PRINCIPLES OF

ENDODONTIC SURGERY

DEFINITION:
Endodontic surgery is the management or prevention of
periradicular pathosis by a surgical approach.

It includes:
Abscess

drainage

Periapical

surgery

Corrective

surgery

Root

removal

RATIONALE:

To remove the causative agents of periradicular pathology.

To restore the periodontium to a state of biologic and

functional health.

OBJECTIVE:

To ensure the placement of a proper seal between the

periodontium and the root canal foramina.

PERIAPICAL SURGERY

INDICATIONS
1.

Anatomic problems preventing complete debridement/

obturation

2.

3.

a.

Calcified (blocked) canals

b.

Severe root curvatures

c.

Constricted canals

Restorative considerations that compromise treatment

a.

Presence of a crown

b.

A tooth that has been restored with post and core

Horizontal root fracture with apical necrosis

4.

Irretrievable material preventing canal treatment or

retreatment

5.

Procedural errors during treatment ( overobturation)

6.

Large periapical lesions that do not resolve with root

canal treatment

7.

Following completion of endodontics, if symptoms are

associated with the tooth (chronic fistula and drainage, pain
and sudden onset of a vestibular space infection).

Contraindications (or cautions) for periapical

surgery
1.

Unidentified cause of root canal treatment failure

2.

When conventional root canal treatment is possible

3.

When retreatment of a treatment failure is possible

4.

Simultaneous root canal treatment and apical surgery

5.

Anatomic structures (e.g., adjacent nerves and vessels) are in

close proximity

6.

Structures interfere with access and visibility

7.

Poor crown/root ratio

8.

Systemic complications (e.g., bleeding disorders)

STEPS IN PERIRADICULAR SURGERY

A.

Anesthesia

B.

Incision and flap reflection

C.

Periapical exposure

D.

Periapical curettage

E.

Root-end resection

F.

Root end preparation

G.

Root-end restoration

H.

Flap repositioning and suturing

I.

Post surgical care

I) FLAP DESIGN

A properly designed and carefully reflected flap

results in good access and uncomplicated
healing

The incisions most commonly used are:

a. Submarginal curved (semilunar)
b. Submarginal ,and
c. Full mucoperiosteal ( sulcular)

a. Semilunar incision

Slightly curved half-moon horizontal incision

in the alveolar mucosa
Advantage:
Easy access and quick access to the
periradicular structures
Gingival attachment is not disturbed
Disadvantage:
Full root surface not seen
Root resection difficult
Slow healing
Excessive hemorrhage
Scarring
Hence, contraindicated for most
endodontic surgery

b. Submarginal incision (LUEBKE OCHSENBEIN) FLAP

The horizontal component of the

submarginal incision is in attached
gingiva with vertical relieving incisions

The incision is scalloped in the

horizontal line, with obtuse angles at
the corners

Indications

Maxillary anteriors

Maxillary premolars

Advantages:
Esthetics
Less

risk of incising over a bony defect

Better

(less incidence of gingival recession)

access and visibility

Disadvantages:
Hemorrhage

along the cut margins into the surgical

site
Occasional,

healing by scarring

C. Full mucoperiosteal flaps(Sulcular incisions)

1. Triangular flap

INDICATIONS:

Maxillary incisors and posterior teeth.

Only recommended flap for mandibular posterior teeth.

ADVANTAGES:

Good wound healing

Ease of flap re-approximation with minimum
number of sutures

DISADVANTAGES:

Limited surgical access

Difficult to expose the root apices of long teeth like
maxillary and mandibular canines
Tension is created on retraction
Gingival attachment violated

2.

Rectangular flap

INDICATIONS:

Anterior teeth

Multiple teeth

Teeth with long roots like maxillary canines

Lateral root repairs.

Large lesions
CONTRAINDICATION : Posterior teeth

ADVANTAGES:
Increased surgical access to root apex
Reduces retraction tension
Facilitates repositioning

DISADVANTAGES:
a.Difficulty in re-approximation of flap margins
b.Gingival attachment violated
recession, crestal bone loss and dehiscence.

3.

Trapezoidal

Similar to rectangular except the 2 vertical incisions intersect

the horizontal incision at an obtuse angle so as to create a
broad based flap with the vestibular part wider than the
sulcular portion

Flap reflection

Flap reflection is the process of separating the soft tissues

(gingiva, mucosa, and periosteum) from the surface of the
alveolar bone.

II) Periapical exposure

A soft tissue lesion is seen

frequently, after flap reflection

If the opening is small, it is

enlarged using a large surgical
round bur, until approximately half
the root and the lesion are visible

Radiographs are used in

combination with clinical findings
to locate root apex

III) Periradicular Curettage

A surgical procedure to remove

diseased tissue from alveolar bone
in the peri radicular area or lateral
region surrounding a pulpless
(RCT) tooth

A suitably sized sharp curette is

used for enucleation of the lesion

Usually, remnants of tissue remain,

which is not a problem

Hemorrhage control to be achieved

IV) Root end resection

Indicated because it removes

the region that most likely had
the poorest obturation

2-3 mm of the root is resected

Bevel of resection
0-10 degrees

V ) Root end preparation and

restoration
Purpose:
To create a cavity to receive a root-end
filling.
The filling seals the canal system, so
that no bacteria or bacterial by
products can enter or leave the canal
Instruments Used:

Small round or inverted cone bur

Ultra sonic tips

RETROGRADE ROOT END RESTORATIVE MATERIALS

Amalgam

Glass ionomer cement

Zinc oxide eugenol cement

Intermediate restorative material (IRM)

Super ethoxybenzoic acid (EBA)

Gutta percha
Mineral trioxide aggregates (MTA)

INSPECTION AT VARYING MAGNIFICATIONS

PRINCIPLES INVOLVING RETRO PREPARATION AND RESTORATION

3mm: root resection, 0-10o bevel

3mm of retrograde restoration

Provides 6mm of seal from original apex thus sealing all

accessory and lateral canals

VI) SOFT TISSUE REPOSITIONING AND

COMPRESSION

The elevated mucoperiosteum is gently replaced to its original

position with the incision lines approximated as closely as
possible.

Tissue compression:
Using a surgical gauze moistened with sterile saline, gently apply
firm pressure to the flapped tissue for 2 to 3 minutes (5 minutes
for palatal tissue) before suturing.

VII ) SUTURING

Purpose:
To approximate the incised
tissue and stabilize the flapped
mucoperiosteum until
reattachment occurs.

Sling suture is demonstrated in

the picture.