Endodontic surgery Classification • Preendo – gingivectomy, elongation of the cinical crown • Emergency - incision • Apical surgery • Hemiextraction Apical surgery Apicoectomy - Removal of the pathological tissues in the periodontal space, and the end of the root, a tergo filling Curretage - periapical - Removal of granulation tissue Indication • Failure of the endo treatment • Blocked root canal - Rigid root canal filling (sealer) - Root canal post - Fractured root canal instrument - Calcification of root canal - obliteration • Perforation in apical part of the root Contraindication • All situations when the root canal treatment is possible • All contraindications of apical surgery • Risk of metastatic infection • Vertical root fracture or stripping • Primary periodontal lesion – resorption of alveolar bone, mobility • External resorption of the root (cervicalor middle third of the root) • Pulpal and periodontal lesions (combination) • Big lost of the vestibular bone – risk of big posttraumatic defect Factors for consideration • Clinical crown/root ratio • Restorability of the tooth • Size of periapical lesion and surrounding structures (Maxillary sinus, mandibular canal) • Approach to the lesion • Status of general health • Compliance Sutgical procedures • Apicoectomy, curretage • Endodontic microsurgery Armamentarium • Common surgical instruments • Special instruments for microsurgery - Stainless steel. Titanium, smal size, special shape • Ultrasound tips • Bone burs • Special handpieces A probe for investigation of the root canal filling Special handpiece Mirrors – common and microsurgical Needle holders Ultrasound for apical surgery • Piezoelectric devices (30 – 40kHz) • Special uz tips for preparation of the root canal in long axis of tooth - Stainless, diamond coated, titanium nitride coated - Smooth - Rough Ultrasound tips Special surface treatment, possibility of bending Anaesthesia • Local – infiltration, nerve blocke Hemostasis • Mechanically - Ethicon • Chemically - Adrenalin - Ferric sulfate • Biologically - Thrombin • Absorbable materials - Fibrin foam - Collagen Incision • Submarginal • Sulcular (preservation of interdantal papilla) Submarginal Sulcular Raise of the flap Approach to the lesion • CBCT in advance • Special instruments Root end resection • Excochelation of the granulation tissue • Removal of apical 3 mm Reasons: - Removal of pathologic proceses (apical deltas, accessor root canals, ramifications, severe curves) - Removal of iatrogenic misshapes (ledging,stripping, separated instruments) - Enhanced removal of granulation tissues - Access to the canal systém when coronal acess is blocked - Check of root canal filling - Creation of apical seal - Better conditions for investigation of the root and discovering of fractures - Reduction of fenestrating root apices 3 mm - 98% reduction of ramifications - 93% reduction of the lateral canals Root end resection Bevel of cut 40° - 60°: risk of incomplete root end removal, leaving of lateral root canals and ramifications, bigger exposure of dentin tubules , higher risk of reinfection 90°: preservation of root length, less chance to miss multiple root canals esp in oral part of the root. Less exposed dentin tubules. Kontrola Preparace a tergo • Vrtáčky • Ultrazvuk úskalí vedení nástroje snazší vedení nástroje v dlouhé ose Incorrect leading of instruments Correct leading of the instrument 3 – 4 mm A tergo filling Materials • MTA Benefits - Excellent marginal seal - Biocompatibility and bioactivity Disadvantages: - Difficult manipulation - Content of metals - Discoloration - Longer setting (today modification) Materials • Other bioactive materials Tricalcium silicate and phosphate (RRM – root canal repair material) Other materials • Amalgám ✓Toxicity, corrosion, tetoo, microfractures • IRM (Intermediate restorative material) ✓Modified ZOE cement reinforced with polymethylmetacrylate resin ✓good tolerance Othe materials • SuperEBA (Super etoxybenzoic acid) ✓Modification of the ZOE cement – etoxybenzoic acid (EBA) EBA - partly replaces eugenol in the liquid Powder: 60% ZNO, 34% SiO2 % , natural resins Liquid: 62,5% etoxybenzoic acid 37,5% eugenol Other materials • SuperEBA ✓Good tolerance ✓Fast setting ✓Volume stability ✓Easy surface treatment - polishing ✓Excellent marginal seal ✓Difficult manipulation ✓Sensitivity to moisture and temperature ✓Less rtg contrast Reposition of the flap, suture Evaluation rtg CBCT CBCT Healing Days Weeks Months+ Hemostasis inflammation Proliferation Remodellation Degranulation of neutrophils Migration of makrophags fagocytosis,cytokins – growth factors Fibroblats New capillars Granulation tissue Connective tisue – reorganization of fibres,closure of the wound Reparation and regeneration Wound Vasoconstriction Agregation of platelets Coagulation Other surgical procedures • Hemiextraction – removal of a part of the tooth • Root amputation - removal of the root