Endodontic Surgery

Endodontic surgery is a surgical procedure performed to remove or correct the causative agents of radicular and peri radicular diseases THAT CANNOT BE TREATED BY CONVENTIONAL MEANS OF ENDODONTIC THERAPY. (Means any pathogen around the root that can't be corrected by conventional RCT) The conventional mean of endodontic therapy is Ortho grade Root Canal Treatment. Ortho-Grade RCT: Access of the root canal through the crown (normal/conventional RCT ( Retro-Grade RCT: Access of the root canal from the apical portion of the tooth (Apex access).

In Endodontic surgery we usually do Retro-grade Endodontic Treatment. Endodontic surgery is the last hope for retention of a tooth (last treatment option( and it shouldn't be an alternative for Endodontic treatment; because the Gold standard treatment for any Endo problem is Endodontic Treatment (RCT).

Types of Endodontic Surgery (6 types):

1. Incision and Drainage 2. Trephination (Incision and drainage through bone) 3. Peri-radicular surgery 4. Repair of perforation 5. Hemi-Section and Root Amputation 6. Intentional re-plantation
In Oral surgery we are only interested in the first three types (Incision and Drainage, Trephination & Peri-radicular surgery) the rest will be covered in Endodontic courses.

Incision and Drainage:

When there is a collection of pus (abscess) and perforated the bone, and it was above the Muscle attachment reaches to the soft tissues in the oral cavity. The patient will present to your clinic with swelling and severe pain, as long as the pus is in a closed cavity it will continue to extend and grow (due to anaerobic

bacterial growth). Therefore the most effective way to deal with a collection of pus is incision and drainage, which works by relieving the pressure (pressure is the cause of pain) and allow the area to be re-circulated. There are multiple ways/routes to drain an abscess: Through the socket, by extraction of the offending tooth. Through the Root Canal, by opening an access (RCT) Opening an incision near the abscess to drain it intra-orally or extra-orally.

Not every abscess drainage is considered surgical drainage; to be considered surgical Incision and drainage, you must also Incise the area (meaning draining through the socket and canal are not considered incision and drainage nor surgical endodontic). Usually in case of an abscess its difficult to extract the tooth, or to open an access canal; that's why we perform surgical Incision and drainage.

Methods of Incision and drainage:

We have two ways to perform incision and drainage: 1. Intra-Orally 2. Extra-Orally The method chosen depends on the location of the swelling, if the swelling is intra-oral (more common) then we incise through the fluctuating area in the abscess (feel an area of fluid movement by your finger) by a blade #11 (Not #15); because #11 is used for incision and drainage, then you insert the hemostat (closed) into the abscess cavity and open it and start moving the hemostat inside the cavity. The objective of moving the hemostat inside the abscess cavity is that most cavities consist of more than one chamber (multilocular) and moving the hemostat inside opens them into each other creating one large cavity( single cavity), then remove the hemostat (opened)! Why we remove the hemostat opened? To avoid grasping any vital structure inside the cavity. So insert the hemostat closed, open it inside and then withdraw it opened. After that the drain itself is inserted into the cavity and sutured into place (you can use a pair of gloves as a drain), the purpose of this drain is simply to keep the hole communicating between the abscess cavity and the surface open; to allow drainage of the fluid. The drain can be removed after two or three days. For extra-oral incision and drainage the concept is very similar, you start by searching for an area of fluid fluctuation (usually in the lower part of the swelling due to gravity). When performing the incision its critical to avoid the anatomical landmarks "Vital structures" (the facial nerve/marginal mandibular nerve should be avoided when working near the lower jaw/neck area; by working two finger widths below the lower border of the mandible).

The initial incision should be very small "minimal", only enough to allow the hemostat into the area, after insertion of the hemostat you open/expand it INSIDE the cavity, then you retract the hemostat from the cavity WHILE KEEPING THE HEMOSTAT OPEN. This is done to avoid grasping any vital structures inside. Extra note: Once you open the abscess cavity you should also flush it extremely well with normal saline to remove any bacteria before inserting the drain.

Advantages of the incision and drainage

Relieve the pressure. The patient will present with sever and acute pain, and relieving the pressure will relieve the pain. Because the abscess will make a capsule around itself so incision and drainage will allow the reintroduced circulation delivers antibiotics (that you prescribe to the patient) as well as the bodys defense mechanisms to the site. It allows relief of the accumulated by-products & bacteria, as well as allowing you to take a sample of the bacteria to identify the causative agent of the swelling. (Antibiotics you prescribe may not work; maybe because the bacteria formed resistance to this kind of antibiotics so you can identify the bacteria's family by taking a sample.) Cases that require incision and drainage CANNOT be treated by simply giving antibiotics; however you may have to prescribe antibiotics after draining the abscess. (The Gold standard treatment is Incision and drainage). So Antibiotics can be added to the treatment.

Trephination:
Trephination is a form of incision and drainage, but the pus collection is only inside the bone and it doesn't reach soft tissue, so rather than placing the incision through soft tissue you have to go through bone/hard tissue.(open a flap and go through the bone) This is done when there is no apparent swelling under soft tissue, with the abscess itself located INSIDE the bone. The process of trephination involves opening a surgical flap and then opening the bone to allow the abscess fluid to leave the cavity and relieve the pain. Trephination is usually performed as an emergency procedure when there is an absence of soft tissue swelling.

Peri-Radicular Surgery / Apicoectomy:

Apicoectomy: is an endodontic surgical procedure whereby a tooth's root Apex is removed giving access to the root canal. And the root end cavity is prepared and filled with a biocompatible material. Rule #1 of Apicoectomy that you dont go for apicoactomy unless you have a good endodontic treatment. (good obturation, good apical sealing, good cleaining and shaping).

The aim of apicoectomy to have a good apical seal. Apicoectomy is the second line of treatment of failure of (or as a supplement to) ortho-grade endodontic treatment.

Apicoectomy is not the treatment for any case that has endodontic failure; you first have to diagnose the cause of endodontic failure (it is NOT an alternative to RCT).

Indications of Apicoectomy:
Failure of endodontic treatment for the apical third of a tooth. (An apical third that is impossible to prepare- ex: pulpal calcification, or severe curvature of the root). Keep in mind that the apical third of the root has the highest percentage of lateral canals, which leads to a high percentage of failures; in this case Apicoectomy is indicated. * Poor endodontic treatment IS NOT an indication for Apicoectomy. 2. Symptomatic Irretrievable broken instrument in canal, especially if the canal has a good obturation or crown & post (to avoid having to remove the obturation material/crown). (Painful) For Asymptomatic broken instruments in the canal, we don't do anything. A pathology at the apical third. (granuloma or radicular cyst).

The cyst has to be removed and it won't go by itself. So you do a good Endodontic treatment then Apicoectomy. Fracture and infected apical third- in case you want to do a biopsy or investigation to a Pathology at the apical third (This is a peri-radicular surgery without apicectomy; to investigate a cyst or a pathology).

Notice that all the indications involve the apical third of the tooth, since Apicoectomy involves cutting the apical third, if the pathology/problem is in the middle third then it is an endodontic related problem.

Contraindications of Apicoectomy:
1. Non restorable tooth. (Mobile for example) we will go for extraction. 2. Crown-Root ratio- cutting from the apical third of the tooth will lead to a decrease in root length; if the root becomes too short then it might not be able to support the tooth anymore, Indication for extraction. 3. Pathology that can be resolved by conventional RCT (Ortho grade) if it can be resolved by conventional treatment then there is no need for Apicoectomy. 4. Health contraindications- such as patients on anti-coagulants, or with recent Myocardial infarctions, since Apicoectomy is considered a minor surgery. 5. Anatomic considerations such as an infected apical third of the lower 7, if the apical third is near the ID nerve then you must weigh the benefits against the risks of the operation. (Apicoectomy is not a very successful procedure). If a patient presents with a failed endodontic treatment, the success rate of a NON-surgical retreatment (redoing the Endo treatment) is 72%. If an Apicoectomy is done with a Retro-Grade filling " apical seal" (refilling the remaining apical portion of the tooth) is 60%, while an Apicoectomy alone (without RRF) is 51%.

Surgical procedure
Prophylactic Antibiotics should be given to the patient before the surgical procedure. Not after; because patients with Apeicoectomy always suffer from acute or chronic infections multiple times.

So this is an indication for prophylactic antibiotics before the procedure and not needed after. To preform Apicoectomy local anesthesia is a must as well as flap, bony window, root intersection.

Flap Designs:
Gingival- in the gingival flap you only perform sulcular incision, and elevate the soft tissue; it is NOT used for peri-radicualr surgery (apicoectomy), it is often used for extractions and perio surgery. Semi-Lunar- Provides very poor access and leads to bleeding intra operatively, and scarring post operatively; but they are occasionally used in the canine area (due to the long roots of the canine).

Triangular- a sulcular incision with one releasing incision (also called two sided Pyramidal flap); this is the most commonly used flap for Peri-Radicular surgery and Apicoectomy; because it provides good access while maintaining a good blood supply (maintain 1-2 mm of mobile mucosa to use while suturing). Rectangular- (Three sided pyramidal flap) a suclular incision with two releasing incisions, used when more access is needed; but is usually not needed. Sub-marginal- the first incision starts 3-5 mm below the attached mucosa then the releasing incisions are added, provides poor blood supply.

The problem with the gingival, triangular and rectangular flaps is that you are starting your incision From the sulcus, once you start suturing this will cause slight recession in the gum line (important if the Patient has a crown) which can lead to some esthetic problems. For this reason the sub marginal flap was made which is esthetically superior, the problem with sub marginal flap is that the blood supply at the attached part (closer to the teeth) is poor and may lead to necrosis.

Most of the times when we make a flap, we make the base wider than the apex, but in apicoectomy (when there in an infection), we can do it vertical, and this would help healing faster and better.

Once you make your flap, and elevate the mucosa you need to identify if there is a pathology (cystic overgrowth, granuloma) around the root end. After which you perform curettage (removal of pathology), and identify the root ending and cut the apical third of the root.

Root End Resection :

Research has found that most apical ramifications are related to the lateral canals found on the apical

3 mm portion of the root. Removing only 1 mm of the root removes only 40% of the lateral canals. Removing 2 mm removes 86% of the canals. Removing 3 mms removes 93% of the lateral canals. As a rule we usually remove 2-3 mms, but of course clinical judgment must be applied as the situation differs between patients. When we remove the apical third we should consider the occlusal force and the Crown root ratio, so if the infected part is 2 mm, we only remove 2 mm.

Sealing :
After root resection you have to ensure that the apical seal is good, good obturation. Depending on the seal you may or may not have to place a RGF (retro grade filling). Another method is to melt the gutta percha thats obturating the rest of the canal and use it as an apical seal.

The recommended retrograde filling material are SuperEBA (super ethoxy benzoic acid), MTA. MTA is the most commonly used RGF material. SuperEBA is the second most used material. Occasionally amalgam is also used to create apical seal; which is one of the most common causes of Amalgam Tattoo.

Suturing
Post-surgical Instructions
He will have pain, swelling. He has to take his medications, Analgesics but (No antibiotics).

And Simple extraction post instructions like not eating hot and hard food, no smoking, etc

Post-Surgical Complications:
Pain that CAN be controlled by analgesics Swelling is related to the amount of trauma induced during surgery and the nature of the patients body; swelling usually increases from the night of the procedure and reaches maximum size after 48 hours, after which it starts to decrease over one week. Infection usually only occurs after one week if at all. Bleeding is usually controlled and not an issue. Hematoma occurrence depends on the suturing, poor suturing with empty gaps under the skin will lead to heamatomas while good suturing will prevent hematomas. Tissue trauma mal alignment of retrograde filling - amalgam tattoo Foreign debris in surgical site Paresthesia if we injured any nerve.

Follow-Up
In the follow up visit you have to take radiographs and examine the radiolucent areas to ensure that they are decreasing. And the site of epiceectomy should be filled with bone later on.

Done By Maher.M.Khatib