Week 3 PP

Question 1

Why Endo Surgery?

Answer 1

When conventional root canal treatment cannot be performed or has not been successful then a surgical root canal procedure may need to be performed.E

Question 2

Endo Surgery may be done to…

Answer 2

• check the end of a tooth’s root for cracks
  -remove parts of a root that could not be adequately sealed during conventional root canal treatment
  -or to clear up an infection that has not healed after conventional treatment

Question 3

Surgical Endodontics - What is Apical Curettage?

Answer 3

This is the procedure where infection & granular tissue is removed form the apical area of the tooth.

Question 4

When is Apical Curettage done?

Answer 4

• usually done after a RCT has been completed, but the infectious tissue is not resorbing or the bone is not healing as desired
• could be done before the endodontic procedure, if the amount of infectins tissue was excessive, and the endodontist was concerned about it draining trough the tooth

Question 5

Apical Curettage Procedure

Answer 5

• Profound local anesthesia is essential
• The tissue at and around the operative site is thoroughly cleaned with an appropriate antiseptic agent
• An incision is made through the periodontium, to the bone, at the apical area extending to one tooth on either side of the affected area
• Using a periosteal elevator, the tissue is elevated away from the bone, creating a ‘flap’, and exposing the bone
• The high speed handpiece with a long shanked, surgical fissure bur, is used to open a window into the bone
• A surgical curette is then used to remove all infected tissue, and to stimulate fresh bleeding within the bone – this will facilitate faster bone re-growth in the area
• The tissue flap is replaced and sutures hold it in place to fully cover the bone site while healing occurs * sutures are removed 5-7 days later
• This shows the retracted tissue flap and curette removing the infected tissue
• The curette would then be used to smooth the bone and create fresh bleeding

Question 6

What is an Apicoectomy?

Answer 6

The most common endo surgery procedure

Apicoectomy is the removal of the apex of the tooth
* usually 2-3 mm must be removed to get to an area where the seal is adequate between the gutta percha and the dentin

Question 7

When is an Apicoectomy completed?

Answer 7

• If the canal length was not properly determined, the apex may be perforated during the debridement and either root canal sealer or gutta percha may extend out the apex of the root – causing constant irritation
• The apical curettage procedure would be done followed by an apicoectomy

Question 8

Apicoectomy Procedure

Answer 8

• Profound local anesthetic
• A ‘flap’ is created and the mucosal tissue elevated as in the apical curettage
• High speed handpiece and surgical bur to gain opening into alveolar bone
• Infectious tissue is removed with the curette
• The apex of the tooth is then removed with the high speed and surgical bur
• The site is curetted to stimulate fresh bleeding – then thoroughly irrigated
  with sterile saline solution to remove all debris
• The flap is replaced and sutured

Question 9

What happens after an Apicoectomy?

Answer 9

Healing and bone remodeling will occur within the next 4-6 months

Question 10

What is a Retrograde Restoration?

Answer 10

This procedure is similar to an apicoecomy, but is for a different purpose:
-here the gutta percha filling in the canal did not reach the apex, and the remaining tissue is causing an ongoing infection.

-the access opening into the bone is the same as for an apicoectomy

• the apex of the tooth is opened with a surgical bur, to the area where gutta percha is visible
  *on a diagonal across the apex
• a small restoration preparation is made in the apex using a very tiny specialized handpiece & bur
• The area is thoroughly irrigated with sterile saline solution, and the tissue flap replaced and sutured
• The patient is recalled in 5-7 days for suture removal and post operative check
• The bone will regenerate to fill the area, over the next few months, the patient will return periodically for radiographic checks on healing

Question 11

Most common cause of endodontic treatment failure?

Answer 11

Curevature of the root canal!!
-often the apex of the tooth is impossible to reach for dibridemet due to curvature, calcification or operator error

*This is the most common cause of
endodontic treatment failure and re-infection
* sometimes the endodontist will attempt to retreat the tooth in a traditional method – and if that fails, the retrograde restoration is done

Question 12

Root Amputation & Hemisection - how common?

Answer 12

These procedures are not commonly performed, as they have limited success

Question 13

What is Root Amputation?

Answer 13

• in the root amputation procedure, one root of a multi-rooted tooth, is removed, leaving the crown intact

Question 14

What is Hemisection?

Answer 14

• The hemisection procedure is performed on mandibular
  molars, and involves bisecting the tooth at the furcation, and removing half the crown and one root

Question 15

Post Op Instructions for All Endodontic Surgeries..

Answer 15

• To limit swelling in the area, a soft ice pack can be placed on the area for 15 minutes out of each hour for the first day
• The patient should gently rinse with warm salt water after meals to eliminate food and bacteria (1 tsp of salt to 8 oz of warm water)
• Semi-solid but nutritional siet
• Gentle brushing with a softened toothbrush - be careful of sutured areas
• Call the office if the bleeding continues out there is exteme pain

Question 16

Post Op Instructions for Temp Fillings

Answer 16

• avoid sticky & hard fillings
  -if the temp filling falls out or becomes dislodged, call the office
• the filling is temporary so you will need to return in 1-2 weeks to have a permanent restoration completed
  -if the bite feels off once the anesthetic wears off, call the office

Question 17

***The following x-rays are required for the diagnosis and completion of endodontic treatment:

Answer 17

Initial radiograph - taken to diagnose BEFORE treatment

Working Length - Used to determine the length of the canal

Final Instrumentation - Taken with the final sized files in the canal(s)

Completion (once procedure is done)- Taken once canals have been filled and sealed

Recall - Taken at post treatment evaluations

Question 18

Endo-Xrays

Answer 18

-taken at the working length and final instrumentation stages of treatment are exposed with isolation materials (ie dental dam) and files or gutta percha still present intraoorally.

Question 19

2 Techniques for Endo rays

Answer 19

Parallelling Technique
Bisecting Technique

Question 20

Importance of angulation when using bisecting technique

Answer 20

the angulation of the PID is CRITICAL
Both the horizontal and vertical angulation must be correct to determine the length of the root canals

the wrong angulation will create distortion

Correct Vertical Angulation = an image that is the SAME LENGTH as the tooth
Incorrect Vertical Angulation = an image that is NOT the same length, it is either elongated or
foreshortened, therefore the image is NOT diagnostic

Question 21

A diagnostic quality endodontic x-ray must have the following qualities:

Answer 21

• Tooth is centered on the image
• Al least 5mm of bone is visible beyond the apex of the tooth
• The image is as anatomically accurate as possible