PERIAPICAL SURGERY

D. SURYA
III –PG
 CONTENTS
Introduction
Definition
History
Pathways of Communication
Indication
Contra- indication
Classification
Treatment planning and procedures
Factors Associated with Success and Failures of
Periapical Surgery
Recent Advances
Studies
Conclusion
 INTRODUCTION
Apical surgery is considered a standard oral surgical

procedure.

The main goal of apical surgery is to prevent bacterial

leakage from the root-canal system into the peri-radicular

tissues by placing a tight root-end filling following root-

end resection.

Periapical surgery is performed to eradicate persistent

infection/inflammation.
 DEFINITION
Periapical (i.e., periradicular) includes resection of a

portion of the root that contains undebrided or

unobturated (or both) canal space. It can also involve

reverse filling and sealing of the canal when conventional

root canal treatment is not feasible.

American Association of Endodontics - 1892

 HISTORY
Surgical endodontics is not a recent innovation. Trephination
and incision and drainage are done since ancient times.

In 11 th century, first case of endodontic surgery was

performed by Abulcasis.

Root end resection (Apicectomy ) was first documented in

1871 and apicectomy with retrograde cavity preparation and
filling with amalgam was documented in 1890.

Root amputation was first introduced by Black and Inlitch in

1886, then was dealt by Younger (1894) and Guerini (1909).
 HISTORY
In 1930, indications for endodontic surgery
were proposed.

In 1940, Triangular flap was first described by

Fischer.

Neumann and Eikan described Trapezoidal

flap in 1940.

Semilunar incision was first described by

Partsch hence it is also known as Partsch
incision.
PATHWAYS OF COMMUNICATION
DEVELOPMENTAL PATHOLOGICAL IATROGENIC
• Apical foramen • Root fractures • Exposure of dentinal
• Accessory canals following trauma
tubules following root
• Congenital absence of • Idiopathic resorption
cementum exposing planning
Internal resorption
dentinal tubules • Accidental lateral
External resorption
• Developmental grooves
perforation during
• Developmental
anomalies such as endodontic procedure.
enamel projections and
• Root fractures caused
enamel pearls.
due to endodontic

procedures
 CLASSIFICATION
Primary endodontic lesion

Primary endodontic lesion with secondary periodontal

involvement

Primary periodontal lesion

Primary periodontic lesion with secondary endodontic

involvement

True combined lesion SIMON,

GLICK,
FRANK
1972
 CLASSIFICATION
• Class I: Tooth in which symptoms clinically and radiographically

simulate periodontal disease but are infact due to pulpal

inflammation or necrosis
Franklin. S.
• Class II: Tooth that has both pulpal and periodontal disease Weine
(1972)
concomitantly.

• Class III: Tooth that has no pulpal problem but required

endodontic therapy plus root amputation to gain periodontal healing

• Class IV: Tooth that clinically and radiographically simulates

pulpal/periapical disease but in fact has periodontal disease.

 CLASSIFICATION
Type 1 – Requiring endodontic treatment only.

Type II – Requiring periodontal treatment only.

Type III – Requiring combined endo-perio treatment

Grossman
1988
 CLASSIFICATION
• Crown down plaque induced periodontal lesion-lesion arises at

gingival margin and progress apically.

• Crown –crown periodontal lesion of endodontic origin- begins

apically and progresses coronally.

Edoardo
• Combined lesions
Foce 2011
• Pseudo endo perio lesion- initial clinical and radiologic exam points

to both endo and perio sources, pulp vitality and periodontal probing

resolve the diagnostic doubt concerning lesion’s true nature.

MAXMEN
(1959)
INCISION AND DRIANAGE
CORTICAL
TREPINATION
Grossman
 TREATMENT PLANNING &
PROCEDURES
• Proper planning is required presurgically before
deciding to subject patient to surgical endodontics.
• Endodontic procedure must be carried out by-
Qualified, well trained, experienced endodontics.
• Endodontics must know his/her limitations of clinical
skills before performing endodontic surgery.
• Informed consent is mandatory.

• All the surgical procedures have to explained in

details to the patient.
 TREATMENT PLANNING & PROCEDURES

STEPS IN ENDOSURGERY

Case Root-end Root-end

Diagnosis preparation resection

Pre operative Access to

Root-end
Surgical root preparation
Note structure

Anesthesia/ Periradicular Root-end

hemostasis curettage filling

Management Soft tissue

Surgical Postsurgical
of soft & hard repositioning
access care
tissues & Suturing
Gutmann and Harrison
(Eriksso
n AR et
al. J Oral
Maxillof
ac Surg
1982
Barnes (1984)
 PERIRADICULAR CURETTAGE
It is a surgical procedure to remove diseased tissue
from the alveolar bone in the apical or lateral region
surrounding a pulpless tooth

. American Association of Endodontics - 1892

 PERIRADICULAR CURETTAGE
Indications

a. Access to the root structure for additional surgical

procedures.

b. For removing the infected tissue from the bone surrounding

the root.

c. For removing overextended fillings.

d. For removing necrotic cementum.

e. For removing a long standing persistent lesion especially

when a cyst is suspected.

f. To assist in rapid healing and repair of the periradicular

tissues.
 ROOT-END RESECTION
(APICOECTOMY, APICECTOMY)
It is the ablation of apical portion
of the root-end attached soft
tissues.

Swiah, EDJ, 1996

 ROOT-END RESECTION
(APICOECTOMY, APICECTOMY)
INDICATIONS
a. Inability to perform nonsurgical endodontic therapy due to anatomical,
pathological and iatrogenic defects in root

canal.

b. Persistent infections after conventional endodontic treatment.

c. Need for biopsy.

d. Need to evaluate the resected root surface for any additional canals or fracture.

e. Medical reasons.
 ROOT-END RESECTION
(APICOECTOMY, APICECTOMY)

INDICATIONS

F. For removal of iatrogenic errors like ledges, fractured instruments,

and perforation which are causing treatment failure.

G. For evaluation of apical seal.

H. Blockage of the root canal due to calcific metamorphosis or

radicular restoration.
 RETROGRADE FILLING
The main aim of the endodontic therapy whether
nonsurgical or surgical is three-dimensional
obturation of the root canal system.

Root canal filling material is placed in the prepared

root-end in a dry field.

To place a material in the retropreparation, it is mixed

in the desired consistency, carried on the carver and
placed carefully into the retropreparation and
compacted with the help of burnisher.
 RETROGRADE FILLING
Finally the root-end filling is finished with carbide finishing bur
and a radiograph is exposed to confirm the correct placement of
the filling.
 RETROGRADE FILLING
IDEAL PROPERTIES

. Should be well tolerated by periapical tissues

1

2. Should adhere to tooth surface.

3. Should be dimensionally stable

4. Should be resistant to dissolution

5. Should promote cementogenesis

6. Should be bactericidal or bacteriostatic

7. Should be non corrosive

8. Should be electrochemically inactive

9. Should not stain tooth or periradicular tissue

10. Should be readily available and easy to handle

11. Should allow adequate working time, then set quickly

12. Should be radiopaque.

 RETROGRADE FILLING
Commonly used root-end filling materials are:
1. Amalgam

2. Gutta-percha

3. Gold foil

4. Titanium screws

5. Glass ionomers

6. Zinc oxide eugenol (ZOE)

7. Composite resins

8. Polycarboxylate cement

9. Poly HEMA

10. Super EBA

11. Mineral trioxide aggregate

Mineral Trioxide Aggregate (MTA)

1. MTA is composed of Tri-calcium silicate, Tri-calcium

aluminate; Tri-calcium oxide and Silicate oxide.
2. Bismuth oxide is added to the mixture for radiopacity.
3. pH-12.5 (when set).
4. Setting time is 2 hr 45 minutes.

5. Compressive strength—40 MPa (immediately after setting) which increases to

70 MPa after 21 days.

Fridland et al 2003
Advantages of MTA
. Least toxic of all filling materials
. Excellent biocompatibility, in contact with periradicular tissues, it forms
connective tissue and cementum, causing only very low levels of
inflammation.
Hydrophilic—Not adversely affected by blood or slight moisture.
. Radiopaque
Sealing ability—Superior to that of amalgam or super EBA.
Disadvantages
More difficult to manipulate
Longer setting time
Expensive
•
 REPLANTATION

Replantation is defined as intentional removal of a tooth and

after examination, diagnosis, endodontic therapy and
repair,placing it back into the original socket.
( Grossman 1966)

Classification
It can be of two types:

a. Intentional replantation
b. Unintentional replantation
 REPLANTATION
INDICATIONS
1. Nonsurgical endodontic treatment not possible because of

limited month opening

2. Persistent infection even after root canal treatment

3. Inaccessibility for surgical approach for periradicular surgery

due to anatomic factors

4. Perforations in inaccessible areas where for surgery excessive

bone loss is required.

(Samuel Kratchman DCNA; 41; 1997)

 TRANSPLANTATION

It is the procedure of replacement of a tooth in a socket other

than the one from which it had been extracted from.

ROOT RESECTION/AMPUTATION
Root resection is defined as removal of a complete root leaving the
crown of tooth intact.
Keough (1982)
ROOT RESECTION/AMPUTATION
Indications for Root Resections

1. Extensive bone loss in relation to root where periodontal

therapy cannot correct it.

2. Root anatomy like curved canal which cannot be treated

3. Extensive calcifications in root

4. Fracture of one root, which does not involve other root

5. Resorption, caries or perforation involving one root

 BICUSPIDIZATION/BISECTION

It is defined as surgical separation of a multirooted tooth into

two halves and their respective roots.
(Glossary of Periodontal terms)

INDICATIONS

1. When periodontal disease involves the furcation area and

therapy does not improve the condition of tooth.

2. Furcation is transferred to make interproximal space which

makes the area more manageable by the patient.

Radiographic verification.
Before suturing, a radio-graph is made to verify that the surgical objectives
are satisfactory. If corrections are needed, these are made before suturing.

Flap replacement and suturing

Silk sutures are generally used, although other materials are suitable,
including 4-0 absorbable suture.
Interrupted sutures are common, although both horizontal and vertical
mattress and sling sutures are applicable in certain situations

•
 POSTSURGICAL COMPLICATIONS

1. Pain
2. Swelling
3. Infection
4. Bleeding
5. Hematoma
6. Tissue trauma
7. Incomplete root resection
8. Foreign debris in the surgical site
9. Parasthesia
 HEALING

Healing after endodontic surgery is rapid because most tissues

being manipulated are healthy, with a good blood supply, and
tissue replacement enables repair by primary intention. Both
soft tissues are involved. Time and mode of healing varies with
each, but involve similar processes.
 RECENT ADVANCES
Recently studies have shown the use of Er:YAG laser and Ho:YAG laser for root end
resection but among these

Er:YAG laser is better as it produces clean and smooth root surface.

Advantages of use of laser in periradicular

surgery over the traditional methods include:

1. Reduction of postoperative pain.

2. Improved hemostasis
3. Reduction of permeability of root surface
.4. Potential sterilization of the root surface.
5. Reduction of discomfort.
6. Extent of resection
 ENDOSCOPE
A more critical and difficult issue is the presence of
dentinal cracks. The use of an (rigid) endoscope
appears to be useful for the detection of dentinal
cracks at the cut root face
(von Arx et al., 2002),
This tendency of consistently high healing rates after
apical (micro-)surgery has been substanti-ated by
several clinical studies published in the last 5 years
(Lindeboom et al., 2005)
 STUDIES
The incision technique and flap design should be
chosen according to clinical and radiographic
parameters Clinical issues include: the patient’s
esthetic demands; condition, biotype and width of
gingival tissues,and presence of a restoration
margin.
(von Arx and Salvi, 2008)..
From a practical point of view, healing is normally
evaluated 1-year postsurgery, although small (<5 mm)
periapical defects might heal within a few months
(Rubinstein and Kim, 1999) A
Recent 5-year longitudinal study found a low success rate of
59% for re-surgeries compared to a high success rate of 86% for
first-time surgeries
(Gagliani et al., 2005).
 CONCLUSION
These are inflammatory lesions appearing in the apical zone of
implants, and which are cleaned and subjected to curettage ; apical
resection of the implant may even be performed in order to avoid
bacterial proliferation and relapse of the eliminated lesion .

Previously cited success rates of 60% to 70% have now increased to

more than 90% in many studies, due to the routine use of ultrasonic
retrograde preparation and the use of mineral trioxide aggregate as a
filling material.
This significant improvement makes apical surgery a much more
predictable and valuable adjunct in the treatment of symptomatic
teeth.