Surgical Endodontics Important Notes
- Cardinal principles of flap design
- The base of the flap should be wider than the free end to ensure adequate circulation into the flap
- The sutured flap margins should rest on sound bone
- Incision should be made with a firm, continuous stroke, perpendicular to cortical bone
- Short, intermittent incisions result in tissue tags and ragged margins
- Trephination is a type of artificial fistulation in which the cortical bone is perforated to release the build-up pressure and exudate around root apex to release pain
- Semilunar incision
- Semilunar incision Advantages
- High healing potential
- Minimal bone damage
- Semilunar incision Disadvantages:
- Inaccessibility
- Excessive haemorrhage
- Delayed healing
- Scarring
- Semilunar incision Advantages
- Replacement resorption
- It is characterized by gradual root resorption including periodontal ligament, cementum and dentin of root with replacement by bone and finally the tooth becomes ankylosed
- It is considered as success of replanted tooth
- Best storage media for avulsed tooth
- Tooth socket
- Patient’s saliva
- Milk
- Water
- Transport media for avulsed tooth
- HBSS [Hank balanced salt solution]
- Coconut water
- Saliva
- Vestibule of mouth
- Milk
- Saline
- Water
- Viaspan
- CPP – ACP [Casein Phosphopeptide – Amorphous Calcium Phosphate]
- Contraindications of periradicular surgery
- Proximity to anatomic structures
- Serious systemic health problems
- Emotionally distressed patient
- Inaccessible surgical sites
- Teeth with poor prognosis
- Types of post
- Tapered or parallel
- Tapered posts
- They are least retentive of all posts
- Produces high incidence of root fracture
- Concentrates stress at the post-core junction
- Parallel posts
- More retentive
- Less incidence of root fracture
- Concentrates stress apically on the post
- Tapered posts
- Threaded or non-threaded
- Threaded posts
- Produces the greatest potential for root fracture
- Recommended for post-endodontic restorations
- Non-threaded posts
- Produces the least stress
- Have the least tendency for root fracture
- Threaded posts
- Metallic or non-metallic
- Tapered or parallel
- Stitch abscess may develop due to
- Local laceration of tissue
- Accumulation of debris at the site of suturing
- Tying of knot in the line of incision
Surgical Endodontics Short Essay
Question 1. Indications for periapical surgery. Add a note on flap designs
Answer.
Indications Of Periapical Surgery:
Surgical drainage:
- Failed non-surgical treatment
- Calcified metamorphosis of pulp space
- Horizontal fracture at the root tip
- Iatrogenic errors
- Anatomic variation
- Biopsy
- Corrective surgery
- Replacement surgery
- Implant surgery
- Exploratory surgery
Read And Learn More: Endodontics Question and Answers
Flap Designs
- Semilunar flap:
- It is a curved horizontal incision with the convex portion of the incision towards the gingival crest
- The incision begins at the mesiobuccal fold and follows a half moon path
- Semilunar flap Indications:
- When incisors are involved
- Semilunar flap Advantages:
- Simple
- Easy to reflect
- Easy to maintain oral hygiene
- Gingival attachment is not disturbed
- Semilunar flap Disadvantages:
- Restricted access with limited visibility
- Limited use
- Luebke Oschenbein flap:
- Named after Luebke and Oschenbein
- It is a modified semilunar flap in which a scalloped horizontal incision is made in the attached gingiva with vertical incisions
- Luebke Oschenbein flap Advantages:
- Greater access and visibility
- The flap is easily displaced and sutured
- Marginal gingiva is not disturbed
- Luebke Oschenbein flap Disadvantages:
- Scarring is possible
- Triangular flap:
- Indicates for surgery involving short rooted teeth
- An incision along the gingival border forms the base of the triangle
- A single vertical incision is carried far into the alveolar mucosa
- Vertical incision is made between the root eminences of teeth
- Triangular flap Advantages:
- The possibility of incision crossing the lesion is eliminated
- Triangular flap Disadvantages:
- Retraction is difficult
- Trapezoidal flap:
- Two oblique incisions are made and the entire flap is retracted toward the vestibule
- Horizontal incisions are made to separate the flap
- Trapezoidal flap Advantages:
- Good accessibility
- Convenient method
- Trapezoidal flap Disadvantages:
- Gingival tissue attachment is lost
Question 2. Apicectomy.
Answer.
Apicectomy
It is the ablation of the apical portion of the root end attached to soft tissues.
Apicectomy Indications:
- Anatomical anomalies
- Persistent infections
- Need for biopsy
- Medical reasons
- Lack of time
- Over fillings
Apicectomy Contraindications:
- Systemic diseases
- Deep pockets
- Acute infection
- Short root length
Apicectomy Preparation:
- Class 1 preparation – 3 mm into root dentin
- Walls are made parallel to pulp space
- Remove all isthmus tissue
- 0-10 bevel is given
- Reset upto 3 mm of the apical portion
- Seal the apical portion
- Closure of flap
- Suturing
Apicectomy Complications:
- Bleeding
- Damage to neighboring root
- Entry into nerve
- Abscess
- Fenestration
- Increased mobility of tooth
Question 3. Root end Filling Materials/Retrograde filling materials.
Answer.
Root End Filling Materials Properties:
- Root End Filling Materials Should be well-tolerated
- Root End Filling Materials Should adhere to tooth surface
- Root End Filling Materials Should be stable
- Root End Filling Materials Should be resistant
- Root End Filling Materials Should be bactericidal
- Root End Filling Materials Should be noncorrosion
- Root End Filling Materials Should not stain
- Root End Filling Materials Should be radiopaque
Root End Filling Materials:
- Amalgam:
- Radiopaque
- Well tolerated
- Slow setting
- Dimensionally unstable
- ZOE:
- Weak
- Long setting time
- Irritation due to Eugenol
- IRM:
- Higher success rate
- Super EBA:
- Low solubility
- Radiopaque
- MTA:
- Least toxic
- Hydrophilic
- Radiopaque
- Composite Resin:
- Technique sensitive
- Gold foil:
- Glass Ionomer:
- Cavit:
- Available in single-paste forms
Question 4. Post and Core.
Answer.
Root End Filling Post: It is a rigid restorative material placed in the root of a non-vital tooth.
Root End Filling Core: It is a supragingival portion that replaces the missing tooth structures
Root End Filling Functions Of Post
- Retains core
- Distributes stresses
Root End Filling Requirements Post:
- Provide maximum protection
- Provide maximum retention
- Easy to place
- Less technique sensitive
- Biocompatible
- Easy to retrieve
- Be esthetic
- Not expensive
Root End Filling Core:
- Biocompatible
- Easy to manipulate
- Sufficient strength
- Stable
- Cheap
- Easily available
Root End Filling Materials:
Root End Filling Post:
- Gold
- High platinum
- Co-Cr-Mo alloys
- Stainless steel
- Titanium
- Carbon fiber
- Zirconium
- Glass fiber
- Plastic
Root End Filling Core:
- Dental amalgam
- Resin modified GIC
- Composite resin
- Cast core
Question 5. Effect of Dental Procedures on Pulp.
Answer.
- Effect of Dental Caries:
- Effect of Tooth preparation: Causes aspiration of nuclei of odontoblast
- Remaining Dentin Thickness [RDT]: Dentin permeability increases with decreased RDT
- Effect of Local Anaesthesia:
- Reduces blood flow
- Increases irritants
- Calcium Hydroxide:
- Causes demineralization
- Stimulate fibroblast
- Reparative dentin formation
- Zinc Oxide Eugenol:
- Reduce nerve impulse
- Zinc Phosphate:
- Toxic to pulp
- GIC:
- Antocariogenic
- Amalgam:
- Inflammation
- Inhibition of reparative dentin formation
- Cytotoxic effect
- Copper is toxic
- PIN Insertion:
- Dentinal fractures
- Irritation to pulp
Question 6. Replanation/Intentional Replanation.
Answer.
Replantation/Intentional Replantation
It is the intentional removal of the tooth and its reinsertion into the socket after retrograde obturation and resection of the root tip.
Replantation Indications:
- Broken instruments in canals
- Calcified canals
- Over filling
- Curved canals
- Presence of foreign body in periapical tissue.
Replantation Contraindications:
- Medically compromised
- Periodontal involvement
- Missing buccal/lingual plate
- Nonrestorable tooth
Replantation Technique:
Question 7. Types and indications of Periradicular surgery.
Answer.
Peri-Radicular Surgery:
- Curettage
- Biopsy
- Root end resection
- Corrective surgery
- Replacement surgery
- Implant surgery
Peri-Radicular Surgery Indications:
- Surgical drainage
- Failed non-surgical treatment
- Calcified metamorphosis of pulp space
- Horizontal fracture at the root tip
- Iatrogenic errors
- Anatomic variation
- Biopsy
- Corrective surgery
- Replacement surgery
- Implant surgery
- Exploratory surgery
Peri-Radicular Surgery Contra-Indications:
- Mobile tooth
- Pockets
- Leukemic patients
- Cardiac surgery
- Uncontrolled hypertension
- Uncontrolled bleeding disorders
- Immuno-compromised patients
- The first trimester of pregnancy
- Apprehensive patient
- Short root length
- Proximity to vital structures
- Non-restorable tooth
- Non-strategic tooth
Question 8. Indications of endodontic surgery.
Answer.
Indications of endodontic Surgical drainage:
- Failed non-surgical treatment
- Calcified metamorphosis of pulp space
- Horizontal fracture at the root tip
- Iatrogenic errors
- Anatomic variation
- Biopsy
- Corrective surgery
- Replacement surgery
- Implant surgery
- Exploratory surgery
Surgical Endodontics Short Questions And Answers
Question 1. Flaps in Endodontics.
Answer.
Flaps in Endodontics Classification:
- Full mucoperiosteal flap
- Triangular
- Rectangular
- Trapezoidal
- Horizontal
- Limited mucoperiosteal flap
- Sub-marginal curved
- Sub-marginal scalloped rectangular
Question 2. Ochsenbein – Luebke flap.
Answer.
Ochsenbein – Luebke flap
- By Neumann
Ochsenbein – Luebke flap Design:
- Vertical incision on either side of the surgical site
- Horizontal incision along attached gingiva.
Ochsenbein – Luebke flap Advantages:
- Unaltered attachment level
- Unexposed bone
- Accessibility
- Good healing
Ochsenbein – Luebke flap Indications:
- Gingivitis/periodontitis
- Bony dehiscence
Ochsenbein – Luebke flap Disadvantages:
- Disturb blood supply
- Flap shrinkage
- Limited apical orientation
- Scar formation
- Difficult wound closure
Surgical Endodontics Viva Voce
- Excessive hemorrhage during apical surgery is controlled by placing epinephrine epinephrine-containing solution in the surgical site
- In apicoectomy, a typical surgical flap used should extend one or two tooth/teeth laterally
- Parallel port is the best-preferred post
- Splinting should be removed in 7-10 days
- Hanks balanced solution is an isotonic salt solution used for preserving avulsed teeth
- Apical surgery is done with great caution on mandibular bicuspids because of their proximity to the mental foramen
- Paraesthesia is common in the mandible, especially in the premolar and molar region
- Ecchymosis results in skin discoloration from extravasation and the breakdown of blood adjacent to the surgical area
- Endodontic surgery should be avoided on lingual surfaces of molars or external oblique ridge of the mandible due to inaccessibility and difficulty in gaining access to the surgical site