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Instructions for Surgical Endodontics-Endodontic Lecture Note

Introduction

The etiology of periapical (peri-radicular) periodontitis is microbial. The presence of micro-organisms within the root canal system induces an inflammatory and immune response within the peri-radicular tissues resulting in discreet bone destruction. In addition, contamination of the peri-radicular tissues by microorganisms and root filling materials may initiate a foreign body reaction and healing cannot then take place.

It is recognized that the aim of root canal treatment is to clean and disinfect the root canal system to reduce microbial numbers and remove necrotic tissue, and then seal the system to prevent recontamination.

 Apexification treatment may be indicated on a tooth with a necrotic pulp which has an immature root. The treatment involves the induction of apical closure over a period of several months. When closure is complete, normal endodontic therapy is performed.

Success rates of up to 95% have been quoted for de novo root canal treatment but failure may occur subsequent to treatment. Options for the treatment of these failures can be

non-surgical and surgical.

Nonsurgical re-treatment may provide a better opportunity to clean the root canal system than a surgical approach, where the coronal part of the root canal system remains untouched. However there are instances when non-surgical intervention is inappropriate.

The clinical evidence comparing particular endodontic procedures is sparse. However, there have been a number of pragmatic trials using various materials and procedures. In a few cases, however, nonsurgical endodontic treatment alone cannot save the tooth. In such a case, dentist or endodontist may recommend surgery.

Indications for surgical endodontics

Surgery can help save your tooth in a variety of situations.

Surgery may be used in diagnosis. If you have persistent symptoms 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.

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 your tooth has this "calcification," your endodontist may perform endodontic surgery to clean and seal the remainder of the canal.

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.

Surgery may also be performed to treat damaged root surfaces or surrounding bone.

Presence of periradicular disease, with or without symptoms in a root filled tooth, where non-surgical root canal re-treatment cannot be undertaken or has failed, or where conventionalre-treatment may be detrimental to the retention

of the tooth. For example, obliterated root canals, small teeth with full coverage restorations where conventional access may jeopardise the underlying core. It is recognized that non-surgical root canal treatment is the treatment of choice in most cases.

Presence of peri-radicular disease in a tooth where iatrogenic or developmental anomalies prevent non surgical root canal treatment being undertaken.

Where a biopsy of peri-radicular tissue is required.

Where visualization of the peri-radicular tissues and tooth root is required when perforation, root crack or fracture is suspected.

Where procedures are required that require either tooth sectioning or root amputation.

Where it may not be expedient to undertake prolonged non-surgical root canal re-treatment because of patient considerations.

There is active root resorption

There is gross over fill of the root canal filling

There is a fracture of the root or perforation at a level where the tooth has a guarded or

better prognosis

There is periodontal involvement requiring root amputation or hemisection

Hemisection may be indicated when there is a fracture dividing the crown and/or roots or there is extensive loss of bone support for one or more of the roots and retention of one half of the tooth is considered necessary for maintenance of function.

Root Amputation may be indicated on multi-rooted teeth when there is extensive loss of bone support on one root and amputation will significantly aid the periodontal condition and the patient’s access for cleaning the involved area. Root canal treatment on the retained portions of the canal system is preferably completed prior to hemisection or root amputation.

An important factor which should be considered for the acceptability of root amputation and hemisection is the accomplishment of suitable hard and soft tissue contours that maximizes the patient’s access for cleaning and minimizes the entrapment of food and oral debris.

Replantation of a tooth may be indicated when the canal system is not accessible and owing to anatomic consideration apical surgery in site is not advisable. Teeth that have been accidentally evulsed from the alveolus may be replanted to their original position. Root canal treatment is performed prior or after replantation although the latter has been recommended.

Occlusal adjustment and stabilization may be necessary. All replanted teeth may show varying radiographic signs of root resorption. Failure of the replanted tooth from root resorption may occur in one or two or more years. The degree or extent of root resorption increases the longer the time interval for returning the tooth to its alveolus.

Success or failure of endodontic therapy is not solely related to the technique which is utilized.

Immediate post operative radiographs are helpful in evaluating the techniques of endodontic treatment but long term success of the treatment is determined by follow-up examinations continued for a minimum of two years after treatment.

 The examinations must include periapical radiographs, clinical examination and a record of the presence or absence of symptoms.

Endodontic cases that lie outside the knowledge and experience of the treating dentist should be referred for consultation and/or treatment.

Proceedural Difficulties

During conventional orthograde root canal treatment, problems may arise as a result of one of the following:

Unusual root canal configurations

It would almost certainly be impossible to carry out  orthograde root canal treatment on this tooth

Freactured instruments within the root canal

This fractured instrument in the apical third of the root canal proved impossible to remove

Open Apex

Orthograde attempts havefailed to obturate this tooth with an open apex

Existing post in the root canal unfavourable for dismantling

It was agreed that any attempt to remove the large post and core in tooth 21 (UL1) to permit orthograde retreatment may result in a root fracture. The patient elected for a surgical approach

Lateral or Accessory Canals 

 

These lower incisors have been treated but symptoms have persisted at tooth 41 (LR1). The radiograph shows that the periodontitis is centred on the portal of exit from a lateral canal, which still must contain infected debris

Contraindications to surgical endontics

There are few absolute contraindications to endodontic surgery.

1-  Patient factors including the presence of severe systemic disease and psychological considerations.

2-  Anatomical factors including:

unusual bony or root configurations

lack of surgical access

possible involvement of the neurovascular bundle

where the tooth is subsequently unrestorable

where there is poor supporting tissue.

The skill, training and experience of the operator also has an influence.

Instructions for Surgical Endodontic Treatment

The treatment will be performed using local anesthesia. There are usually no restrictions after the procedure concerning driving or returning to work. One of our doctors are available for consultation at all times should a problem arise after your treatment.

Continue all medications for blood pressure, diabetes, thyroid problems and any other conditions as recommended by your physician. Anti-coagulation agents such as Coumadin or aspirin are only a concern if the needed treatment involves surgery and generally have to be stopped prior to such treatment. This will be arranged with your physician at the time of the examination. If there are any questions, please call our office prior to your appointment.

Please eat a full breakfast or lunch as applicable.

If you have been advised by your physician or dentist to use antibiotic premedication because of mitral valve prolapse (MVP), a heart murmur, hip, knee, cardiac or other prosthesis, or if you have rheumatic heart disease, please make sure you are on the appropriate antibiotic on the day of your appointment. If there are any questions, please call our office prior to your appointment.

If you can take ibuprofen (Advil) or naproxen sodium (Aleve), it does help reduce inflammation when taken pre-operatively. We recommend 2 tablets of either medication 2-4 hours before endodontic therapy.

General Instructions

It said to the patient that your tooth and surrounding gum tissue may be slightly tender for several days as a result of manipulation during treatment and the previous condition of your tooth. This tenderness is normal and is no cause for alarm.

Do not chew food on the affected side until your endodontic therapy is completed and your tooth is covered with a protective restoration.

You may continue your regular dental hygiene regimen.

Discomfort may be alleviated by taking ibuprofen (Advil), aspirin, or acetaminophen (Tylenol) as directed.

NOTE: Alcohol intake is not advised while taking any of these medications.

 Should you experience discomfort that cannot be controlled with the above listed medications, or should swelling develop, please contact this office immediately.

After Completion of Endodontic Treatment

Endodontic treatment has now been completed. The root canal system has been permanently sealed. The endodontist may have placed a final restoration or a temporary. You will be informed of the type of restoration that is placed. If a temporary restoration has been placed, a follow-up restoration must be placed to protect your tooth against fracture and decay. Please telephone your restorative dentist for an appointment. A complete report of treatment will be sent to your restorative dentist. If a follow-up visit is needed this will be made. This appointment will require only a few minutes and no additional fee will be charged for the first checkup visit. Please call for an appointment during the following month.

Guide to Tooth Pain

Symptom	Possible Problem	Action
Constant pain and pressure, gum swelling, sensitivity to touch.	Abscessed tooth causing gum and bone to become infected.	Endodontic evaluation and treatment to relieve the pain and save the tooth.
Dull ache and pressure in upper teeth and jaw.	Sinus headache or grinding of teeth can cause these symptoms.	See your dentist for relief of teeth grinding. Endodontic evaluation needed for severe or chronic pain
Chronic pain in head, neck or ear.	Pulp-damaged teeth may be the cause of pain in the head and neck.	Endodontic evaluation needed. If the problem is not related to your tooth, we will refer you to an appropriate specialist.
Sensitivity to hot or cold foods after dental treatment.	Momentary discomfort to hot and cold sensations does not signal a serious problem. This may be caused by a loose filling or gum recession.	Use a toothpaste made for sensitive teeth and brush appropriately.
Sensitivity to hot or cold foods after dental treatment.	Dental work may inflame pulp or nerves.	Wait 4 to 6 weeks. If the pain continues, see your general dentist.
Sharp pain when biting down on food.	Decay, loose filling, or a crack in the tooth. Possible pulp damage.	See your dentist for evaluation. If the problem is pulp related, your dentist will refer you to our practice.
Lingering pain after eating hot or cold foods.	Pulp damage by deep decay or trauma.	See our practice immediately to save the tooth with root canal treatment.

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.

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 the 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 but within limited time not exceeding one hour.

Corrective Surgery

Corrective surgery may be required to seal a perforation or resect a root. The position of the perforation is of paramount importance in determining whether it is surgically accessible; parallax radiographs will help to determine the site. Perforations in the apical third of the root may be handled by removal of the apex and sealing the canal with a retro filling. Ideally, perforations resulting from post crowns should have the offending post removed and a new one placed within the root canal.

 Surgical correction then resembles the placement of a retro filling in the side of the root. If the post is not removed, it must be cut back sufficiently to allow an adequate margin for finishing the retro filling. Many perforations are now managed by internal perforation repair, precluding the need for surgery. Surgical root resection may be indicated on multirooted teeth that have not responded to treatment or have a hopeless periodontal prognosis. Other reasons for root resection include extensive resorption, root fracture or gross caries.

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, functioning, natural tooth for the rest of your life.

What kind of Materials are placed in the Root end filling process?

A sealing material such as Mineral Trioxide Aggregate (MTA or Portland Cement), Zinc Oxide and Eugenol, and/or composite/glass/resin ionmer (glass and organic acid +/or plastic resin).  It will NOT contain amalgam when completed in our office.

 Complications

There are few complications associated with surgical endodontics. Infection is a rare complication and the prescription of anti-microbials prophylatically is not indicated except in patients who are medically compromised.

Outcomes

Regular review is necessary to conduct a clinical and radiological examination. Success is indicated by the presence of no signs and symptoms. It is expected that there will be evidence of bony regeneration in the peri-radicular tissues but repair may be by fibrous scar formation.

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Gypsum Products used in Dentistry

Introduction

Gypsum products used in dentistry are based on calcium sulphate hemihydrate (CaSO4.2H20)

The current ISO Standard for Dental Gypsum Products identifies five types of material as follow:

• Type 1 Dental plaster, impression
• Type 2 Dental plaster, model
• Type 3 Dental stone, die, model
• Type 4 Dental stone, die, high strength, low expansion
• Type 5 Dental stone, die, high strength, high expansion

Composition

Dental plasters(plaster of Paris): Dental plaster is produced by a process known as calcinations.

Plaster remains the most important model material for many dental restorations. As the precision of fit of restorations and orthodontic appliances depends on the quality of the dental plaster/stone, they must comply with the high quality demanded in dental technology.

Dental stone

Manipulation and setting characteristics

Plaster and stone are mixed with water to produce a workable mix. Hydration of the hemihydrate then occurs producing the gypsum model or die.

Water/powder ratios for gypsum model and die materials.

	Water (ml)	Powder(g)	W/P ratio (ml/g)
Plaster	50-60	100	0.55
Stone	20-35	100	0.30
Theoretical ratio	18.6	100	0.186

For hand mixing a clean, scratch free rubber or plastic bowl having a top diameter of about 130 mm is normally recommended.

Flexible Mixing Bowls

The material should be used as soon as possible after mixing since its viscosity increases to the stage where the material is unworkable within a few minutes.

            The setting reaction is exothermic, the maximum temperature beibg reached during the stage when final hardening occurs.

Control of setting times:

Factor which control the settings of gypsum products can be divided into those controlled by manufactures and those controlled by the operator.

The manufacture can control the concentration of nucleating agents in the hemihydrated powder

Operator controls temperature and W/P ratio and mixing time.

Properties of the set material

The strength gypsum depends, primary, on the porosity of the set material and the time for which the materials is allowed to dry out after settings.

Since stone is always mixed with at a lower W/P ratio than plaster it is less porous and consequently much stronger and harder. (When porous increased, strength decreased).

The ability of dental gypsum products to reproduce surface details of hard or soft tissues either directly or from impression is central to their suitability as model or die materials. This ability is judged by measuring the extent to which accurately machined lines in a block of stainless steel can be reproduced in a sample of the material.

Applications

When strength , hardness and accuracy are required dental stones are normally used in preference to dental plaster.

The stone materials are less likely to be damaged during the playing down .

Thus , these materials are used when any work is to be carried out on the model or die as would be the case when constructing a denture on a model or a cast alloy crown on a die.

                When mechanical properties and accuracy are not of primary importance the cheaper dental plaster is used.

Advantages and disadvantages

Advantages

Inexpensive and easy to use

Accuracy and dimensional  stability

Disadvantages:

Mechanical properties are not ideal.