Local Anaesthesia:Conventional techineques [ infiltration and regional block analgesia using aspiration techinique] are applicable.Satisfactory analgesia is required of both the buccal and palatal soft and hard tissues.
Flap design: there are three principal flap designs:
A two sided flap, with broad base and a gingival margin incision that can be extended around gingival margin.
A three sided flap with divergent relieving incisions.
The semilunar flap.
Flap reflection: Avoid tearing the periosteum when raising the mucoperiosteal flap to because this can result in more postoperative pain and swelling.
Bone removal: If there has been loss of buccal bone through pathological resorption then it is easy to determine the site of bone removal. Otherwise it may be possible to identify the apex of the tooth if a sharp probe is pushed into the buccal plate to identify the pathological cavity around the apex. A medium size round bur is then used to create a window in the buccal plate and expose the apical tissues.
The apical portion [3mm or more] of the root is excised to ensure obliteration of the apical delta of the root canals. However the length of the root, the amount of bone support and the extent of root filing should be considered when planning the position of the apicectomy. A flat fissure bur is suitable for the apicectomy cut.
A bevel cut is prepared so that the entire root surface may be visulaised. The extent of the bevel depends upon the tooth to be apicected.e.g. upper lateral incisor tends to be more retroinclined than the central incisor, so a more oblique angle of bevel may be required for lateral incisor. The angle of the cut is generally 45 degrees for maxillary and greater than 45 degree for mandibular teeth.
The surface of the apicected root should be examined for evidence of root fracture before the retrograde cavity is cut. Any orthograde filling material that is present should be visible once the surface of the root has been sectioned.
The root end filling is inserted to seal the root surface. Amalgam is the traditional choice. Others are silver points, gutta percha, gold foil, polycarboxylate cement, composite resin, Cavit, Restodent, and other ZOE mixtures. MTA[minarel trioxide aggregrate] is also showing great promise as an ideal root end filling material.
A curette is used to separate the granuloma from the bone. The apex is cut off at a bevel of 45 dg.
Retrograde cavity is cut to include the margin of canal. The root end filling has been placed
[ the root margin is avoided] [packing removed]
Once the surgical field has been thoroughly debrided, some operators take a radiograph before the closure to check the location of the retrograde filling. The interdental papillae are repositioned to their correct anatomical location without undue tension on the flap before placing the first suture. Simple interrupted sutures may be placed to secure the edges of the mucoperiosteal flap. After the flap has been repositioned into its place, gentle pressure is applied to the flap for a few minutes to aid in haemostasis. Post operative radiograph should be taken now.[if not taken before closure]
Postoperative instructions are given to the patient verbally and in writing after surgery is completed. If the tooth is to be crowned, it is preferable to wait at least 6 months after surgery.
Control of post operative infection:
The use of antibiotics to prevent postoperative wound infection after surgical endodontics is quite controversial. But preoperative antibiotics are suggested in order to provide adequate tissue concentrations at the time of surgery.