Cons Sheet 6 (1) PDF

Doctor: Ahmad maaita Writer: Omar Alobeid Corrector:  Surgical endodontics -2 This lecture continues what we started last lecture… What are the complication that may happen during endodontic surgery ( apical surgery ) ? a) Hemorrhage : This could happen during or after surgery (pos...

Doctor: Ahmad maaita Writer: Omar Alobeid Corrector:  Surgical endodontics -2 This lecture continues what we started last lecture… What are the complication that may happen during endodontic surgery ( apical surgery ) ? a) Hemorrhage : This could happen during or after surgery (post-op) , To avoid : Good history taking: you should define patients with bleeding disorder or patient with high bleeding tendencies you should perform your surgery with Atraumatic technique as possible ( you should do your best to avoid hitting artery ) lower arch tend to have more arteries around the inferior alveolar nerve ( small arteries ) and if you hit the lingual artery its very hard to control bleeding (it’s a nightmare) so do your best avoiding such thing and know your anatomy well. Use LA with vasoconstrictor (1:50,000 adrenaline ) Helps a lot with some local majors. Post operative bleeding can be avoided by assuring that the patient is doing our instructions like good pressure and ice packs , avoiding hot food or drinks and the patient should have a good rest ( no exercising ) b) Pain during curettage of granulation tissue : We focus on the area we are working on but we should avoid inflamed areas when we give LA because it wont be effective so we might go for nerve block in this cause ( ID Block , infra orbital nerve …) c) Damage to adjacent teeth : Best Avoided by good planing and judicious bone removal. So if you need CBCT or surgical guide go ahead. d) Perforation of the lining of the maxillary antrum : While working near the maxillary sinus the membrane can be toured so be-careful not to push your tools to the sinus and after finishing your procedure if it’s a tiny little tear you can stitch it and if it’s a big tear you need to use a membrane. e) Surgical Emphysema ( subcutaneous tissue emphysema It could happen in your surgical work or in non surgical work. It happens because we use compressed air that escape into the facial spaces , it’s annoying because the patient face will swell rapidly and this make the patient afraid of what is happening. And crepitus sound might appear and may be elicited on palpation. -Management : Most of the time its self limiting (3-10 days ) the air get absorbed and it goes away but it carries the risk of infection elsewhere and in worst case it might carry the infection the the chest and result in chest pain.  Most of the time we need Antibiotics prescription. Pneumonediastinum is a rare complication of SE Air embolism is the worst case( its an emergency life threatening complication and there is a reported case of death because of air embolism after surgical emphysema during RCT ! ) During RCT when you try to dry the canal by Air syringes don’t direct you syringe vertically into te canal because that comprised air can escape, you should direct it 90 degrees to the tooth and Avoid long time usage).! f) Unsatisfactory placement of the root filling : The most common complication of apical surgeries. It happens because after removing part of the Root the clinician didn’t perform a class 1 retrograde cavity and we ended up with amplitude apex with a non retentive restoration above As in this Radiographs —>  g) Post-operative pain : As any other surgery , inflammation will happen after surgery and most of the time its painful. 99%of pain after surgery is part of the healing process and can be controlled with bob- narcotics analgesics , we can give Long acting LA at the end of the procedure too. But some long term pain might be because of surgical damage to the peripheral nerves which is called ( amputation neuroma ) and its very painful and happens in Macro or micro levels. h) Post-operative swelling : Compression with ice packs for the first 4-6 hours after surgery will help. It’s a part of healing unless you used Non sterile instruments or your technique were non sterile this might induce infection. Because the area is inflamed its hard to keep it clean and maintain good OH so its advised to give CHX mouthwash - In jordan they like to give the patient Dexamethasone and seratopeptidase to decrease inflammation. But dexamethasone is a steroid so it compromise our immunity which we need after surgery and seratopeptidase is a proteolytic enzyme that cause lysis of protein ( the doctor don’t think that they are needed and should not be given ) assuring the patient that e might have a little bit of swelling is better than adding medications  i) Ecchymosis : Risk should be explained in the informed consent Its normal and the more aggressive you are the more bruising you have Usually its self limiting condition and resolve within two weeks after surgery. j) Infection : May result in secondary hemorrhage , cellulitis or local abscess formation. Be careful during the surgery of Cross infection control and close your wound properly. Give post op instructions and include OH instructions. Antibiotics are prescribed for patient who need them only like ( immune compromised patient or patient with history of Infective endocarditis or patient with prosthetic valves or any new prosthetic joints ). k) Recession of the gingival margin : You need to asses it pre-op. If the patient has high lip line then you need to do all you can to preserve the gingival Architecture. - Arise because : Inadequate repositioning of the muco-periosteal flap Excessive pressure and retraction during procedure ( causes compromised circulation) Poor flap design  Make sure to have A clear , written post-operative instructions given to the patient together with telephone communication within 24H , Avoid misunderstanding and allows further supportive care and advice. Now moving on to the next part of the lecture which is other Surgical endodontic procedures: 1. Incision and drainage : Its important. Every GP should learn it and understand when and how to do it. It a palliative procedure ( Not a treatment) to relieve symptoms and get the patient a few days to receive a special treatment or rake the tooth out We need to drain pus ( As the name implies) and it decrease pressure, swelling and pain. Patient with Acute Apical abscess. ( I think the doctor means chronic ) usually come without pain because pus managed to find a way out By incision and drainage you remove large amount of bacteria. We need to find a fluctuating mass intra-orally because any extra-orall non fluctuating mass might be cellulitis ( not our job to drain send the patient To Maxillofacial Surgeon )  Incision technique: Number 11 blade is used in a staple motion all the way down to the bone and cut the periosteum then you assess the need of a drainage tube. And most of the time you should give Antibiotics. Or in case you have time to remove the cause ( RCT or extraction ) then you might skip Antibiotics and remove the cause. When we have abscess it hard to perform LA so you should inject your anesthesia in a ring form around the infected area and always inform the patient that its hard to reach a 100% Anesthesia. Or you can go for a nerve block 2. Trephination : Procedure where we perforate the buccal bone plate to relieve pressure from pus. There is no justification to do this procedure. In the past They used to perforate the skull for patient diagnosed with epilepsy because they though that they have devils inside.  This case to clarify drainage: 13y.o patient had RCT done and the tooth remained symptomatic. They took an X ray and saw RL extending to tooth4 and 5 and decided to do RCT for both despite being intact teeth. Symptoms didn’t resolve and when Dr ahmad saw the patient and took an X ray he asked for CBCT and that’s what he saw, this scary expansion on the bone plate and displacement of the roots on this very young patient and the first thing comes to mind is SCC , after Dr yazan came aspirated some fluid of the lesion and sent to histopathology , the report came and suggested that it’s a cystic fluid and the next step was relieving pressure by doing malsupialisation and drainage tube applied and left there for 4 month. 6 month later another CBCT shows good amount of healing.  3. Exploratory surgery : A minimally invasive procedure that allows for access and inspection of the root and the periradicular tissues and identify any hidden problems. Its used when we are not sure about our definitive diagnosis. Next surgical procedures are not commonly used and they are a little bit funny 4. Hemisection : The removal of A root and its coronal portion from a multi-roated tooth and leave the other part in its place There is some indications for it ( Dr doesn’t know what are the indications and he don’t use it at all ) This is an example ofthis procedure —>  5. Root amputation : Its similar to the last one , it’s the removal of a root from a multi-rooted tooth , leaving the coronal portion of the tooth intact. Just get rid of the root Its slightly better for upper tooth with 3 roots. This is an example —> 6. Bicuspidization: The separation of a multi-rooted tooth by a vertical cut through the furcation. Turning molar into 2 premolars when there is bifurcation involvements ( thinks that if the bifurcation involvement is that bad why we just take the tooth out and do prosthesis )  7. Internal replantation : This one is important and easy and even GP can do it. Simply its done by extracting the tooth and asses it and do apical surgery extra-orally and then put it back in and splint it May be considered when no other course of endodontic treatment is possible. - Indications: When your non surgical endodontic (re)treatment is not possible or has a poor prognosis ( irreparable procedure error , root resorption ). When apical surgery is not a good option or very challenging( limited access or visibility, proximity to vital structures like Lower 7 and premolars ) Extraction should be easy and straight forward ( sound coronal tooth tissue , converging and short roots ) ( difficult extraction is contraindication for this procedure). Medical conditions/ fear of surgery. - Advantages: Easy procedure  When its indicated , its simple , cost effective, alternative to extraction. Allows inspection of the roots surface for the presence of cracks , grooves or other defects. Has a resonable outcome: Survival :93% (12years) / success :77%(3years) - Disadvantages: Not suitable when extraction is expected to be difficult. ( long or divergent roots or badly destructed crown ) If the root fracture during extraction it cannot be repositioned. Extraction may damage the PDL cells ( because of dryness of cells ). Ankylosis :3% and 29% ( when extra-oral time was less than or more than 15 min respectively). External inflammatory root resorption its worse than ankylosis because we cant control the infection and we are dealing with tip of the root and because it cause loosing the tooth and bone around it so it affects future implants. This case by Dr Ahmad : This tooth was treated by Dr ahmad RCT done and the tooth restored by A crown but RCT were not enough to treat the lesion and the patient refused to extract the tooth. Next step was intentional replantation , root resection , retro grade filing and sealed with MTA and t reimplantation done and stabilized with sutures on the occlusal surface and the sinus tract resolved and healing occurred ( doctor prefers in lower 6 to see the mesial canal apical ending if they are joined then he might try surgery other than that he thinks that it would be hard to reach the ML canal apical opening so he prefer Intentional Replantation ) Notes for intentional replantation: Make sure it’s a gentle extraction and don’t do excessive widening of the sockets , don’t damage PDL cells and extract using forceps and avoid elevators. Time outside the socket should be less than 15 min Post-op care: X-ray to confirm the correct repositioning of the tooth ( in multi-rooted tooth its easy because the tooth clicks but for single rooted teeth its better to take X-ray to be sure its in right place ). Splinting Sufficient stability in case of multi-rooted teeth hardly needs splint usually we use suture above the occlusal surface with or without composite to fix the suture for 1 week is enough. Inadequate stability : a flexible splint with a steel wire (0.3- 0.4mm ) allowing physiologic tooth mobility for 2 weeks to reduce the risk of Ankylosis. Substantial mobility : splinting may be extended up to 6 weeks. Occlusal adjustment to ensure relief from occlusal contacts ( if the tooth is functioning in a group guidance its not a good candidate for this procedure). Maintain good OH Pain control Antibiotics( if medically fit no needed ) Regular follow up Another case : This tooth were restored lately with post and core and build up and the patient didn’t want to lose the crown so Dr Ahmad tried to do intentional Replantation Pre op —> Post op —> 8 years later —> There is evidence of Ankylosis but the tooth will serve for 12 years so why not  8. Perforation repair : Perforation can result in local infection and inflammation of the periradicular tissue. If accessible such perforation may be sealed surgically but sometimes we cant This patient with upper right 6 with cervical root resorption approaching the pulp. The tooth started to give him this nagging pain but not clear cut of irreversible pulpitis CBCT shows cervical root resorption. The Dr sealed it surgically and waited for the outcome Biodentine used for sealing. And this is the result post-op the lesion sealed and the tooth survived without RCT  9. Autotransplantation: It refers from taking a tooth from a patient and put it inside the same patient. The extraction of the tooth ( erupted or unerupted ) and its placement in an extraction or surgically prepared socket within the same person. A pre-op CBCT allows the clinician to creat a 3D replica of the donor tooth or to creat a 3D-printed guiding template CBCT gives actual dimensions and this 3D printed replica can be used for trial of the tooth in the socket to decrease the time of the tooth extra-orally thus increasing success rate We don’t take out the donor tooth unless we are 100% sure that the replica fits properly in the socket This is a case About Autotransplantation : 11years old boy Avulsion of his permanent central incisors 1 month later Clinical and Radiographic examination revealed a prominent vertical and horizontal deficiency of Alveolar bone and soft tissue They decided to take the unerupted 5’s and put them in place of Centrals because the age of the patient contra-indicate implant or bridge and RPD is a nightmare for child and you cant leave him without tooth he will get bullied. So the plan was : Autotransplantation of 5’s then treat the Aesthetically and ortho treatment to close spaces. This virtual system helped us to do our procedure virtually and be sure that there is a place for our 5’s and to do a surgical guide This is the surgical guide and the 3D printed models of 5’s are being tried in the socket This is both 5’s after Autotransplantation This is the veneers that are going to be cemented As restorations This is post cementation ‫‪And this is 12 month after procedure done‬‬ ‫☺ ‪That’s it Thank you‬‬ ‫‪405days‬‬ ‫اللهم بحق عزتك أرينا عجائب قدرتك انصرهم على األعداء‪.‬‬ ‫اللهم ال تمر هذه االيام إال وقد فرجت عنهم بقدرتك يا قادر يا رحيم‪.‬‬ ‫اللهم عليك بأعدائك أعداء الدين‪ ،‬اللهم رد عنا كيدهم وقل حدهم وأزل دولتهم واذهب عن أرضك سلطانهم‬ ‫وال تدع لهم سبيالً على أحد من عبادك المؤمنين‪.‬‬