Q1. Indications and Contra Indication of Periapical Surgery
Indications for Periapical Surgery:
v
Anatomic problems preventing complete
debridement/obturation
v
Teeth with radicular cysts
v
Horizontal apical root fracture
v
Irretrievable material preventing canal treatment
or retreatment.
v
Procedural errors during treatment
v
Large periapical lesions that do not resolve
with root canal treatment
Contraindications (or Cautions) for Periapical Surgery
v
When conventional root canal treatment is
possible
v
Periodontal diseases /mobile tooth/
v
Vertical root fracture or horizontal root
fracture around tooth cervix
v
Anatomic structures (e.g., adjacent nerves and
vessels) are in jeopardy
v
Structures interfere with access and visibility
v
Compromise of crown/root ratio
v
Systemic complications (e.g., bleeding
disorders)
v
Primary teeth
Q2. Hemisection
Modern advances in all phases of
dentistry have provided the opportunity for patients to maintain a functional
dentition for lifetime. Therapeutic measures performed to ensure
retention of teeth vary in
complexity. The treatment may involve combining restorative dentistry,
endodontics and periodontics so that the teeth are retained in whole or in
part.
Such teeth can be useful as
independent units of mastication or as abutments in simple fixed bridges.1 Thus tooth resection procedures are used to
preserve as much tooth structure as possible rather than sacrificing the whole
tooth
The term tooth resection denotes
the excision and removal of any segment of the tooth or a root with or without its
accompanying crown portion. Various resection procedures
described are: root amputation,
hemisection, radisection and bisection. Root amputation refers to removal of
one or more roots of multirooted tooth while other roots are retained.
Hemisection denotes removal or
separation of root with its accompanying crown portion of mandibular molars.
Radisection is a newer terminology for removal of roots of
maxillary molars. Bisection /
bicuspidization is the separation of mesial and distal roots of mandibular
molars along with its crown portion, where both segments are then retained
individually.
Root amputation procedures are a
logical way to eliminate a weak, diseased root to allow the stronger to
survive, whereas if retained together, they would collectively fail. Selected
root removal allows improved access for home care and plaque control with
resultant bone formation and reduced pocket depth.
Hemisection procedure represents a form of
conservative dentistry, aiming to retain as much of the original tooth
structure as possible.
On radiographic examination ,
grossly carious 46 was evident along with the external root resorption of both
the mesial and distal roots. 47 was found to have been
improperly root canal treated.
In the view of above findings, it
was decided to first carry out re-endodontic treatment of 47 followed by the
hemisection of the mesial root of 46 while retaining- the distal root (as
adequate bone support was
present), followed by root canal treatment of the distal root and fabrication
of crown and bridge over 45 and47 using distal root of 46 as an abutment.
after the removal of full metal crown from 47,
retreatment of the mesial canals was carried out . After the proper obturation
of 47, hemisection was carried out in relation to 46, with the vertical cut
method.
Q3. Luebke ochsenbein flap
Apicectomy is always a technique-sensitive procedure for oral surgeons
and endodontists.1 They always
desire to improve methodology of this procedure by means of instrumentation,
materials and different approaches to have better success rates. The visibility
of the area during the procedure is the key step for an improved postoperative
healing and to reduce the complications occurring during surgery due to
improper visibility. To attain this task, many surgical flaps have been
designed and practiced since decades.1 A review of these flap procedures
resulted in gingival and subgingival flap
designs. These are classified as:
1. Gingival
Flaps: Triangular and Trapezoidal
2. Subgingival Flaps: Semilunar and Ochsenbein – Luebke (O-L) Flap.
These flaps have distinct
indications, advantages and disadvantages, but it is more the experience and
the choice of the operator according to the situation and need of the apicectomy case that determine the final outcome
of the procedure. Many studies have been done on selection of the appropriate
flap design,1-3 but since the introduction of Ochsenbein-Luebke flap, some surgeons prefer this design
of flap.
The two most commonly used Flap procedures currently in
vogue are a) Trapezoidal Flap and b) Ochsenbein-Luebke Flap,
because of their specific advantages. However the Ochsenbein-Luebke procedure offers additional advantages
such as sparing of the marginal gingival, non-exposure and minimal loss of crestal bone and ease of reapproximation of the flap.2,3
The Trapezoidal technique involves two vertical releasing
incisions and one horizontal intra-sulcular (gingival) incision (Figure 1). This
is a marginal incision, as opposed to the O-L flap, which is a submarginal incision
Briefly the O-L technique involves
a scalloped horizontal incision in attached gingiva and two vertical releasing
incisions (Figure-2).2,3 Incisions correspond to the contour of
the gingival. There must be an adequate band of gingiva present (3–5 mm). This
requires an analysis of attachment level along the entire length of the
horizontal incision.
The O-L technique is basically a
modified semilunar or trapezoidal flap in which a
scalloped horizontal incision joins two vertical incisions. The vertical
incisions are made at least one tooth lateral to surgery side. The horizontal
incision is scalloped following the contour of gingival margin 3-5 mm from
gingival margin.2,3
Overall, the O-L technique appears
advantageous for both surgeons and patients. However, very few studies have
been done to compare the advantages of selecting one technique over the other.
There have been no studies in Pakistan in this regard, and it is not even
known to what extent oral surgeons practice one or the other technique. The
present study was undertaken to compare both techniques and evaluate the O-L
method for selective advantages over the Trapezoid method.
MATERIAL AND METHODS
The study was conducted at the Punjab Dental Hospital
Lahore Pakistan for a period of six months, from May
to October 1998. The study involved 120 patients of age 12 years and above, and
of both sexes, undergoing apicectomy for
a variety of periapical lesions (granulomas and cysts) involving two-thirds of the
root. Only those patients who had disease localized to the anterior teeth, were
otherwise medically fit and not suffering from any other systemic diseases were
included. Patients with periodontal pocketing and class III periodontal
mobility were excluded.
Patients were subjected to detailed history, clinical
examination, and investigations as needed. Patients were selected for either
the Trapezoidal or the O-L technique on a non-random basis; surgery was performed according to
standard procedures. All the procedures were done under local anaesthesia in
Minor Oral Surgery Department, Punjab Dental Hospital Lahore. Equal numbers of
patients were assigned to the two groups (60 each).
Evaluation of technique(s) involved assessment of
intra-operative technical considerations as well as postoperative morbidity,
healing and cosmetic results.
Duration
of surgery was noted by using a stopwatch, timed from the first nick to the
last reflection of the flap.
Technical
problems related to the surgical procedures of both groups were noted as
tearing of the flap or damage to wound edges.
Ease of
operation and visibility were assessed by the operator’s personal experience
during holding of flap by assistant, facilitation of visibility during bone and
apex cutting and assistance in lip retraction.
For
stitching, 3-0 silk thread and half circle needle at cutting edge was used for
both procedures. Comparison was done immediately, after 24 hours, after 3 days
and after 5 days at the time of removal of stitches. The edges were noted after
14 days. Approximation was measured as:
1. + = Maximum approximation
2. ++ = Flap has defect in approximation
in one to two stitched areas of flap.
3. +++ = More than two areas of the flap
have defective approximation in the stitched area.
Haemorrhage
was assessed by the duration of bleeding from the wound edges at the start of
incision till the start of bony procedure. Duration was recorded by use of a
stopwatch.
Oedema/Swelling was assessed on clinical basis as follows:
1. + = swelling confined to surgery flap.
2. ++ = Swelling involves upper lip as well.
3. +++ = Swelling beyond lip area or in
canine fossa.
Findings were noted after 24 hours, 3 days, 5 days and
after 14 days.
Statistical analysis was done using SPSS ver 8.0 computer software. The chi square
test was used to test for differences of frequencies and the Student’s T test
was used for differences of means. A p value £ 0.05
was considered significant.
Q4. Flap design endodontic surgery
Surgical flap design is variable
and depends on a
number of factors, including:
• access to and size of the
periradicular lesion
• periodontal status (including
biotype)
• state of coronal tooth
structure
• the nature and extent of
coronal restorations
• aesthetics
• adjacent anatomical structures.
Relieving incisions should be
placed on sound bone. The lack of predictability in determining the size of the periapical lesion, combined with increased
incidence of scarring associated with a semilunar flap, precludes its use in endodontic surgery.
It is not desirable to remove
bleeding tags of tissue from the exposed
bone or periodontal ligament fibres that
were severed during tissue reflection as they will facilitate healing.
The raised flap must be protected
from damage and desiccation during
surgery and retractors should rest on
sound bone.
Q5. Masserann Kit
The Masserann trepan should only be used in the
straight part of the root canal to free the coronal 2 mm of the silver point or
post. as it is very destructive of dentine. Once 2mm are exposed, the end can
be gripped with with either the Masserann extractor or a smiler size trepan.
The
Masserann kit consists of a series of hollow trepans of differing sizes that
can be used to cut around obstructions in the root canal.
The right hand trepan shows flaring out of the
edges. Use of this trepan would lead to unnecessary removal of dentine,
weakening the root further.
A trepan holding a removed core. It can be
activated either manually or with the slow speed handpiece
Q6. Bicuspidization
As dentistry aims to maintain the dentition in a healthy and
functional state, many procedures and treatment options are now available.
Bicuspidization is a procedure which represents a form of conservative
dentistry which aims to retain as much of the original tooth structure as
possible. The results are often predictable if the procedures performed are
proper . In this paper a case is presented in which bicuspidization was done
because the tooth was grossly carious along with furcation involvement. The
tooth was resected from the furcation area so that they can be utilized as an
individual tooth .
Hemisection denotes removal or separation of root with
its accompanying crown portion of mandibular molars. This procedure represents
a form of conservative dentistry, aiming to retain as much of the original
tooth structure as possible. The results are predictable and success rates are
high. In this paper a case is presented in which hemisection was done because
the tooth was grossly carious along with furcation involvement. Mesial half of
tooth was extracted and the remaining tooth was restored as premolar which
helped to reduce the masticatory load.
Hemisection (removal of one root) involves removing
significantly compromised root structure and the associated coronal structure
through deliberate excision. Because of two roots present in mandibular molars,
one half of the crown and associated root is removed. Thus tooth resection
procedures are used to preserve as much tooth structure as possible rather than
sacrificing the whole tooth. It differs from bicuspidization, in which a
separation is made between the two roots in the furcation area without removal
of any root. The separated roots along with its crown part are then restored as
premolars. Selected root removal allows improved access for homecare and plaque
control with resultant bone formation and reduced pocket depth.
Q7. Procedure of Apicoectomy
maxillary central incisor
Apicoectomy:
Definition: It is the cutting off, of the apical
portion of the root and curettage of the periapical
necrotic, granulomatous, inflammatory or cystic lesion.
Synonym: Apical Surgery, Root Resection, Endodontic
Surgery, Root Amputation
Indications of Apicoectomy:
1. Apical anamoly of root tip-dilacerations, intracanal
calcifications
2. Presence of lateral/accessory canal/apical region perforations
3. Roots with broken instruments
4. Root with overfilling
5. Fracture of apical third of root
6. Formation of periapical granuloma and cyst
7. Draining Sinus tract
8. Non responsive to RCT
9. Over extension of root canal cement beyond the Apex
10. Teeth with Ceramic Crowns
11. When patient with chronic periapical infection
12. Teeth with Apical resorption
Contraindications of Apicoectomy:
1. Medically compromised patients
2. Teeth with deep periodontal pocket and excessive
mobility
3. Teeth with poor Accessibility
4. When there is extensive 4. involvement of Bone
5. Danger of involvement of
anatomical structure
Step by Step Surgical Procedure of Apicoectomy:
1. Design of Mucoperiosteal Flap
2. Reflection of Mucoperiosteal Flap
3. Exposure of Periapical Pathology and Root Tip
4. Removal of Periapical pathology
5. Ressection of Root Apex (Apical 1/3rd)
6. Sealing of the Apex
7. Toilet of the wound
8. Smoothing of the Sharp Bony margins
9. Bleeding Control
10. Closure of the Surgical Wound – Suturing
Postoperative instructions, medication and care
Complications of Apicoectomy:
1. Infection Flare up
2. Cellulitis
3. Ludwigs Angina
4. Fracture of Maxilla and Mandible
5. Soft tissue injury
6. Opening of Maxillary Sinus – Oro Antral Fistula
7. Secondary Hemorrhage
8. Secondary hemorrhage
9. Non vitality of Adjacent teeth
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