 Hello everyone, welcome back to another session in dentistry and more We have entomotic surgery today. It's a very vast topic. I have included very selected topics Like insertion and drainage, trefination, various flap designs for very radical surgery and the corrective surgery is such as hemi section by conspiracy Routery section So the questions which were asked for university paper are included so moving on The periradicular surgery has continued to evolve into the precise biologically based adjunct to non-surgical root canal therapy Although non-surgical and derided treatment gives good results in most of the cases surgery sometimes indicated for teeth with persistent periradicular pathology Which are not responding to non-surgical approaches, but most of the time the problem will be resolved without any surgical Involvement, I mean procedure So angle defined It has a surgical procedure related to problem of the pulplice or predominantly involved tooth requiring root amputation and entomotic therapy So the rationale is to remove the positive agents for the periradicular pathology There is a focus of lesion and also to restore the peridontium to a state of biologic and functional health The main objective is to ensure the placement of a proper seal between the peridontium and the root canal foramina The classification of entomotic surgery includes Facility surgery such as IND, trefination and decompression periradicular surgery such as curatage, routine resection routine filling, corrective surgery Disperfuration repair, peridontal management and intentional re-implantation So surgical drainage it is indicated when purulent Or hemorrhagic exudates forms within the soft tissue and I'll roll a ball As a result of an asymptomatic periradicular abscess So we can either perform a IND or cortical trefination So IND is by giving a local anesthesia and a horizontal incision with number 11 or 12 will be played at the base of the flexor in the area and we can just remove the pus Commonly used diada from gauze, rubber dang material and pentrose drain Trefination is a cortical trefination It's a procedure involving the perforation of the cortical plate to accomplish the release of pressure So it's a procedure like IND, but it is Going into the cortical bone So the idea is to remove the exudate which is formed within the alveolar bone We can use a burr number six or eight burr Mostly from the buckle side. The objective is to create pathway through the Canceler's burn to the vicinity of the involved periradicular tissues Now the periradicular surgery Mostly It involves a flap procedure. So first we need to learn the principles of flap So the base of the flap should be wider than the free end Avoiding the incision over a bony defect include the full extent of the lesion Then avoid sharp corners and avoid incision across a bony eminence Avoid incision in the mucous javel junction Then taking care during retraction, incision should be made with firm continuous stroke which is perpendicular to the cortical plate And the future flap margin should rest on solid cortical bone plate Now we have classification. So basically we know the full thickness and partial thickness Full thickness is known as mucoperiosteal and this is split Full thickness consists of epithelium connected tissue and periosteal whereas the partial consists of epithelium and connected tissue There is no periosteal So full mucoperiosteal and limited mucoperiosteal is based on the Guttmann and Harrison classification Full mucoperiosteal is full mucoperiosteal flap. There is no attached shinjaiva around the neck of the crown Whereas limited mucoperiosteal showing remaining attached shinjaiva Then full mucoperiosteal flap includes it is based on the shape Triangular, rectangular, trapezoidal, horizontal or trapezoidal base limited Is a sub marginal curved or semi-runner Sub marginal, scalloped, rectangular, loop K Option bin flap Advantages of full mucoperiosteal flaps are rapid phone healing, good surgical access Minimal disruption of blood supply, minimal uh post surgical sequel Then optimal apical orientation primary healing But the problem is loss of soft tissue attachment loss of crystal bone height and post surgical flap dislodgement whereas the Uh advantages of the limited mucoperiosteal flaps are marginal and individual shinjaiva not involved unaltered soft tissue attachment level crystal bone is not exposed adequate surgical access and good bone healing potential but the main problem is flap shrinkage and disruption of blood supply to the unflap tissues difficult to Uh re-approximate the flap delayed secondary wound healing and limited apical orientation now let's see the designs of flap the first one is triangular flap indicated in mild root perforation repair or periapical surgery in posterior areas with short roots Tell good good wound healing minimal disruption of vascular supply to flap tissue ease of flap re-approximation with minimum number of sutures But the problems are limited surgical access difficult to expose root apex of long teeth like maxillary and mandibular canine Tension is created on retraction. So this is how it looks like we are creating a triangle I can see a triangular flap here and we'll reflect it so this is why it is known as triangular flap because of this shape can see how it is going we are reflecting this spot that is a triangular part but as a rectangular flap which is indicated in mandibular anterias and for multiple teeth or teeth with long roots like maxillary canine it has got uh increased surgical access to root apex reduced to retraction tension but the problem is difficulty in re-approximation and poor surgical stabilization is quite difficult potential attachment uh violated and there is chances of potential recession crystal bond loss may occur triangular flap both sides are hitting vertical incision and we're just reflecting a flap in this way now the rectangular flap in triangular flap it was released only on one side but as a trapezoidal flap which is almost similar to rectangular except the two vertical incision intersect the horizontal incision okay and then obtuse angle so there is an obtuse angle this angle is obtuse to create a broad based flap with vestibular part wider than the sector part so this part is wider than this part so in order to create instead of going straight going like a little bit wider that is creating an obtuse angle but the disadvantages are it is angled incision uh it cuts more vital structures and there are chances of uh bleeding disruption of vascular supply to non-flap tissues and shrinkage of flap tissues the horizontal flap is a different one it is not having any vertical incisions it has got very limited application that is repair of cervical defects like root repair reception or resorption of caries hemisection and root amputation advantages is of repositioning as no vertical incision but the problems are limited access difficult to reflect and retract because there is no vertical incision predisposed to stretching and tearing so this is a different uh type sub-marginal curved semi-luna flap which is a limited muco periosteal flap it is indicated in ascetic grounds and for trafination so this is a completely uh not following a conventional method there is no vertical uh incision and it is way from the normal area that is it is at the cervical part of the root so it reduces incision and reflection time it maintains integrity of ginger attachment eliminates potential crystal bone loss since it is not affecting all these vital parts there is no chance of uh recession or crystal bone loss when we have concerns of aesthetics we can go for this sub-marginal curved or semi-luna flap but the problems uh the access and visibility will be less tendency for increased hemorrhage process root eminence may not include entire lesion predisposed to stretching and tearing repositioning is difficult healing is associated with scar the second one sub-marginal scalloped rectangular or loop k ocean bin flaps commonly asked question it is a rectangular flap which is in the same position this is just a semi-lunar flap but this is a rectangular flap in that position so it is having horizontal incision is placed in the buckle attached in jiva and it is scalloped follows the contour of the marginal ginger and it is having two vertical incision but it is way away from the marginal ginger and it is more towards the root apex it is indicated in trostatic crowns period radical assertive anterior region or longer roots the advantages are ease of incision and reflection enhanced visibility and access use of repositioning maintains the integrity of attachment it prevents ginger or recision avoid descents prevent crystal bone loss but the problems are horizontal component disrupt blood supply vertical components crosses the muco ginger or junction and may enter muscle tissues and difficult to alter if size of lesion is judged now we have corrective surgery it's very commonly asked these categorized as surgery involving the correction of the defects in the body of the root other than apex okay so it is mainly on the body of the root so corrective surgical procedures may be necessary as a result of procedural accidents resorptions it could be internal or external root carries or root fractured blood on the lysis it involves basically root resection hemi section and intentional replantation which root resection hemi section are very important root amputation procedures are a logical way to eliminate a weak diseased root to allow stronger roots to survey if retained together they would collectively fail so in order to have a better prognosis we are removing a part of a tooth or a single root of a multi-rooted teeth in order to save the other two otherwise it would have collectively failed so distance between pulp chamber and floor and coronal aspect of the root separation should be 3mm and 2mm width should be there for the establishment of the supracrestal attachment apparatus and 1mm for the placement of the crown margins so indications are existence of erodontal bone loss to the extent that erodontal therapy and patient maintenance do not sufficiently improve the condition destruction of a root through resorptive processes carries our mechanical perforations and surgically inoperable roots that are calcified contain separated instruments or are grossly curved the fracture of one root that does not involve the other conditions that indicate the surgery will be technically feasible to perform and the prognosis is reasonable but the contraindications are lack of necessary or should support for the remaining roots and fused roots or root in unfavorable proximity to each other remaining root or roots enteroendically inoperable lack of patient motivation next we have hemisection okay hemisection is defined as separation of multi-rooted tooth and the removal of a root and the associated portion of the clinical crown so we are completely splitting a tooth from the root end to the crown tip so when there is deep erodontal pocket we can raise a flap then resect the tooth and sutures be placed whereas a bisection or bicaspiration it refers to division of a crown that leaves the two halves and the respective roots so bicaspiration should be considered we are not removing it we are just making it too so it should be considered in mantibulomolas and versus the periodontal disease as invaded the bifurcation and repair of internal percussion perforation has been unsuccessful so when this involved in that bifurcation area we can just split the tooth not removing it so the percussion is then turned into intraproximal space so we are making it as a two teeth so these intraproximal space will be more manageable by the patient after the bicaspiration so this is how it is done we are changing it to a two teeth okay so once it is healed the patient will be able to clean this teeth or it is it can be crowned or make it as a two primolas so that was all about receptive surgery the bicaspiration hemisection and root amputation are most commonly asked question with the flap design these flaps are very important this various types of flap neocoperous flap and limited neocoperous flap so all these flaps are very important so that was all about the enterontic surgery i have included only the very important questions of enterontic surgery so i'll come up with a new topic in enterontics thank you