Surgery Lecture 5

‫بسم ال الرحمن الرحيم‬ ‫بسم ال الذي ل يضر مع اسمه شيء ل في الرض ول في السماء وهو السميع العليم‬

Principles of endodontic surgery First of all am so sorry for being late, but that's becoz I want to put the slide in the lec. To make it easier and helpful, and unfortunately I don’t have the soft copy of them, so I typed them for you. You don’t have to go back to the handout unless f u want:p

There is a misconception that surgery can resolve or treat any problem, this is not always right… becoz of that, many endodontic surgeries were performed for the wrong reason, where other modalities such as root canal treatment or retreatment, may be prefared and may solve the problem and result in a satisfactory treatment. For ex. If we have a tooth that has RCT and still has complaint, we shouldn’t go directly to and do surgery…we just simply re- treat the tooth by RCT and this might solve the problem. satisfactory results. And f we use surgery for everything this will lead to failure …. SURGERY is NOT ALWAYS INDICATED Definition:Endodontic surgery: is prevention or management of peri-radicular pathology by asyrgical approach. In general, this includes abcess drainage, periapical surgery, corrective surgery, intentional implantation.and root removal. What’s the meaning of Peri radicular pathology? It’s a pathological entities that develop around the root. SO we want to prevent or manage them PIC FIG 1 page 2 This is a tooth has pathology at its apical part ---- abscess drain through bone into soft tissue either… Intra-orally or extra-orally. Peri-apical surgery has different schools, it includes a variety of procedures or variety of treatment options like… management of abcesses but but baisically we mean by peri-apical surgery: 1apecectomy 2curettage.

1

Drainage of an Abscess:An abscess is a collection of pus which is related to the oral cavity and related to teeth, so it is either presented intra orally or extra orally, why is that?? What are the factors which determine that it’s either located intra or extra – orally? It’s muscle attachment… for ex. Lateral incisor has an apex which is located more palatally another one has an apex which is located more labially.. upper 1st molar has 3 roots: MB, DB, and P.. f the the infection is related to the palatal root then u might find the w]swelling palatally. Immunity can also affect, but its another factor, not our topic today. Drainage of an abcess will release purulent or hemorrhagic transudates and exudates from focus of liquefaction necrosis. When u drain an abcess what would u achieve? 1relief pain becoz we’ve pressure that coz pain 2improve circulation. What are themethods or techniques of drainage an abscess? 1through the root canal. 2using an intraoral incision. 3using an extraoral incision. 4Through the alveolus of the extraction. 5Drainage may also be performed with trephination of the buccal bone, when the root canal is inaccessible. PIC…FIG 2 page 3 We have a swelling which present intraorally and we use a knife to incise it, after that pus can be present in more than one compartment, we take the mosquito or the artery forceps and insert it through the incision while it’s closed then we open it inside the lesion, why?? To convert the pus that present in multiple compartmentinto single ones… so the pus from different compartment will drain through ur incison. Next step: we need to keep this incision open to allow pus and exudates to drain, how can we do that?? By insertion of a DRAIN DRAIN is made from rubber… we fix it to the margin of incision with suture and leave it for 24-48 hrs. After that if there is any pus it should drain and then we release the pressure,, we remove the drain and most of the time we don’t need to do anything… we just remove the drain and that's it. Another option of incision and drainage is to extract the tooth and drain pus from the socket. 2

We will try to know when it is indicated to do priapical surgery:1- Anatomical factors: Conditions that may compromise RCT, that prevent instrumentation, obturation, or both. These conditions include: 1. Calcifications. 2. Sever root curvature. 3. Constricted canals. 4. Dental anomalies. ( dens in dente) PIC " sorry I don't have it" Dens in dente: is simply tooth within tooth… it’s not easy to do RCT. 2- Restorative considerations: 1. when attempting RCT through a restoration could compromise the restoration's retention or perforate the root. 2. failed RCT on a tooth that has been restored with a post and core. Many posts are difficult to remove or may coz root fracture during removal. PIC x-ray" I don't have it also" : fractured apical part  remove it, clean apical area -- it will heal nicely. PIC another fracture. 3- Horizontal root fracture: After traumatic root fracture, the apical segment undergoes pulp necrosis. Becoz this cannot be predictably treated from coronal approach, the apical segment is removed surgically after root canal treatment of the coronal portion. 4- Irretrievable materials in canal: Objects such as separated instruments, restorative materials, segments of posts, or other foreign objects occasionally block canals. those materials must be removed surgically. 5- Procedural errors: The followings may result in RCT failure: 1. Breakage of small instruments in the canal. 2. foreign bodies driven into periapical tissues 3. gross overfills 4. Perforations of the inferior wall of pulp chamber or perforation of the root. 5. Surgical correction is necessary in these situation. 6- Large unresolved lesions after RCT: Very large periradicular lesions do not heal or may even enlarge after adequet debridement and obturation. These are gently best resolved with decompression and not curettage, which may damage adjacent structures. 3

Contraindications of periapical surgery: These are cautions not pure contraindications, i.e. f we ‫ عدلناهم‬they may become an indications for periapical surgery. 1unidentified cause lead to treatment failure: doing surgery to correct a treatment failure for which the coz cannot be identified is often unsuccessful. i.e. f we don’t know the coz of surgery this will lead to failure surgery. 2A when orthograde conventional RCT is possible. 3Simultaneous RCT and apical surgery. 4Anatomic consideration: 1. Teeth close to maxillary sinus. 2. external oblique ridge over mandibular second and third molars. 3. zygomatic buttress may inhibit access to maxillary molar apices. 4. a prominent chin creats a shallow vestibule with limited access to mandibular anteriors 5. the mental foramen is of concern but is easily avoided by identifying its position radio graphically and during flap reflection. 5Poor crown and root ratio:  Teeth with very short root have compromised bony support and are poor candidate for surgery  However, shorter roots may support a relatively long crown if the surrounding cervical periodontium is healthy. 6Medical complication: There is no specific ones for endodontic surgery exist that would not be similer to those for other types of oral surgical proceadures.

What are the surgical procedure for apicectomy and periapical curettage?? 1234567-

891011-

Local anesthesia. Falp design. Incision and reflection. Acess to the apex. Curettage. Root end resection. Root end preparation and filling. Radiographic verification. Flap replacement and suture. Postoperative instructions. Sutural removal.

4

12-

Long- term evaluation.

II- Flap Design : a carefully reflected flap will result in good acess and u'll be able to see wt are u going to do and performing the surgery with ease. We have three types of flaps: semilunar, submarginal, and full mucoperiosteal. Semilunar: ‫))هللي‬ Slightly curved half-moon horizontal incision in alveolar mucosa. It’s performed 2 mm away from the margins of the teeth for esthetic reasons, otherwise there will be recession and exposure of the apical part of the tooth especially the anterior area. 1-

It's not advocated today for these reasons:1. It provides a restricted surgical access . 2. It also carries the danger of postsurgical defects by incising through tissues that are not supported by bone. 3. It compromises blood supply, which could lead to shrinkage, gapping, and secondary healing. 4. Close proximity of the incision to the osteotomy site, which makes hemostatic control more challenge. FIG 3 in the slide page 6. 2-Submarginal Flap: The horizontal component is in attached gingiva with one or two accompying vertical incisions. It’s scalloped in the horizontal line, with obtuse angles at the corners. It is used successfully in the maxillary anterior region. The major advantage is esthetic: leaving the gingiva intact around the margins of crowns is less likely result in bone resorption with tissue recession and crown margins exposure. Compared to semilunar flap, it provides less risk of incising over a bony defect and provides better access and visibility. Disadvantages: Hemorrhage along the cut margins. Occasional healing by scaring, compared with full mucoperiosteal flap. FIG 4 in the slide page 7. 2- Full mucoperiosteal flap: 5

It is an incision in the gingival sulcus, extending to the gingival crest. This procedure includes elevation of interdental papilla, free gingival margin, attached gingiva, and alveolar mucosa. Advantages: 1.Maximum access and visibility. 2.Not incising over the lesion or bony defect. 3.less tendency for hemorrhage 4.complete visibility of the root. 5.Allowance of root planning and bone contoring 6.Reduced likelihood of healing with scar formation Disadvantages: 1.More difficult to place and replace a suture 2.Gingival recession frequently develops, exposing crown margins or cervical root surfaces. FIG 5 in the slide page 8. It has 2 types: A.Triangular flap (three corners): Indicated in the anterior and post. Regions of both maxilla and mandible. Requires horizontal intrasulcular incision and single vertical incision. The horizontal one: is made with the scalpel held near vertical position, extending through the gingival sulcus and the gingival fibers down to the level of crestal bone. When passing through the interdental region, care should be taken to ensure that: the incision is separating the buccal and lingual papillae . A clean incision is vital to prevent sloughing of the papillae due to compromised blood supply and to prevent unaesthetic look of double papillae. The vertical one: is prepared between the root eminences parallel to the long access of the root." In the anterior surgery, vertical incision is prepared closest to the surgeon. While in posterior surgery, it always constitutes the mesial of the flap." It is important to keep the base of the flap as wide as the top so that the vertical incision is kept parallel to the vertically positioned microvasculature. So the least number of vessels and fibers are severed, which will lead to fast healing without scarring. It should meet the tooth at the free gingival margin with 90 degree, and should terminate at the mesial or distal to the tooth.

6

Triangular flap has disadvantage, which is limited surgical access. So a rectangular flap design should be considered f maximum access is required. FIG 6, 7 page 8 and FIG 8 page 9. B.Rectangular flap ( four corner): It is very similar to triangular design except for addition of a second vertical releasing incision. It is indicated for: Anterior surgery when more access is needed. Used when multiple teeth will be operated on or when roots are long. Disadvantages: include technique sensitive wound closure and higher chance for flap dislodgement. FIG 9 page 10. Rectangular submarginal flap design: Does not include the marginal and inter dental gingival. It can be used in both maxillary anterior or posterior regions but when sufficient width of attached gingival is available. Indication: 1.In teeth with existing fixed restoration. 2.Where aesthetic is the major concern. Contra indications:  In the mandible, coz the attached gingival is narrow, and aesthetic is not the major concern. About 2mm of the attached gingival from the depth of the gingival sulcus must be present before this flap design is selected. This design is formed by scalloped horizontal incision and one or two vertical incisions depending on surgical access that is needed. This incision reflects the contours of the marginal gingival and provides adequate distance from the depth of the gingival sulci. It also serves as guide for correctly re-positioning the flap for suturing. FIG 10 page 11. All flap corners should be rounded to promote smoother healing and minimize scar formation. The angle of the incision should be 45 degree in relation to the cortical plate, to allow the widest cut surface and better adaptation for the flap when it is repositioned. FIG 11 page 11. This angulation will add an additional safety measure to protect the 2mm of attached gingival. Advantages: 7

Leaving the marginal and interdental gingival intact in addition to leaving crestal bone unexposed. Disadvantages: The severance of supraperiostal vessels, which could leave the unreflected tissue without blood supply. This can be prevented by preserving an adequate width of un-reflected gingival tissue, so this will derive secondary blood supplies from PDL and interaosseous blood vessels. The healing of this flap is quite similer to the full mucoperiosteal flap.

III- Incision and Reflection: It is important to incise and reflect a full- thickness flap to minimize hemorrhage and to prevent tearing of the tissues. This incision should be firm and made theough the periosteum to bone. Reflection: reflect the flap from the vertical incision down to bone, then raising the horizontal component. When reflect the periosteum the elevator must firmly contact bone while the tissue is raised. FIG 12 page 12. Once you reflect the flap u can seen area of apex of root most of the time.

IV- Periapical exposure: Coz the lesion perforates the bone so u can see the perforation area, but sometimes in the lateral incisor for ex. Is inclined palatally so bone may be intact, how can u locate the site of the apex?? Root tip may be located with a radiograph, and u can measure it by perio probe and apply into bone, this will give u estimation of the position of root apex. or, u can use a file. FIG13 page 13. Now if the lesion perforate the bone and the area is small, u can widen it by using round bur,- on vented high-speed hand-pieces or electrical surgical hand-pieces otherwise the use of hand- piece that direct the air water and abrasive particles into the surgical site shouldn't be used -,to remove bone and increase the exposure of periapical area… So u will have better access.

V-curettage: Most of the granulomatous inflamed tissues surroundingthe apex should be removed to: 1.Gain access and visibility of the apex.

8

2.Obtain a biopsy for histological examination. 3. Minimize hemorrhage. Some areas of the lesion may be inaccessible to the curettes, such as the lingual aspect of the root. Portions of inflamed tissue or epithelium may be left, without compromising healing, so total removal is not necessary. If hemorrhage from soft or hard tissue is excessive, which compromise visibility, homeostatic agents are useful. The best hemorrhage control is to apply and hold direct pressure over the bleeding site with gauze. FIG 15 page 14. The material that we remove can be used as biopsy.

VI- Root end resection: It is not always indicated. It is useful in two situations: 1.To gain access to the canal for examination and placement of a root end preparation and restoration. 2.To remove an undebrided or unobturated portion of the root. This is may be necessary in cases with dilacerated roots, ledged or blocked canals, or apical canal space that is inaccessible due to restorations, and in accessing of lingual structures. (I.e. f we remove this part of root we can see the lingual aspect of it and see it clearly). The apical part of root has lateral canals, and f there are more than one they will not be filled by root canal material … so the bacteria will gain access to the canals, mostly they are in the last 3-4 mm of most apical area of root. SO… removal of this part will lead to removal of un cleaned canals. Procedure: 1-A trough is created around the apex with tapered fissure bur to expose and isolate the root end. 2-The resection is with the same tapered fissure bur. 3-Bevel: a bevel of varying degrees is made in facio-lingual angle depending on the location and whether a root end preparation is to be placed. We can make this bevel either at zero angle or at 45 degree. Advantages of zero bevels: 1.Ensure equal resection of the root apex on both buccal and lingual aspects. 2.Minimal exposure of dentinal tubules, which result in reduction in apical leakage.

9

3.the root canal anatomy is no longer elongated in buccolingual direction, thus facilitating retropreperation and retrofilling procedures. 4. Amount of root removed Sufficient root apex should be removed to provide a larger surface and to expose the additional canals 1.2-3 mm of the total root length is usually adequate 2.One-half to one third of the root may be resected for apical access. 45-degree bevel: Using this bevel will enable us to see some of the lateral canals.  Number of dentinal tubules that are exposed are more  more leakage. FIG 16 page 15, FIG 17 page 16. Even f u want to do zero bevel, u can’t do it sometimes becoz of the angulation of the root and the angualtion of the handpiece. U'll reach 10 -15 degree not zero. So the ideal is 10 degree bevel… the 45 degree bevel cannot either be made for the same reason.

VII- root end preparation and restoration: It is indicated f there is an inadequate apical seal. It is like class I preparation should extend to at least 3-4mm in to the root.

Root end preparation done: 1by slow speed. 2- Specially designed hand piece. 3Ultrasonic tips. Advantages of ultrasonic instruments: 1. control and ease of use. 2. permit less apical root removed 3.formation of cleaner shaped preparation FIG 19 page 17.

VIII- root end filling materials: The root end filling material should:1seal well 2be tissue tolerant 3easily inserted 4- minimally affected by moisture 10

5visible radio graphically 6-must be stable and non resorbable

the material that can be used: 1. Amalgam 2.mineral trioxide aggregate(MTA) 3.reinforced zinc oxide cements ( IRM and super EBA) 4. Glass Inomer cement. Q. dose amalgam do any irritation? A. placing amalgam inside the tooth is more irritant than place it at the apex, imagine that u are placing amalgam in a huge number of dentinal tubule while here we are putting it at the apex only.

IX- Irrigation: The surgical site is flushed with normal saline to remove soft and hard tissue debris, hemorrhage, clots and excess root end filling material.

X-Rdiografic verification: It is important to be made before suturing, to verify the surgical objects are satisfactory. And f correction are needed to make them before suturing.

XI-Flap replacement and suturing XII_ Postoperative instructions XIII recall Suture removal. Recall evaluation Some failure after surgery are evidenced only by radiographic finding. A 1- year follow- up is good indicator. Failure: 1-persistant symptoms, pain, swelling, presence of sinus tract, deep probing defect, or other adverse findings. 2-F after 1 year, radiograohic evidence shows no decrease in lesion size or lesion size increase. Adjuncts: Some of the newer devices and materials have improved surgical procedures. These includes: 1.Light and magnification devices: 1- surgical microscope. 2Fiber optics.

11

2.Technique of guided tissue regeneration. Now the doctor put a slide show for a case, but unfotunatly I don’t have the PIC… but this is the description on them: It is a periapical area for a tooth with adequate RCT, despite this there is persistent of the lesion and the apical part is not completely obturated… 1)Design our flap, full thivkness mucoperiosteal flap, four corners. 2)Release the flap by mucoperiosteal elevator, so u can see the bone 3)Curette the area, f there is perforation widen it by bur or curette, F not located use perio prbe and file on the radio graph so u can locate it. 4) Resection 45 degree or zero bevel. How much we remove from the root apex? About 90% of the lateral canals\ accessory are present in the final 3-4 mm of the root. F u need to remove more u need to know that is there much root left? Becoz f u remove half of the root the prognosis will be poor So we remove 2,3,or 4 mm . 4)prepare the cavity and then fill it 5) suture it.

THE END This was my first time, so plz forgive me f u find any mistake… thank u for reading it.

12

‫و هل اجا وقت الهداءات اللي هي اهم شي بالمحاضرة و اللي كلنا منفتح عليها قبل ما نقرأ‬ ‫المحاضرة و اللي كمان نحنا منكتبا اول شي او بالحرى منفكر شو بدنا نكتب فيها قبل ما نسمع‬ ‫المحاضرة‪ ...‬‬ ‫اول شي و قبل الكل بحب اهديها ييييي ييي ي ييي يييي ياللي ما فيني عيش من‬ ‫دونكن وال يستر شو بدو يصير فيني سنة الجاية بعد ما تتركوني‪ ...‬‬ ‫طبعا اول الكل فرح عبد المعيد و فاطمة الطائي ) عنجد معكن بيهون كل شي‪ ...‬يعني انتو رفيقتا‬ ‫الدرب(‬ ‫امل العمري " يمكن كلمة أحلى بارتنر قليلة عليكي‪ ...‬شكرا لنك عم تتحمليني"‬ ‫وطبعا جمانة تيسير‪ "..‬حبيبة قلبي"‪ ..‬جمانة شمساه " يارايقة"‪ ..‬زينب الشايب" وين صورتي؟؟!!"‪..‬‬ ‫سناء الديمي " ‪...‬ال يديم البتسامة على وجهك"‪ ...‬نور حمدان و ربى ابو ريمة" يعني شكرا انكن‬ ‫شجعتوني اني اكتب المحاضرة‪ ..‬بس بصراحة‪ ....‬مو نصيحة"‬ ‫وطبعا جروب ‪A1+A2‬‬ ‫ايمان الراس " الشيبس طيب ‪ ..‬صح؟"‪ ..‬نور الرحمون‪ ..‬تينا " بلييز خلي نور تعلمك تقولي اسمي‬ ‫صح"‪ ..‬جمانة طعامنة " ماما"‪ ..‬ديمة " ام الزهري"‪ ..‬زين الصمادي‪ ..‬اسراء شطارة‪ ..‬غادة ‪ ..‬دانة‬ ‫" شكرا كتير عالمساعدة"‪ ..‬عزام‪ ..‬لؤي‪ ..‬عماد‪ ..‬باسل‪ ..‬أمين‪ ..‬همام‪ ..‬أسامة‪ ....‬محمد شعبان "‬ ‫شكرا عا الهداء"‬ ‫وطبعا ختامها مسك بحب أشكرك فاطمة أسعد" شكراكتييير عزبتك معي"‬ ‫و اسفة ازا نسيت حدا بس اكييد مو مقصودة‬

‫‪..Goog Luck‬‬

‫‪13‬‬