. B, After flap reflection and exposure, retreatment, then apicectomy, curettage, the defect is repaired and a root end amalgam fill. 30 march 2016 LIMU Dr. Rafik AL Kowafi 9 Periapical surgery (Apicoectomy) • Contraindications: A. Local contraindications: 1. Possibility of retreatment. 2. Unidentified cause of treatment failure. 3. Teeth with poor prognosis. 4. Poor access to the periapical tissues. 5. Anatomical structures may compromise flap design e.g. a short sulcus depth or prominent frenal or muscle attachments. 6. Poor crown/root ratio. 7. Close proximity to: Inferior alveolar nerve, mental nerve and maxillary sinus. 8. Coexisting periodontal disease such as horizontal or vertical bone loss. 30 march 2016 LIMU Dr. Rafik AL Kowafi 10 5

Periapical surgery (Apicoectomy) B. Systemic contraindications: 1. Severe uncontrolled metabolic diseases. 2. Uncontrolled leukemias and lymphomas. 3. Severe uncontrolled cardiac diseases. 4. Severe uncontrolled hypertension. 5. Severe bleeding diathesis 30 march 2016 LIMU Dr. Rafik AL Kowafi 11 Treatment planning for apicoectomy 1. History. 2. Clinical examination. 3. Radiological examination. 4. Case selection. 5. Referral of patients. 6. Pre operative medications. 7. Instrumentation. 8. Surgical procedure. 30 march 2016 LIMU Dr. Rafik AL Kowafi 12 6

History • The patient may complain of pain, swelling, unpleasant taste “as pus discharge”, tenderness or mobility of the tooth on biting. 30 march 2016 LIMU Dr. Rafik AL Kowafi 13 Clinical assessment A. Extraoral examination – A thorough examination should be undertaken, in particular noting: 1. Regional lymph nodes. 2. Swelling. 3. Mouth opening. 30 march 2016 LIMU Dr. Rafik AL Kowafi 14 7

Clinical assessment B. Intraoral examination 1. General status of the mouth 2. Presence of local infection, swelling and sinus tracts 3. Presence, quantity and quality of restorations, caries and cracks 4. Quality of any cast restorations (marginal adaption, aesthetics, history of decementation) 5. Periodontal status, including the presence of isolated increased probing depths 6. Occlusal relationship – is the tooth a functioning unit or is there potential for function? 7. Sensibility and percussive testing of the suspected tooth, adjacent teeth. 30 march 2016 LIMU Dr. Rafik AL Kowafi 15 Radiological assessment • Periapical X-ray. – At least 3mm of the tissues beyond the apex of the roots should be radiographically assessed. – If a large periradicular lesion is suspected further radiographs such as OPG, occlusal views or CBCT may be required. – If a sinus tract is present then a radiograph should be taken with a gutta-percha cone in place to delineate the tract. – During radiographic assessment, the root morphology, periapical pathology, adjacent structures(nerves, maxillary sinus), quality of the RCT and the location of the # instrument if present, all should be evaluated. 30 march 2016 LIMU Dr. Rafik AL Kowafi 16 8

Case Selection • For GDP surgery should initially be restricted to maxillary incisors or canines. • Other teeth pose clinical problems that diminish the chance of success as narrow or curved roots in mandibular incisors or restricted access to the palatal root of maxillary molars and premolars. Also it may be difficult to seal a lateral root perforation because of restricted access. • As experience is gained, it becomes possible to undertake more demanding surgery. 30 march 2016 LIMU Dr. Rafik AL Kowafi 17 Referral of Patients • Patient should be referred for specialist care: – If the dental surgeon feels that he or she has inadequate experience to undertake the surgery. – If there is any doubt about the patient’s medical history. – If there are anatomical or pathological features that may complicate surgery. 30 march 2016 LIMU Dr. Rafik AL Kowafi 18 9

Pre Operative Medications • The drugs prescribed will vary according to the individual preferences and specific needs of the patient. • Some of whom may have coexisting medical disease. • Anxiolytics “e .g. Diazepam” may be prescribed to reduce patient anxiety. • Antibiotics (if needed). • An antimicrobial mouth rinse such as Chlorhexidine Gloconate 0.2% is recommended to cleanse the mouth before surgery. 30 march 2016 LIMU Dr. Rafik AL Kowafi 19 Instrumentation • Adequate lighting source. • Microhead handpiece and burs or ultrasonic preparation tips. • Apical retrograde micro- mirror and micro-explorers. • Local anesthetic syringe and cartridges. • Scalpel handle and blade No. 15. • Needle holder and scissor • Mirror. • Surgical handpiece with surgical burs. • Bone file 30 march 2016 LIMU Dr. Rafik AL Kowafi 20 10

Instrumentation • Surgical curettes with different sizes. • Periosteal elevator. • Cotton pliers. • Small hemostat. • Suction tips (small, large). • Suture material. • Flap retractor • Irrigating syringe. • Miniaturized amalgam applicator for retrograde fillings. • Narrow amalgam condensers. 30 march 2016 LIMU Dr. Rafik AL Kowafi 21 Instrumentation 30 march 2016 LIMU Dr. Rafik AL Kowafi 22 11

Periapical surgery (Apicoectomy) • Periapical surgery includes the following: 1. Local anesthesia. 2. Incision and flap design. 3. Flap reflection and retraction. 4. Bone removal and exploration of the root surface for fractures or other pathologic conditions. 5. Curettage of the apical tissues. 6. Resection of the root apex. 7. Retrograde cavity preparation. 8. Placement of the retrograde filling material. 9. Wound debridement. 10. Radiographic verification 11. Flap replacement and suturing. 30 march 2016 LIMU Dr. Rafik AL Kowafi 23 Incision and flap design • Type of flaps: a) Triangular (one vertical releasing incision). b) Rectangular (two vertical releasing incisions). c) Trapezoidal (broad-based rectangular). d) Envelope or horizontal (no vertical releasing incision). e) Semilunar flap. f) Submarginal scalloped (Luebke-Ochsenbein). 30 march 2016 LIMU Dr. Rafik AL Kowafi 24 12