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O5 EndoSurgery

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Endodontic Surgery1

Endodontic surgical procedures

  • Incision and drainage
    • An acute procedure for abscesses that general dentists should also be proficient in.
  • Periapical curettage
    • The most common endodontic surgery, involving the removal of pathological tissue from around the root apex.
  • Apicoectomy
    • The surgical removal of the apical portion of the tooth root, often performed with curettage.
  • Retrograde endodontic treatment
    • ==Treating and sealing the apical end of the root canal from the apex-down, often involving a retrograde root filling.==
  • Perforation repair
  • Root resection
  • Hemisection (± root removal)
  • Exploratory surgery
  • Intentional replantation

Possible indications for periapical surgery2

  • When a biopsy of the periapical lesion is required

    • When conventional treatment fails to show signs of repair, surgery allows for removal and histopathological analysis of tissue to identify issues like:
      • A periapical true cyst
      • A foreign body reaction (to extruded materials, which may or may not be radiopaque)
      • An extra-radicular infection

  • Foreign body reaction with extruded material

  • Perforation repair (that can not be done conservatively)

  • If non-surgical treatment is not feasible - such as:

    • Very long or wide post; Post not in line with canal
    • Canal blocked by broken file, calcifications, etc
    • Tooth is not likely to be suitable for further restoration

  • Patient factors

    • Medical / dental condition, time, costs, recent crown, etc.

Warning

If removing existing restorations for retreatment would leave the tooth unrestorable, this is considered a compromised treatment with a poor long-term prognosis.

Periapical surgery considerations3

  • Psychological aspects
    • Patients are reluctant to have any form of surgery
  • Non-surgical endodontics has a higher success rate
    • Grung et al – 28% higher success if non-surgical re-treatment was done prior to surgery
      • ==The best outcomes are achieved when retreatment is performed before surgery becomes necessary.==
  • Surgery is a “one visit” technique
    • Cannot disinfect the canal with irrigants and/or medicaments
      • Standard root canal irrigants cannot be used due to toxicity to exposed bone.
  • There is no IDEAL retrograde filling material
    • Many have been tried & most do not “seal” canals well
  • Surgery “entombs” bacteria rather than killing or removing them
    • And only “treats” the apical 2–4 mm of the canal
  • Surgery does not remove the pathway of entry along which the bacteria have entered & infected the tooth
    • This is usually caries, a defective restoration, or a crack
  • Over-extended root filling materials
    • Will not always cause a foreign body reaction
    • Hence, always watch and reassess over time

Info

The presence of extruded root filling material is not an automatic indication for surgery. Many cases remain asymptomatic and should be monitored over time.

  • Large, well-defined radiolucencies
    • Are not always cysts as often thought by many dentists
    • Can be any form of periapical pathosis
    • Size and borders indicate time & speed of development

Radiographic Interpretation

  • The size and appearance of a lesion on a radiograph or CT scan cannot definitively diagnose its nature (granuloma, abscess, cyst, etc.).
  • A large lesion may indicate a long-standing or rapidly aggressive process.
  • Well-defined borders suggest a slow-growing, long-standing lesion.

Conservative treatment of a large periapical lesion4

Potential post-operative sequelae

  • Swelling and bruising

  • Infection

  • Pain / discomfort

  • Anaesthesia / Paraesthesia

    • Numbness or altered sensation can occur due to nerve fiber damage during incision.

  • Tissue discolouration

    • ==Can be caused by certain materials, such as an amalgam tattoo.==

  • Scarring

  • Gingival recession

  • Loss of interdental papilla

    • ==A significant aesthetic concern, especially in the anterior region, leading to

  • Altered aesthetics

  • “It must be recognised that few true indications exist for the endodontic surgical approach” — Gutman JL. Surgical Endodontics 1991: 50

Endodontic surgery - stages56

a) Consultation, Diagnosis, Treatment Plan b) Local Anaesthesia c) Periosteal Flap d) Curettage e) Apicoectomy f) Retrograde Endodontic Treatment

  • Apical Bevel, Canal Preparation, Root Filling g) Wound Closure - sutures h) Post-operative Instructions i) Follow-up & Review

Flap designs7

  • Semi-Lunar
  • Gingival crest
    • Triangular
    • Trapezoidal
    • Gingival
  • Luebke-Oschenbein

Semi-lunar flap8

Verdict

Considered the worst flap design for endodontic surgery and is not recommended for modern use.

  • In the mucobuccal fold and attached gingiva
    • Poor access
    • Incision often over the lesion
    • Difficult moisture control (haemorrhage)
    • Difficult to reposition
    • Uncomfortable during healing
    • Leaves scars

Gingival flap9

  • Gingival crest incision

    • Extended horizontal incision
    • No vertical incision
    • No access to apex
    • May be useful for coronal third perforations
    • Used for palatal flaps
      • But difficult!

  • ==It is not suitable for periapical surgery and is difficult to raise and reposition, often requiring an acrylic stent for healing.==

Triangular flap1011

  • Horizontal incision in the gingival sulcus
  • One vertical incision
  • ✔ “First choice” flap for endodontic surgery
    • Good access
    • Good vision
    • Good moisture control
    • Heals without scars
    • Easy to reposition

Trapezoidal flap121314

  • Horizontal incision in the gingival sulcus
  • Two vertical incisions
  • “Second choice” for endodontic surgery
  • Begin as a triangular flap and then do 2nd vertical incision if extra access required
    • Good access & vision
    • Good moisture control
    • Heals without scars
      • when handled properly
    • Easy to reposition

Indications for trapezoidal flap

  • When a triangular flap is insufficient.
  • For surgery on multiple adjacent teeth.
  • For teeth with very long roots or very large lesions.
  • Often the first choice in the lower anterior region due to muscle attachments making flap reflection difficult.

Luebke-Oschenbein flap15

  • Scalloped horizontal incision in attached gingiva
    • 3 - 5 mm short of the gingival margin
    • Follows contours of the gingival margin
  • Vertical incisions
    • 1 or 2 → Depends on how much access is required
  • Little, if any, scarring
  • Use for anterior teeth with crowns
    • ==Primarily used on teeth with existing crowns that are not being replaced.==
  • To avoid gingival recession
    • The scalloped design helps camouflage any potential scar.

Incision and flap elevation technique16

  • Incision: ==Made with a single, firm stroke down to the bone. Vertical incisions should be truly vertical, not angled, to preserve the vertical blood supply to the flap and papilla.==
  • Flap Elevation: ==A periosteal elevator is used, starting from the vertical incision and working down towards the gingival margin. This prevents crushing the blood vessels at the base of the papilla, which can cause recession and papilla loss.==

Scalpel blades1718

  • No. 15 - for periosteal flaps
  • No. 11 - for incision and drainage
    • Stabbing action

Apical bevel1920

Historical vs. Modern Approach

  • Historical Approach: A significant bevel (angle) was cut on the root tip. This was necessary to allow visibility for preparation with older, larger equipment (straight handpieces).
  • Problems with Beveling:
    • Unnecessary removal of tooth structure, weakening and shortening the root.
    • Exposes a large surface area of dentinal tubules, creating a potential pathway for leakage of bacteria or toxins.
  • Modern Approach: With the advent of ultrasonic tips, a bevel is no longer necessary. The root is resected with a straight, 90-degree cut to the long axis, preserving tooth structure.

Equipment212223

  • Micro-head Handpieces (Older): Smaller than standard handpieces but still bulky, often requiring a large bony window and a beveled root for access.
  • Ultrasonic Tips (Modern): These are very small, come in various angles and lengths (3, 6, 9 mm), and allow for the preparation of a conservative retrograde cavity directly in line with the root canal, eliminating the need for a bevel.

Micro-mirrors2425

Info

These are essential tools for endodontic surgery. Their small size allows for visualization of the surgical site (e.g., the prepared root end), which is impossible with a standard intraoral mirror. They are critical when using a surgical microscope.

Curettage techniques26

  • Technique: A curette is used with its back surface to get the tissue off the tooth , use a gracey to get tissue off the palatal aspect of the root

Retrograde filling materials272829

Materials – past and present

  • Amalgam
  • Cavit
  • IRM
  • Super-EBA
  • Composite resins
  • Gutta percha
  • Glass ionomers
  • MTA (ProRoot)

Amalgam30

Danger

Amalgam was once common but is now considered obsolete and should never be used for retrograde fillings.

Disadvantages & Problems

  • Corrosion
  • Galvanism (with posts)
  • Tattoo on mucosa
  • Expansion
  • Dimensional changes
  • Marginal breakdown
  • Excess not absorbable
  • Mercury release
  • Difficult to condense
  • Condensation scatter
  • Cavity large
  • Undercuts needed
  • Poor adaptation to walls
  • No anti-bacterial action
  • Difficult to remove for re-treatment

IRM + Super-EBA3132

Disadvantages & Problems

  • Poor tissue compatibility
    • Due to continuous release of eugenol
      • This is irritating to periapical tissues, promoting fibrosis (scar tissue) instead of true healing.
    • Fibrosis of adjacent tissue
  • Soluble
  • Large cavity required
  • Difficult to handle material
    • Esp. Super-EBA

Glass ionomer33

Info

Materials like Ketac Silver or Riva Silver are sometimes used.

Advantages

  • Low tissue toxicity
    • Bone apposition
  • Good sealing ability
  • Chemical bond to dentine
  • Radiopaque
  • Easy to mix & place
  • Colour contrast to tooth
  • Short setting time

Disadvantages

  • Moisture control
    • Haemorrhage
      • This is a significant disadvantage as moisture is difficult to control during surgery.
  • Relatively large cavity required

Mineral trioxide aggregate34

Info

MTA is a popular, biocompatible material, chemically similar to Portland cement.

Advantages

  • Low tissue toxicity
    • Bone apposition
    • PDL repair
  • Good sealing ability
  • Radiopaque
  • Colour contrast to tooth
    • Grey version

Disadvantages

  • Moisture control
    • Haemorrhage
  • Relatively large cavity required
  • Difficult to handle
  • Difficult to place
  • Long setting time
    • Various times / forms
  • Expensive

Gutta percha + cement35

Advantages

  • Low tissue toxicity
  • Good sealing ability
  • Radiopaque
  • Colour contrast to tooth
  • Conservative cavity only
  • Anti-bacterial (cement)
  • Easy to mix & place
  • Good physical properties
  • Satisfies requirements of root filling materials
  • Proven and acceptable material for RCF’s for over 120 years

Logical Choice

  • If it’s the best material for orthograde fillings, it is also an excellent choice for retrograde fillings.
  • This technique is ideal for small, round canals. For larger, ovoid canals, GI or MTA may be considered.

Treatment outcome studies of gutta percha and cement as retrograde filling material

Success

Literature reviews show that studies using Gutta Percha and cement as the retrograde material report some of the highest success rates for endodontic surgery.

Surgical procedure walkthrough (with GP + AH26)36

Endodontic surgery - stages

a) Consultation, Diagnosis, Treatment Plan

Info

Done at a separate appointment to allow for informed consent and pre-operative preparation.

b) Local Anaesthesia c) Periosteal Flap d) Curettage e) Apicoectomy f) Retrograde Endodontic Treatment

  • Apical Bevel, Canal Preparation, Root Filling g) Wound Closure - sutures h) Post-operative Instructions i) Follow-up & Review

Consultation37

  • Occurs at a separate appointment.
  • Involves providing prescriptions for post-op analgesics (e.g., Ibuprofen) and, if necessary, antibiotics.
  • ==Patients are instructed to begin a chlorhexidine mouthwash the day before surgery.==

Local anaesthesia

  • ==Xylocaine with 1:80,000 Adrenaline is used for profound anesthesia and hemorrhage control.==
  • ==May be supplemented with a long-acting anesthetic like Marcaine (bupivacaine) for long or difficult cases.==

Instruments38

Incision + periosteal flap39

Bone removal & curettage

  • A surgical bur in a straight handpiece may be used to remove the labial cortical plate if the lesion is not already exposed.
  • The lesion is thoroughly curetted, leaving a clean bony defect with the root apex visible.

Retrograde canal preparation

  1. ==The apical foramen is located with a Briolt probe.==
  2. ==The apical 3-4 mm of the canal is cleaned and shaped using ultrasonic tips to create a conservative preparation.==

Haemorrhage control4041

  • Achieved first with pressure from gauze packed into the defect.
  • ==If bleeding persists, gauze soaked in 1:1,000 adrenaline is applied with pressure for a few minutes.==
  • ==Bone wax is avoided if possible, as retained wax can cause a foreign body reaction.==

Paper points42

Cement - AH 2643

Gutta percha

Cement - placement

  • The Briolt probe is used to carry and place the AH26 cement into the prepared cavity.

Retrograde root filling44

  1. A segment of gutta percha (coated in cement) is placed into the cavity.
  2. A hot instrument (e.g., Glick #2) is used to sear off the excess gutta percha.
  3. A custom-shaped plugger is used to condense the softened gutta percha into the preparation.
  4. The process is repeated until the preparation is filled flush with the resected root surface.
  5. ==The final filling is burnished smooth with a small cotton pellet lightly dampened with eucalyptus oil.==

Suturing454647

  1. The entire surgical site is irrigated thoroughly with saline.
  2. The flap is carefully repositioned.
  3. ==4-0 silk (non-resorbable) sutures are used to close the incisions. Non-resorbable sutures are preferred as they allow for a follow-up appointment for removal (5-7 days), ensuring the site is healing well, and they are more comfortable for the patient than resorbable sutures that can take weeks to dissolve.==

Post-operative instructions

ALSO:

  1. Post-op Radiograph
  2. Suture Removal
    • 4-5 days
  3. Reviews
    • 3-4 months
    • 12 months
    • 3 years

Post-operative review48495051

Suturing5253

Post-operative instructions

ALSO:

  1. Post-op Radiograph
  2. Suture Removal
    • 4-5 days
  3. Reviews
    • 3-4 months
    • 12 months
    • 3 years

Overview

Endodontic surgery is a specialized procedure considered after non-surgical options, primarily endodontic retreatment, have been explored. It is not a first-line approach for managing persistent or new periapical radiolucencies. It is emphasized that endodontic surgery should be performed by a trained endodontist, often after an endodontic consultation and retreatment of the root canal system. General dentists are not typically trained to perform these complex procedures.

Footnotes

  1. Original PDF page 1: O5 EndoSurgery, p.1 ↩

  2. Original PDF page 2: O5 EndoSurgery, p.2 ↩

  3. Original PDF page 5: O5 EndoSurgery, p.5 ↩

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  8. Original PDF page 10: O5 EndoSurgery, p.10 ↩

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  10. Original PDF page 12: O5 EndoSurgery, p.12 ↩

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  12. Original PDF page 14: O5 EndoSurgery, p.14 ↩

  13. Original PDF page 15: O5 EndoSurgery, p.15 ↩

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  17. Original PDF page 19: O5 EndoSurgery, p.19 ↩

  18. Original PDF page 20: O5 EndoSurgery, p.20 ↩

  19. Original PDF page 21: O5 EndoSurgery, p.21 ↩

  20. Original PDF page 22: O5 EndoSurgery, p.22 ↩

  21. Original PDF page 23: O5 EndoSurgery, p.23 ↩

  22. Original PDF page 24: O5 EndoSurgery, p.24 ↩

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  25. Original PDF page 27: O5 EndoSurgery, p.27 ↩

  26. Original PDF page 28: O5 EndoSurgery, p.28 ↩

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  30. Original PDF page 32: O5 EndoSurgery, p.32 ↩

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  33. Original PDF page 35: O5 EndoSurgery, p.35 ↩

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  40. Original PDF page 42: O5 EndoSurgery, p.42 ↩

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  43. Original PDF page 45: O5 EndoSurgery, p.45 ↩

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  45. Original PDF page 47: O5 EndoSurgery, p.47 ↩

  46. Original PDF page 48: O5 EndoSurgery, p.48 ↩

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  53. Original PDF page 55: O5 EndoSurgery, p.55 ↩

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