**Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 1 **Endodontic Surgery** **Endodontic Surgical Procedures** - Incision and drainage - Periapical curettage - **Apicoectomy** - Retrograde endodontic treatment - **Perforation repair** - Root resection - **Hemisection (± root removal)** - Exploratory surgery - **Intentional replantation** ## **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** **Endodontic Surgery** W/Prof. Paul V. Abbott AO **Endodontic Surgical Procedures** - Incision and drainage - Periapical curettage - **Apicoectomy** - **Retrograde endodontic treatment** - Perforation repair - Root resection - Hemisection (± root removal) - Exploratory surgery - Intentional replantation **Possible Indications for Periapical Surgery** - When a biopsy of the periapical lesion is required 2nd Year DMD - 2020 Page 2 ## **Possible Indications for Periapical Surgery** - 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== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 3 - **51 yr old male** - **8 yr history of pain and “numbness of the palate”** - **Endodontic treatment - three times by three dentists** **Diagnosis:** **Adeno-Cystic Carcinoma** **Treatment:** **Hemi-maxillectomy and radiotherapy** 5 6 ### **Case Study: Necessity of Biopsy** - **51 yr old male** - **8 yr history of pain and “numbness of the palate”** - **Endodontic treatment - three times by three dentists** #### **Diagnosis:** **Adeno-Cystic Carcinoma** #### **Treatment:** **Hemi-maxillectomy and radiotherapy** **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 4 --- **Possible Indications for Periapical Surgery** - When a biopsy of the periapical lesion is required - 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. --- **Periapical Surgery Considerations** - 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 - Surgery is a “one visit” technique - Can not disinfect the canal with irrigants and/or medicaments - 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 > [!warning] > If removing existing restorations for retreatment would leave the tooth unrestorable, this is considered a compromised treatment with a poor long-term prognosis. - Patient factors - Medical / dental condition, time, costs, recent crown, etc. ## **Periapical Surgery Considerations** - 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 - Can not disinfect the canal with irrigants and/or medicaments - ==Standard root canal irrigants cannot be used due to toxicity to exposed bone.== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 5 **Periapical Surgery Considerations** - 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 **Periapical Surgery Considerations** - Over-extended root filling materials - Will not always cause a foreign body reaction - Hence, always watch and reassess 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 - 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 - ==The concept of - 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 > [!tip] 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. **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 6 **Conservative Treatment of a Large P-ap Lesion** GP + AH26 Pre-op 1 Yr later Courtesy Dr Geoff Heithersay – Adelaide **Periapical Surgery Considerations** - **Potential post-operative sequelae** - Swelling and bruising - Infection - Pain / discomfort - Anaesthesia / Paraesthesia - Tissue discolouration - Scarring - Gingival recession - Loss of interdental papilla - Altered aesthetics ### **Conservative Treatment of a Large P-ap Lesion** > [!example] Case Example (Prof. Heathersay) > A very large, well-defined radiolucency associated with a lateral incisor, which most practitioners would diagnose as a cyst, healed completely following only conventional root canal treatment. This demonstrates that even large granulomas can resolve once the internal source of bacteria is removed. GP + AH26 Pre-op 1 Yr later Courtesy Dr Geoff Heithersay – Adelaide ### **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 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 7 --- **Possible Indications for Periapical Surgery** - *“It must be recognised that few true indications exist for the endodontic surgical approach”* — Gutman JL. *Surgical Endodontics* 1991: 50 --- **Endodontic Surgery** *(Slide 14 contains 4 images: intraoperative view, anatomical diagram with red arrow, excised tissue specimen, and periapical radiograph — no extractable text beyond slide title)* --- 13 14 - *“It must be recognised that few true indications exist for the endodontic surgical approach”* — Gutman JL. *Surgical Endodontics* 1991: 50 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 8 --- **Endodontic Surgery - Stages** 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** --- **Endodontic Surgery** *But first – some general principles* 15 16 ## **Endodontic Surgery - Stages** 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** *But first – some general principles* **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 9 --- ### **Flap Designs** - **Semi-Lunar** - **Gingival crest** - Triangular - Trapezoidal - Gingival - **Luebke-Oschenbein** --- ### **Semi-Lunar Flap** - In the mucobuccal fold and attached gingiva --- Diagram illustrating flap designs and semi-lunar flap placement ## **Flap Designs** - **Semi-Lunar** - **Gingival crest** - Triangular - Trapezoidal - Gingival - **Luebke-Oschenbein** ### **Semi-Lunar Flap** > [!failure] Verdict > Considered the **worst flap design** for endodontic surgery and is **not recommended for modern use**. - In the mucobuccal fold and attached gingiva **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 10 --- **Semi-Lunar Flap** - 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 19 --- **Semi-Lunar Flap** 20 Clinical image showing semi-lunar flap in anterior dentition, illustrating gingival contour and incision placement. - Poor access - Incision often over the lesion - Difficult moisture control (haemorrhage) - Difficult to reposition - Uncomfortable during healing - Leaves scars **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 11 --- **Gingival Flap** - Gingival crest incision - Extended horizontal incision - No vertical incision **Gingival Flap** - 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!** ### **Gingival Flap** - 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.== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 12 **Gingival Flap** 23 **Triangular Flap** - Horizontal incision in the gingival sulcus - One vertical incision 24 ### **Triangular Flap** - Horizontal incision in the gingival sulcus - One vertical incision **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 13 --- **Triangular Flap** - 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 Triangular Flap surgical procedure images showing incision and flap retraction - ✔ “First choice” flap for endodontic surgery - Good access - Good vision - Good moisture control - Heals without scars - Easy to reposition **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 14 --- **Triangular Flap** 27 **Triangular Flap** *Recall - 6 Months* 28 *Recall - 6 Months* **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 15 **Triangular Flap** *Recall - 3 Months* *Recall - 6 Months* **Trapezoidal Flap** - Horizontal incision in the gingival sulcus - Two vertical incisions 29 30 *Recall - 3 Months* *Recall - 6 Months* ### **Trapezoidal Flap** - Horizontal incision in the gingival sulcus - Two vertical incisions **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 16 --- **Trapezoidal Flap** - 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 - Easy to reposition --- **Trapezoidal Flap** *(Clinical images showing surgical site and post-operative view)* --- 31 32 - “Second choice” for endodontic surgery - Begin as a triangular flap and then do 2nd vertical incision if extra access required > [!tip] Indications > - 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. - Good access & vision - Good moisture control - Heals without scars - ==when handled properly== - Easy to reposition *(Clinical images showing surgical site and post-operative view)* **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 17 --- **Trapezoidal Flap** *Recall - 6 Months* --- **Luebke-Oschenbein Flap** - 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 *Recall - 6 Months* ### **Luebke-Oschenbein Flap** - 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 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 18 --- **Luebke-Oschenbein Flap** - Use for anterior teeth with crowns - To avoid gingival recession 35 --- **Luebke-Oschenbein Flap** 36 - 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 Technique** - **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.== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 19 Luebke-Oschenbein Flap - Recall at 6 Months **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 20 --- **Scalpel Blades** - **No. 15** - for periosteal flaps - **No. 11** - for incision and drainage - *Stabbing action* --- **Scalpel Blades** *(Image showing scalpel blade in use with measurement标注)* --- 39 40 ## **Scalpel Blades** - **No. 15** - for periosteal flaps - **No. 11** - for incision and drainage - *Stabbing action* *(Image showing scalpel blade in use with measurement标注)* Diagrams illustrating incision placement and flap elevation techniques in periosteal flaps. **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 22 --- **Apical Bevel** 43 **Apical Bevel** 44 Apical Bevel diagram and clinical image showing tooth anatomy and surgical site ## **Apical Bevel** > [!note] 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. **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 23 --- **Apical Bevel** 45 --- **Apical Bevel** 46 Diagram showing apical bevel with tubule density labels: 28,000, 18,000, 13,000 tubules per mm² Diagram showing incorrect apical bevel techniques (A, B, C) with a red “X” over them, and correct technique (D) Endodontic equipment close-ups, including tips and handpieces **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 25** --- **Equipment** *Image: Two radiographs showing endodontic treatment, with a red arrow pointing to a feature on the right radiograph. Labeled "49".* --- **Equipment** *Image: A dental handpiece and several endodontic files arranged on a blue surface. Labeled "50".* ## **Equipment** *Image: Two radiographs showing endodontic treatment, with a red arrow pointing to a feature on the right radiograph. Labeled "49".* *Image: A dental handpiece and several endodontic files arranged on a blue surface. Labeled - **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.== "50".* **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 26** --- **Equipment** 51 --- **Equipment** 52 Image of a hand holding a dental ultrasonic scaler labeled "NEOSONIC" with controls for "POWER", "MODE", and "SCALING". Two radiographic images comparing root canal preparation: - Left: "with tips" - Right: "with hand piece" **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 27** --- **Equipment** 53 --- **Micro-Mirrors** 54 Image showing two small, rounded dental instruments on a blue background. Image showing a set of dental mirrors, including a large round mirror and two smaller, slender mirrors, arranged on a blue background. ### **Micro-Mirrors** > [!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. **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 28 --- **Curettage Techniques** 55 **Curettage Techniques** 56 Clinical images showing intraoperative views of curettage procedures during endodontic surgery. ## **Curettage Techniques** - **Technique:** ==A curette is used with its back surface to **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 29 --- **Curettage Techniques** 57 --- **Curettage Techniques** 58 Diagram illustrating curettage techniques with labeled anatomical structures and instruments. Two side-by-side illustrations showing detailed views of curettage procedures on tooth roots. **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 30** --- **Curettage Techniques** 59 --- **Curettage Techniques** 60 Clinical image showing curettage technique with green arrows indicating tissue removal from periapical area. Clinical image showing curettage technique with green and red arrows indicating direction of tissue removal. **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 31** --- **Retrograde Filling Materials** **Materials– Past and Present** - Amalgam - Cavit - IRM - Super-EBA - Composite resins - Gutta percha - Glass ionomers - MTA (ProRoot) ## **Retrograde Filling Materials** ### **Materials– Past and Present** - Amalgam - Cavit - IRM - Super-EBA - Composite resins - Gutta percha - Glass ionomers - MTA (ProRoot) **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 32 --- **Amalgam** **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 --- **Amalgam** Radiographic and clinical images showing amalgam restoration with associated tissue tattoo and structural details. ### **Amalgam** > [!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 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 33 --- **Amalgam** 65 **Amalgam** 66 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 34 **Amalgam** 67 **IRM + Super-EBA** **Disadvantages & Problems** - **Poor tissue compatibility** - Due to continuous release of eugenol - Fibrosis of adjacent tissue - **Soluble** - **Large cavity required** - **Difficult to handle material** - Esp. Super-EBA 68 ### **IRM + Super-EBA** #### **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 **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 35** --- ### Glass Ionomer **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 - Relatively large cavity required --- ### Mineral Trioxide Aggregate Product image of "PRO ROOT MTA" Root Canal Repair Material by Dentsply Sirona, showing packaging with features: "Now Tooth-Colored Formula", "One Visit Pulp Capping", "5x1gram", and reference number "REF-A 0405 000 001.00". ### **Glass Ionomer** > [!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 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 36 --- **Mineral Trioxide Aggregate** **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 --- Mineral Trioxide Aggregate slide with clinical application diagram and product image ### **Mineral Trioxide Aggregate** > [!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 - ==It has a granular, - Difficult to place - Long setting time - Various times / forms - Expensive **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 37 **Gutta Percha + Cement** **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 **Treatment Outcome Studies** <table> <thead> <tr> <th>Reference</th> <th>Favourable</th> <th>Uncertain</th> <th>Unfavourable</th> </tr> </thead> <tbody> <tr> <td>Nordenram et al 1970</td> <td>56 %</td> <td>36 %</td> <td>8 %</td> </tr> <tr> <td>Harty et al 1970</td> <td>90</td> <td>-</td> <td>10</td> </tr> <tr> <td>Rud et al 1972</td> <td>83</td> <td>14</td> <td>3</td> </tr> <tr> <td>Malmström et al 1982</td> <td>74</td> <td>17</td> <td>9</td> </tr> <tr> <td>Forsell et al 1988</td> <td>68</td> <td>21</td> <td>11</td> </tr> <tr> <td>Amagasa et al 1989</td> <td>95</td> <td>-</td> <td>5</td> </tr> <tr> <td>Grung et al 1990</td> <td>85</td> <td>14</td> <td>1</td> </tr> <tr> <td>Friedman et al 1991</td> <td>70</td> <td>30</td> <td>-</td> </tr> <tr> <td>Rapp et al 1991</td> <td>56</td> <td>33</td> <td>11</td> </tr> <tr> <td>Abbott 1999</td> <td>92.3</td> <td>4.2</td> <td>3.5</td> </tr> <tr> <td>All re-treats after retro. amalgam</td> <td>73</td> <td>74</td> <td></td> </tr> </tbody> </table> ### **Gutta Percha + Cement** #### **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 > [!tip] 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** > [!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. <table border="1" style="width:100%; border-collapse: collapse;"> <thead> <tr> <th style="padding: 8px; border: 1px solid black;">Reference</th> <th style="padding: 8px; border: 1px solid black;">Favourable</th> <th style="padding: 8px; border: 1px solid black;">Uncertain</th> <th style="padding: 8px; border: 1px solid black;">Unfavourable</th> </tr> </thead> <tbody> <tr> <td style="padding: 8px; border: 1px solid black;">Nordenram et al 1970</td> <td style="padding: 8px; border: 1px solid black;">56 %</td> <td style="padding: 8px; border: 1px solid black;">36 %</td> <td style="padding: 8px; border: 1px solid black;">8 %</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Harty et al 1970</td> <td style="padding: 8px; border: 1px solid black;">90</td> <td style="padding: 8px; border: 1px solid black;">-</td> <td style="padding: 8px; border: 1px solid black;">10</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Rud et al 1972</td> <td style="padding: 8px; border: 1px solid black;">83</td> <td style="padding: 8px; border: 1px solid black;">14</td> <td style="padding: 8px; border: 1px solid black;">3</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Malmström et al 1982</td> <td style="padding: 8px; border: 1px solid black;">74</td> <td style="padding: 8px; border: 1px solid black;">17</td> <td style="padding: 8px; border: 1px solid black;">9</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Forsell et al 1988</td> <td style="padding: 8px; border: 1px solid black;">68</td> <td style="padding: 8px; border: 1px solid black;">21</td> <td style="padding: 8px; border: 1px solid black;">11</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Amagasa et al 1989</td> <td style="padding: 8px; border: 1px solid black;">95</td> <td style="padding: 8px; border: 1px solid black;">-</td> <td style="padding: 8px; border: 1px solid black;">5</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Grung et al 1990</td> <td style="padding: 8px; border: 1px solid black;">85</td> <td style="padding: 8px; border: 1px solid black;">14</td> <td style="padding: 8px; border: 1px solid black;">1</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Friedman et al 1991</td> <td style="padding: 8px; border: 1px solid black;">70</td> <td style="padding: 8px; border: 1px solid black;">30</td> <td style="padding: 8px; border: 1px solid black;">-</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Rapp et al 1991</td> <td style="padding: 8px; border: 1px solid black;">56</td> <td style="padding: 8px; border: 1px solid black;">33</td> <td style="padding: 8px; border: 1px solid black;">11</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">Abbott 1999</td> <td style="padding: 8px; border: 1px solid black;">92.3</td> <td style="padding: 8px; border: 1px solid black;">4.2</td> <td style="padding: 8px; border: 1px solid black;">3.5</td> </tr> <tr> <td style="padding: 8px; border: 1px solid black;">All re-treats after retro. amalgam</td> <td style="padding: 8px; border: 1px solid black;">73</td> <td style="padding: 8px; border: 1px solid black;">74</td> <td style="padding: 8px; border: 1px solid black;"></td> </tr> </tbody> </table> **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 38 **Endodontic Surgery** - with GP + AH26 **Endodontic Surgery - Stages** 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** 75 76 ## **Surgical Procedure Walkthrough (with GP + AH26)** ### **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** **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 39 --- **Consultation** 77 --- **Local Anaesthesia** 78 ### **Consultation** - ==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.== **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 40** **Instruments** 79 **Incision + Periosteal Flap** 80 ### **Instruments** ### **Incision + Periosteal Flap** **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 41 --- **Bone Removal & Curettage** 81 **Retrograde Canal Preparation** 82 ### **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.== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 42 --- **Retrograde Canal Preparation** 83 --- **Retrograde Canal Preparation** 84 Slide 83 showing "Retrograde Canal Preparation" with three images: a surgical view of a tooth being prepared, a close-up of a dental handpiece, and a set of retrograde preparation instruments on a blue cloth. Slide 84 showing "Retrograde Canal Preparation" with two images: a retrograde preparation instrument on the left and a surgical view of a tooth with exposed root and bleeding tissue on the right. **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 43** --- **Retrograde Canal Preparation** 85 --- **Haemorrhage Control** 86 Image showing a tooth with retrograde canal preparation, labeled "Retrograde Canal Preparation" Image showing a bottle labeled "Adrenaline Solution" and a package labeled "ETHICON BONE WAX", with the title "Haemorrhage Control" ### **Haemorrhage Control** - ==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.== **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 44** --- **Paper Points** 87 --- **Cement - AH 26** 88 Image showing paper points and a dental procedure Image showing AH 26 cement product and application ### **Paper Points** ### **Cement - AH 26** **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 45** --- **Gutta Percha** 89 --- **Cement - Placement** 90 Image showing multiple gutta percha points on a blue background Two images: left shows a dental instrument placing cement into a tooth; right shows a close-up of cement being applied ### **Gutta Percha** ### **Cement - Placement** - ==The Briolt probe is used to carry and place the AH26 cement into the prepared cavity.== **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 46 --- **Retrograde Root Filling** 91 92 Two clinical images showing surgical site and bone defect Image of a dental device and a surgical instrument ### **Retrograde Root Filling** 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**.== **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 47** --- **Retrograde Root Filling** 93 --- **Retrograde Root Filling** 94 Slide 93: Title "Retrograde Root Filling" with images of dental instruments and a tooth with a root-end preparation. Slide 94: Title "Retrograde Root Filling" with images of a tooth with a root-end preparation and dental instruments. **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 48 --- **Retrograde Root Filling** 95 **Retrograde Root Filling** 96 Figure showing Eucalyptus Oil bottle label and small object on blue background Figure showing close-up of teeth with retrograde root filling material visible **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 49 --- **Suturing** --- **Post-Operative Instructions** **ALSO:** 1. Post-op Radiograph 2. Suture Removal - 4-5 days 3. Reviews - 3-4 months - 12 months - 3 years --- Suturing slide showing suture packaging and intraoral images of sutures in place Post-Operative Instructions slide with printed handout and bulleted list of follow-up steps ### **Suturing** 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 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 50 Pre-op and Mid-surgery radiographic comparison of endodontic surgery # **Endodontic Surgery** > [!info] 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. W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 51 Radiographic review images showing "Review - 3 months" and "Review - 12 months" with periapical radiographs of endodontically treated teeth. **Endodontic Surgery** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 52** 103 104 Radiographic review after 3 years showing periapical healing and successful endodontic surgery outcomes. Radiographic image of teeth with endodontic treatment, demonstrating post-operative status. **Endodontic Surgery** W/Prof. Paul V. Abbott AO --- **Post-op** 105 **Review - 8 years** 106 --- 2nd Year DMD - 2020 Page 53 ## **Post-op** ## **Review - 8 years** **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 54 Radiographic comparison of RCF + Surgery cases pre-op, post-op, 6 mth RC, and 1 Year RC {{PAGE_55} - ==This can take hours, making it susceptible to washing out from the surgical site before it hardens.== } **Endodontic Surgery** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 55 Two sets of dental radiographs labeled "RCF + Surgery" showing pre-operative, post-operative, and follow-up images at 6 months and 2 years. Labels include "Pre-op", "WL", "Post-op: RCF + Surgery", "6 Mths RC", and "2 Years RC". # **Suturing** # **Post-Operative Instructions** **ALSO:** 1. Post-op Radiograph 2. Suture Removal - 4-5 days 3. Reviews - 3-4 months - 12 months - 3 years [[O5 EndoSurgery.pdf#page=1|O5 EndoSurgery, p.1]] [[O5 EndoSurgery.pdf#page=2|O5 EndoSurgery, p.2]] [[O5 EndoSurgery.pdf#page=3|O5 EndoSurgery, p.3]] [[O5 EndoSurgery.pdf#page=4|O5 EndoSurgery, p.4]] [[O5 EndoSurgery.pdf#page=5|O5 EndoSurgery, p.5]] [[O5 EndoSurgery.pdf#page=6|O5 EndoSurgery, p.6]] [[O5 EndoSurgery.pdf#page=7|O5 EndoSurgery, p.7]] [[O5 EndoSurgery.pdf#page=8|O5 EndoSurgery, p.8]] [[O5 EndoSurgery.pdf#page=9|O5 EndoSurgery, p.9]] [[O5 EndoSurgery.pdf#page=10|O5 EndoSurgery, p.10]] [[O5 EndoSurgery.pdf#page=11|O5 EndoSurgery, p.11]] [[O5 EndoSurgery.pdf#page=12|O5 EndoSurgery, p.12]] [[O5 EndoSurgery.pdf#page=13|O5 EndoSurgery, p.13]] [[O5 EndoSurgery.pdf#page=14|O5 EndoSurgery, p.14]] [[O5 EndoSurgery.pdf#page=15|O5 EndoSurgery, p.15]] [[O5 EndoSurgery.pdf#page=16|O5 EndoSurgery, p.16]] [[O5 EndoSurgery.pdf#page=17|O5 EndoSurgery, p.17]] [[O5 EndoSurgery.pdf#page=18|O5 EndoSurgery, p.18]] [[O5 EndoSurgery.pdf#page=19|O5 EndoSurgery, p.19]] [[O5 EndoSurgery.pdf#page=20|O5 EndoSurgery, p.20]] [[O5 EndoSurgery.pdf#page=21|O5 EndoSurgery, p.21]] [[O5 EndoSurgery.pdf#page=22|O5 EndoSurgery, p.22]] [[O5 EndoSurgery.pdf#page=23|O5 EndoSurgery, p.23]] [[O5 EndoSurgery.pdf#page=24|O5 EndoSurgery, p.24]] [[O5 EndoSurgery.pdf#page=25|O5 EndoSurgery, p.25]] [[O5 EndoSurgery.pdf#page=26|O5 EndoSurgery, p.26]] [[O5 EndoSurgery.pdf#page=27|O5 EndoSurgery, p.27]] [[O5 EndoSurgery.pdf#page=28|O5 EndoSurgery, p.28]] [[O5 EndoSurgery.pdf#page=29|O5 EndoSurgery, p.29]] [[O5 EndoSurgery.pdf#page=30|O5 EndoSurgery, p.30]] [[O5 EndoSurgery.pdf#page=31|O5 EndoSurgery, p.31]] [[O5 EndoSurgery.pdf#page=32|O5 EndoSurgery, p.32]] [[O5 EndoSurgery.pdf#page=33|O5 EndoSurgery, p.33]] [[O5 EndoSurgery.pdf#page=34|O5 EndoSurgery, p.34]] [[O5 EndoSurgery.pdf#page=35|O5 EndoSurgery, p.35]] [[O5 EndoSurgery.pdf#page=36|O5 EndoSurgery, p.36]] [[O5 EndoSurgery.pdf#page=37|O5 EndoSurgery, p.37]] [[O5 EndoSurgery.pdf#page=38|O5 EndoSurgery, p.38]] [[O5 EndoSurgery.pdf#page=39|O5 EndoSurgery, p.39]] [[O5 EndoSurgery.pdf#page=40|O5 EndoSurgery, p.40]] [[O5 EndoSurgery.pdf#page=41|O5 EndoSurgery, p.41]] [[O5 EndoSurgery.pdf#page=42|O5 EndoSurgery, p.42]] [[O5 EndoSurgery.pdf#page=43|O5 EndoSurgery, p.43]] [[O5 EndoSurgery.pdf#page=44|O5 EndoSurgery, p.44]] [[O5 EndoSurgery.pdf#page=45|O5 EndoSurgery, p.45]] [[O5 EndoSurgery.pdf#page=46|O5 EndoSurgery, p.46]] [[O5 EndoSurgery.pdf#page=47|O5 EndoSurgery, p.47]] [[O5 EndoSurgery.pdf#page=48|O5 EndoSurgery, p.48]] [[O5 EndoSurgery.pdf#page=49|O5 EndoSurgery, p.49]] [[O5 EndoSurgery.pdf#page=50|O5 EndoSurgery, p.50]] [[O5 EndoSurgery.pdf#page=51|O5 EndoSurgery, p.51]] [[O5 EndoSurgery.pdf#page=52|O5 EndoSurgery, p.52]] [[O5 EndoSurgery.pdf#page=53|O5 EndoSurgery, p.53]] [[O5 EndoSurgery.pdf#page=54|O5 EndoSurgery, p.54]] [[O5 EndoSurgery.pdf#page=55|O5 EndoSurgery, p.55]]