surgical endodontics.pptx

7/30/2019 SURGICAL ENDODONTICS.pptx

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SURGICALENDODONTICS


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Presurgical Preparation

Patients interview.

Medical evaluation.

Oral Examination. Radiological Evaluation.

Premedication.


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Patients Interview

Patient Preferences.

Benefits.

Risks. Prognosis.

Cost.

Other treatment Options.


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Medical Evaluation

Medical History and assessment of vital signs.

Medical conditions like Recent myocardialinfarction, Stroke, Cardiac arrhythmias,Diabetes, Radiation therapy in the Head andNeck region, Immunocompromising

conditions, Seizure disorders, adrenalsuppression, Liver or Kidney disease,Bleedingdisorders and Pregnancy.(consult physician).


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Medicines in use like bisphosphonates,Immunosuppressive drugs like

Glucocorticoides, Nsaids, Aspirin, Warfarin,

etc. Herbs , Dietary supplements, and vitamins like

ginkgo biloba, ginger, garlic, ginseng, feverfew,

and vit E inhibit platelet aggregation andincrease risk of bleeding.


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Oral Examination

Visual .(oral hygiene, Small oral opening, )

Palpation.

Percussion. Mobility.


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Radiological Evaluation

Periapical radiograph, OPG, CBCT.

Check size of lesion.

Location of anatomic structure like Foramen,Sinuses , Nerves, and Vessels.


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Premedication

Painkillers.(NSAID s , Long acting localanesthesia)

Anxiolitics.

Sedatives.

Antibiotics.( prophylaxis for infectiveendocarditis patients. immunosuppressed

patients, diabetic patients,). Chlorhexadine. (start two days before surgery

till suture are removed.)


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Conscious sedation by either oral route ornitrous oxide/ oxygen inhalation.

Benzodiazepines 1 hour before surgery .


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Principles and Guidelines for Flap

Design

Combinations of Vertical and Horizontal

Incisions are used to achieve certain flap

design.


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Vertical Incision

The general principles for placement of a vertical relieving

incision are:

1. The incision should be made parallel to the supraperiosteal

vessels in the attached gingiva and submucosa.

2. No cuts should be made across frenum and muscle

attachments.

3. Frenum and muscle attachments should not be located inthe reflected tissue if possible.

4. The incision should be placed directly over healthy bone.

5. The incision should not be placed superior to a bony

eminence.

6. The dental papilla should be included or excluded but notdissected.

7. The incision should extend from the depth of the vestibular

sulcus to the midpoint between the dental papilla and the

horizontal aspect of the buccal gingival sulcus.


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Horizontal Incision

Three types of horizontal incisions

An intrasulcular incision that includes the dental papilla.

An intrasulcular incision that excludes the dental papilla

(papillary-based incision). This technique consists

of a shallow first incision at the base of the papilla and

a second incision directed to the crestal bone.

An incision made in the attached gingiva (a submarginal

or Ochsenbein-Luebke flap).

Incision is given 2mm below sulcus depth with an angle of45

Also 2mm of attached gingiva must be preserved toprevent mucogingival degeneration.


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this technique has a narrow margin of safety.recommended for use in the maxilla, especially where theesthetics of existing crown margins are a concern.

the papillary-based incision results in rapid recession free

healing. In contrast, complete mobilization of the papilla

led to a marked loss of papillary height

use of the papillary-based incision in aesthetically sensitive

regions could help prevent papillary recession and surgical

cleft, or double papilla.


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diagrams


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Classification of surgical flaps(gutmann

and Harrison)

1. Full mucoperiosteal flaps . (intrasulcular incisionincluding the dental papilla or papillary based)

a. Triangular: one vertical relieving incision

b. Rectangular: two vertical relieving incisions

c. Trapezoidal: two angled vertical relieving incisionsd. Horizontal: no vertical relieving incision

2. Limited mucoperiosteal flaps.

a. Curve submarginal (semilunar)

b. Freeform rectilinear submarginal (Ochsenbein-

Luebke


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Considerations for different type of

flaps

1 Triangular flap.

Indications

Midroot perforation repair.

Periapical surgery. Posterior areas.(mandibular posterior teeth)

Short roots.

Advantages

Good wound healing.

Easily repositioned.

Maintain blood integrity.


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Disadvantages

Limited access and visibility in long roots.

Tension is created.

Vertical incision penetrates alveolar mucosa.


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2. Rectangular flap.

Indications. Periapical surgery

Mandibular anterior teeth.

Multiple teeth.

Long roots like maxillary canines.

Advantages.

Provides maximum access and visibility.

Reduces retraction tension.


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Disadvantages.

Reduces blood supply to flap.

Increased incision and reflection time.

Difficulty in re approximation.

Gingival attachment violated.

Gingival recession. Crestal bone loss.

May uncover dehiscence.

Suturing is difficult.

Not Recommended For Posterior Teeth


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3. Trapezoidal flap.

similar to rectangular flap except two vertical

incisions intersect horizontal incision at anobtuse angle.

Since blood vessels and collagen fibers in

mucoperiosteal tissues are oriented in avertical direction, the angled vertical releasingincisions will severe more blood vessels hencemore bleeding and shrinkage of tissues.

So it is contraindicated in periradicularsurgery.


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4. Horizontal flaps.

Limited application because of limited surgical

access.

Indications.

Repair of cervical defects like root caries, root

perforations, and root resorption.

Hemisection and root amputation.


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Limited mucoperiosteal flaps

1. Semilunar flap.

Indications.

In the presence of aesthetic crowns.

Abscess drainage.

Trephination.

Advantages.

Reduces incision and reflection time. Maintains integrity of gingival attachment.

Maintains crestal bone level.


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Disadvantages.

Limited access and visibility.

Tendency for increased hemorrhage.

Crosses root eminences.

May not include the entire lesion.

Predisposed to stretching and tearing.

Repositioning is difficult.

Scar tissue is formed.

Not recommended for periradicular surgery.


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2. Freeform rectilinear submarginal flap

(Ochsenbein- Luebke flap).

Indications.

Presence of crowns.

Periapical surgery.

Anterior region.

Teeth with longer roots.

Wide band of attached gingiva..


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Advantages.

Ease in incision and reflection.

Enhanced visibility and access.

Ease in repositioning.

Maintains integrity of gingival attachment.

Prevents gingival recession.

Avoids dehiscence.

Prevents crestal bone loss.

Disadvantages.

Horizontal component disrupts blood supply.

Vertical component crosses mucogingival junction andmay enter muscular area.

Difficult to alter the shape of flap.


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THANKYOU

surgical endodontics.pptx

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