INTRODUCTION

Preservation of the dentition and maintenance of function are dental professions ultimate goal.
The advances in non surgical endodontic therapy has been explosive, but it has also been a mixed blessing.
It has led to procedural errors such as, broken instrument ,ledges etc
It is indicated in fewer than 5% of endodontically treated teeth. The success rate of endodontic surgery is high, ranging from 73-99%.

OBJECTIVE:
To ensure placement of a proper seal between periodontium and root canal foramina.
CLASSIFICATION
I. ACCORDING TO GROSSMAN-
1. Root Resection / Apical curettage following orthograde filling.
2. Orthograde filling during root resection or periapical curettage.
3. Root resection and Retro grade filling (in cases when access to PA region is not possible from coronal end).
4. Root Resection and Retrograde filling following orthograde filling.

II ACCORDING TO INGLE:
I. SURGICAL DRAINAGE

a) Incision
b) Drainage
II RADICULAR SURGERY:
Curettage and
a) Apical Surgery: Apicectomy
Retro filling
b Corrective surgery Perforative repair : Mechanical,
Resorptive
Periodontal repair:
GTR, Resection
III REPLACEMENT SURGERY:
Intentional
a) Replant surgery
Post Traumatic
Endodontic
b) Endosteal implant
Osseo Integrated.
INDICATIONS
I According to Grossman:
The primary Indication of periradicular surgery is any circumstances in which direct vision and access to the periradicular area are needed for proper placement of a seal between the canal system and periodontium
1. Any condition / obstruction that prevents direct access to periradicular region. Eg.
a) Anatomic calcifications, curvatures, bifurcations , Dens in dente, pulp stones.
b) Iatrogenic Ledging, Blockage from debris, broken instruments, old root canal fillings and cemented posts
2) Periradicular disease associated with a foreign body overfilled canals, excessive cement in the PDL, Broken instrument protruding into the apical tissue.
3) Apical Perforations: Any perforation that cannot be sealed properly by filling material in the canal.
4) Incomplete Apexogenesis: with blunder buss canals / other apices that do not respond to apical closure procedures (apexification).
5) Horizontally fracture root tip with periradicular disease
6) Failure to heal following skilled non surgical endo Rx
7) Persistent and recurring exacerbation during non surgical Rx / persistent, unexplainable pain after completion of non surgical Rx (weeping canal)
8  ) Rx of any tooth with a suspicious lesion that requires a diagnostic biopsy.
9) Excessively large and intruding periapical lesion
10) Destruction of apical constriction of RC due to uncontrolled instrumentation that results in an apical foramen that cannot be adequately sealed with an ortho grade filling.
 Contraindications
Indiscriminate Surgery:
Endodontic surgery should not be a cover up for the mishaps / short comings occurring in routine therapy.
Poor Systemic Health.
Medically compromised / Brittle pt.
Patient with an active systemic diseases
Eg: uncontrolled Diabetes, T.B, syphilis, Nephritis, Blood Dyscrasias, osteo radio necrosis / any other medical condition in which the health of the Pt. restricts surgical Rx.
Emotionally Distressed patient.
Limitations in surgical skill and experience of operator.
Local Anatomical considerations.
• Localized acute inflammation
• Procedures that penetrate the mandibular canal; maxillary sinus; mental foramen; nasal floor; greater palatine vessels should be avoided.
• Inaccessible surgical sites, inaccessible position and location of root apices, especially in posterior teeth, external oblique ridge of mandible, lingual surface of molars.
• Teeth with poor prognosis like short rooted teeth; advanced periodontal disease; vertically fractured teeth, non restorable teeth; non strategic teeth.
2) Surgical Instruments and Materials:
1) Anaesthetic : Aspirating syringe, disposable needle, lidocaine HCl 2% with 1:80,000 epinephrine
2) Isolation : 2 x 2 gauge, cotton pellets, alcohol sponge
3) Incision : B.P handle, No 15 Blade, periodontal probe to determine flap design.
4) Elevation & Periosteal elevator
5 Retraction Removal of cortical bone plate,
root resection & straight hand piece, Burs
retrograde filling hand chisel, saline,
contra angle micro head
6) Curettage : Goldman Fox No.3 curette ,
surgical excavator.
7) Retrograde filling – Apical amalgam carrier,
Apical amalgam plugger,
plastic instrument.
Materials: Amalgam,ZOE,IRM,EBA,GIC,composites,MTA
8    ) Suturing – Needle Holder [Hemostat]
3-0 silk suture needle.
9) Surgical Tray – Cotton pliers, explorer, mirror and cotton

SURGICAL PROCEDURES:
1) Flap design
2) Exposure of surgical site
a) Incision
b) Flap reflection
c) Flap retraction
d) Osteotomy
3) Curettage and biopsy
4) Apicectomy
5) Retro preparation
6) Retro filling
7) Flap closure – repositioning of flap and suturing
FLAP DESIGNS
Flap design
Flap design and reflection allows necessary bone removal, optimum vision and instrument access with minimal trauma to the tissues.
It consists of horizontal incision which determines the lateral extension and a vertical incision determines the length of the flap.
It allows for repositioning that helps in wound healing.
GUIDELINES:
Local anatomy – includes height and depth of vestibule, radicular eminences and frenum size , shape and attachment.
Shallow vestibule – difficult to retract flap , so more oblique vertical incision.
2) Flap should extend one or two teeth laterally to allow for relaxed retraction and prevent stretching of tissues.
3) Vertical incision should be sufficient to allow the retractor to seat on solid bone, leaving the apex well exposed .