Assessment Assessment before<unk>  involves a thorough history and clinical exam, followed by special investigations. Clinical assessment considers a number of factors. Oral hygiene and overall dental condition indicates the patient's motivation for treatment and the tooth's restorative prognosis. Gum health is important to ensure optimum healing and appearance after surgery. Cortical bone thickness, regional anatomy, and root fracture or resorption indicate possible difficulties. Special investigations include radiography, vitality testing of adjacent teeth and an occlusal loading assessment. Radiography identifies disease presence, including<unk>  pathology. A periapical radiograph is usually the radiograph of choice. When examining the tooth which will receive surgery, the quality of the root treatment and canal anatomy (sclerosed or missed canals) is noted. More than one radiograph may be required to indicate possible treatment success. The root filling should be optimal. The relationship of the tooth to neighbouring structures (the inferior dental nerve, mental foramen and maxillary sinus) or to adjacent roots must be noted, to anticipate operative complications and inform the patient. At least 3 mm of tissue beyond the apex of the roots should be radiographically assessed. Anaesthesia and haemostasis Haemostasis is imperative during surgery to allow optimum visualisation. It is achieved preoperatively with a local anaesthetic. The anaesthetic's adrenaline targets the smooth muscle of arterioles by acting on the alpha adrenergic receptors. Haemostasis is continued throughout the procedure. The main methods are: #Topical epinephrine pellets #Ferric sulphate, which forms a plug by agglutinating the blood proteins; however, it is cytotoxic and can cause necrosis of the oral tissues. #Calcium sulphate mechanically blocks open vessels and aids bone regeneration. Bleeding in the bone is also affected by the local anaesthetic's vasoconstriction and topically-applied agents. These topical agents should be removed before closing the surgical site. When the flap has been sutured in position, haemostasis is maintained postoperatively. Digital pressure on a damp gauze controls bleeding and stabilises the flap. An ice pack is recommended (15 minutes on, 30 minutes off) for the first six hours. Flap design Two main flap designs used in endodontic surgery are full and limited mucoperiosteal flaps. Full mucoperiosteal flaps involve an intrasulcular horizontal incision with reflection of the marginal and interdental gingival tissue. They can be two- or three-sided or envelope-shaped. A two-sided (triangular) flap is made with a horizontal, intrasulcular incision and a vertical relieving incision. The first horizontal incision follows the contours of the tooth, cutting the gingival sulcus (including the mesial or distal papilla. The relieving incision begins at the gingival margin and extends to the attached gingiva. For posterior teeth, the horizontal incision is always mesial. A three-sided (rectangular) flap is made with a horizontal, intrasulcular incision and two vertical relieving incisions. Although this flap increases surgical access, it is difficult to re-approximate the tissue. An envelope (horizontal) incision is a horizontal, intrasulcular incision with no vertical relieving incision. This design provides little surgical access to the root surface. Limited mucoperiosteal flaps have a submarginal horizontal or horizontally-oriented incision, and do not include marginal or interdental tissues. A submarginal curved (semilunar) incision begins in the alveolar mucosa, dips down into the attached gingiva and extends back into the alveolar mucosa. Semilunar flaps have poor healing potential, and often lead to scarring. A submarginal scalloped (Ochsenbein-Luebke) flap is similar to the rectangular flap, but the horizontal incision is in the attached gingiva. It is scalloped, following the contour of the gingival margins below. This flap is also prone to delayed healing and scarring. Wound closure Before closing the wound, it should be well-irrigated (to prevent infection) and the flap compressed to reduce the risk of haematoma. The flap is re-approximated, and the first suture should be placed in the interdental papilla. After suturing the flap, a sterile damp gauze should be compressed on the wound for several minutes; an ice pack can be used (15 minutes on, 30 minutes off) by the patient. Sutures should be removed two to four days after surgery, depending on type.
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