CLINICAL

THE DENTAL OPERATING MICROSCOPE IN ENDODONTICS

Eudes Gondim Jr, DDS, MS, PhD1 Frank Setzer, DDS, MS, PhD2 The operating microscope has greatly enhanced endodontic therapy. The increased magnification and illumination offered by the microscope and the use of associated microendodontic and microsurgical techniques provide clinicians with better treatment options for improved long-term prognoses. This article reviews the correct indications of the microscope for both surgical and nonsurgical endodontics and demonstrates the most commonly used microendodontic or microsurgical techniques by case examples. Int J Microdent 2010;2:2027

Adjunct Assistant Professor, Department of Endodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA; private practice, So Paulo, Brazil. 2 Instructor, Department of Endodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
1

Correspondence to: Dr Eudes Gondim Jr Rua do Rocio, 423 cj.1109 So Paulo 04552000 Brazil Email: gondimjr@mac.com

Endodontics was recognized by the American Dental Association (ADA) as a specialty of dentistry in 1963. Since then, endodontic techniques have changed dramatically. Culturing became obsolete as reliable intracanal medications and potent irrigation protocols for disinfection were established. Stainless steel instruments were complemented by highly flexible nickel-titanium instruments, which can be used manually or be machine driven.1 Silver points and paste fillings were replaced by gutta-percha as the standard filling material, and now gutta-percha itself is about to be replaced by resin-based adhesive intracanal obturation materials. Precise length determination using electronic apex locators can prevent underpreparation as well as overfill. A quantum leap, however, was the adaptation of the dental operating microscope with the associated microendodontic techniques by endodontists.2 The high magnification of the microscope provides for a safer procedure since it allows for a more cautious application of the correct instruments.

High-quality endodontic treatment requires a lot of knowledge, expertise, energy, and patience. This can be strenuous for the dentist. Thankfully, proper use of the dental operating microscope also allows for a highly ergonomic posture.

NONSURGICAL MICROENDODONTICS
The operating microscope is a powerful tool that increases the clinicians visualization capability for nonsurgical and surgical endodontic procedures alike. Magnification and coaxial illumination allow the clinician to identify problems before they occur and improve every step of the technical procedure. Although the clinical outcome of an endodontic treatment is affected by many factors, the clinicians ultimate goal is the elimination or prevention of apical periodontitis. In vital cases, remnant pulp tissue must be removed to leave no nutritional sources for potentially reinvading microorganisms and to achieve a complete obturation. In

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Table 1Magnification ranges used for nonsurgical and surgical endodontic procedures
Nonsurgical Low magnification (~ 4) Orientation Inspection of surgical site Initial osteotomy Ultrasonic tip alignment Suturing ( 6/0) Suture removal Mid-magnification (~ 10) Access Orifice identification Fracture identification Obturation Hemostasis Tissue removal Root-tip identification Root-tip resection Root surface inspection Root-end preparation Root-end filling Root amputation High magnification (~ 20) Orifice identification Fracture identification Calcified canal location Identification of fine anatomical details Documentation Root surface inspection Root-end preparation inspection Root-end filling inspection Identification of fine anatomical details Documentation Surgical

necrotic cases, all infected pulp tissue must be removed, and disinfecting irrigants must be used to reach contaminated dentin. In both instances, unobstructed access to the root canal system and the identification of intricate structures of its anatomy are key to a successful therapy.3 Endodontic access has always been considered a challenge. The visualization and preparation of particular root canals can be difficult, especially in teeth that are heavily restored, rotated, suffer from severe decay, show extensive damage from aggressive access attempts during previous treatments, or have calcified root canals. Whenever

the original anatomy of the tooth has changed, clinical knowledge of anatomical landmarks and the configuration of the root canal system provides greater certainty about the location and actual number of root canals. The enhanced visualization with the microscope provides the clinician with a better three-dimensional idea of the tooth contours, pulp chamber, and canal orifices. Table 1 gives an overview of appropriate magnification ranges for use during nonsurgical and surgical endodontics. The access cavity is crucial to success in two important aspects. First, the access to the canals must provide a straight path to fa-

cilitate easier preparation of curved canals by reducing the severity of the initial curvature. Enhanced vision decreases the risk of iatrogenic perforations removing tooth structure unnecessarily. Second, it allows access to the apical third of the root canal after negotiating the coronal two-thirds using hand instruments, irrigants, Gates-Glidden drills, nickel-titanium shaping files, and, if necessary, ultrasonic tips. During this procedure, the canal walls must be inspected carefully to locate dilacerating canals, fins, isthmuses, cracks, or other canal irregularities and unusual anatomy (Figs 1 and 2).

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Fig 1Case 1: Mandibular right first molar with unusual anatomy. (a) Inspection of refined access cavity during nonsurgical retreatment. (b) Four separate mesial canals (mb1, mb2, ml1, ml2; circles). (c) Direct view of apical canal terminus through the microscope (circle). (d) High magnification of first mesiolingual canal reveals a vertical fracture line stained with calcium hydroxide (small arrows) at the second appointment, eventually leading to extraction.

access through a new restoration. Three mesiobuccal canals (mb1, mb2, mb3), p, palatal; db, distobuccal.

Fig 2Case 2: Maxillary left first molar with unusual anatomy. (a) Post-obturation radiograph with five canals. (b) Minimal

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Figs 3Case 3: Access cavity refinement in a mandibular right first molar. (a) Pretreatment situation. (b) Pulp stone
(arrows) removal during debridement. (c) Final result after cavity refinement, isthmus (small arrows) cleaning, and close inspection for additional canals.

Fig 4Case 4: Location of a previously missed canal in the retreatment of a mandibular right first molar. (a) Situation after gross debridement of canal orifices. Note gutta-percha remnants in the main canals and the presence of a widening in the mid-mesial portion of the isthmus structure (arrow). (b) Initial instrumentation with a no. 6 hand instrument. (c) Access preparation to the mid-mesial canal (mm).

Diamond or zirconium nitrate coated ultrasonic tips are used to locate and access hidden or calcified canals. The slim design of microendodontic ultrasonic tips allows for unobstructed views of the working area, and the coating enables back-and-forth brush stroking motions, which is considerably safer than using a bur with a vertical

motion inside an access chamber or within a root canal. These design features of ultrasonic access tips can facilitate various procedures, including cutting, digging, modeling, refining and opening spaces inside the canal, or removing separated instruments and blockages under the microscope. Cases 3 and 4 (Figs 3 and 4) demonstrate how

after the use of a no. 4 round bur followed by a tapered diamond bur to make the access walls regular, access is gained to the pulp chamber, thus allowing for an ideal line angle extension for endodontic instruments. Ultrasonic tips (CPR-1, Obtura Spartan) were used to remove the roof of the pulp chamber and refine the access cavity.

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Fig 5Case 5: Location of second mesiobuccal canal (mb2) in a maxillary left first molar. (a) Use of ultrasonic tip to uncover, flare, and locate the mb2 orifice. (b) Initiation of instrumentation (arrow). (c) Result after cleaning and shaping of both mesiobuccal canals.

Fig 6Case 6: Obturation of the two buccal canals in a maxillary left first premolar with three canals. (a) Preparation

for obturation after canal instrumentation and ultrasonic refinement. (b) Mesiobuccal and distobuccal canals filled with gutta-percha. (c) Final radiograph.

In regard to calcified canals, one common situation in endodontics is the location, access, and preparation of the second mesiobuccal canal in maxillary first molars as demonstrated in case 5 (Fig 5). According to a meta-analysis of published literature, the incidence of a second mesiobuccal canal was 56.8%.4 However, a clinical incidence of 93.0% of maxillary first molars with a second mesiobuccal canal was reported with the

exclusive use of the dental operating microscope versus loupes after the application of microendodontic techniques.5 Under the microscope, ultrasonic tips can be used to remove calcifications in the pulp chamber and to grind the floor until dark colored dentin is encountered (CPR-2, BUC-2, Obtura Spartan) (Fig 3c; Fig 6). Differently shaped tips (BUC-1, Obtura Spartan) can be used to precisely follow the

groove between the palatal and mesiobuccal first canal until the second mesiobuccal canal orifice is located (Figs 5b and 5c). Under magnification, the color difference between secondary dentin, which is generally colorless or opaque, from the darker and grayer pulp chamber floor is more visible. Differently colored dentin areas can be seen clearly in Figs 5a and 5b. In very difficult cases, when the canal orifices are not visible and

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Fig 7Case 7: Removal of a separated rotary nickel-titanium instrument from a mandibular right second molar. (a) Preoperative radiograph with separated instrument in the mesiolingual canal. (b) Ultrasonic instrument (CPR-6) creating a space to remove the instrument. Note the mesiobuccal canal. (c) Removed instrument fragment (arrow) and refined orifice access. (d) Radiographic verification of canal patency.

Fig 8Case 8: Removal of a separated stainless steel hand instrument from a mandibular left central incisor. (a) Preoperative radiograph with separated instrument. (b) Retrieval procedure using a 23-gauge obtura tip to disengage the instrument fragment. (c) Removed fragment. (d) Obturation control radiograph.

the different dentin colors cannot be distinguished even under high magnification, the use of ultrasonic tips is the only option to locate the canals safely and to follow calcified canals until patency is achieved (Fig 4). To avoid perforations, extreme care by constant surveillance under magnification must be taken. The dentin must show color and texture indicating the previous root canal space. Similar microscopic procedures apply to the removal of posts, separated rotary nickel-titanium (Fig 7) or stainless steel instruments (Fig 8), or other intracanal obstructions.

ENDODONTIC MICROSURGERY
Nonsurgical root canal treatment, including primary endodontic ther apy and retreatment, does not always result in clinical success, even when performed to the highest standard of care. The possible reasons for treatment failure may include the presence of microorganisms, previously missed canals, or iatrogenic errors such as perforations or fractured instruments. Understanding the reasons for failure and the methods to correct that failure is a major key for endodontic treatment planning.6,7 If

the initial endodontic therapy lacks the signs of optimum care or the root canal system is reinfected by intraoral bacteria, nonsurgical retreatment should be considered first. However, the nonsurgical treatment must allow access to the coronal and apical root canal space without endangering the restorability of the tooth. Today, traditional endodontic surgery has evolved into endodontic microsurgery. When proper inclusion and exclusion criteria are applied, and modern techniques, including the dental operating microscope, ultrasonic root-end preparation, and biologically compatible

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Fig 9Case 9: High-magnification in-

spection during surgical retreatment. Location of initial fracture line after root-end resection (arrow).

filling materials such as mineral trioxide aggregate or Super-EBA, are used, a clinical success rate of about 90% can be achieved.8,9 The predictability and superior outcomes of modern periapical microsurgery make it viable to choose surgical retreatment over nonsurgical retreatment if the disassembly of the existing restoration cannot be considered sufficiently safe. Periapical pathologies may develop or persist after nonsurgical endodontic therapy. Microorganisms may not only be found within the coronal aspects of the root canal system, but also in the apical third, the apical foramen, or even within a periapical lesion if a critical amount of bacteria exists within the root canal. It is now known that the type of apical pathology may influence the outcome.6,10 The majority of periapical lesions are inflammatory and not of infectious origin or a neoplastic nature. Healing can be expected in approximately 80% of periradicular lesions after root canal treatment, but a lesion larger than 5 mm and the cystic nature of apical processes may negatively influence the outcome. Among all inflammatory periapical lesions, the incidence of periapical cysts ranges from 15% to 20%.8,11 Pocket cysts do have a connection to the root canal system and apex, whereas true cysts are isolated

entities. A clinical diagnosis cannot be made for either type of cyst. Cystic lesions, extraradicular infections (including symptomatic abscessed lesions or periapical actinomycosis), or reactions to foreign bodies and cholesterol crystals may not heal after nonsurgical treatment. For these cases, endodontic microsurgery would be the treatment of choice.6,9 The clinical execution of a microsurgical procedure calls for profound anesthesia and excellent hemostasis. The most commonly preferred solution is Lidocaine 2% with 1:50000 epinephrine. Access is made by using surgical microblades to lay flaps that provide the utmost protection of the soft tissue architecture. To preserve the papillae, either a modified submarginal Ochsenbein-Luebke flap or a papilla base flap are preferred.12 To achieve the best esthetic outcome, the patient should be advised to maintain perfect oral hygiene before and after the procedure and to use adjunctive mouth disinfectants. When a horizontal incision is made, it should follow the contour of the marginal gingiva and stay within the attached keratinized gingiva to avoid scar formation. Vertical incisions must be placed with the natural fiber line. It is advised not to cross convexities but to stay in the areas with natural shadow between the

roots. A vertical release can also be masked by placing it next to a frenulum. A critical recommendation is to change the scalpel at the first sign of bluntness. Incisions must be made swiftly and with little trauma to the tissues. Flap elevation should be carried out with microelevators. It is important to avoid traumatizing the tissues with the retractor and to constantly remoisten the flap with isotonic saline solution to prevent dehydration and flap shrinkage before repositioning. A microscopic osteotomy should be carried out with a fine Lindemann bur and should not exceed 3 to 4 mm in diameter in the case of an intact bony plate. Alternatively, clinicians may rely on piezosurgery for osteotomy and root-end resection. After the root tip and inflammatory tissues are removed, the resected root surface must be stained with methylene blue and carefully inspected under high magnification with a micro-mirror for calcified canal spaces, missed or underprepared canals, microfractures (Fig 9), or isthmuses connecting root canals (Fig 10). Ultrasonic tips are then used to prepare the root-end cavity at a mid-magnification level to provide an overview of the root curvature and prevent iatrogenic perforation. This is followed by another close inspection at high magnification to

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Fig 10Case 10: High-magnification stages of surgical retreatment. (a) Resected root-end inspection reveals untreated second mesiobuccal canal (mb2) and an isthmus (small arrows) in a maxillary right first molar. (b) Situation after root-end cavity preparation. (c) Root-end filling with mineral trioxide aggregate (ProRoot, Dentsply).

ensure that there are no material remnants or infected tissues left on the root canal wall (Fig 10b). During microendodontic treatment, every step has its allocated magnification range (see Table 1). The root end filling material is placed with microcondensers and micropluggers. A final close-up inspection ensures that all excessive filling and foreign body materials such as cotton fibers are removed (Fig 10c). Monofilament suturesat least 6-0 for the vertical and horizontal incisions and at least 7-0 for the papilla base sutureare required for flap closure. Along with periapical microsurgery, the microscope is used for

retrograde instrument removal, inspection of microfractures, and placement of grafting materials and membranes. As endodontists increasingly incorporate dental implants into their specialty, microsurgical techniques will in turn be used more frequently for periimplant soft tissue management.

restoration and preservation of the natural tooth. Together with modern treatment planning approaches, the incorporation of the dental microscope and microendodontic techniques into modern endodontics will provide patients with optimum and predictable outcomes.

CONCLUSION
The objectives of nonsurgical and surgical root canal therapy are to clean, shape, and fill the root canal system to achieve a successful long-term prognosis and enable

Acknowledgments
The authors thank Prof S. Kim in our department for his guidance and review of the article.

References
1. Pettiette MT, Delano EO, Trope M. Evaluation of success rate of endodontic treatment performed by students with stainlesssteel K-files and nickel-titanium hand files. J Endod 2001;27:124127 . 2. Gondim EJ, Murgel CAF , Souza Filho FJ. Surgical Operating Microscope: The New Frontier of XXI Century Clinical Dentistry. Rev Fed Odontol Latin Amer 1997;3:147152. 3. Gorni FG, Gagliani MM. The outcome of endodontic retreatment: A 2-yr follow-up. J Endod 2004;30:14. 4. Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006;32:813821. 5. Stropko JJ. Canal morphology of maxillary molars: Clinical observations of canal configurations. J Endod 1999;25:446450. 6. Lin LM, Skribner JE, Gaengler P . Factors associated with endodontic treatment failures. J Endod 1992;18:625627 . 7 . Karabucak B, Setzer F . Criteria for the ideal treatment option for failed endodontics: Surgical or nonsurgical? Compend Contin Educ Dent 2007;28:391397 . 8. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006;32:601623. 9. Nair PN. Apical periodontitis: A dynamic encounter between root canal infection and host response. Periodontol 2000 1997;13:121148. 10. Sundqvist G, Figdor D, Persson S, et al. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:8693. 11. Simon JH. Incidence of periapical cysts in relation to the root canal. J Endod 1980;6:845848. 12. Velvart P , Peters CI. Soft tissue management in endodontic surgery. J Endod 2005;31:416.

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