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C A D > Apical Surgery > Flashcards

Apical Surgery Flashcards

https://case.edu/dental/sites/case.edu.dental/files/2021-10/Duan%20-%20Practical%20Steps%20in%20Endo%20Surgery.pptx.pdf

1
Q

What is apical surgery also know as?

A

Endodontic surgery / root end surgery / apicoectomy

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2
Q

How would we deal with a perforation/resorption repair?

A

Open a flap and close with GIC

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3
Q

What is involved in a hemisection?

A

Cutting a tooth in half (PREMOLARISATION- cutting a molar to split it, making it look like 2 premolars)

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4
Q

What does trephination involve?

A

A hole in bone is made to release accumulated tissue exudate, increasing healing

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5
Q

What does decompression involve?

A

Placing a surgical drain to rid cystic fluid from a large lesion to shrink it

This makes a second surgery to remove granulation tissue much easier

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6
Q

What does intentional reimplantation involve?

A

Extracting a tooth as atraumatically as possible, root fill the tooth and reimplant it.

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7
Q

What is the difference between orthograde and retrograde?

A

Orthograde: Access the tooth through the crown
Retrograde: Access the tooth from root tip

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8
Q

How do we assess failed endodontics?

A
  1. Clinical and radiographic findings
  2. Patient factors: medical, cooperation, motivation, consent
  3. Oral factors: Maintenance, function, aesthetics, adjacent teeth
  4. Tooth factors: Coronal seal, quality of RCT, access to canal/root end/structures
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9
Q

How can we gauge whether an apex of a tooth is close to any nerves?

A

Take a CBCT scan

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10
Q

What affects success of Endodontic surgery?

A

Depends on tooth and operator experience

Lower success rates if pre treated edodontically

Coronal seal quality is VERY important

  • None surgical treatment is better than surgical treatment - it is a final approach
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11
Q

What is apical surgery? IN SIMPLE TERMS

A

In simple terms:
1. Cleaning out tissue at the top of the tooth
2. Chop off tip from root
3. Put in filling material
4. Stitch up and wait for healing

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12
Q

Stages of apical surgery in detail?

A
  1. Identify region to be managed
  2. Determine flap design
  3. Once flap raised, identify lesion and apex. Then curettage of apical tissue (be sure to send for biopsy as occasionally apical infection can be cancer)
  4. Root end resection - tip of root with abnormal anatomy removed with high speed surgical handpiece
  5. Root end filling materials- instrumentation
  6. Would closure
  7. Post-op care and review
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13
Q

What do we do if there is bone impeding access to the apical part of tooth?

A

We do an osteoectomy to remove the bone.
Often there will be a fenestration in the bone (resorbed cortical plate) to guide where to widen the it.

Must use plenty of irrigation to reduce heat generation, preventing bone necrosis

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14
Q

What factors must we compromise between in flap design?

A
  1. Access
  2. Vision
  3. Recession (hence why we usually extend flap to roughly the teeth either side)
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15
Q

What factors affect flap design?

A
  1. Size and site of lesion - must not incise over lesion
  2. Presence of crowns/veneers - risk of recession
  3. Depth of sulcus/vestibule
  4. Presence of frena/bony prominences/thin tissue biotypes/muscle attachments (cutting through it can cause muscle weakness)
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16
Q

Types of flap designs?

A
  1. Full muco-periosteal flaps - from gingival margin to sulcus
    -triangular: 2 sided flap - 1 vertical relieving incision (how we surgically extract teeth)
    -rectangular: two vertical relieving incisions
    -trapezoid: two angled vertical relieving incisions
  2. Limited mucoperiosteal flaps
    -submarginal AKA Ochsenbein–Luebke flap: Cut at junction between keratinised and non-keratinised tissue to minimise recession.
    -papilla base: two vertical realising incisions connected by horizontal incision at papilla base (do over submarginal if lesion is larger)

SEE DIAGRAMS ON NOTES

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17
Q

Why would we use a full mucoperiosteal flap?

A
  1. Easy to reflect and reposition
  2. Easy access to lesion
  3. Good healing
    BUT may lead to post-op recession so ideally leave 3mm of gingivae from margin.
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18
Q

Why would we use a limited mucoperiosteal flap?

A
  1. Avoids recession
  2. Easy reference points for reattachment
  3. Limited scarring
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19
Q

Why might a flap result in scarring?

A

If the suture to close it isn’t well done

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20
Q

What part of a flap should you suture first?

A

Base of contour first (see diagrams - slide 30)

21
Q

Which needles should we use to suture flaps?

A

Small needles because gingival is tighter so reduces risk of tearing tissue

22
Q

Where are lesions usually situated in lateral incisors?

A

Distally

23
Q

How do we describe a lesion that once excised, leaves no palatal cortical tissue left?

A

Through and through

Healing processes are more difficult to achieve in these lesions

24
Q

How do we do a root end resection

A
  1. Usually with a bur
  2. Tip of root removed - studies show apical 3mm have most accessory anatomy/abnormal anatomy and area that is most difficult to clean
  3. Done at a 90 degree angle - historically did 45 degrees to facilitate vision of root end for prep and filling but now we have better microsurgical techniques that allow for a biologically better option (the 90 degree option)
  4. Small class 1 cavity made into tip of tooth (root dentine) to remove around 3mm of GP to be filled
25
Q

Why is tip of root chopped off at 90 degrees better than 45 degrees?

A

Much less exposure of dentinal tubules if resected at 90 but this can be hard especially in lower incisor region (imagine the positioning of the bur in that area!)

26
Q

What are micro mirrors used for?

A

Allows vision of tooth tip - we can cut root at right angles

27
Q

What are Peizon tips used for?

A

Used to prepare class 1 cavity

28
Q

How do we do a root end preparation?

A
  1. Retropreparation using ultrasonic tip to remove 2-3mm of GP
  2. Pack root filling (MTA or other bio ceramic cement) into retro prep cavity
29
Q

What material did they use historically as a root filling?

A

Amalgam but can lead to amalgam tattoos

30
Q

How can we improve vision field to allow easy MTA packing?

A

Pack a gauze saturated with adrenaline to reduce bleeding

31
Q

How can we spot through and through resorption on a radiograph?

A

Area is really black, no bone (otherwise it is just radiolucent)- see slide 54

32
Q

What are the success rates of root filling materials?

A

Amalgam: 75%
Reinforced eugenol cements (IRM/ Super EBA) : 90-95%
MTA: 95-97%

33
Q

What are the properties of MTA?

A
  1. Slowly sets in moisture
  2. High pH - antimicrobial
  3. Good sealing ability and biocompatible
  4. Osteoconductive: bone can grow directly on MTA
  5. Osteoinductive: induces bone growth onto its surface

Disadvantages:
Hard to use, its like packing wet sand but they have put in a plasticiser to combat this
Very expensive

34
Q

What colour did MTA used to be and what colour is it now?

A

Used to be grey like amalgam, now it is white

35
Q

What are the indications for apical surgery?

A
  1. Remove source of infection of Endodontics origin where this isn’t possible non-surgically
  2. Repair damage (pathological or iatrogenic) that can’t be accessed non-surgically
  3. Extruded material with no symptoms, can remove
  4. Need a sample of apical tissue for biopsy
  5. Assess teeth where a definitive diagnosis cannot be made without direct visual access
36
Q

What are the indications for re-treatment (non-surgical)?

A
  1. Persisting symptoms/signs
  2. Inadequate cleaning, shaping or obturation
  3. Missing canals
  4. Poor coronal seal/replacement of coronal restoration
37
Q

What are the contraindications of apical surgery?

A
  • In most cases non-surgical pre-treatment have better prognosis
  1. Poor operator experience
  2. Patient factors (Medical-complex/Psychological- nerves as it can get quite stressful)
  3. Access to surgical site ( Lower incisors: hard to reach apical area/ Frenum high: hard to get it flat/ canine: long tooth/upper 6: palatally risk of sinus/limited mouth opening: hard to access posterior teeth)
  4. Local anatomical factors- sinus, nerves and vessels
  5. Poor restorative or periodontal prognosis
38
Q

Advantages of orthograde approach?

A

Allows us to kill microbes in the root canal system with irrigant

Allows clear access to all of the root canal system

We can use magnification to view extra canals

Avoids surgical procedure

Randomised controlled trials shows it has the highest success rates

39
Q

Disadvantages of orthograde approach?

A

Longer treatment times/ may require multiple visits

There is a risk of root fracture (especially if we have to remove a post)

Highly dependent on the skill of the operator

More expensive

40
Q

How would we close the wound after the procedure

A

We place the flap back to either:

  1. Where we removed the flap from
  2. Slightly coronal to where we removed the flap (recession takes it back to original place)

We can use sling or oblique sutures

41
Q

What pre-operative factors affect outcome?

A
  1. AGE
  2. Sex - males heal better
  3. Health- eg diabetics have worse healing
  4. Tooth location- anterior better bc easy access
  5. Clinical signs/symptoms: symptomatic/sinuses reduce change of success
    6.Size of lesions
  6. Bone loss- limited support
  7. Coronal seal- no coronal seal reduces success
  8. Resurgery- less success bc resecting more of the tooth means less root, less support, more perio issues
42
Q

Intra-operative factors affecting outcome?

A
  1. Degree of bevel/level of resection - 90 degrees is best
  2. Retrograde prep method- ultrasonics better than straight bur
  3. Retrograde root filling/material - MTA> amalgam
  4. Haemostatic agent - better vision
  5. Magnification
  6. Bone grafting- if not much bone there however we tend to avoid doing this as we want to regenerate natural bony infill
43
Q

Why would we do apical surgery even if we are planning on getting rid of the tooth eventually?

A

Pre-implant theory:

By doing apical surgery, we encourage the generation of natural bone. This means that even if we extend the tooth’s life by only a few years, we increase the bone levels we would’ve otherwise had, making implants a more viable option for patients later down the line.

44
Q

Why does classic literature suggest apical surgery success rates are lower?

A

They do not reflect contemporary methods (90 degrees instead of the old 45 degrees etc) and we have better idea of case selection/ knowledge of why endo txt fails.

45
Q

What issues could you encounter with doing surgery on anterior maxillary teeth?

A

o Apex of lateral tend to lie deep if the teeth are proclined
o Canines are long teeth, so the apex is at the side of your nose

46
Q

What issues could you encounter with doing surgery on anterior mandibular teeth?

A

o The apex tends to lie deep & difficult to get to
o Have to be mindful of mentalis

47
Q

What issues could you encounter with doing surgery on posterior mandibular teeth?

A

o ID nerve can tend to cause an issue
o Have to be mindful of buccinator

48
Q

What issues could you encounter with doing surgery on posterior maxillary teeth?

A

o The sinus can get in the way
o Palatal roots are difficult to access
o The zygomatic buttress can tend to get in the way

49
Q

Signs of a successful surgery?

A

Absence of symptoms
No sinus tract
No loss of function
Soft tissue healing
Bony infill

If these are reached within 4 years = success

C A D (17 decks)

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