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CONTENTS

INTRODUCTION

INDICATIONS AND CONTRAINDICATIONS

CLASSIFICATION OF ENDODONTIC SURGICAL

PROCEDURES

STEPS IN PERIRADICULAR SURGERYPREMEDICATION

LOCAL ANAESTHESIA AND HAEMOSTASIS

SOFT TISSUE MANAGEMENTHARD TISSUE MANAGEMENT

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Any condition or obstruction that prevents direct access to the

apical third of the canal

Anatomic -calcification, curvatures, dens in dente, pulp stones

Iatrogenic -ledging, blockage from debris, broken instruments,

old root canal fillings, cemented posts

Periradicular diseases associated with a foreign body- Overfilled canals, excessive cement in periodontium, broken

instrument protruding into the apical tissue, loose retrograde fillings

Apical perforations

Incomplete apexogenesis with blunderbuss or other apices that

do not respond to apexification and are inadequately sealed with

orthograde filling

INDICATIONS

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Horizontally fractured root tip with periradicular diseases

Failure to heal following skilled non surgical endodontic treatment

Persistent and recurring exacerbations during nonsurgical treatment or

persistent unexplainable pain after completion of non surgical treatment.

Treatment of any tooth with a suspicious lesion that requires adiagnostic biopsy

Large and intruding periapical lesion

marsupialization decompression

Destruction of apical constricture of root canal

-uncontrolled instrumentation

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CONTRAINDICATIONS

GENERAL CONSIDERATIONS

medically compromised or brittle patient

emotionally distressed patient

limitation in the surgical skill and experience of theoperator

LOCAL CONSIDERATIONS

localized acute inflammationAnatomic consideration

Inaccessible surgical sites

Teeth with poor prognosis

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CLASSIFICATIONOF ENDODONTIC SURGICAL

PROCEDURES

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SURGICAL DRAINAGE

- When purulent and/or hemorrhagic exudate forms within thesoft tissue or the alveolar bone as a result of a symptomatic

periradicular abscess

Incision and drainage of the soft tissue

Trephination of the alveolar cortical plate

INCISION AND DRAINAGE

If the swelling is intraoral and localized I&D

If it is extra oral and diffuse surgical drainage + systemic antibiotic

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TRAY SET UP FOR I&D

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LOCAL ANESTHESIA

Nerve block is preferred for LA

Oral mucosa dried with 2 x 2 gauze and topical anesthesia is

applied

LA deposited peripheral to swollen mucoperiosteal tissuesInjection directly in to swollen tissue is avoided

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INCISION

The surgical area is isolated with sterile 2x2 gauze sponges

Incision should be horizontal placed at dependent base of

fluctuant area

Incision is done with pointed scalpel blade no.11 or no. 12

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PLACEMENT OF DRAIN

Frank et al rubber dam drain - Patency of surgical opening

McDonald and Hovland

Rubber dam or iodoform gauze H shaped or Christmas tree

shape

Indicated in moderate to severe cellulitis or aggressive infective

process

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CORTICAL TREPHINATION

Perforating the cortical plate to

accomplish the release of pressurefrom the accumulation of exudate

within the alveolar bone

Guttmann and Harrison

Should be at midroot level ininterdental bone (mesial or distal to

affected tooth)

No6 or No8 round bur in high

speed HP

Pass the reamer or K file through

cancellous bone into viscinity of

periradicular tissues to allow release

of exudate

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PERIRADICULAR SURGERY

TRAY SET UP

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STEPS

Local anesthesia and haemostasis

Management of soft tissue

Management of hard tissue

Surgical access both visual and operative

Access to root structure

Periradicular curettage

Root end resection

Root end preparationRoot end filling

Soft tissue repositioning and suturing

Post surgical care

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PREMEDICATION

1.Anti inflammatory analgesicsIbuprofen-400 mg

2.Tranquilizers

Triazolam sublingually -15-30min before surgery

3.Antibiotics

advanced diabetes, heart valve problems

4.Antibacterial rinses

0.12%chlorhexidine gluconate mouthrinse

Night before surgery, the morning of surgery,1 hour

before surgery

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HEMOSTASIS

PRESURGICAL PHASE

SURGICAL PHASE

POST SURGICAL PHASE

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PRE SURGICAL PHASE

Local anesthesiaanesthesia

hemostasis

Good topical anesthetic ointment or transoral lidocaine

patch for 2 minutes

Lidocaine+vasoconstrictor

Lidocaine 2%HCl and 1:50000 epinephrine

Comfort of the patient

Working efficiency of the surgeon

OS A C CO O G S G

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HEMOSTATIC CONTROL DURING SURGERY

CLASSIFICATION OF TOPICAL HEMOSTATS

Mechanical agents (nonresorbable)

Bone wax

Chemical agents

Epinephrine saturated cotton pellets

Ferric sulphate solution

Biologic agents

Thrombin USP

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Absorbable haemostatic agents

Intrinsic action

gelatin - gelfoam, spongostanabsorbable collagen - collatape , actifoam

microfibrillar collagen hemostat - avitene

Extrinsic action

surgicel

Mechanical actioncalcium sulphate

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BONE WAX

Effective haemostatic agent in periradicular surgery Selden ,1972

Highly purified bees wax

Softening and conditioning agents

When placed under pressure plugs the vascular openings

Disadvantages

Persistent inflammation

Foreign body giant cell reaction

Delayed wound healing

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EPINEPHRINE PELLETS

(RACELLETS)

Cotton pellets containing racemicepinephrine HCL

- Grossman

No.3 - 0.55mg racemic epinephrine

No.2 - 0.2mg racemic epinephrine

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Monsels solution(FeSo4-20%) - 1857

Agglutination of blood proteins from the

reaction of blood with both ferric and

sulphate ions and the acidic Ph of the

solution

The agglutinated proteins form the plugthat occlude the capillary orifices

Useful for small and slow bleeding

vessels on buccal plate

Readily applied and easily removed by

irrigation

FERRIC SULPH TE

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Yellowish fluid turns to dark brown or greenish

brown on contact with blood

It is cytotoxic and cause tissue necrosis Damage bone and cause delayed healing when used

in max.amount

THROM IN Used wherever wounds are oozing blood from small capillaries and

venules

Initiate intrinsic and extrinsic clotting pathways

Only topical and may be life threatening if injected

Used in neuro surgery, cardiac surgery and burn surgery

Difficulty in handling and high cost

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CALCIUM SULPHATE

Used in surgery for more than 100 years

As a barrier in guided tissue regeneration

Available as powder and liquid putty consistency

Plugs the opening of vascular channels

Biocompatible, resorbs in 2-4 weeks

It is porous, exchanges fluid , prevents flap necrosis if left in

place following surgery

Inexpensive

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GEL FOAM AND SPONGOSTAN

Gelatin based , water insoluble, resorbable

Made of animal skin gelatin, turns soft on contact with blood

Acts intrinsically Promotes disintegration of platelets

Releases thromboplastin

Form thrombin in interstices of sponge

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COLLAGENObtained from bovine sources sheets - collatape

sponge pads - actifoam

MECHANISM OF HEMOSTASIS

Stimulation of platelet aggregation, adhesion and release action Activation of factor 8(Hagemen factor)

Mechanical temponade action

Release of serotonin

Hemostasis is achieved in 2-5 minutes

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MICROFIBRILLAR COLLAGEN HEMOSTAT

Avitene and Instat

Derived from purified bovine dermal collagen

Shredded into fibrils

Converted into insoluble partial hydrochloric acid salt

Acts by Providing collagen framework Platelet adhesio

Application is difficult, tedious because affinity for wetsurface Applied to surgical site by spray technique

Inactivated by autoclave, expensive

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SURGICEL

Oxidation of regenerated cellulose (oxycellulose), which is

spun into threads, then woven into a gauze that is sterilized with

formaldehyde

Initially act as a barrier to blood then as sticky mass that acts

as an artificial coagulum or plug

Results inflammation and foreign body reaction

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POST SURGICAL HEMOSTASIS

Ice cold sterilized gauze placed over sutures for 1 hour

Stabilizes suture

Control oozing of blood from surgical site

Ice pack over cheek, 10 min on , 5 min off for 1-2 days

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SOFT TISSUE MANAGEMENT

oTo gain adequate access to surgical site

oTo ensure good post surgery healing

Flap design

Incision

Elevation

Retraction

Repositioning

Suturing

FLAP DESIGN

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FLAP DESIGN

1. FULL MUCOPERIOSTEAL FLAPS

a. Triangular ( 1 vertical releasing incision)

b. Rectangular ( 2 vertical releasing incisions)

c. Trapezoidal ( broad based rectangular)

d. Horizontal (no vertical releasing incision )

2. LIMITED MUCOPERIOSTEAL FLAPS

a. Submarginal curved (Semilunar)flap

b. Submarginal scalloped rectangular (Luebke-Ochsenbein)

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RECTANGULAR FLAP

Intrasulcular, horizontal incision

and 2 vertical releasing incisions.

ADVANTAGE

Increased surgical access to root

apex

Mandibular anterior teeth, multiple

teeth, teeth with long roots.

Difficulty in reapproximation of the flap margins and wound closure

Post surgical stabilization is difficult as flapped tissues are held in

position solely by sutures Flap dislodgement

Not recommended in posterior teeth

DISADVANTAGE

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TRAPEZOIDAL FLAP

Similar to rectangular flap but vertical

incision meets horizontal incision at

obtuse angle

Contraindicated in periradicular surgery

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HORIZONTAL FLAP

Created by a horizontal, intrasulcular incision -------no verticalreleasing incisions

Limited surgical access

Used for repair of cervical defects (root amputations,resorptions, caries) and hemisections

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LIMITED MUCOPERIOSTEAL FLAPS

SUB MARGINAL CURVED (SEMILUNAR) FLAPIncision at alveolar mucosa and attached gingiva

Incision starts from alveolar mucosa, extends to attached

gingiva and curves back to alveolar mucosa.

Poor surgical access, poor wound healing scarring

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SUBMARGINAL SCALLOPED

RECTANGULAR FLAP

(Luebke- Ochsenbein) flap

Modified form of rectangular flap

ADVANTAGE

Does not involve marginal or interdental

gingiva and crestal bone is not exposed

DISADVANTAGE

Vertically oriented blood vessels andcollagen fibers are severed

More bleeding, flap shrinkage, delayed

healing and scar formation

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INCISION

HORIZONTAL INCISION

FOR FULL

MUCOPERIOSTEAL FLAP

Begins in gingival sulcus

Fibers of gingival attachment

Crestal bone

The horizontal incision is done using as

few incision strokes as necessary to

minimize trauma to marginal gingiva

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HORIZONTAL INCISION FOR

LIMITEDMUCOPERIOSTEAL FLAP

Begins in attached gingiva 2mm

coronal to MG junction

Incision should be scalloped following

the contour of marginal gingiva

Never be placed coronal to the depth ofgingival sulcus

No.15 or No.15C are used

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VERTICAL INCISION

Placed b/w adjacent teeth over interdental bone

Never placed on radicular bone

Single stroke of scalpel Cannot penetrate mucosa, gingiva ,periosteum

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FLAP REFLECTION

Process of separating the soft tissue (gingiva, mucosa,

periosteum) from alveolar bone.

Begin in vertical incision

Undermining elevation

ELEVATORS

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MENTAL FORMEN

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If retractor too large ------ trauma to surrounding tissue

If retractor small --------- flapped tissue falls over theretractor and impairs the surgeons access

Always rest on solid cortical bone

FLAP RETRACTION

Longer the flap retraction

Greater post surgical morbidity

Irrigate with saline (0.9%)

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HARD TISSUE MANAGEMENT

Involves removal of bone to gain access to root apex

How to locate root apex?

no.6 or no. 8 round bur with coolant is

used

-Less inflammation

-smooth cut

-Shorter healing time

Impact air 45 high speed

handpiece

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PERIRADICULAR CURETTAGE

Inject LA with vasoconstrictor into

soft tissue mass

- reduce discomfort to patient during

debridement

- hemorrhage control

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ROOT END RESECTION

Factors considered before root resection

Instrumentation

Extent of root end resection

Angle of the resection

INSTRUMENTATION

Ingle et al no.6 and no 8 round burs

at low speed straight hand piece

Guttmann and Harrison- high speed

hand piece and plain fissure bur

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MISERENDINO

Rational for use of LASER

1. Improved hemostasis and better visualization of operative

field

2. Potential sterilization of contaminated root apex

3. Potential reduction in permeability of root-surface dentin

4. Reduction of postoperative pain

5. Reduced risk of contamination of surgical site - elimination

of aerosol producing hand pieces

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EXTENT OF ROOT END RESECTION

Factors that determine extent of root end resection

Visual and operative access to surgical site---buccal root of I PM

resected to see Palatal root

Anatomy of root (curvature, length, shape)

No. of canals and their position in root

Need to place root end filling surrounded by solid dentin

Presence and location of procedural errors ( perforation), ledge,

broken Inst.Presence and extent of periodontal defects

Level of remaining crestal bone

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ANGLE OF ROOT END RESECTION

Proposed earlier- 30-40 degree bevel as it enhances visibility

Open dentinal tubules communicate with root

canal space

Apical leakage

As the bevel increases More opening of dentinal

tubules

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ROOT END PREPARATION

Preparing a cavity to receive root end filling

Carr and Bentkover

Class I preparation at least 3mm into root dentin with walls

parallel to and coincident with the anatomic outline of the

pulp space.

1. The apical 3mm of the root canal must be freshly cleaned

and shaped

2. The prep must be parallel to and coincident with the

anatomic outline of pulp space3. Adequate retention form must be created

4. All isthmus tissue, when present, must be removed

5. Remaining dentin walls must not be weakened

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BUR PREPARATION

Preparing a class I cavity along root canal with miniature contra angle or

straight hand piece with round or inverted cone bur

Depth 1-5mm

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ULTRASONIC ROOT END PREPARATION

Richmann 1957- ultrasonic chisel to remove bone and root

apices

Bertrand and colleagues- ultrasonic scaling tips

Advantages

Smaller preparation size

Less need for root end beveling

Deeper preparation

Parallel wall for better retention of root end filling material

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ROOT END FILLING

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GARTNER AND DORN

Able to prevent leakage of bacteria and their by-products into

periradicular tissues

Non toxic

Noncarcinogenic

Biocompatible

Insoluble in tissue fluids

Dimensionally stable

Unaffected by moisture during setting

Easy to use

Radioopaque

Should not stain tissue (tatto free)

ROOT END FILLING MATERIALS

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Gutta-percha

Amalgam

Cavit

IRM

Super EBA

Glass ionomer

Composite resins

Carboxylate cements

Zinc phosphate

Zinc oxide eugenol cement

MTA

ROOT END FILLING MATERIALS

PLACEMENT AND FINISHING OF ROOT END FILLING

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PLACEMENT AND FINISHING OF ROOT END FILLING

MATERIALS

Amalgam - small K-G carrier

Deeper lying root apices

messing gun

ZOE, IRM, Super EBA

MTA

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FINISHING

Burnishing with ball burnisher

A moistened cotton pellet

Carbide finishing bur in a high-speed handpiece with

air/water spray.

SOFT TISSUE REPOSITIONING AND SUTURING

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SOFT TISSUE REPOSITIONING AND SUTURING

Take a radiograph to see for proper

root end filling

Any root fragments

Remove coagulated protein ,if

Fe3So4 is used as hemostat

Examine underside of flap, space

b/w mucoperiosteum and alveloar

bone

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REPOSITIONING AND COMPRESSION

Full mucoperiosteal flap gives more resistance than limited

while repositioning the flap

Apply gentle but firm pressure with moistened gauze over flap-

2-3 min

approximates wound edges

helps in intravascular clotting in severed vessels

reduces clot formation between flap and alveolar bone

SUTURING

Approximates incised tissues and stabilize the flapped

mucoperiosteum until reattachment occurs

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1.Absorbable

Non absorbable

2.According tosize -USP- 3-0, 4-0,5-0

Higher the first number smaller the diameter of suture

3.Physical design

Monofilament

Multifilament

Braided

Twisted

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SILK

Made of protein fibers (fibronectin) bound together with biological glue

(sericin)

Non absorbable, multifilamentous, braided

High capillary action------movement of fluids b/w fibers---severe oral tissue

reaction

Accumulation of plaque within few hours.

ADVANTAGE

Ease of manipulation

Not the suture of choice for endo surgery

(tissue reaction)

Post operative rinse with Chlorhexidine

GUT

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PLAIN GUT

Made of collagen derived from sheep or bovine intestine

Treated with formaldehyde to increase strength

monofilament

Absorbable-10 days

CHROMIC GUT

Treated with chromic oxide to delay absorption

No advantage

Less biocompatible than plain gut

Marketed in sterile packets containing isopropyl alcohol

Hard and non pliable due to dehydration

Placed in distilled water for 3 -5min

COLLAGEN

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COLLAGEN

Bovine tendon after it has treated with cyanoacetic acid and

then coagulated with acetone and dried

Available in small sizes

Exclusively used in microsurgery

Absorption rate and tissue reaction similar to gut

POLYGLYCOLIC ACID

Made from polymerized glycolic acid, absorbable in

mammalian tissue ----16-20 days

Multiple filaments, braided,

Handling character similar to silk

1stsynthetic absorbable suture, dexon

POLYGLACTIN

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Craig and coworkers,1975

Copolymer of lactic acid and glycolic acid - polyglactin910

Braided, absorbable, multiple filaments

Absorption rate similar to polyglycolic acid vicryl

NEEDLE SELCTION

Carry suture material through tissue with minimal trauma

Needle with reverse cutting edge is preferred Available in arcs of 1/4th,1/2, 3/8, 5/8 of circle

SUTURE TECHNIQUES

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SUTURE TECHNIQUES

Interrupted suture better flap adaptation

continuous

SINGLE INTERRUPTED SUTURE

Interrupted loop(interdental) suture

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Interrupted loop(interdental) suture

VERTICAL MATTRESS SUTURE

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VERTICAL MATTRESS SUTURE

SLING SUTURE

POST OPERATIVE INSTRUCTIONS

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POST OPERATIVE INSTRUCTIONS

1. Avoid alcohol and chewing tobacco for 3 days

2. Have good diet , drink lot of liquid,juices,soups

3. Do not lift up the lip and pull back cheek suture gets loose

4. Rinse with chlohex for 5 days

5. Use ice bag on the face. keep it for 20 min take it off for 20 min

6. Soft wet hot towel over the face placed next day for 2-3 days

SUTURE REMOVAL

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SUTURE REMOVAL

1.Clean the suture and surroundingmucosa with cotton swab

containing mild disinfectant

followed by H2o2

2.Apply topical anesthetic withswab at surgical site

3.Cut the suture with sharp scissor

,grasp the knotted portion with

pliers and remove the suture

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CORRECTIVE SURGERY

Periradicular surgery

Root resection

Hemisection

Intentional replantation

REPARATIVE DEFECTS OF ROOT AND ASSOCIATED

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REPARATIVE DEFECTS OF ROOT AND ASSOCIATED

PROCEDURES

I.Perforation repair

a. Mechanical

b. Resorptive/caries

II.Periodontal repair

a. Guided tissue regeneration

b. Root resection/hemi section

c. Surgical correction of radicular lingual groove

PERFORATION REPAIR (MECHANICAL)

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PERFORATION REPAIR (MECHANICAL)

Occur during root canal or post space

preparationPulp chamber floor of molars

Distal aspect of mesial root of mand.molars

Mesiobuccal root of max.molarsInternal repair - corrective surgery

STRIP PERFORATION (mand.molars ,max.molars)

Intentional replantation

- root resection

- hemi section

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Mid root perforation (post core)

Intracanal dressing with Ca(OH)2

Large perforations --- reflect the flap ---- locate the site - repair

PERFORATION AT ROOT END

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RESORPTION

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ROOT AMPUTATION

Eli i t k di d t t ll th t t t

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Eliminate a weak, diseased root to allow the stronger roots to

survive when, if retained together ,they would collectively fail.

Improved access for home care and plaque control

Bone formation

Reduced pocket depth

INDICATIONS

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Existence of periodontal bone loss

Destruction of a root through resorptive process, caries,or

mechanical perorations

Surgical inoperable roots that are calcified, contain separated

instrumentd or / are grossly curved

Fracture of 1 root that doesnot involve the other

Conditions that indicate the surgery will be technically feasible

to perform and the prognosis is reasonable

CONTRAINDICATIONS

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lack of necessary osseous support for the remaining root or

roots

Fused roots or roots in unfavourable proximity to each other

Remaining root or roots endodontically inoperable

Lack of patient motivation to properly perform home-care

procedures

Radiograph

root size, curvature, furcal

location and fused roots.

Root amputation for mandibular molars

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p

HEMISECTION OF MANDIBULAR MOLARS

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PROBLEMS DURING HEMISECTION

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RADECTOMY

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RADECTOMY

BUCCAL ROOTS OF MAXILLARY MOLARS

PALATAL ROOT OF MAXILLARY MOLARS

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PALATAL ROOT OF MAXILLARY MOLARS

SURGICAL CORRECTION OF RADICULAR LINGUAL GROOVE

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SURGICAL CORRECTION OF RADICULAR LINGUAL GROOVE

Maxillary Central and lateral incisor

Precludes deposition of cementum in groove preventspdl attachment

Narrow perio pocket

Bacterial pathway till root apex

retro infection of pulp

REPLACEMENT SURGERY

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(EXTRACTION/REPLANTATION)

The act of deliberately removing a tooth and-following

examination,diagnosis,endodontic manipulation,and

repair-returning the tooth to its original socket.

-Grossman 1982

INDICATION

1. Inadaquate interocclusal space to perform nonsurgical

treatment caused by the patients limited range of motion

of the TMJ and associated muscles

2. Nonsurgical or retreatment are not feasible because of

canal obstruction (calcification, post ,instruments)

4.Surgical approach for periapical surgery is not practical because of

li i i i f ( l h i )

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limiting anatomic factors (mental nerve parasthesia)

5.Nonsurgical and surgical treatment have failed and symptoms

and/or pathosis persist

6.Root defects(resorption,perforation) exist in areas that are not

accessible through a periradicular surgical approach without

excessive alveolar bone loss.

7.To thoroughly examine the root or roots on all surfaces to identify

or rule out the presence of a root defect, such as crack or root

perforation

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IMPLANT SURGERY

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ENDODONTIC IMPLANTS

OSSOINTEGRATED IMPLANTS(ENDOSSEOUS

IMPLANTS

ENDODONTIC IMPLANTS

TECHNIQUE SENSITIVE

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FACTORS FOR SUCCESSFUL IMPLANTS

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1. Severity of the initial infection

2. Location of root relative to alveolus

3. Residual bone (B-L and corono-apically)

4. Vascularity and density of residual bone

5. Quality of cancellous marrow spaces

6. Availability of bony walls to contain bone-graft material

7. Soft tissue available for closure

8. Experience of the operator

9. There should be adequate bone apical to the extraction socket

(3-4mm)and buccolingually to secure initial stability of the implant

10. Absence of localized inflammation

IMPLANT PLACEMENT

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IMPLANT PLACEMENT

The implant apex should be stabilized in atleast 3-4 mm of bone

Implant head should be positioned to conform to

Central fossa - posterior teeth

Cingulum - anteriors FOR SCREW RETAINED PROSTHESIS

FOR CEMENT RETAINED PROSTHESIS

Anterior - Implant head in line with incisal edges of adjacent teeth

Posterior head placed slightly buccal to central fossa of planned restoration

BONE GRAFT AND MEMBRANE PLACEMENT

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Used to promote bone growth around implant and to

preserve or restore labial dimensions

Commonly used bone graft - demineralized freeze-dried

bone allograft

Bone graft material is hydrated with saline and packed

into void

SOFT TISSUE CLOSURE

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Maintain and preserve soft tissue during incision and tooth extraction.

primary closure is the closure of choice

cover the site with nonresorbable membrane or connective tissue graft

if primary closure is not possible

SUPPORTIVE THERAPY

Broad spectrum antibiotics

Amoxicillin, cephalexin, clindamycin for 7-14 days

NSAIDS promote healing

Chlorhexidine oral rinses

remove the sutures after 2 weeks

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MICROSURGERY

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Vision enhancement devices

loupes

Surgical telescopes

Head mounted surgical fiber-

optic lamps

Better the visual access higher

the quality of treatment

SURGICAL MICROSCOPE

Otologists 1940s

Ophthalmology, neurosurgery,

urology,

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X10 16

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X10 x16

root end resection and root end preparation

X18 x30

For observing and evaluating fine detail

ADVANTAGES ( Rubinstein)

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ADVANTAGES( Rubinstein)

Visualizing surgical field

Evaluating the surgical technique

Reducing the number of radiograph needed

Expanding patient education through video use

Providing reports to referring dentists and insurance

companies

Creating documentation for legal purposes

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REFERENCES

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1.Bacterial leakage of mineral trioxide aggregate as compared

with zinc free amalgam, IRM,and super EBA as root end filling

material: J Endod. 1998 Mar;24(3):176-9

2. Ultrasonic root end preparation: Influence of cutting angle on

the apical seal .J Endod 1998;24:726

3. Ingle JI, Bakland Lk :Text book of endodontics,5thedition:669-

746

4.Grossmans Text book of Endodontics

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Advances in endodontics are making it possible to

save teeth that even a few years ago would have

been lost. And, when endodontic treatment is not

effective, endodontic surgery may be able to save

the tooth.

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