Surgical Endodontics PDF

Doctor: Ahmad maaita Writer: Nadeem al faweer Corrector: Dania Saad  Surgical endodontics - Any surgical procedure undertaken on the roots and the periapical tissues. - An extension of non-surgical root canal treatment as the underlying aetiology of the diseas...

Doctor: Ahmad maaita Writer: Nadeem al faweer Corrector: Dania Saad  Surgical endodontics - Any surgical procedure undertaken on the roots and the periapical tissues. - An extension of non-surgical root canal treatment as the underlying aetiology of the disease process and the objectives of treatment are the same which prevention or elimination of apical periodontitis (which means, that the original aim and objective for endodontic treatment in general is the same, whether it surgical or nonsurgical, which is prevention or elimination of apical pathology. This is why we do endodontic treatment.) For today we talk about apical surgery. Peri-radicular surgery: - Apical surgery/ apicectomy/ apico-ectomy ( other names to this procedure) - A surgical procedure that involves raising a flap, curettage of the apical granulation tissue/ cyst, root-end resection, retrograde cavity preparation and the provision of a retrograde fluid-tight seal by biocompatible material.  (A) The objective of apical surgery is to seal the residual infection within the root canal space and prevent its progression to the peri-apical tissues. So (a)this is a root with root filling material. And the black dots is infection. So this is basically an infected root canal treated tooth. We have 2 ways of managing it. If we go for nonsurgical root canal treatment, the aim is to eradicate the infection within the root canal. We can use chemo mechanical disinfection methods. But sometimes going for a nonsurgical approach is either not feasible or is not expected to solve the problem. So we go for surgery. We're not gonna eradicate the infection. But our aim is to prevent that infection from communicating with the peri radical tissue or to isolate that infection We prevent nutritional supply that comes from the apical tissues and create a barrier between the infection within the root and the periapical tissues. And by doing this, we can stop the progress of the apical inflammation. Indications for peri-radicular surgery 1- Non-surgical re-treatment is impractical - Long threaded posts (We remove the crown and remove the post that is threaded. We may be successful removing them or we can end up with a non restorative tooth. So we need to think of retro grade approach) - Recently cemented complex prosthesis( if tooth is a part of complex restoration like is abutment for long stand bridge) 2- Non-surgical re-treatment is not expected to improve the situation  - Persistent apical pathology in well-treated teeth (despite a good RCT) - Overextended filling material - A separated instrument that cannot be retrieved non-surgically - Unrepairable procedural error (perforation, transportation, ledge… etc) 3- Surgical biopsy/ exploration is needed - Cysts - Vertical root fracture Contraindications for peri-radicular surgery 1- Local anatomical factors - Limited access to the periapical tissues. ( upper and lower 7s) - Anatomical structures may compromise flap design, e.g. a short sulcus depth, or prominent frenum and muscle attachments. - Anatomical structures in close proximity (e.g.: the inferior alveolar or mental neurovascular bundles, or the maxillary antrum). The doctor said “the sinus doesn't scare me. We can easily do, apical surgery safely even if the, apical pathology is communicating with the sinus” 2- Medical conditions - Patient’s medial health status/ ASA - Bleeding disorders (heavy anticoagulants) - Previous radiotherapy to the face and jaws (it’s a lifetime contraindication to elective surgery) - Bisphosphonates( depends the duration of treatment, whether it's oral or IV, whether they take any other medication in combination with the bisphosphonates The higher the risk the more unlikely to do the surgery) Clinical considerations: 1- Haemostasis and local anesthesia 2- Flap (incision) design 3- Flap reflection and retraction 4- Exposure of peri-apical site 5- Excision of the peri-apical granuloma/ cyst 6- Root-end resection 7- Retrograde cavity preparation 8- Placement of the retrograde restoration 9- Closure of the surgical site 10- Post-operative care 1- Local anesthesia and Haemostasis Conventional labial/ buccal & lingual/ palatal infiltration(nowadays use 4% articaine 1:100,000 adrenaline because is the best local anaesthesia in Jordan, but use lidocaine 1:50,000 adrenaline back to UK that’s mean the adrenaline highly concentrated and it gives amazing haemostasis. To cover the whole area of surgery including the area of releasing incisions (Think of your flap design and then suturing afterwards it’s not similar to just anaesthetizing a tooth for a cavity or a root canal You need to go wider.) Anaesthetic solutions with higher concentration of vasoconstrictors are recommended (2% lidocaine with 1:80,000 adrenaline) Sufficient time should be allowed before surgery commences in order to achieve vasoconstriction (We all know that as soon as we inject the local anaesthesia. pain control starts straight away. But for hemostasis to take effect, you need to give it some time at least 10 minutes) A long-acting LA (0.5% bupivacaine with 1:200,000 epinephrine) can be used at the end of treatment to reduce post-operative pain 2- Flap design: - Must allow for unrestrained visualization and access of the operative field - Has both a vertical and horizontal components We need unrestrained visualization of the operative field We know the wider we go both vertically and horizontally the more access and the better visual field we have. Thus, the more aggressive and probably invasive we are with wider flaps. So it needs to be balanced. - Vertical: The margins of the flap must rest on sound bone after surgery is completed (When you are planning to do apical surgery on the upper lateral your vertical releasing incision should at least include the central or the canine. We don’t want the Vertical releasing incision to sit on the bony crypts that we create.) The vertical releasing incision should be parallel to the supra-periosteal vessels (in the past they said the base must be wider than the tip of the flap to preserve the blood supply and avoid flap necrosis. Reality shows the opposite. Actually, blood vessels of the apical tissues run vertically. If you go for an oblique incision, you're more likely to cut blood vessel compared to a vertical incision. So nowadays, we just go vertical straight, not bevelled at all) Must avoid cutting through frenum and muscle attachments, and dental papilla (If your patient is aesthetically demanding, you don't wanna touch the papilla because it's the one part of the periodontium that you cannot regenerate. Make sure you assess that preoperatively how aesthetically demanding is your patient, whether they have a high lip or a low lip, and how much visibility you need) - Horizontal incision: a) Semilunar flap(It's literally a curved line in the oral mucosa just in the area where you want to operate, it doesn't give you enough visibility, especially if the area you're working on is is large area and A You want to remove a large cyst a semilunar incision does not give you the access that you want. And most of the time while you're doing your osteotomy the margins of your incision are going to sit on the bony crypt that you B created And, if you see a patient who's undergone a semilunar incision, you're going to see a very nasty scarring. Sometimes it's ugly and uncomfortable for the C patient b) Sulcular (intrasulcular) incision (At the depth of the sulcus, advance your scalpel or blade all the way to the bone) ç) Sub-marginal incision (Ochsenbein-Luebke) (The idea is you need to have it on the keratinized attached D gingiva You cannot have it on oral mucosa. It needs to be a keratinized tissue. But, again, it needs to be away from the depth of the sulcus. So you need to do the math. Just assess how much keratinized tissue you have, Measure the depth of the sulcus /pocket that you have. If you think you still have enough keratinized tissue, go for it because you're preserving the papilla You're not gonna end up with recession or ugly scarring, and it's very easy to be repositioned when you're done. Again, it gives you a great access. Problem is most patients don't have that enough thick, keratinized tissue.) d) Papillary-base incision ( periodontist use on treat black triangle) So you go for a sulcular incision around the necks of the teeth and then when you come between the teeth, you spare the papilla. You go around on it. But it goes in 2 planes, a superficial horizontal one and then an oblique one that goes all the way to the bone and that's essential for repositioning of the flap. This incision design is important for patients who are aesthetically demanding and who don't have enough keratinized tissue 3- Flap reflection and retraction: We need to full thickness we need to raise the periosteum preferably with the flap we reflecting ,The muco-periosteum should be raised as a complete unit (tears can result in more postoperative pain and swelling). we need a very sharp periosteal elevator is recommended these tend to blunt easily with use. Smaller instruments for papilla reflection. Start with the easiest area to reflect ( keratinised tissue on the vertical incision) if we doing revisit after surgery the Flap reflection may be difficult in the presence of a discharging sinus tract, thick gingiva or fibrous scar tissue from previous surgery. - Flap must be retracted to: Provide adequate space for bone removal and root-end resection Prevent soft tissue trauma ( while retracting the flap the retractor should to be in bone not in soft tissue imaging the retractor in soft tissue until end the surgery will end up with necrosis) - Different retractors are available - Minnesota is the doctor’s favourit one. Minnesota  - so, this is what we need to see good access and good visibility. 4- Exposure of the peri-apical site and bone removal: - When see apical pathology on X ray it’s mean ether the Buccle or lingual bone plate has been resorbed , so when removing the flap and no Buccle bone and start with excavator to remove the soft tissue but some time especially if we work on lower teeth the buccle bone still intact so you need to be accurate in where you start your drilling because the more bone we removal more invasive and more morbidity to patient , so healthy bone should be preserved (micro- osteotomy) - Heat generation must be minimized (Make sure you don't generate heat while you're drilling. Make sure you use enough coolant. Ideally, we should be using a drill hand piece with saline or sterile water as a coolant) - Site of bone removal If buccal bone plate has been lost, it is simple! (Go with your excavator and try to eradicate the apical soft tissue.) Push a sharp probe through the buccal cortical plate to identify the pathological cavity around the tooth apex. Use the preoperative radiograph to estimate where exactly you need to start. CBCT it’s easier. 5- Curettage of the apical tissues - Most common radiolucent apical lesion? Granuloma then the cyst - 1-2% is not granuloma and not cyst lesions may present. - That soft tissue that you excavated ideally should go to histo pathology, most apical surgery we do actually is granuloma or cyst but to be 100% sure.  - Granuloma is a fragile and with excavator will tear and difficult to remove it as one piece. - Cyst is a thick lining with excavator removed as one piece. Curettage is undertaken to remove: Foreign bodies such as excess root-filling material. Periapical soft tissue which MUST be sent for histopathologic examination A curved spoon excavator, periodontal currette or a Mitchell’s trimmer can be used in a peeling manner. 6- Localized hemostasis: - Good hemostasis during surgery: Enhances visbility Reduces contamination of the root-end filling Reduces surgery time and blood loss Post-operative haemorrhage and swelling - Starts pre-operatively with good medical history investigation and appropriate anesthesia selection - Atraumatic surgical approach is important in reducing the amount of bleeding ( because of that we must use a very sharp elevators). - Haemostatic agents used work in 2 mechanisms either form an artificial clot(physical barrier) or enhance the clotting mechanism( coagulation cascade) and vasoconstriction (or both) 1- Collagen-based materials (collagen pulge , collagen tape)(Collagen actually induces the coagulation pathway somehow But mostly with bleeding it creates a physical barrier like an artificial clot. They do not interfere with healing. Even if you leave the collagen clot behind and you don’t remove it, it's not going to cause any adverse effects. Okay. So simple, easy, cheap, readily available, and you can leave it in the cycle of surgery 2- Surgicel : it’s oxide cellulose, like gouze in shap , so with exposure to blood make blood coagulation (It can delay healing. Don't leave it there. Make sure you remove it and clean the bony crypt properly, irrigate it with saline because last thing you want is to leave your, surgical behind)  3- Bone wax for older generation it’s the best 85-90% Bees wax but (It can induce infection, allergic reactions. If you leave it behind, the area is not clean. It's not even good to create hemostasis So definitely official. Definitely don't use it.) 4- Ferric sulfate , aluminium sulfate : make protein agglutination, if we use them in small amounts it’s fine but with large amounts they may interfere with wound healing. 5- Calcium sulfate (calcium sulfate it is gypsum study cast. Working cast. But if you're going to use it for surgery, you need to make sure you use a surgical calcium sulfate Sterilized virgin. You can create a disaster if you use that. So cs the good thing about it, you mix it to a thick consistency, and then you fill the whole bony crypt with it and tap it with gauze. You wait for it to initially set, and then you carve your way in. The carved away instrument You create a path until you expose the tip of the root. So what you get is 100% haemostasis, not a drop of blood. And once you're done, you just flick it off and you carry on. If you leave remnants behind, it's fine. You can leave all of it behind. It does not interfere with surgery. It's also osteoconductive. ( favourite material but expensive). 6- Epinephrine pellets (vasoconstriction) there are concerns about systemic effects of epinephrine) 7- Cautery/ electrosurgery : overheating or burning blood vessels cause coagulation, make sure you don’t overheat ) 7- Root-end resection: - The apical 3mm of the root are resected if there’s overextension or extrusions of filling material we need to get rid of them,, and it’s depends on the length of the root (some cases when you end up with crown root ratio that’s less than 1to1 in this case, don't go for it. Even if you can pack your MTA.) - A straight fissure bur or shoulder bur in a straight handpiece is used - A handpiece with a rear air exhaust (Grap the handpiece and turn it on without the water coolant and feel the air if it comes to your face then don’t use it in surgery because will cause emphysema). - No bevel is needed! - The surface of the apicected root is examined to exclude a root fracture before the retrograde  cavity is cut. So use of Methylene blue dye ( very cheap) aids identification of a root fracture. So that's, a picture of a clear tooth. You can see the presence of apical dentals and lateral canals. So, if you've cut 3 millimetres, you're actually getting rid of 98% to 93% of ramifications and lateral canals, respectively The issue with the bevel is that the lateral canals run obliquely towards the apex. So if you create a bevel, a steep one, and you go for a 3 millimeter retrograde prep, you're not sealing the dentinal tubules apically. And they may still leak, cause constant irritation to the periradicular tissue. So nowadays, we don't do any bevels at all because we have magnification, illumination, micromerrors. We don't have to bevel the root surface in order to see. We can do it 90 degrees 8 -Retrograde cavity preparation The ideal preparation is a class I cavity prepared along the long axis of the tooth to a depth of at least 3mm. (If you believe that the purpose of apical surgery is to isolate the infection from the peri radicular tissues, then you need a cavity that's retentive to your retrograde filling material. It doesn't matter which material you use, but if it's not retentive, it's not gonna stick It is not gonna bond to the root surface, apically It's not an a bond friendly environment.) A rose head bur in a microhandpiece vs ultrasonic tips (So the best way to create a class one cavity is by ultrasonic tips you cannot create a retrograde class 1 cavity with the rose head bur. Don't kid yourself. It's not gonna be sealing. It's not gonna stick. So this is where endodontists come You need an endodontist with their magnification, illumination, micro instruments, ultrasonic tips in order to create that.) 9-Retro-grade restoration: - A root-end filling is inserted into the retrograde cavity preparation to seal the root surface. - Many dental materials have been used including: ▪ Amalgam ( used in the past because it sets in the presence of blood ,moisture,whatever , but has two problems. 1- it creates amalgam tattoo 2- seals properly because of its corrosion products, but it's a passive material) ▪ Zinc-oxide eugenol cements: ✓ IRM ✓ Super EBA cement ▪ Composite resin ▪ GIC/ RMGIC ▪now days use MTA and calcium silicates. (. Bioactive materials which means they do push your body to deposit hard tissue material on top of it That is what we actually need for healing) (gold standard). Mechanism of MTA: once you mix them, they release calcium hydroxide, which reacts to the phosphate and the tissue fluid and creates a layer of calcium phosphate, which is the basic constituent of bone and cement. So, it attracts the undifferentiated cells from the periphery, and they all turn into cementoblasts, fibroblasts, osteoblasts, whatever. And this is how it works - A selection of micro-pluggers are available commercially, we need micro pluggers and carrying device you need to carry MTA into tiny class one cavity.  MTApallets MTA carriers ( map systems basically like amalgam carriers but in micro level. Debridement: After the root-end filling is inserted, the tissues are irrigated with sterile saline and an excavator is used to remove debris, check radiograph can be taken at this stage before suturing because some time need to adjust. This provides an opportunity to: Correct an inadequate apical seal before wound closure. Removal of any residual debris within the apical tissues. 9-Closure of the surgical site: a) Flap repositioning: - if you’re going for a sulcular The interdental papillae are first repositioned to their correct anatomical location because there the most important tissue to back in place. A moist gauze can be used to apply gentle pressure. b) Suturing: - Simple interrupted sutures is sufficient in most cases to secure the edges of the mucoperiosteal flap. The knots should be placed away from the incision line. Gentle pressure is applied to the flap for a few minutes with a moist gauze swab to obtain haemostasis. We can use different materials. Don't use silk for sure because Silk attracts infection, attracts bacteria to grow on its surface. Don't use it. If it's the only suture that you have, good luck dealing with the complications. Vicryl is good. It's absorbable. If I'm going for a sulcular incision, it's fine or the Ochsenbein-Luebke. But if I'm going for a papillary based incision, then you need to be very delicate with thew papilla. And I go for a 6O proline nylon sutures. Very delicate, very small needle. You don't wanna tear the papilla while you're suturing. 10- Post-opertaive care: - Postoperative instructions should be given in writing. - Management of post-operative pain: NSAIDs (Ibuprofen 400 – 800mg) This can be alternated with paracetamol Long-acting LA immediately after surgery is completed -Antibiotics given to prevent postoperative wound infection after surgical endodontics is controversial. -Ice pack applications (20 mins on/ 20 mins off) VERY IMPORTANT ( immediately after surgery is probably the single most important thing to do to reduce the amount of swelling) - Sutures removal: 2-4 days after surgery (If all is good and no signs of wound breakdown and good initial healing, I will get rid of them in 3 days) - Review appointment in 7-10 days (after sutures removal) and then 3-12 months after surgery The micro-surgical technique: Basically the same as the macro surgical technique but Involves the use of: 1- Microscope magnification( if we have loops with good magnification X3 or above is enough) 2- Microsurgical instruments (micro-mirrors, micro-pluggers…) 3- Micro-sutures: 6/0 prolene vs 4/0 vicryl 4- Micro-osteotomy (3-4mm vs. 8-10) 5- Ultrasonic retrograde cavity prep 7- Bioactive retrograde filling material ** if we use all these you can call yourself a micro surgical endodontist. Assessing the outcome of surgical endodontics: a) Clinically: absence of signs and symptoms of persistent peri-radicular pathology. (Pain, discomfort, tenderness, swelling, abscess, sinus tracts, mobility, soft tissue defects.) ( if it last for two weeks then your treatment failed and any sign that last for 2 months don’t take a radiograph just admit your treatment failed) If absent of clinical symptoms you should to follow up. b) Radiographically: resolution of the apical radiolucent lesion (complete regeneration of periapical bone and an intact lamina dura). - However, a persistent apical radiolucency after surgery does not necessarily indicate an unsuccessful outcome. The capacity for bone regeneration diminishes with age, and healing with scar tissue is not uncommon. In this picture the doctor was asking why the radiolucent shrunk in size but hasn’t disappeared ? the answer is( repair not regeneration occurs) when you look at Apex of the central. You can see intact lamina dura around the apex. So, it’s healed. But this tooth,look at the size of the apical pathology it is through and through lesion The buccal and the palatal bony plate were resolved. In these cases, you're not going to get 100% bone healing. You're going to get scar tissue as well. But what we care about is the lamina dura. So, this case is successful. Who should do the surgery?? Surgeon or endodontist? The surgeon are great with cutting , retracing, excavating, root resection but that sets. The decisive factor in apical surgery is the retrograde l don’t need to oral surgeon in the first part for me and then retrograde and suturing,, so you don’t need to ednodontist to do any general dentist with smart skilled and they now how to select their cases you can do apical surgery.