ENDODONTIC SURGERY

ENDODONTICS

1. Know endodontic surgical indications and rationale.

2. Why should failing RCT be retreated nonsurgically first, instead of surgically?
3. What are alternatives to apical surgery?
4. Discuss the various flap designs and indications for each.
5. Which flap design is indicated when gingival recession is a concern?
6. Why is the semilunar flap generally contraindicated?
7. Draw a Ochsenbein-Luebke flap design for #8, 9 with PFM crowns; discuss scalloping.
8. Discuss principles of vertical releasing incisions.
9. What is the rationale for root-end resection? How about for the amount removed, i.e. the level of cut?
10. What is the purpose of an apical bevel? Be able to draw location of root end resection, bevel and root-end
preparation relationship.
11. Is it always necessary, and when should you prepare and fill the resected root end?
12. How do you manage a root-end with 2 foramina and interconnecting isthmus? Be able to draw the
preparation design.
13. Describe the use of ultrasonics in endodontic surgery.
14. Discuss filling materials options.
15. Discuss mineral trioxide aggregate, its advantages, compressive strength, and setting time. Contrast with
IRM and Super-EBA. Rationalize your material choice.
16. Compare ingredients of Super-EBA vs. those of IRM.
17. What are indications for surgical cortical plate trephination? Discuss the technique.

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TYPES OF ENDODONTIC SURGERY
1. Fistulative
a. Incision and drainage
b. Surgical trephination
Please refer to your INCISION AND DRAINAGE/SURGICAL TREPHINATION handout and
briefing notes (discussed during the ENDODONTIC EMERGENCIES lecture), for specifics on
these types of endodontic surgery.
c. Cystic decompression
2. Corrective
a. Perforation repair
b. Resorption repair
3. Extraction-replantation
4. Periodontal
a. Root amputation
b. Hemisection

5. Periradicular

Apicoectomy: Some patients need a surgical procedure called Apicoectomy. It involves

an area at the tip of the root. Dr. Davis would make a small incision in the gum tissue,
exposing the end of the root. The infected area of the root and its surroundings are
then removed. A filling is placed inside of the root end and a few small sutures are
placed. After a week, you will need to return to Dr. Davis to have your sutures
removed and she will periodically check your healing progress thereafter.

Your Guide to Endodontic Surgery

You are probably reading this because your dentist or endodontist believes endodontic
surgery may help save your tooth. To understand endodontic surgery, it helps first to
know something about the nonsurgical endodontic procedure, or ―root canal. ‖ A root
canal is necessary when the soft inner tissue, or ―pulp,‖ of the tooth becomes inflamed
or infected. This may happen as a result of deep decay, repeated dental procedures on
the tooth or a blow to the tooth. Endodontic treatment removes the damaged pulp.
Then the tooth’s canals are cleaned and filled to help preserve the tooth. In a few cases,
however, nonsurgical endodontic treatment alone cannot save the tooth. In such a case,
your dentist or endodontist may recommend surgery.

3 Your Guide to Endodontic Surgery

You are probably reading this because your dentist or endodontist believes endodontic surgery
may help save your tooth. To understand endodontic surgery, it helps first to know something
about the nonsurgical endodontic procedure, or ―root canal.‖ A root canal is necessary when
the soft inner tissue, or ―pulp,‖ of the tooth becomes inflamed or infected. This may happen as

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a result of deep decay, repeated dental procedures on the tooth or a blow to the tooth.
Endodontic treatment removes the damaged pulp. Then the tooth’s canals are cleaned and filled
to help preserve the tooth. In a few cases, however, nonsurgical endodontic treatment alone
cannot save the tooth. In such a case, your dentist or endodontist may recommend surgery.
Who performs endodontic surgery? All dentists received training in endodontic treatment in
dental school. However, because endodontic surgery can be more challenging than providing
nonsurgical treatment, many dentists refer patients needing surgery to endodontists.
Endodontists are dentists with at least two additional years of advanced education and training
in root canal techniques and procedures. In addition to treating routing cases, they are experts in
performing complicated procedures including surgery. They often treat difficult cases—such as
teeth with unusual or complex root structured or small, narrow canals. This special training and
experience can be very valuable when endodontic surgery is necessary.
Why would I need endodontic surgery? Surgery can help save your tooth in a variety of
situations.
o Surgery may be used in diagnosis. If you have persistent symtoms but no problems appear on
your x-ray, your tooth may have a tiny fracture or canal that could not be detected
during nonsurgical treatment. In such a case, surgery allows your endodontist to
examine the root of your tooth, find the problem and provide treatment.
o Sometimes calcium deposits make a canal too narrow for the cleaning and shaping
instruments used in nonsurgical root canal treatment to reach the end of the root. If you
tooth has this ―calcification,‖ your endodontist may perform endodontic surgery to
clean and seal the remainder of the canal.

o Usually, a tooth that has undergone a root canal can last the rest of your life and never need
further endodontic treatment. However, in a few cases, a tooth may fail to heal. The
tooth may become painful or diseased months or even years after successful treatment.
If this is true for you, surgery may help save your tooth.
o Surgery may also be performed to treat damaged root surfaces or surrounding bone.

Although there are many surgical procedures that can be performed to save a tooth, the most
common is called apicoectomy or root-end resection. When inflammation or infection persists
in the bony area around the end of your tooth after a root canal procedure, your endodontist
may have to perform an apicoectomy.

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What is an apicoectomy? In this procedure, the endodontist opens the gum tissue near the tooth
to see the underlying bone and to remove any inflamed or infected tissue. The very end of the
root is also removed.
A small filling may be placed to seal to end of the root canal and a few stitches or sutures are
placed in the gum to help the tissue heal properly.
Over a period of months, the bone heals around the end of the root.
Are there other types of endodontic surgery? Other surgeries endodontists might perform
include dividing a tooth in half, repairing an injured root or even removing one or more roots.
Your endodontist will be happy to discuss the specific type of surgery your tooth requires.
In certain cases, a procedure called intentional replantation may be performed. In this procedure,
a tooth is extracted, treated with an endodontic procedure while it is out of the mouth and then
replaced in its socket.
These procedures are designed to help you save your tooth.
Will the procedure hurt? Local anesthetics make the procedure comfortable. Of course, you
may feel some discomfort or experience slight swelling while the incision heals. This is normal
for any surgical procedure. Your endodontist will recommend appropriate pain medication to
alleviate your discomfort.
Your endodontist will give you specific postoperative instructions to follow. If you have
questions after your procedure, or if you have pain that does not respond to medication, call
your endodontist.
Can I drive myself home? Often you can, but you should ask your endodontist before your
appointment so that you can make transportation arrangements if necessary.
When can I return to my normal activities? Most patients return to work or other routine
activities the next day. Your endodontist will be happy to discuss your expected recovery time
with you.
Does insurance cover endodontic surgery? Each insurance plan is different. Check with your
employer or insurance company prior to treatment.
How do I know the surgery will be successful? Your dentist or endodontist is suggesting
endodontic surgery because he or she believes it is the best option for you. Of course, there are
no guarantees with any surgical procedure. Your endodontist will discuss your chances for
success so that you can make an informed decision.
What are the alternatives to endodontic surgery? Often, the only alternative to surgery is
extraction of the tooth. The extracted tooth must then be replaced with an implant, bridge or
removable partial denture to restore chewing function and to prevent adjacent teeth from
shifting. Because these alternatives require surgery or dental procedures on adjacent healthy
teeth, endodontic surgery is usually the most cost-effective option for maintaining your oral
health.
No matter how effective modern tooth replacements are—and they can be very effective—
nothing is as good as a natural tooth. You’ve already made an investment in saving your tooth.
The pay-off for choosing endodontic surgery could be a healthy,

NONSURGICAL ENDODONTIC RETREATMENT IS INDICATED WHENEVER POSSIBLE

PRIOR TO PERIRADICULAR SURGERY!
Success rates are higher for nonsurgical retreatment than for surgical retreatment. Typically the nonsurgical
retreatment is successful and endodontic surgery can be avoided. When surgery must follow nonsurgical
retreatment, the potential for long-term success is much better than if the retreatment had not been
accomplished, since the canal system will be as clean and leak-proof as possible. Nonsurgical retreatment
optimizes the surgical environment for healing.

INDICATIONS FOR PERIRADICULAR SURGERY

1. General indications:
a. Failure of previous nonsurgical retreatment (―failure to heal‖) and minimal hope for success
following another nonsurgical approach

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 b. Nonsurgical retreatment is not possible
2. Specific indications (presuming nonsurgical RCT has failed to heal):
a. Inability to debride apical canal system
(1) Anatomic variation (anomalies, extreme curvature)
(2) Impassable ledge
(3) Canal transportation
(4) Calcified canal
(5) Irretrievable post
b. Gross GP overextension
c. Perforation
d. Progressive root resorption
e. Persistent postoperative pain
f. A biopsy or periradicular exploration/inspection is necessary

CONTRAINDICATIONS FOR PERIRADICULAR SURGERY

1. Relative contraindications
a. No attempt made to nonsurgically treat or retreat.
b. Anatomic considerations
(1) Significant structures may be subject to a moderate or high risk of injury.
(a) Mental neurovascular bundle (mental foramen)
(b) Inferior alveolar neurovascular bundle (mandibular canal)
(c) Maxillary sinus or floor of nose
Sinus exposure usually causes few complications.
Potential for sinus injury is rarely a surgical contraindication.
(2) Deeply positioned root apices potentially pose a challenge/impediment to
safe visual/instrument access.
(a) Palatal roots of maxillary bicuspids and molars
(b) Mandibular first/second molar roots beneath a thick external oblique
ridge/buccal cortical plate
2. True contraindications
a. Advanced periodontal disease of the tooth requiring periradicular surgery
b. Patient unable to tolerate surgery
(1) Medical/systemic/psychological reasons
c. Lack of adequate surgeon skill and ability

INFORMED CONSENT
1. Potential intraoperative complications
a. Neurovascular bundle damage and paresthesia
b. Maxillary sinus/floor of nose perforation
c. Damage to adjacent tooth roots
d. Diagnosis of unsalvageable condition and need for extraction
2. Potential post-surgical sequelae
a. Pain
b. Hemorrhage
c. Facial edema
d. Ecchymosis
e. Paresthesia
(1) Mental
(2) Inferior alveolar
f. Maxillary sinus/floor of nose perforation and/or fragment complication
g. Infection

PRE-SURGICAL CONSIDERATIONS
Systemic Considerations
Review of medical history
Consultations
Psychological Evaluation
Patient motivation
Patient apprehension

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 Esthetics
Scarring; position of smile line
Exposure of crown margins
Prosthetic Considerations
Presence of crowns and bridges
Restorability
Type of post material
Anatomic
Radiographic evaluation
Periapical films at different angles and panoramic films to evaluate root length, location of
adjacent roots, and location of major anatomical structures. Occlusal films may also be useful,
especially for palatal lesions and root fractures.
Phillips JL, Weller RN, Kulild JC. The mental foramen: part 1. Size, orientation and positional
relationship to the mandibular second premolar. J Endodon 1990;16:221-3.
Bottom line: mental foramen is directly below the buccal cusp tip of the 2nd premolar 63% of the
time and within 2mm mesial or distal the other 37%. The mental foramen is generally located at
a point that is 60% of the total distance from the buccal cusp tip of the 2nd premolar to the
inferior border of the mandible.
Lin L, Chance K, Skovlin F, Skribner J, Langeland K. Oroantral communication in periapical
surgery of maxillary posterior teeth. J Endodon 1985;11:40-4.
8 Bottom line: possible involvement of the sinus must be evaluated and the patient informed
about potential for sinus exposure and displacement of foreign bodies into the sinus. Maxillary
2nd premolar has the highest incidence of sinus involvement, followed by the maxillary molars.

Clinical evaluation
Limitations of opening
Pre-existing scar tissue
Extent of tori/exostoses
Vestibular depth
Quality of existing restoration(s)
Depth of palatal vault
Muscle attachments
Periodontal evaluation
Width of attached gingiva
Fenestration/dehiscence
Pocket depths
Status of gingival health
Height and width of alveolus

REGIONAL ANESTHESIA
2% lidocaine with 1:100,000 epinephrine for initial anesthesia
2% lidocaine with 1:50,000 epinephrine for hemostasis
0.5% bupivacaine with 1:200,000 epinephrine near end of procedure, for long-acting anesthesia
and analgesic effects
MUCOPERIOSTEAL FLAP CONSIDERATIONS
Basic principles of flap design:
Evaluate periodontal attachment levels carefully
Maintain maximum blood supply to reflected and unreflected tissues
Plan adequate flap size – extend at least one full tooth to each side of the tooth
undergoing surgery
Ensure proper placement of horizontal and vertical incisions over sound bone – place horizontal
incisions on attached gingiva or in the gingival sulcus and vertical incisions in the trough between root
eminences
Place incisions over sound bone
Avoid incisions over bony eminences
Avoid creating sharp corners
Do not reflect flap from sulcus. Apply undermining elevation – begin reflection laterally in vertical
releasing incision. Do not scale root surfaces or allow to desiccate. Preservation of root-attached tissues
prevents epithelial downgrowth and loss of soft tissue attachment levels!

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 Use care in retraction and handling soft tissues
Size and geometry of flap depend upon many factors:
Amount of access needed
Number of teeth involved
Length and shapes of the roots involved
Presence of pathosis
Dimensions of the pathosis
Anatomic structures
Depth of periodontal sulci/pockets

Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery. I.
The incisional wound. J Endodon 1991;17:425-435.
Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery.
II. The dissectional wound. J Endodon 1991;17:544-552.
Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery.
III. The osseous excisional wound. J Endodon 1992;18:76-81.
The above series of studies by Harrison and Jurosky have suggested a new way of reflecting endodontic
surgical flaps. During flap reflection, a thin layer of connective tissue and epithelium remains attached to the
root surface above the alveolar crest. Preservation of these tissues is generally feasible in endodontic surgery
because they are relatively ―healthy‖. Conversely, during periodontal surgery, the root surfaces are commonly
scaled and root-planed to remove diseased cementum.
Preservation of the healthy ―root attached tissues‖ leads to very rapid re-attachment in endodontic surgery and
virtually eliminates epithelial downgrowth from the incision. Consequently, the following flap reflection and
flap management procedures are recommended for endodontic surgery when there is no need for concurrent
periodontal treatment (i.e., root planing):
Consider the use of microsurgical blades for intra-sulcular incisions. These small blades allow careful severing
of the epithelial attachment with minimal trauma to the root surface and the ―root attached tissues‖.
Reflection of flaps, particularly those with intra-sulcular incisions, should start at the releasing incision and
undermine the tissues laterally. Then the papillae and coronal aspects of the flap are released by moving the
periosteal elevator coronally and lifting the tissues from underneath. This will preserve the ―root attached
tissues‖.
The traditional technique of initiating reflection by pushing down into the sulcus or against the coronal flap
margin with the periosteal elevator should be avoided! This technique damages the ―root attached tissues‖ and
can predispose the case to epithelial downgrowth. It also damages the edges of the flap and delays healing.
Protect the root attached tissues during the surgery and keep them moist with frequent application of
saline. Re-position the flap carefully. Consider suturing techniques like the vertical mattress to
avoid piercing the papillae if possible. Use non-wicking sutures. Before suturing, clean the
under-side of the flap to remove accumulated fibrin. After suturing, apply firm pressure with
damp gauze for 3-5 minutes to help stabilize the flap and minimize the fibrin clot layer.
Minimizing the fibrin layer will speed flap re-attachment and healing.

FLAP DESIGNS
Semilunar flap
Seldom used due to scarring, poor access and other problems

Advantages

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 No primary advantages
Fast, easy to reflect
Marginal and interdental gingiva are not involved
Unaltered soft tissue attachment level
Crestal bone is not exposed
Oral hygiene capability available immediately
May be used for an extremely long root in rare situations (long maxillary canine)
Disadvantages
Disruption of blood supply to unflapped tissues
Excessive scarring
Flap shrinkage
Difficult flap re-approximation and wound closure
Delayed, secondary intention healing with more postsurgical sequelae
Limited apical orientation (cannot visualize root eminences and other landmarks)
May cross bony cavity
Cannot extend flap
Least amount of access and convenience

Triangular flap
One vertical releasing incision and a horizontal intrasulcular incision
Normally the endodontic surgery flap of choice

Advantages
Excellent wound healing potential
Minimal disruption of vascular supply to flapped tissues
Excellent visibility
Incisions not over bony defect
Can view the entire root and overlying cortical and crestal bone
Good for viewing and treating periodontal defects and root fractures
Excellent apical orientation
Easy to extend, if needed
Minimal flap tension or tearing
Good flap re-approximation
Easy to suture
Disadvantages
Slightly difficult to incise and reflect
Surgical access slightly limited due to the single releasing incision
Possibility of slight gingival recession
Negligible when tissues managed appropriately

Rectangular flap
Two vertical releasing incisions and a horizontal intrasulcular incision
Indicated when additional access is needed

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 Advantages
Enhanced surgical access
Minimal flap tension or tearing
Excellent wound healing potential
Minimal disruption of vascular supply to flapped tissues
Does not deprive unreflected tissues of blood supply
Trapezoidal design not recommended
Excellent visibility
Indicated for long roots, multiple-tooth surgery and retroclined teeth (e.g. mandibular incisors)
Can view the entire root and overlying cortical and crestal bone
Good for periodontal defects and fractures
Excellent apical orientation
Disadvantages
More difficult to incise and reflect
Flap re-approximation, wound closure and post-surgical stabilization are more difficult than with
the triangular flap
Possibility of slight gingival recession
Negligible when tissues managed appropriately

Submarginal (Luebke-Ochsenbein) flap

Formed by scalloped horizontal incision in attached gingiva and two vertical releasing incisions.
Scalloped incision corresponds to the contour of the marginal gingiva. There must be an adequate
band of attached gingiva present (2 mm minimally) coronal to the horizontal incision. This requires
a very careful analysis of attachment level along the entire length of the horizontal incision.

Advantages
Does not involve marginal or interdental gingiva
Does not expose crestal bone
Minimizes gingival recession where crowns are in place and esthetics is a concern
Minimizes crestal bone loss
Disadvantages
Unable to extend flap, if needed
Disruption of blood supply to marginal gingival tissues, must rely on collateral circulation (which
may not exist, resulting in sloughing of marginal gingiva)
Possible incision over bony lesion
Limited use in mandibular surgery
Possible delayed healing, especially vertical incisions

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 Probably flap shrinkage and scarring
Full root and crestal bone are not exposed, so apical orientation is limited, and periodontal defects
and root fractures are difficult to visualize and treat
Difficult flap re-approximation, wound closure and post-surgical stabilization

Gingival (envelope) flap

Intrasulcular horizontal incision without vertical releasing incisions. Generally not used for surgery
in the apical area except occasionally for palatal roots of maxillary molars. Used for root resections,
root amputations, hemisections and repair of cervical perforations or resorptive defects.

Advantages
A gingivectomy can be performed
Gingival levels can be changed
Repositioning is simplified
Disadvantages
Flap can be difficult to reflect
Tension on flap can be excessive
Gingival attachment is disturbed
Compromised access and visualization

Palatal flap
Only two flap designs for palatal surgery are recommended, triangular or envelope. Both provide for
excellent healing.
The triangular design provides greater access and visibility. To minimize hemorrhage, the
releasing incision for the triangular palatal flap is placed where the smallest terminal branches of the
anterior and posterior palatine arteries interdigitate. This incision is generally placed from the mesial
of the first premolar to a point near the palatal midline.
Releasing incisions in the posterior area are not recommended due to possibility of transecting the greater
palatine artery! A small (2-4 mm) ―relaxing‖ incision can be placed at the distal line angle of the maxillary
second molar if necessary.
Use of a post-surgical stent is recommended.

BONE REMOVAL AND EXPOSURE OF ROOT END

Bone removal is best done using a high-speed handpiece (with rear air exhaust, e.g. the Impact Air), a #2 or #4
round bur and copious liquid coolant
No periradicular lesion – intact cortical bone
Ensure you have the necessary radiographic views in order to three-dimensionally localize the apex.
Note the angle of the root and crown radiographically as well as clinically, with the flap reflected.
Observe the cortical plate for any radicular eminence. Measure the tooth’s length and position of its
apex from an accurate radiograph, and transpose this point to the tooth using a sterile ruler. Probe
the bone with moderate force at this location, using an endodontic explorer, for any defect. Shave
away a small amount of bone, using a bur or #15 blade, while carefully observing for the root. If
necessary, place a sterile, radiopaque marker, and make a radiograph. Carefully bur away bone over
the apex and adjacent to the root to create a window, of adequate size and orientation, which
provides good visibility and working space. You will need room to curette any soft tissue present, to
resect the root-end and to establish an apical seal. The root surface may be distinguished from bone
by the observing the following: root structure is yellowish, does not bleed upon probing, its surface
is smooth and it is entirely surrounded by periodontal ligament. Methylene blue dye may be used to
facilitate identification and orientation.

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Periradicular lesion – intact cortical bone
It is often possible to penetrate the cortical plate using an explorer or sharp periosteal elevator tip.
Undermined bone may be removed using bur, rongeur forceps, hemostat or sharp curette. Define the
extent of the lesion and expose its osseous borders. If it is not possible to penetrate the bone by hand
instrument, shave away the bone using a bur as previously described. Once the lesion’s position is
identified, remove the bony cortex around the borders of the lesion laterally, as opposed to cutting
into the lesion. If the lesion is extending toward adjacent tooth roots, terminate the bone removal
before uncovering roots not involved in the surgical procedure. Generally an opening of a few
millimeters on either side of the root apex will be sufficient.
Periradicular lesion – fenestrated cortical bone
Removal of the remaining cortical plate over the apex proceeds as previously described. Extend the
borders of the bony window slowly, without disturbing the underlying soft tissue. If indicated for
hemostasis, you may inject anesthetic into the soft tissue mass. If possible, leave a shelf of bone
apical to the lesion on which to place your tissue retractor.

CURETTAGE OF SOFT TISSUE PATHOSIS

Submit specimen for histopathologic analysis, if available
The diagnosis is usually periapical cyst, periapical granuloma or scar
ROOT-END RESECTION
There appears to be little debate in the literature that when periradicular surgery is performed, apical
resection of the root end is indicated. By resecting the root, you dramatically reduce the number of
potential apical ramifications and anatomic variations, thus increasing the chance for success.
Additionally, your ability to see is improved, thus making the diagnosis of vertical root fractures or
other reasons for failure easier to confirm. On the other hand, there is considerable debate about
what to do with the resected root surface. Some authors believe that this surface should be sealed
with cavity varnish while others prefer to remove the smear layer to promote better connective
tissue healing. Bevel only as much as necessary for optimal visualization of the root face, in order
to locate possible additional canals, isthmi, anatomic variations and vertical root fractures.

Indications
Removal of pathological processes and anatomic variations
Increased number of accessory canals in apical 3 mm
Removal of operator errors
Iatrogenic complications prevent apical seal
Enhance removal of soft tissue lesion
Access the canal system
Evaluation of adaptation of canal filling material
Enhance adaptation of canal filling material
Facilitates placement of root-end filling to produce an apical seal
Reduction of apices which have penetrated bone
Exploration for aberrant canal anatomy or root fractures
Procedure
The traditional 45º bevel has been replaced by a less steep angulation (0-20º)
Resect the entire root-end
Remove 3mm if possible, but remember to leave 3mm for root-end preparation and root-end filling
(may need to resect less if a post is close to the apex)
Do not jeopardize crown-root ratio
Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retrograde filling. J Endodon 1994;20(1):22-6.
Bottom line: increasing the depth of root-end filling significantly decreased apical leakage and there
was a significant increase in leakage as the amount of bevel increased. The minimum depths for a
root-end cavity preparation (measured from the buccal aspect of the cavity) are 1.0 mm, 2.1 mm,
and 2.5 mm for 0º, 30º, and 45º angles of resection, respectively.

ROOT-END PREPARATION
Many endodontists feel that a root-end filling is required 100% of the time. Harrison and Todd have
demonstrated that this is not true. The decision to place a filling needs to be based on the actual

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 visualization of the nonsurgical filling once the root has been resected. If there is any doubt about the
quality of the debridement or obturation of the root canal, a root-end filling should be placed.
Armamentarium
Microhead handpiece
Too large for area
Requires large osseous window or excessive root bevel
Difficult to achieve preparation in long axis of root
- Makes large preparation (often too large for isthmus preparation)
Ultrasonic tips
There has been a natural progression to the utilization of ultrasonics for the preparation of the root end
to receive a filling material. The literature suggests many advantages of ultrasonic debridement of
the root end, including:
Easier access (requires smaller osseous window), thus reducing the angle of the resection bevel
Cleaner root-end preparations
Smaller, easier to achieve preparation in long axis of root
May create more microfractures of root than microhead handpiece

Waplington M, Lumley PJ, Walmsley AD. Incidence of root face alteration after ultrasonic retrograde cavity
preparation. Oral Surg 1997;83:387-92.
Bottom line: Ultrasonic root-end preparations made using light pressure with instruments set at low to medium
power cause fewer cavosurface chips than higher settings. The Neosonic instrument does not appear to cause
root cracks.
Note: this study used a machine of relatively low power (Neosonic). Some studies do show
cracking with units that have more power and/or used for longer preparation periods, but other
studies do not agree. The final answer is not known, but it is probably better to use lower power,
light touch and minimal contact time. Another option is to remove the gutta percha with a heated
instrument and then just refine the preparation with the ultrasonic instrument.

Types of preparation
Class I preparation - 3 mm deep into canal, centered in the long axis of root, and
preparing the isthmus commonly found between canals
Hsu YY, Kim S. The resected root surface - the issue of canal isthmuses. Den Clin N
Amer 1997;41: 529-40.
Bottom line: when a resected root exhibits more than one canal, assume an isthmus
exists between them and design the root end preparation accordingly. C-shaped canal
systems can have unusual configurations, calling for complex root-end preparations.
Slot preparation - prepared on the side of the root in the long axis, including the entire
depth of the canal - useful when carbide or diamond burs must be used to resect posts or
other hard materials that cannot be cut with ultrasonic tips or conventional
microhandpiece burs

HEMOSTASIS
The best hemostatic agent is adequate infiltration of anesthetic solutions containing epinephrine (1:50,000
preferred).
Additional hemostatic agents and methods include:
Epinephrine-containing cotton pellets, ferric sulfate (Cut-Trol - 37% or Astringedent - 15.5% - keep off soft
tissue), bone burnishing and cautery. Ferric sulfate is cytotoxic. 15.5% works fine in endodontic surgery.
There is really no need to use the more caustic 37.5%.
Jeansonne BG, Boggs WS, Lemon RR. Ferric sulfate hemostasis: effect on osseous wound healing. II. With
curettage and irrigation. J Endodon 1993;19:174-6.
Bottom Line: Ferric sulfate must be removed by curettage and irrigation before flap replacement or healing
will be impaired.
Aurelio J, Chenail B, Gerstein H. Foreign-body reaction to bone wax. Report of a case.
Oral Surg Oral Med Oral Pathol 1984 Jul;58(1):98-100.
17 Bottom line: The use of bone wax as a hemostatic agent is discouraged due to its
likelihood of causing a foreign body reaction and interfering with repair of the surgical
site.

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ROOT-END OBTURATION
The ideal root-end filling material should:
Seal canal in three dimensions
Be well tolerated, with no inflammatory reaction
Be nontoxic
Not promote, and preferably inhibit, the growth of pathogenic microorganisms
Stimulate the regeneration of normal periradicular tissues
Not be affected by moisture
Not be absorbable within the confines of the tooth, but excess should be resorbable
Be dimensionally stable
Not corrode or be electrochemically active
Not stain the tooth or tissues
Be easily distinguishable on radiographs
Adhere or bond to the tooth without undercuts
Materials
Contemporary options include IRM, Super-EBA mineral trioxide aggregate (ProRoot
MTA), glass ionomer cement and resin bonded materials.
Others include gutta-percha, Cavit and amalgam.
IRM powder - zinc oxide 80%, polymethylmethacrylate 20%
IRM liquid - eugenol 99%, acetic acid 1%
Super EBA powder - zinc oxide 60%, alumina 30%, natural resin 6%
Super EBA liquid - eugenol 37.5%, ortho-ethoxybenzoic acid 62.5%
Dorn S, Gartner A. Retrograde filling materials: a retrospective success-failure study of
amalgam, EBA and IRM. J Endodon 1990;16:391-4.
Bottom line: In a retrospective study found a success rate for amalgam root end fillings
to be 75%, compared to 91% success with IRM and 95% success with EBA. There was
no significant difference between IRM and EBA.
Bondra DL, Hartwell GR, MacPherson MG, Portell FR. Leakage in vitro with IRM,
high copper amalgam, and EBA cement as retrofilling materials. J Endod 1989
Apr;15(4):157-60
Bottom line: Found IRM and EBA to have less dye leakage than amalgam with
Copalite in retro-preparations. No statistical difference between IRM and EBA.
MTA powder - 75% Portland Cement (tricalcium silicate, tricalcium aluminate,
dicalcium silicate, tetracalcium aluminoferrite), 20% Bismuth Oxide, 5% Gypsum
MTA liquid – sterile water
Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral
trioxide aggregate for root-end filling in dogs. J Endodon 1995; 21(12): 603-08.
Bottom line: less periradicular inflammation with MTA compared to amalgam.
Also found that cementum will actually form on MTA surface.
Frank A, Glick D, Patterson S, Weine F. Long-term evaluation of surgically placed
amalgam fillings. J Endodon 1992;18:391-8.
Bottom line: in a retrospective study found success rate for amalgams over 15 years to be
only 57.7%.
Placement of root-end filling materials
Microcarrier or Prima Endo-Gun for amalgam and MTA
Tip of wax spatula or plastic instrument for IRM or EBA
Messing gun, Centrix syringe with tube tip or similar instruments may be useful
Radiographs
One or more before flap closure, to ensure all excess filling material has been removed
and all aspects of surgery (multiple roots, resections, fillings, etc) are visible.
Citric acid application
Apply 50% citric acid (pH 1) to the root end for 2 minutes to demineralize the dentin and
expose collagen for attachment and new cementum deposition. Questionable value.
Craig K, Harrison J. Wound healing following demineralization of resected root ends in
periradicular surgery. J Endodon 1993;19(7):339-47.
Bottom line: resected root ends demineralized by application of 50% citric acid
at a pH of 1.0 for 2 minutes showed more cementum deposition and better healing than
undemineralized root surfaces. Note: study done in dogs – may or may not happen in
humans, but currently thought to be a good thing to do.

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SITE DEBRIDEMENT AND CLOSURE
Completely debride site (particularly of any ferric sulfate used) and irrigate copiously using
sterile saline.
Inject post-surgical bupivacaine-HCl/epinephrine 1:200,000.
Reapproximate the flap and compress tissues against bone with moist 4x4 gauze for 5 minutes
Suture from unattached to attached tissue
Place minimum number of necessary sutures
Place suture knots on fixed tissue
Interrupted sutures are commonly used.
Most techniques bisect papilla when suturing interproximal area. Consider vertical mattress to
minimize trauma to papilla. Horizontal sutures for releasing incision can minimize trauma to
small papilla at end of flap
Avoid excessive tension
Different types of sutures are available (non-wicking, monofilament are best)
Hydration of some suture material is important (gut, silk)
Apply firm pressure again for 3-5 minutes after suturing

POST-SURGICAL CARE
Post-op vital signs
Post-op radiograph (consider making film before closure to minimize disruption of flap post-
surgically and to rule out residual tooth fragments or restorative materials)
Flap compression - place firm pressure on the flap for 5-10 minutes. Leave gauze dressing on
surgical flap and instruct patient to remove in 30 minutes.
Application of cold - provide patient with initial ice pack and demonstrate proper placement.
15-20 minutes on, 15-20 minutes off, for 3-4 hours (some references recommend 6-8 hours
Discuss and reemphasize any medication regimens.
Prescriptions
Analgesic (NSAID)
Narcotics (rarely necessary if NSAID is given pre-operatively and tissues are managed carefully)
Chlorhexidine mouth rinses
Antibiotics, if needed

Discuss post-surgical instructions with patient and escort (if applicable) and provide written
post-surgical instructions, with your phone number in case of emergency.
Schedule patient for removal of sutures in 2-4 days (no later than 5 days).
Follow-up telephone call
Recall (1, 3, 6, 12 months, yearly)
Most patients do very well after endodontic surgery. A careful, minimally traumatic, and sterile
technique will help to minimize complications. Optimizing use of the following adjuncts is also
important. The use of Marcaine (bupivacaine) at the end of the procedure will often provide the
patient 6-10 hours of post-surgical anesthesia/analgesia. A nonsteroidal anti-inflammatory agent,
such as Motrin (ibuprofen) should be used pre-surgically, and continued post-surgically, unless
contraindicated. Most patients state that they only needed to take the Motrin for 24-48 hours.
Also, Peridex

RECENT ADVANCES IN ENDODONTIC SURGERY

Surgical microscope
Improved instruments for microsurgical preparation
Ultrasonic tips for preparation
Surgical Impact Air 45 high-speed handpiece
Micro-mirrors, blades, condensers, and other instruments
Stropko irrigator
Improved root-end filling materials
Use of regenerative techniques during endodontic surgery

EXTRACTION-REPLANTATION (“INTENTIONAL REPLANTATION”)

Indications:
Nonsurgical endodontic therapy and conventional surgical endodontics are not possible and
tooth would otherwise be lost

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 Patient unable to tolerate or not a good candidate for lengthy conventional endodontic
surgery
Contraindications:
Non-restorable tooth
Severe periodontal disease
Widely divergent or dilacerated roots that might fracture during extraction (a relative
contraindication - it may still be possible to replant a tooth when a curved root has
fractured during extraction)
Technique
Attempt nonsurgical endodontics as well as can be performed
Restore access with amalgam or resin to prevent fracture (consider bonded restoration)
Relieve occlusion
Oral prophylaxis/degerming with chlorhexidine
Antibiotics, to prevent inflammatory resorption
Atraumatic extraction (2 operators, one for endodontic procedures and one for extraction
and socket). Avoid injury to cementum
Keep tooth moist (Hanks Balanced Salt Solution best; saline 2nd choice)
Minimize extraoral time
Do not curette walls of socket
Root-end resection and root-end filling or other procedures
Replant, manually compress cortical plates over replant
Splint, if necessary

CYSTIC DECOMPRESSION
Indications
Large lesion where surgery might devitalize the pulp of an adjacent tooth and healing may
be slow if only nonsurgical endodontics was done
Technique option
Fabricate tube with collar using heated spatula and section of IV tubing (pediatric
nasogastric tubing is even better. It is radiopaque and easier to visualize on radiographs or
find if displaced)
Aspirate lesion
Create a small vertical incision into osseous fenestration
Trim tube to fit into depth of lesion without protruding
Insert tube and instruct patient in saline irrigation - 10 ml three times daily
Monitor patient weekly and remove tube when no more debris is removed by flushing
procedures
Mucosal opening should heal within 1 week
Follow resolution of lesion with radiographs every few weeks initially
When radiographic evidence of lesion resolution is evident, follow every 3 months
If lesion does not show evidence of healing, surgical treatment and biopsy are indicated

PERFORATION REPAIR
Consider non-surgical repair if defect accessible from within tooth and significant bone would have to be
removed for surgical access.
Do not sacrifice bone support of adjacent teeth.
Extraction may be prudent
Access and visualization of the defect are essential for successful surgical repair.
Consider extraction and replantation procedure if surgical access will be difficult/impossible
Envelope or triangular flaps are best
Excellent flap management, repositioning and suturing will minimize development of periodontal defect
Refer to Endodontic Misadventures section for further details

PERIODONTAL MANAGEMENT
Root amputation
Must have smooth contour with no ledge or ―lip‖ of root
Two types:
Vertical root amputation
Horizontal root amputation
Hemisection

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Remaining root prone to fracture due to occlusal forces of restoration not in line with long axis of the root
Consider minor tooth movement to align root so occlusal forces are along long axis
Do not restore as a cantilever
Regeneration Techniques
Grafting materials:
Demineralized Freeze-dried Bone
Hydroxyapatite
Calcium Sulfate (surgical plaster of paris)
Ceramics
Membranes
Resorbable
Non-resorbable
Rankow HJ, Krasner PD. Endodontic applications of guided tissue regeneration in endodontic
surgery. J Endodon 1996;22(1):34-43.
Bottom line: the following are possible applications of GTR in endodontic surgery:
Apical pathosis
Apical pathosis that communicates to alveolar crest
Dehiscence
Proximal bone loss
Developmental grooves
Root or furcation bone loss caused by perforations
Cervical root resorption
Oblique root fracture
Ridge augmentation in conjunction with root resection or extraction

INCISION AND DRAINAGE/SURGICAL TREPHINATION

1. Understand and discuss coronal leakage and contamination of RCT, and its relationship to case failure.
2. Describe the pathogenesis for periradicular pathosis development.
3. Which bacteria are often associated with apical periodontitis and endodontic infections? Discuss the %s
of the various types found in an endodontic abscess (i.e. gram +/-, aerobic/anaerobic).
4. Discuss potential sources of pulpal bacteria in a traumatized tooth with an intact, unrestored crown.
5. Describe the mechanism of anachoresis.
6. When do you consider performing an incision and drainage (I&D) procedure?
7. Discuss the various interfascial space infections and their boundaries.
8. Discuss the potential etiologies and dangers of cavernous sinus abscess.
9. List teeth potentially responsible for the various space infections.
10. Discuss the management of a medically compromised patient, e.g. a diabetic, with failing RCT and
phoenix abscess; discuss diagnostic work-up and immediate treatment needed. Also discuss your antibiotic
considerations/choice and rationale.
11. Discuss Garre’s osteomyelitis.

1. Odontogenic Infections
Maxilary Teth
Most maxillary teeth erode
22 through cortical plate
below muscle attachment
Appear initially as vestibular abscess
Occasional palatal abscess
Lateral incisor
Lingual inclination
Maxillary first molar
Palatal root
Space infections
Canine space infection

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 Long maxillary canine
Above levator anguli oris insertion
Buccal space infection
Maxillary molars
Above buccinator muscle attachment
Mandibular Teth
Mandibular incisor, canine and premolar infections usually erode
Through facial cortical plate
Above muscle attachment
Result in vestibular abscess
Mandibular first molars
Drain either buccally or lingually
Mandibular second molars
Perforate either buccally or lingually
Usually to lingual
Mandibular third molars
Infections almost always erode through the lingual cortical plate
Infections that drain lingually
Mylohyoid muscle attachment determines pathway
Sublingual space above mylohyoid muscle
Submandibular space below mylohyoid muscle

Determine Severity of Infection

U

How long has infection been present?

Time of onset
Duration
Rapidity of progress
Signs and symptoms
Dolor – pain
Tumor – swelling
Calor – warmth
Rubor – erythema
Functio laseo – loss of function
How does patient feel?
Malaise
Patient feels fatigued, hot, sick, or ―out of sorts‖
―Generalized reaction to moderate or severe infection‖
Vital Signs – Severe Infection
U

Temperature – elevated to 101 to 102F or higher

May be lower if patient has taken aspirin or acetaminophen
Blood pressure – mild elevation in systolic pressure
Pulse rate – increased above 100 beats per minute
Respiratory rate – elevated to 18-20 breaths per minute

Intraoral examination
U

Diagnostic tests
U

Radiographic examination
U

Diagnosis
U

Pulpal diagnosis
Necrotic pulp (or failing RCT)
Periradicular diagnosis
Acute apical abscess (has no periradicular radiolucency)
Phoenix abscess (has periradicular radiolucency)
Management
U

Remove cause of infection

Pulpectomy
Extraction
Establish surgical drainage
Pulpectomy or extraction
Incision and drainage

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 Systemic antibiotic, if indicated
Indications for systemic antibiotic
Systemic signs of infection
Immune-compromised host
Infection refractory to conservative therapy
Recurrent infection

2. Incision and Drainage

Rationale for incision and drainage

U

Decreases number of bacteria

Reduces tissue tension
Alleviates pain/trismus
Improves circulation to region
Prevents spread of infection
Alters oxidation-reduction potential in tissue
Accelerates healing!

Technique
U

Anesthesia
Regional nerve block
Infiltration
Anterior and posterior to area to be drained
Avoid needle track infection
Mepivacaine has lowest pKa
Obtain culture specimen, if indicated
Indications for culture and antibiotic sensitivity testing
Rapidly spreading infection
Nonresponsive infection
Recurrent infection
Compromised host defenses
Carried out as initial portion of surgery
Disinfect surface mucosa
Betadine/Peridex scrub
Dry with sterile gauze
Insert needle into abscess cavity
18-gauge needle, 5 cc syringe
Aspirate 1-2 cc pus
Deliver specimen directly to microbiology lab
This method permits
Aerobic cultures
Anaerobic cultures
Gram staining
Incision
No. 11 blade
Most dependent area of swelling
Subperiosteal
1-2 cm opening
Blunt dissection
Periosteal elevator, curved hemostat
Insert closed
Open to separate tissues
Extend into adjacent spaces
Obtain specimen for culture, if indicated
If no specimen obtained previously
Copious sterile saline lavage
Insert drain, if indicated
Penrose drain
Insert using hemostat

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Suture to healthy tissue
Drain should remain until drainage stops
Usually 2-5 days
Postoperative care
(Possible depressed host defense mechanisms)
Maximize hydration
High calorie nutritional supplements
Warm saline rinses/soaks
Optimize oral hygiene efforts
Prescribe chlorhexidine gluconate rinses, analgesics
Emphasize compliance with antibiotic regimen (if indicated) each visit
Careful follow-up
Daily follow-up (for infections with systemic signs) until symptoms subside
Improvement should occur by 72 hours
Consult early/provide referral in refractory cases

3. Cortical Plate (Surgical) Trephination

When severe periapical inflammation or infection is present and the cortical
plates of bone are intact, the patient may experience excruciating pain. There is little or no
place for the exudate and the corresponding pressure to escape. Ideally, drainage would be
created through the root canal space, by removal of obturating materials (if present) and
apical trephination, if necessary (extending small files, up to size #25, 1 mm beyond apical
foramen). Occasionally, however, the canal space is blocked (by a post, e.g.) and canal
drainage is not possible. Surgical trephination is a procedure, which penetrates through the
cortical plate of bone to allow drainage and relief of pressure to occur. This procedure can
be accomplished with a small incision and penetration through bone with an endodontic
hand instrument or bur. Surgical trephination is strongly considered when pain cannot be
controlled through intracanal drainage procedures, and when systemic analgesics have
proven ineffective.
Definition
U

A surgical technique used to alleviate acute pain caused by an accumulation of

purulent material, when drainage through the root canal is impossible.

Cases requiring trephination

U

Characteristic findings
Tremendous pressure
Excruciating pain
Sometimes referred to as ―intraosseous acute apical periodontitis or apical abscess‖
Example:
Patient presents with
Severe pain
Extreme percussion tenderness
No swelling
Previous root canal treatment
Post and core
Periapical radiolucency
Example:
Patient presents with
Severe pain
Extreme percussion tenderness
No swelling
No previous root canal treatment
Small periapical radiolucency
No drainage from canal, upon opening and debridement
Continued severe post-op pain

Technique
U

Presurgical periapical radiograph

Establish tooth length
Detect

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 Presence of lesion
Status of the root canal
Root angulations
Relationship of adjacent teeth and significant anatomical structures
Anesthesia
Block anesthesia
Infiltration anesthesia
Incision
Vertical mucoperiosteal incision to cortical bone
Approximately mid-root
Either M or D to apex, considering anatomy
Avoid significant structures
Choose interradicular region having greatest dimension/safety
Avoid trephination into root eminence
Tissue reflection
Reflect tissue
Expose cortical bone
Inspect bone for fenestration
Cortical bone penetration
Penetrate cortical plate with endodontic explorer or round bur
Create pathway through cancellous bone to apex using file
Floss tied to handle
Confirm proper position with radiograph
Be aware of anatomy!
Inferior alveolar nerve
Mental foramen
Adjacent roots
For additional orientation information
Place lead foil into osseous wound
Make radiograph
Compare actual location with desired location
Post-operative follow-up
Same as with I&D
Follow course of recovery
Remember
Cortical trephination only relieves symptoms and is not definitive treatment!

4. Antibiotics

Choice of antibiotic
Chosen empirically – initially
Drug of choice
Penicillin
Alternative drugs
Clindamycin
Metronidazole

Penicillin
First drug of choice
Spectrum
Gram (+/-) aerobic cocci
Most anaerobic rods
Dosage
1-2 gm loading dose
500 mg every 6 hours for 7-10 days

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Clindamycin
Second drug of choice
Allergy to penicillin
No change in patient after 48 hours on penicillin
Spectrum
Gram (-) anaerobic rods
Gram (+) aerobic streptococci
Dosage
300-600 mg loading dose
150-300 mg every 6 hours for 7-10 days
Potential problem
Antibiotic related colitis (pseudomembranous colitis)
Diarrhea – 6 or more loose stools in 24 hours
More common in debilitated patients on long-term antibiotics

Metronidazole (Flagyl)
Spectrum
All anaerobic gram (-) rods
Anaerobic gram (+) cocci
Facultative aerobes are resistant!
Dosage
250 mg every 6 hours
500 mg every 8 hours
Used in conjunction with other antibiotics
Inactive against most aerobic bacteria
Combine with penicillin
Adverse effects
Antabuse effects

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