Endodontic surgery.

By Chong BS, Rhodes JS

Date: 08/2015
Journal: Br Dent J

Summary: 

Purpose: to provide a contemporary and up-to-date overview of endodontic surgery.

 Indications:

Persistent disease (with or without symptoms) in a previously root filled tooth where non-surgical RCT cannot be done or has failed.

Correction of iatrogenic errors not possible with a non-surgical approach.

Biopsy or surgical investigation required.

As a combined approach, with non-surgical retreatment to resolve multiple technical problems.

•Where patient factors dictate that it may be more practical to consider a surgical treatment.

Contraindications:

Preoperative Assessment:

•Medical & Dental history

•Extra and intra-oral examinations

•Radiographs (2D, 3D/CBCT)

•Discussion with the patient (Risks, difficulties.. etc) •Soft tissue biotype & proximity to sinus.

Surgical Equipment:

Operating microscope

Surgical kit

Endodontic Surgery Steps:

Anaesthesia:

•profound anaesthesia and good haemostasis are essential.

•Lidocaine combined with a vasoconstrictor is suitable

•LA solution should be delivered into the loose connective tissue of the alveolar mucosa near to the root apices.

Preemptive Analgesia

• administration of a pain management protocol before  the anticipated noxious stimuli.

•Paracetamol  & NSAIDS (Ibuprofen) are most commonly used.

Flap Design:

•Depends on the surgical access required •Has to provide an adequate blood supply.

•Types:

1.Semilunar Flap:  oinadequate surgical access oassociated with many post-operative complications including pain, swelling and scarring

oContra-indicated for periradicular surgery.

2. Full thickness marginal Flap :

oOne relieving incision (triangular)  or two (rectangular)

oHealing is normally by primary intention opost-operative complications are rare.

oA papilla-base incision has been advocated to preserve the interdental papilla  & reduce recession

3.Submarginal (Luebke-Ochsenbein) Flap

oUseful in the anterior maxilla especially for preservation of gingival contours adjacent to crowns.

oRisk of flap shrinkage, delayed healing and scarring

o 4.Palatal Flap :

oProvides access to Palatal roots.

ohigh risk of severing the palatine neurovascular bundle

oDifficult flap reflection as the tissues are thicker and more firmly bound.

Post operative Instructions:

•The patient should be instructed to rest; strenuous activity should be avoided for at least 24 hours.

•An ice pack should be applied for two to four hours immediately following the procedure to help reduce the risk of swelling and resultant post-operative discomfort  (intermittent application).

•Avoid applying unnecessary tension and pulling out the sutures.

•Tooth brushing starting from the following day

•Chlorhexidine mouthwash; one minute, twice daily.

•Antibiotics are rarely required.