Color Atlas of

color atlas of
color atlas of
MICROSURGERY
IN ENDODONTICS
*
color atlas of
fpi L
JLj JL
SYNGCUK KIM, DDS, PhD

Louis I. Grossman Professor and Chairman
Department of Endodontics
University of Pennsylvania
School of Dental Medicine
Philadelphia, Pennsylvania
Private Practice,
New York, New York
GABRIELE PECORA, MD, DDS RICHARD A. RUBINSTEIN, DDS, MS

Adjunct Associate Professor Adjunct Assistant Professor
Department of Endodontics Department of Endodontics
University of Pennsylvania University of Pennsylvania
School of Dental Medicine School of Dental Medicine
Philadelphia, Pennsylvania Philadelphia, Pennsylvania
Private Practice, Private Practice,
Rome, Italy Farmington Hills, Michigan
jUTTA DORSCHER-KIM. MA
Assistant to the Dean for Clinical Research
Associate Director, Pulp Biology Laboratory
Department of Endodontics
University of Pennsylvania
Philadelphia, Pennsylvania
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COLOR ATLAS OF MICROSURGERY IN ENDODONTICS ISBN 0-7216-4851-7
Copyright © 2001 by W.B. Saunders Company
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PREFACE
T hroughout the history of endodontics,

never before have there been as many
underway. As new techniques and technology
emerged, we kept rewriting to incorporate the
changes as in the last decade. Before that, as newest understanding and the newest relevant
much as was known about the root canal system, developments. We finally feel that these years of
the endodontist was dependent on his textbook rapid advances are reaching a plateau and that
knowledge of tooth anatomy, his experience, and this book contains a complete discussion of the
his tactile sense. There was nearly no visual guid¬ best and newest information.
ance and no visual feedback. Even areas in plain When writing this book, we described the meth¬
view, such as the pulp chamber floor, were seen ods we use to teach at the University of Pennsylva¬
only in their grossest configuration. nia, and the way we practice in our private prac¬
Changes have been particularly dramatic in tices in New York, Rome, and Michigan. We made
endodontic surgery. New microsurgical tech¬ an effort to organize the material so that the needs
niques and instruments have been developed in a real clinical situation took precedence over
along with new concepts based on basic and clin¬ other considerations. Of particular interest to clin¬
ical research results. Beginning with the opera¬ icians is Chapter 2, which covers indications and
tion microscope, the sudden ability to see into contraindications in order to clearly delineate the
root canals, whether orthograde or retrograde, “real” need for surgical intervention, and Chapter
has fundamentally changed our understanding 15, which discusses special cases.
of the morphology and its complexity. We are fortunate to work together across the
There is an immense difference between tradi¬ Atlantic with a deep commitment to share valu¬
tional endodontic surgery and microendodontic able knowledge. We sincerely hope that our
surgery. The traditional way of using a high speed readers will benefit from this collection of our
or microhandpiece with a round bur to prepare experience.
the apical root end to place the retrofilling can be
dramatically compared with the “new” way, using SYNCCUK KIM, DDS, PhD,
ultrasonic retropreparation under focused light of Philadelphia, Pennsylvania
the surgical operating miscroscope, which pro¬
vides X4 to X26 magnification. The main purpose GABRIELE PECORA, MD, DDS,
of this book is to introduce such advancements to Rome, Italy
the dental community.
The idea for this book was conceived in 1990, RICHARD RUBINSTEIN, DDS, MS,
when the change toward microsurgery was well Farmington Hills, Michigan
v
4
ACKNOWLEDGMENTS
IT II T" e are grateful for the help we received from many of our colleagues and
1/|/ graduate students at the University of Pennsylvania School of Dental
V W Medicine, Department of Endodontics. We would especially like to
thank Dr. Siva Rethnam for her contribution to Chapters 5 and 8, Dr. Samuel
Krachman for his contribution to Chapter 13, Dr. Yeung Yi Hsu for her research
and organization of suggested readings for this book, Drs. Francesco Maggiore
and Helmut Walsch for their photography of microsurgical instruments, and Dr.
Julio Galvez for his excellent computer-generated pictures.
I owe special thanks to Drs. Gary Carr, George Watzek, and Mahmoud Tora-
binejad for generously sharing their illustrations. Also, thanks to Glen Der¬
byshire of Studio 2050 for use of the tip image on the cover.
I want to express my special thanks and appreciation for my wife and partner,
Jutta, for her extraordinary efforts in editing, rewriting, and organizing each of
the chapters into their present form. We had the ideas and clinical experience,
but Jutta’s editing skills and extensive knowledge in clinical endodontics have
made this text focused and readable.
-V
■
CONTENTS
1 Comparison of Traditional and Microsurgery

in Endodontics, 1
2 Case Selection: Indications and Contraindications, 13
3 Presurgical Evaluation and Premedication, 25
4 Microsurgical Instruments, 31
5 Use of the Surgical Microscope, 45
6 Positioning for Surgery, 57
7 Anesthesia and Elemostasis, 63
8 Soft Tissue Management: Flap Designs, Retraction,
and Suturing, 73
9 Osteotomy and Apical Root Resection, 85
10 The Resected Root Surface and Isthmus, 95
11 Retropreparation, 105
12 Retrofilling Materials and Techniques, 115
13 Tooth Replantation, 125
14 Surgical Sequelae and Complications, 137
15 Selected Cases and Success of Microsurgery, 141
color atlas of
MICROSURGERY
IN ENDODONTICS
CHAPTER
COMPARISON OF TRADITIONAL
AND MICROSURGERY
IN ENDODONTICS
THE CURRENT STATE OF ENDODONTIC tive field, endodontic surgery is perceived as dif¬
PRACTICE ficult; the location of anatomical structures, such
Preservation of the dentition and maintenance of as large blood vessels, the mental foramen, and
function are the dental profession’s ultimate the maxillary sinus, must often be approximated
goals. More patients expect and demand that by the surgeon. These structures must be care¬
their teeth be saved and not extracted, which is fully managed to avoid potentially troublesome
reflected in the increase in endodontic treat¬ consequences.
ments. The introduction of new instruments and Endodontic surgery can be subcategorized into
devices to improve nonsurgical endodontic treat¬ apical and periradicular surgery. Apical surgery
ment has been explosive in the past decade, but it consists of apicoectomy and retrofilling; peri¬
has also been a mixed blessing. Procedural errors, radicular surgery involves correction of procedural
such as broken instruments, have increased as errors, management of root fractures, intentional
endodontists familiarize themselves with this extrusion, replantation, transplantation, hemisec-
new equipment. In most endodontic specialty tion, and root amputation. If experts accept the
practices, significant clinical time is spent on re¬ premise that the success of endodontic therapy
treatment. Although retreatment can be per¬ and endodontic surgery depends on the removal
formed more precisely and easily under the mi¬ of all necrotic tissue and a complete seal of the en¬
croscope and with new kinds of instruments, tire root canal system, the reasons for surgical fail¬
retreatment endodontics is still less successful ure become clear. Examination of failed clinical
than original endodontic therapy. This has cre¬ cases and extracted teeth with the surgical opera¬
ated an increased need for endodontic surgery, as tion microscope reveals that the surgeon cannot
patients and endodontists seek to save these predictably locate, clean, and fill all the complex
teeth. apical ramifications without the magnification
and illumination provided by the microscope. An¬
other reason for skepticism is periapical surgery’s
PROBLEMS IN TRADITIONAL poor success rate. In addition, endodontic surgery
ENDODONTIC SURGERY is usually performed under local anesthesia, so
Although nonsurgical endodontic therapy has there is the additional challenge of working on a
gained wide acceptance, endodontic surgery has conscious and often nervous patient. For all these
remained an enigma. Because of its invasive na¬ reasons, endodontic surgery is viewed as the last
ture, endodontic surgery does not have a posi¬ resort. The following two case studies examine the
tive image in the dental profession. In addition, types of failures encountered when traditional sur¬
because of its restricted access and small opera¬ gical methods are used.
1
2 Color Atlas of Microsurgery in Endodontics
Fig. 1-1 Presurgical radiograph of tooth #30 with a large PAR

on the mesial apices (left)- The surgery was performed with the
traditional apical surgery technique using ZOE as retrofilling
material. A radiograph 3 months postoperatively shows a failed
endodontic surgery (right). The lesions are larger, the symptoms
are worse, and the tooth will have to be extracted.
Fig. 1-2 X8 magnification of the apices of the extracted tooth

of Fig. 1-1. It shows a perforation of the DB apex and untreated
ML and DL apices. Only the MB was sealed by the retrofilling
(left)- X16 magnification of the mesial root clearly shows the
missed ML and isthmus and the overly large retrofilling in the
MB apex (right).
CAUSES OF FAILURE WITH

TRADITIONAL APPROACHES:
CLINICAL CASES
CASE 1
This is an example of a failed molar surgery of the distobuccal apex was perforated (Fig. 1-2). In
tooth #30 performed with a traditional surgical the first instance, this failure is caused by an in¬
method. The radiographic image reflects a mesial ability to inspect the resected root surface. As a re¬
root filling that appears to be filled correctly, al¬ sult, the isthmi were neither identified nor treated.
though the distal retrofilling looks off center (Fig. In addition, the retropreparation was not made in
1-1). Microscopic examination of the apices fol¬ the apical canal space but in a bur-created space
lowing extraction revealed that the mesiobuccal at an excentric angle to the apical foramen. This
retrofilling was too large (a common problem as¬ case clearly demonstrates the limitations and prob¬
sociated with bur preparations), the mesiolingual lems associated with the traditional approach to
and the distolingual apex were totally missed, and endodontic surgery.
CASE 2
Incomplete resection of the apex is another fre¬ aligned with the root canal, a common mistake as¬
quent mistake involving premolar and molar sociated with the traditional surgical method (as
surgery. As shown in Figs. 1-3 and 1-4, only half also shown in Case 1). Microscopic examination of
of the mesiobuccal root tip was resected, leaving the resected root surface during surgery would
the lingual portion of the root tip behind. Further¬ have prevented this mistake.
more, retropreparation of the mesial canal is not
Chapter 1 Comparison of Traditional and Microsurgery in Endodontics 3
Fig. 1-3 Failed surgery on tooth #15 and the extracted mesial
root.
Fig. 1 -4 The root of Fig. 1 -3. Only half of the mesiobuccal root
tip was resected, leaving the lingual portion of the root tip be¬
hind. The retrofilling is placed outside of the apical canal in a
bur-created space (right). A close examination of the resected
root surface under the microscope can prevent mistakes like
this one.
CHANGES IN SURGICAL TECHNIQUES

The view that endodontic surgery is the last resort
is based on past experience with unsuitable sur¬
gical instruments, inadequate vision within the
surgical site, and postoperative complications
and failures that often lead to extraction of the
tooth. Fortunately, this era ended when ultrason¬
ics and the microscope were introduced and
when surgical instruments were miniaturized to
accommodate the small-scale needs of endodon¬
tic surgery. The concurrent development of mi¬
croscopic techniques has resulted in a new un¬
derstanding of the apical anatomy, better surgical
Fig. 1-5 The Zeiss MKM microscope with computer guidance
and apical resection techniques, better patient re¬
and a built-in CAT scan system used in neurosurgery. The op¬
sponse, and greater treatment success. These de¬ tical components of this microscope are the same as those used
velopments marked the beginning of the en¬ in the dental microscope.
dodontic microsurgery era.
DEFINITION OF MICROSURGERY for the first time in neurosurgery and ophthal¬

Microsurgery is defined as a surgical procedure on mology (Figs. 1-5,1-6). Today, 40 years later, most
exceptionally small and complex structures with microvascular, neurological, ophthalmological,
an operation microscope. The microscope enables and otolaryngological surgical procedures are
the surgeon to assess pathological changes more performed with the operation microscope. It was
precisely and to remove pathological lesions with only a matter of time that other fields, including
far greater precision, thus minimizing tissue dam¬ endodontics, would recognize the advantages the
age during the surgery. microscope offers.
The concept of microsurgery in the medical Because of the restricted access to the surgical
field began in the late 1950 and early 1960s. In field, precision is a key element in endodontic
1960, the surgical operation microscope was used microsurgery. The surgical area must be well illu-
Fig 1-6 The first microscopes were incorporated into the oph- Fig. 1 -7 The bright, focused light of a surgical operation mi¬
thalmological field in the early 1960s. croscope illuminates the entire surgical field.
Fig- 1-8 This resected root surface reveals two apical orifices;
the main apex was filled, but the other was missed, which re¬
sulted in failure.
F'g 1-9 A microfracture caused the failure of this amalgam

retrofilling.
minated and magnified. A standard operating suits showed that it is better than most materials
light and X2 or X3.5 loupes, which are adequate tested. Most recently, mineral trioxide aggregate
for simple operative procedures on larger struc¬ (MTA) was introduced. In vitro and animal test re¬
tures, are not sufficient to see and treat the mi¬ sults showed that MTA has good sealing ability
crostructures and defects common in endodon¬ and that it induces a cementum-like hard tissue
tic surgery. The surgical operation microscope, a zone around the apex. Comparisons of retrofill¬
standard instrument in neurosurgery, otolaryn¬ ing materials including amalgam, SuperEBA,
gology, and ophthalmology, provides the neces¬ resins, and MTA also indicate that MTA’s tissue
sary illumination with a bright, focused light and compatibility and bone growth stimulation are
magnification up to X32 in endodontic micro¬ superior to other retrofilling materials.
surgery (Fig. 1-7). This enhanced visibility allows
surgeons to locate and treat anatomical varia¬
tions that previously escaped their attention. NEW DIMENSIONS IN ENDODONTIC
These include the partial or complete isthmus, MICROSURGERY
multiple foramina, C-shaped canals, and apical Guided tissue regeneration (GTR), also referred to
root fractures (Figs. 1-8,1-9). These variations of¬ as membrane barrier technique or guided bone re¬
ten cannot be treated by nonsurgical means. Fail¬ generation, has also proven successful in specific
ure to treat them by surgical means will also lead endodontic surgical cases. On occasion, after rais¬
to failure. The microscope has changed surgical ing the flap on the buccal surface, a surgeon may
endodontics from a “blind” technique to one that discover that there is no buccal plate. In the past,
is visually dominated. all the surgeon could do was close the flap and
hope for the best. Today, GTR is used to help the
body regenerate the lost bone. Periodontists have
DEVELOPMENT OF been using GTR for the last 10 years to treat simi¬
MICROINSTRUMENTS AND lar lesions. Although GTR is not a panacea, it can
RETROFILLING MATERIALS be used effectively in selected endodontic cases.
The microscope has led to the development of Several clinical studies have demonstrated GTR’s
special instruments with revolutionary designs success with complicated endodontic lesions.
and functions. Ultrasonic tips for retrograde With the development of resorbable membranes,
preparations enable the surgeon to prepare clean this technique may contribute significantly to the
canals with the correct axial alignment to a depth restoration of alveolar bone and thus to the reten¬
of 3 mm. Micromirrors allow the inspection of the tion of the natural dentition.
resected root surface for anatomical details. Spe¬ When a flap is reflected, the surgeon may en¬
cial micropluggers have been designed to permit counter a fractured tooth, usually associated
more compact retrograde fillings. Miniaturization with a post and crown restoration. As of this writ¬
of surgical instruments was necessary to work in ing, there is no treatment technique to repair a
the confined space of a bone crypt and under root fracture and to maintain such a tooth.
large magnification. The Stropko drier/irrigator Therefore the usual result is an extracted tooth
guarantees the complete drying of the retropre- with either a subsequent three-unit bridge repair
pared canals. Simultaneously, with the develop¬ or an implant restoration after the extraction
ment of microinstruments, the controversy arose wound heals. A fresh socket implant (the more
regarding the use of amalgam in restorative den¬ immediate repair takes advantage of the natural
tistry. Regardless of the outcome of the suitability socket) is a more satisfactory and logical option,
of amalgam for restorative dentistry, the authors especially for those well-trained in endodontic
have found independently that amalgam is not a microsurgery.
good retrofilling material because of percolation Thus the endodontic dimensions have changed
through the apical seal and because of apical mi¬ from straight apical surgery to microsurgical en¬
crofractures resulting from expansion of the ma¬ dodontics with GTR and fresh socket implants.
terial. Thus research focused on the suitability of An aging and more dentally sophisticated popu¬
other materials as retrograde filling agents. Rein¬ lation fully expecting to maintain its own teeth
forced zinc oxide eugenol cement such as will require endodontists to use these techniques
SuperEBA has become popular after research re- successfully.
Magnification
Fig. 1-10 The triad of endodontic microsurgery—magnification,

illumination, and instruments-provides greater accuracy in api¬
cal retropreparation and retrofillings.
Fig. 1-11 Composite picture of the most popular operation mi¬

croscopes in dentistry (Global, Jedmed, Zeiss).
THE TRIAD OF ENDODONTIC struction of less healthy bone to gain access to the
MICROSURGERY root apices has resulted in less patient discomfort
The triad of endodontic microsurgery encom¬ and faster healing of bone and soft tissues.
passes magnification, illumination, and instru¬ The third element of the triad is instrumenta¬
ments (Fig. 1-10). Without any one of these ele¬ tion. Working in a magnified surgical site requires
ments, microsurgery would not be possible. The a different set of surgical instruments. The stan¬
operation microscope has existed for many dard endodontic surgical instruments are too
decades and has been used in other disciplines of large for the microsurgical approach. Except for
medicine for many years. Smaller instruments the handles, everything had to be reduced in size.
had been developed to operate on this micro¬ Ultrasonic tips, condensers, pluggers, curettes,
scopic level in all these fields. and mirrors were reduced in size to comfortably
In dentistry the instrumentation was devel¬ fit into an osteotomy no larger than 5 mm to gain
oped only recently, and changes are still being access to the canals (Fig. 1-12). In sharp contrast
made. Illumination and magnification are pro¬ were the traditional standard endodontic instru¬
vided by the surgical operation microscope and ments, which created osteotomies of 10 mm or
have fundamentally changed the way endodontic larger to gain access to the root apices. With this
surgery is performed (Fig. 1-11). With bright, fo¬ technology, today’s surgeon can execute apical
cused light on a X4 to X31 magnified surgical site, surgery with confidence and accuracy (Fig. 1-13).
the surgeon can see every detail of the apical The entire surgical field is visible, accessible, and
structures and can execute treatment more pre¬ nothing is left to guesswork. Subsequent chapters
cisely. As an additional benefit, the magnification will elaborate on current microsurgical technol¬
has also resulted in smaller osteotomies. The de¬ ogy and techniques.
Fig. 1-12 Essential microinstruments for endodontic micro¬

surgery: ultrasonic tips (top right), Stropko irrigator/drier (center),
micropluggers (bottom right), micromirrors (top left), and mi¬
croball burnisher (bottom left).
Fig. 1-13 A microsurgery team performing apical microsurgery

(Microscope Training Center, University of Pennsylvania, De¬
partment of Endodontics.)
PROCEDURE TRADITIONAL SURGERY MICROSURGERY
Identification of the apex Difficult Precise

Osteotomy Large (10 mm) Small (<5 mm)
Root surface inspection None Always
Bevel angle Large (45°) Small (<10°)
Isthmus identification Nearly impossible Easy
Retropreparation Approximate Precise
Root end filling Imprecise Precise
COMPARISON OF TRADITIONAL Microsurgery’s main advantages are easy iden¬

ENDODONTIC SURGERY AND tification of the root apex, smaller osteotomies,
MODERN ENDODONTIC and shallow resection angles, which conserve
MICROSURGERY cortical bone and root structure. In addition, a re¬
Endodontic microsurgery, as it is now called, sected root surface under high illumination and
combines the magnification and illumination magnification readily reveals anatomical details
provided by the surgical operation microscope (e.g., isthmuses, canal fins, microfractures, lateral
and new microinstruments. Endodontic micro¬ canals). Combined with the microscope, the ul¬
surgery can be performed with precision and trasonic instrument permits conservative, coaxial
predictability and eliminates the assumptions root end preparations and precise root end fill¬
inherent in traditional endodontic surgery. ings, which satisfies the requirements for me¬
The table above summarizes the differences chanical and biological principles of endodontic
between traditional endodontic surgery and surgery. Comparison of the radiographic appear¬
microsurgery. ances of amalgam retrofilling material using tra-
Fig. 1-14 Notice the round, bur-shaped amalgam retrofillings. Fig. 1-16 3-mm SuperEBA retrofillings in the MB and DB
They are too large in proportion to the root end and missed the canals. Even the elongated isthmus was prepared and filled
isthmus completely. These are two of the shortcomings en¬ easily with the microsurgical method.
countered when traditional methods are used.
the canal. This will be discussed more in later

chapters.
CLASSIFICATION OF ENDODONTIC
MICROSURGICAL CASES
Endodontic microsurgery can be classified as fol¬
lows: Class A represents the absence of a periapi¬
cal lesion but unresolved symptoms after non-
surgical approaches have been exhausted. The
symptoms are the only reason for the surgery
(Fig. 1-17). Class B represents the presence of a
small periapical lesion and no periodontal prob¬
ing depth (Fig. 1-18). Class C represents the pres¬
ence of a large periapical lesion progressing coro-
nally but without a periodontal pocket (Fig. 1-19).
Class D represents a clinical picture similar to
Class C with a periodontal pocket (Fig. 1-20).
Class E classifies a periapical lesion with an
endodontic-periodontal communication but no
root fracture (Fig. 1-21). Class F represents a
tooth with an apical lesion and complete de-
nudement of the buccal plate (Fig. 1-22).
Fig. 1-15 Small, round amalgam retrofillings in anterior teeth, Classes A, B, and C present no significant treat¬
which only seal part of the elongated apices, causing leakage. ment problems, and the conditions do not ad¬
versely affect treatment outcomes. However,
classes D, E, and F present serious difficulties. Al¬
ditional surgery and the microsurgical methods though these cases are in the endodontic do¬
with SuperEBA as retrofilling material is pre¬ main, proper and successful treatment requires
sented in Figs. 1-14 to 1-16. The amalgam retro- not only endodontic microsurgical techniques
filling looks like a highly opaque dot at the apex, but also current periodontal surgical techniques
whereas a retrofilling made with the new tech¬ (e.g., the membrane barrier technique). These are
nique looks like an elongated filling 3 mm into the challenges faced by the endodontic surgeon.
Fig. 1-17 Class A tooth-there is no periapical lesion, but the

tooth is symptomatic.
Fig. 1-18 A, Class B tooth with a small periapical lesion. B, Clinical view of a Class B tooth af¬
ter an osteotomy, which demonstrates small periapical lesions. From Beer/Baumann/Kim: Color
atlas of dental medicine: Endodontology; New York, 2000, Thieme Verlag Stuttgart.
Fig. 1-19 Class C tooth-a periapical lesion covers approxi¬ Fig. 1 -20 Class D tooth—a Class B or Class C tooth with a pe¬
mately half the root. riodontal pocket.
Fig. 1-21 A, Class E tooth-a Class B or Class C tooth with a periodontal communication to the
apex. B, Clinical view of a Class E tooth showing periodontal communication in the buccal sur¬
face of the mesial root.
Fig. 1-22 A, Class F tooth-total buccal fenestration. B, Clinical view of a Class F tooth, which
shows the absence of a cortical plate.
SUCCESS OF ENDODONTIC Dahlin C, Linde A, Gottlow J et al: Healing of bone defects by

MICROSURGERY guided tissue regeneration, Plast Reconstr Surg 81:672-
676, 1988.
A clinical study of cases in the Class A, B, and C Duggin SL, Clay J, Himel V et al: A combined endodontic
categories was conducted by the authors on 128 retrofill and periodontal guided tissue regeneration
patients. Using only SuperEBA as sole retrofilling technique for the repair of molar endodontic furcation
material, microsurgery was performed on anteri- perforations: report of a case, Quintess Int 25:109-114,
ors, bicuspids, and molars, with strict adherence 1994.
Frank AL, Glick DH, Patterson SS et al: Long-term evaluation
to microsurgical techniques. After 1 year, 94 of the
of surgically placed amalgam fillings, J Endodont 18:391-
patients were available for a recheck; there was a 398, 1991.
radiographic and clinical success of 96.8% (see Friedman S, Lustman J, Shaharabany V: Treatment results of
Chapter 15). The same patients were called after 5 apical surgery in premolar and molar teeth, J Endodont
to 7 years, and the recheck results indicate that 17:30, 1991.
over 91% of the cases were successful (unpub¬ Gilheany P, Figdor D, Tyas M: Apical dentin permeability and
microleakage associated with root end resection and ret¬
lished data). Compared with other published stud¬
rograde filling, J Endodont 20:22-26, 1994.
ies (with success ranging from 47% to 90%), this Harty FJ, Parkins BJ, Wengraf AM: The success rate of api-
success rate is impressive, especially when con¬ coectomy. A retrospective study of 1016 cases, Br Dent J
sidering that other studies did not include molars. 129:407-413, 1970.
Based on the results from this study, the authors Kim S: Principles of endodontic microsurgery, Dent Clin
North Am 41:481-498, 1997.
conclude that microsurgical techniques produce
Kim S, Rethnam S: Hemostasis in endodontic microsurgery,
a more successful endodontic surgical outcome. Dent Clin North Am 41(3):499-511,1997.
Leubke RG: Surgical endodontics, Dent Clin North Am 18:
SUGGESTED READINGS 379-391, 1974.
Allen D, Newton C, Brown C: A statistical analysis of surgi¬ Mattila K, Altonen M: Follow-up study of apicoectomized
cal and nonsurgical endodontic re-treatment cases, JEn- molars, Int J Oral Surg 7:33-40, 1976.
dodont 15(61:261-266,1989. Oynick J, Oynick T: A study of a new material for retrograde
Carr GB: Microscope in endodontics, J Calif Dent Assoc fillings, J Endodont 4:203-206, 1978.
20:55, 1992. Pecora G, Andreana S: Use of dental operating microscope
Carr GB: Ultrasonic root end preparation, Dent Clin North in endodontic surgery, Oral Surg Oral Med Oral Pathol
Am 41 (3):541-554, 1997. 75:751-758, 1993.
Pecora G, Baek SH, Rethnam S et al: Barrier membrane tech¬ Rubinstein R: The anatomy of the surgical operation micro¬
niques in endodontic microsurgery, Dent Clin North Am scope and operation positions, Dent Clin North Am
41(3):585-602, 1997. 41:391-413, 1997.
Pecora G, Andreana S: Use of the dental operation micro¬ Rud J, Andreasen JO, Jensen JE: A follow-up of 1000 cases
scope in endodontic surgery, Oral Surg Oral Med Oral treated by endodontic surgery, IntJ Oral Surg 1:215-228,
Pathol 75:751-758, 1993. 1972.
Pecora G, Kim S, Celletti R et al: The guided tissue regenera¬ Ruddle C: Microendodontics nonsurgical retreatment, Dent
tion principle in endodontic surgery. One year postoper¬ Clin North Am 41(3) :429-454, 1997. A
ative results of large periapical lesions, Int Endodont J Ruddle C: Nonsurgical endodontic retreatment: post re¬
28:41-46, 1995. moval simplified, Dent Today, pp. 48-53, May 1998.
Pecora G, Baek SH, Rethnam S et al: Barrier membrane tech¬ Sjogren U, Hagglund B, Sundqvist G et al: Factors affecting
niques in endodontic microsurgery, Dent Clin North Am the long term results of endodontic treatment, J En¬
41:585-602, 1997. dodont 16:498-504, 1990.
Persson G: Periapical surgery of molars, IntJ Oral Surg 11:96- Torabinejad M, Watson TF, Pitt-Ford TR: Sealing ability of a
100, 1982. mineral trioxide aggregate when used as a root end fill¬
Rubinstein R, Kim S: Short term observation of the results of ing material, J Endodont 19:591-595, 1993.
endodontic surgery with the use of a surgical operation Weller RN, Niemczyk SP, Kim S: Incidence and position of
microscope and Super EBA as root-end filling material, J the canal isthmus. I. Mesiobuccal root of the maxillary
Endodont 25:43-48, 1999. first molar, /Endodont 21:380-383,1995.
CASE SELECTION: INDICATIONS
AND CONTRAINDICATIONS
KEY CONCEPTS dodontist is faced with a humbling and con¬
• Endodontic microsurgery is the treatment of founding experience. With a firm understanding
choice after all retreatment options are exhausted. of the complexity of the root canal system, how¬
• In certain situations, the surgical approach ever, even a competent clinician with a good
is more conservative than nonsurgical re¬ technique may not be able to enter, clean, and fill
treatments. all canal spaces completely. When faced with ap¬
• Microsurgical techniques overcome the tradi¬ parent endodontic failure, the quality of the en¬
tional problems of operating near the mental dodontic treatment must be carefully considered.
nerve and the sinus. An eccentric-angle radiograph, for instance, may
• Microsurgical techniques have eliminated the show a missed canal or an inadequate filling (Fig.
technique-sensitive contraindications for en¬ 2-1). Microsurgery is indicated only when the
dodontic surgery. clinician has determined that retreatment is not
possible or will not correct the problem.
Successful endodontic surgery depends on the The definitions of endodontic success and fail¬
complexity of the root canal system but also on ure remain controversial: the clinical definition of
the clinician’s ability and thoroughness. The success is a tooth without symptoms, the radi¬
maxim “A good surgeon knows how to cut, but an ographic definition is the resolution of periapical
excellent surgeon knows when to cut” is an excel¬ radiolucency, and the histological definition is the
lent guiding principle. Thus when presented with reestablishment of normal periapical cell struc¬
endodontic failure, the causes of the failure ture in the absence of any inflammatory cells. As
should be determined carefully, and nonsurgical most periapical regions, even successfully treated
retreatment should be considered first. If retreat¬ asymptomatic teeth, show histological evidence
ment is impossible or unwise, endodontic micro¬ of inflammatory cells and cell disruption, the clin¬
surgery is the treatment of choice. Clinical symp¬ ical and radiographic definitions are accepted cri¬
toms, such as continuous pain (or pain upon teria for success in clinical practice.
percussion and/or palpation), swelling, fistula- Contrary to what is commonly believed, the
tion, periapical radiolucency, as well as any re¬ size of a lesion is not a decisive factor for or
storative history of the tooth determine whether against surgery. A large periapical lesion without
surgery is required. In many cases, a treatment other complications should be treated by con¬
plan, surgery, or retreatment depend greatly on a ventional endodontic therapy first. If the lesion
dentist’s experience and ability. The following sec¬ persists despite conventional endodontic retreat¬
tion examines the primary indications for surgery. ment, the endodontic microsurgical approach
should be considered. The character of a radiolu¬
cency, combined with the size (e.g., a through-
INDICATIONS and-through defect), determines the type of treat¬
When a patient returns with persistent postoper¬ ment. A through-and-through defect, in addition
ative discomfort or a flare-up with periapical to endodontic surgery, also requires measures to
swelling after having completed endodontics promote bone regrowth in the area (e.g., guided-
with a perfect radiographic obturation, the en- tissue regeneration procedures) (Fig. 2-2).
13
Fig 2-1 Failed endodontic therapy (left)- Surgery was not

needed since an untreated mesial canal, found on an eccen¬
tric angle radiograph, was identified and treated nonsurgically.
Fig. 2-2 A, A preoperative radiograph showing a through-and-through defect requiring the

barrier membrane technique in addition to microsurgery. B, The defect healed within 6 months.
Failure of Previous Endodontic Therapy CASE 1
The cause of endodontic failure is usually the An already nonsurgically retreated tooth, al¬
same: failure to sterilize the root canal system by though asymptomatic and without swelling or
thorough cleansing and failure to provide a her¬ fistula, may have a persistent or enlarging peri¬
metic seal at the apex. However, the clinical man¬ apical radiolucency (Fig. 2-3). The cause of the re¬
ifestations of endodontic failure are numerous peated failure was a long buccal/lingual root with
and diverse. When a patient is in considerable a ribbon-shaped apex that was never completely
pain with or without swelling, and the periapical cleaned and obturated. Some anterior teeth have
bone appears normal, the previous endodontic similar ribbon-shaped apices. Such cases illus¬
therapy seems radiographically successful. In this trate that complex apical canal systems cannot be
case, there is a high probability that necrotic pul- completely accessed, cleaned, and obturated with
pal remnants in the apical area (possibly in an conventional endodontic techniques.
isthmus) are responsible for the symptoms.
Chapter 2 Case Selection: Indications and Contraindications 15
CASE 2
After nonsurgical retreatment, the tooth remains

symptomatic, and a periapical radiolucency per¬
sists. The main problems are canals or canal ram¬
ifications, which cannot be reached and cleaned
because of the complex apical canal system.
CASE 3
After endodontic therapy, a periapical rarefac¬

tion persists or enlarges, and the tooth has a per¬
manent post and crown restoration (Fig. 2-4). In
fixed prosthetics, placement of a post and core to
support a crown is common. When endodontic
treatment fails in such a case, nonsurgical re¬
treatment may be possible, but it is often difficult
and may actually damage the tooth the en-
dodontist is trying to save. Root fractures and
root perforations are common during attempts to
remove a post with a conventional bur and post
removers. Such retreatments are more successful
now with the use of ultrasonic tips (e.g., CPR tips)
and the microscope, which minimize the need for
canal enlargement and thus the chances of per¬
foration and fracture. Flowever, in many situa¬ Fig. 2-3 Numerous retreatments of this anterior tooth failed,
necessitating endodontic microsurgery. The cause of the failure
tions the surgical approach is the treatment of was an elongated buccal-lingual canal, which was only partially
choice. In fact, in some situations the surgical ap¬ filled.
proach is the more conservative treatment option.
For instance, in the process of removing the post,
the tooth is seriously weakened by the necessary
removal of root structure. In addition, the post, complete debridement and subsequent obtura¬
core, and crown restoration will also have to be tion of the root canal system are more common
redone, which is expensive and time consuming. than previously thought. Such teeth should be
considered for surgery. In young children, a blun¬
derbuss apex, which cannot be sealed, is also an
There are many causes of endodontic surgery indication for surgery. Many of these teeth are
failure, but one of the main causes is apical leak¬ treated with endodontic therapy first, and the le¬
age (Fig. 2-5). Not only were these fillings causing sion is observed at intervals for signs of resolu¬
leakage, but the isthmus was not treated, and a tion. If the lesion heals and the patient has no
large osteotomy caused the iatrogenic loss of the symptoms, the treatment is considered success¬
buccal plate (Class E). A comparison of en¬ ful. Flowever, if neither the lesion nor the symp¬
dodontic surgical techniques before and after the toms resolve, microsurgery should be considered.
introduction of the microsurgical approach is
presented in Chapter 1. Procedural Errors
Endodontic therapy fails in a significant number
Anatomical Deviations of teeth because of procedural errors. A clinician
Many teeth have some form of anatomical devia¬ may ledge, block, or perforate the canals during
tion. Tortuous roots, severe S- and C-shaped instrumentation, break an instrument inside the
canals, sharp angle bifurcations, pulp stones, cal¬ canal (Fig. 2-6), overfill it (Fig. 2-7), or underfill it
cifications, and other elements that prevent the because of apical blockage (Fig. 2-8). Procedural
Fig 2-4 The radiograph of this maxillary anterior tooth shows

a post restoration and a persistently enlarging periapical lesion.
Fig 2-5 Failed surgeries performed with pre-microsurgical techniques. A, Notice the round
amalgam "dots" at the apices. The root resection in this case was too acute, resulting in the loss
of buccal plate. B, A similar situation to A but with a less acute root resection angle. None¬
theless, this case also failed because of neglect of the isthmus between the apices. From
Beer/Baumann/Kim: Color atlas of dental medicine: Endodontology, New York, 2000, Thieme
Verlag Stuttgart.
Fig 2-6 A, Tooth #14 with a broken instrument at the MB

apex and a draining fistula, which is traced with a gutta per-
cha point. B, Tooth #19 was symptomatic with an irremov¬
able broken instrument in the apical end, but without PAR.
C, Tooth #13 with broken and overextended instruments in
the canals and a post restoration.
Fig. 2-7 A, Maxillary anterior tooth with overfilling beyond the scope of retreatment and a
dense and large periapical lesion, which suggests a through-and-through defect. B, Mandibu¬
lar anterior teeth with periapical pathosis and gross overfilling-the "Spaghetti" phenomenon.
Fig- 2-8 Tooth #19 with poor endodontics and a large PAR, to- Fig. 2-9 A radiograph suggesting a fractured tooth (left). The
tal canal calcification in the apical half, and a broken instrument extracted fractured root (right).
at the apex.
errors usually result in an incomplete filling or an surgical procedure, the microscope is critical
insufficient apical seal, which eventually causes for its success.
periapical pathology. If the procedural error oc¬
curred in the apical third of the root (see Fig. 2-6), Exploratory Surgery
the crown-root ratio favors an apicoectomy. This Despite careful radiographic evaluation and thor¬
is a relatively simple surgical correction to the ough examination and questioning of the pa¬
problem and offers a good prognosis. However, if tient, a firm diagnosis is often difficult. An expe¬
the procedural error occurred in the middle of the rienced surgeon may make an educated “guess”
root, especially if it occurred on the lingual aspect about the problem with exploratory surgery,
where surgical instruments cannot easily reach, which usually provides the missing information
the solution is more problematic. The visual mag¬ for a definitive diagnosis. Once the flap is raised,
nification of the canal provided by the microscope the surgeon should be prepared to do whatever
allows very accurate management of procedural is necessary to correct the problem. If a root frac¬
errors. If all nonsurgical attempts to correct the ture is identified, for instance, the surgeon should
problem fail, replantation may be the only solu¬ decide to either resect or hemisect the root or to
tion for saving the tooth. This option will be dis¬ extract the tooth (Fig. 2-9).
cussed in detail in Chapter 13. To ensure that the patient understands and ac¬
A broken instrument in a canal and perfora¬ cepts a procedure, the complexity of the case
tion do not automatically require endodontic and the treatment options should be thoroughly
surgery. If the instrument is broken where it can explained and discussed with the patient before
be bypassed and the canal can be properly exploratory surgery. A drawing of the tooth in
cleaned and filled, nonsurgical endodontics is question or the patient’s radiograph are simple but
the more conservative treatment approach. The effective ways to illustrate the nature of the prob¬
same is true for some teeth with post and core lem and the solution. Once the patient fully un¬
restorations, which can be successfully loos¬ derstands the options, consent for the exploratory
ened and removed with ultrasonic CPR tips, surgery is usually given, and the loss of the tooth
and retreatment can be performed. If a root or (if necessary) is more readily accepted.
the furca becomes perforated during retreat¬
ment with ultrasonics, the microscope is essen¬
tial for accurate and complete repair of the de¬ CONTRAINDICATIONS
fect. The perforation is sealed first with calcium There are very few contraindications for endo¬
sulfate as a barrier and then with MTA as a dontic microsurgery when it is performed by a
sealer. When this procedure is performed im¬ knowledgeable and skilled surgeon. Many condi¬
mediately, complications can be avoided. Al¬ tions that would eliminate surgery as a treatment
though this type of perforation repair is a non¬ option are temporary. As soon as those condi-
Fig. 2-10 The second premolar and the first molar, which are in Fig- 2-11 The mandibular second molar is a poor candidate for
close proximity to the mental foramen and the mandibular surgery because of poor access and a thick buccal plate. Inten¬
canal. The proximity must be ascertained before surgery. tional replantation is a better treatment option.
tions are corrected, surgery can be performed. often makes a routine surgical approach difficult,
Nonetheless, contraindications to endodontic if not impossible. In this situation, extraction and
surgery still exist. These include the anatomy and replantation after treating the tooth extraorally is
the periodontal health of the tooth and the pa¬ the treatment of choice. If the second molar is
tient’s medical condition. These contraindica¬ positioned favorably and access is adequate, it
tions are not absolute, but they are determined should be treated intraorally (see the section on
by the limitations of endodontic surgical tech¬ intentional replantation in Chapter 13 for more
nique and the patient’s medical condition. In the information).
following sections, each contraindication will be
examined in detail. The Maxillary Sinus
The proximity of the sinus is not a factor when
Anatomical Factors determining whether surgery should be per¬
Proximity to Neurovascular Bundles formed. Many roots of the maxillary premolars
The neurovascular bundles progress close to the and molars are located very close to the sinus or
apices of the mandibular second premolars and even inside the sinus, separated only by a thin
first molars (Fig. 2 -10). In most situations this is not membrane (Fig. 2-12, A). A radiographic exam¬
difficult for the experienced surgeon, especially if ination of the roots and careful dissection un¬
the surgeon works with the microscope and uses der the microscope usually prevents a sinus
the groove technique to prevent accidental slip¬ perforation during surgery. However, even if the
page of an instrument into the nerve bundle (see sinus is accidentally perforated, the outcome of
Chapter 8). Under a microscope’s intense illumi¬ the surgery is not necessarily compromised
nation, subtle color differences, which identifythe (Fig- 2-12, B).
location of the mandibular canal and foramen, can
be detected and serve as guides for the osteotomy. Periodontal Considerations
However, unless the surgeon is experienced and When considering endodontic surgery, the
works with a microscope, an improperly per¬ periodontal health of the tooth is an important
formed procedure may lead to permanent nerve factor. Tooth mobility and periodontal pockets are
damage. This is no place for a novice. the two key elements the surgeon must consider.
Studies have shown that endodontic surgery can
The Second Mandibular Molar Area have more than a 91% long-term success rate if
In most patients, the second mandibular molar there is no periodontal involvement (Class A, B,
has the following characteristics: the buccal plate and C). Since periodontal defects are common,
is too thick, the roots are inclined lingually, and surgeons must carefully assess the periodontal
the apices are very close to the mandibular canal condition before surgery. If the tooth has no mo¬
(Fig. 2-11). In addition, the more restricted access bility but a large periodontal defect, the surgeon
Fig. 2-12 A, The mesiobuccal root of tooth #14 is in or near the sinus membrane but should
not be automatically disqualified from surgical intervention. B, The sinus membrane was in¬
fringed during the surgery, but the case had a successful outcome nonetheless.
must determine whether the periodontal defect anticoagulant medicines (e.g., Coumadin). Con¬
is of endodontic or periodontic origin. In most sultation with the patient’s physician is essential
cases, surgery should be performed. before surgery so that medications taken by the
A periodontal defect always compromises the patient can be titrated or temporarily terminated.
chances of successful endodontic surgery, espe¬ Surgery should also be postponed if a patient has
cially if the surgery is likely to cause an endodon¬ had radiation treatment of the jaw because the ir¬
tic/periodontic communication. Surgery on a radiation reduces the blood supply to the area
short-rooted tooth with a deep periodontal defect and may induce osteoradionecrosis. Because of
is very likely to create a communication between the risk of miscarriage in the first trimester of
the endodontic and the periodontic lesions. If this pregnancy, endodontic surgery should be post¬
occurs, treatment failure and subsequent loss of poned for pregnant women.
the tooth are inevitable. In this situation, extrac¬ On the other hand, in patients with a controlled
tion may be the best solution. disease such as diabetes, endodontic surgery does
not pose a significant health risk if the patient
Medical Factors is treated with proper antibiotics. The surgeon
In most cases, the patient’s medical condition should always consult the treating physician before
does not preclude endodontic microsurgery. Pa¬ proceeding with the surgery.
tients with such diseases as leukemia or neutrope¬
nia in the active state; severely diabetic patients; The Surgeon s Skill and Ability
patients who have recently had heart surgery or The most important contraindication to en¬
cancer surgery; and older, ill patients are the rare dodontic surgery is the clinician’s surgical skill
exceptions. Endodontic surgery should not auto¬ and knowledge. When clinicians encounter situ¬
matically be eliminated for older patients. A con¬ ations beyond their ability, they should refer such
siderable number of surgeries are performed on patients to endodontists or oral surgeons with
septuagenarians and octogenarians without any microsurgical training and experience with com¬
complications. However, the patients were usually plex cases.
healthy and had a good tolerance for the proce¬
dure. The decision for endodontic surgery should
be evaluated on a case-by-case basis and, if nec¬ LOCAL FACTORS
essary, in consultation with the patient’s primary The Complexity of the Root Canal System
physician. Although there is still controversy about how to
most effectively debride and obturate the root
Postponement of Surgery canal system, experts generally agree that an api¬
Surgery should be postponed if a patient is recu¬ cal lesion develops when toxins and bacteria
perating from a myocardial infarction or taking from the root canal enter the periapical space.
Fig 2-13 A, A human anterior tooth studied by W. Hess in 1917, which shows many lateral
canals at the apical 4 mm of the root. B, A human premolar tooth studied by Hess, which shows
two tortuous main canals at the apical half with many interconnecting canals. C, A human mo¬
lar tooth studied by Hess, which shows the complexity of the root canal system.
There is universal agreement that the apical proved that the root canal morphology is so var¬
lesion will heal after the entire canal system has ied and complex that it is impossible to clean and
been completely cleaned and sealed at the obturate the canal system completely. Figs. 2-13
apices. The 1917 Indian ink perfusion pictures of and 2-14 illustrate Hess’ work and the more re¬
the root canal system by Walter Hess definitively cent work by K. Takahashi and Y. Kishi with root
Figs. 2-14 A-C, Three-dimensional hologram of three types of human molars studied by K.
Takahashi and Y. Kishi, which illustrate the complexity of the root canal system in 3D.
during the subsequent post restoration. It takes

hours to carefully “tease” the post out and to re¬
treat the tooth. From a mental and physical stand¬
point, many patients have difficulty with such a
lengthy procedure. Finally, retreatment is very ex¬
pensive. The cost of the post removal, followed by
retreatment and a new tooth restoration, presents
a financial challenge to most patients.
Unless there is a significant degree of certainty
that the post can be removed without compro¬
mising the root, that retreatment can correct the
problem, and that the patient can endure the
lengthy procedure, endodontic microsurgery may
Fig. 2-15 Retreatment or surgery? This tooth had a broken be the more conservative approach. Regardless of
instrument in the mesial canal and a post in the distal canal. the preferred treatment option, the patient should
A new crown restoration had been placed in the last year. be involved in the decision-making process.
SUGGESTED READINGS
canal systems. Careful examination and analysis
Allen RK, Newton CW, Brown CE: A statistical analysis of sur¬
of the root canal system clearly demonstrate that
gical and nonsurgical re-treatment cases, / Endodont
total success in nonsurgical endodontics is un¬ 15:261-266, 1989.
obtainable and that endodontic surgery must be Brynolf I: A histological and roentgenographical study of the
a part of the equation to correct endodontic periapical region of human upper incisors, Odontologisk
pathology. Revy 18:1-176, 1967.
Carr GB: Surgical endodontics. In Cohen S, Burn RC, editors:
Patient Management: Nonsurgical Pathways of the pulp, ed 7, St Louis, 1998, Mosby.
Gutmann JL, Harrison JW: Posterior endodontic surgery:
Retreatment or Surgery?
anatomical considerations and clinical techniques, Int
When a clinician cannot decide on nonsurgical Endodont J 18:8-34, 1985.
retreatment or surgery he or she must inform the Gutmann IL: Clinical, radiographic, and histologic perspec¬
patient of the cost, time, and possible complica¬ tives on success and failure in endodontics, Dent Clin
North Am 36:379-392, 1992.
tions associated with the removal of the existing
Hess W, Zurcher E: The anatomy of the root canals of the per¬
root canal filling, including a post if present, and manent dentition, New York, 1925, William Wood & Co.
the subsequent retreatment. Furthermore, the Lin LM, Skirbner JE, Gaengler P: Factors associated with en¬
clinician must also inform the patient that if the dodontic treatment failures, ]Endodont 18:625-627,1992.
post cannot be safely removed, a surgical proce¬ Reit C, Grondahl HC: Endodontic decision-making under
dure is required to save the tooth. The patient will uncertainty: a decision analytic approach to manage¬
ment of periapical lesions in endodontically treated
usually appreciate this careful and thoughtful ap¬
teeth, Endodont Dent Traumatol 3:15-20, 1987.
proach even if the tooth is treated unsuccessfully Rud J: A study of failures after endodontic surgery by radi¬
and surgery is needed later. One of the most fre¬ ographic, histologic and stereomicroscopic methods, Int
quent reasons for surgery is failed endodontics in J Oral Surg 1:311, 1972.
a tooth with a post restoration (Fig. 2-15). This Seltzer S, Bender IB, Smith J et al: Endodontic failures: an
analysis based on clinical, roentgenographic and histo¬
tooth has a PAR with two broken files in the
logic findings. I, II, Oral Surg 23:500-530, 1967.
mesial root and a post in the distal canal. In this Siaai IH: Endodontic perforations: their prognosis and treat¬
case, the post and crown restoration had been ment, J Am Dent Assoc 95:90-95, 1997.
placed within the last year. Although removing the Souyave LCJ, Inglis AT, Alcalay M: Removal of fractured en¬
post and retreating the tooth with a nonsurgical dodontic instruments using ultrasonics, Br Dent J 159:
endodontic technique is sometimes possible, 251, 1985.
Stabholz A, Friedman S: Endodontic re-treatment: case se¬
there is often a price to pay: the post removal ne¬
lection and technique. II. Treatment planning for re-treat¬
cessitates removal of healthy root structure by ul¬ ment, J Endodont 14:607-614, 1988.
trasonic or other means. This often weakens the Wong R, Cho F: Microscopic management of procedural
root significantly enough to lead to a root fracture errors, Dent Clin North Am 41:455-480,1997.
'
’
CHAPTER 3
PATIENT EVALUATION
AND PREMEDICATION
KEY CONCEPTS geon the opportunity to assess the patient’s state
• Medical, oral, and radiographical examinations of mind and physical condition and allows the pa¬
should be completed before surgery. tient to develop trust in the surgeon. This rapport
• An interview with the patient should be con¬ is extremely important because a local anesthetic
ducted in layman's terms, preferably during a is used for most surgery. Although the patient
separate visit before surgery feels no pain during the surgery, the person’s an¬
• Patients who have diabetes mellitus or chronic xiety level usually is quite high.
disorders must be given the appropriate pre¬ The surgeon should also explain to the patient
operative antibiotics. that a surgical microscope and microsurgical
• If questions about medications arise, the pa¬ methods will be used. For most patients this
tient’s physician should be consulted. probably will be the first experience with a surgi¬
• Any anticoagulative agents (e.g., aspirin, cal microscope, and having it come within a few
Coumadin) and other drugs that interfere with inches of the face can be very intimidating.
the blood clotting mechanism must be discon¬
tinued a few days before surgery.
• Almost all surgery is done using a local MEDICAL EVALUATION
anesthetic. A systematic approach is essential in determin¬
• The patient’s anxiety should be alleviated as ing the patient’s medical condition. To compile a
much as possible. thorough medical history, especially a history of
• Surgery should last as long as necessary but be allergic reactions and a list of prescribed medica¬
as short as possible; ideally, it should be com¬ tions taken, the surgeon must listen carefully to
pleted within 1 hour. the patient. Patients may forget that they have
taken a certain medicine intermittently or that
they had an allergic reaction to a drug a few years
PATIENT INTERVIEW ago. The surgeon sometimes must ferret out this
The patient interview is an important part of the information by persistent probing because aller¬
diagnostic workup. It should be done before the gic reactions and current medications must be
surgery, preferably on a separate visit. Most pa¬ considered when prescribing postoperative
tients face endodontic surgery with apprehension drugs. Fortunately, only a few medicines may not
and sometimes outright fear. Therefore it is most be taken with postoperative medications such as
important to establish a rapport with the patient antibiotics and analgesics.
and to explain in everyday language the reason for Although there are few medical contraindica¬
the surgery, the procedure itself, the postopera¬ tions to endodontic surgery, advanced diabetes
tive sequelae, and the prognosis. The clinician mellitus and cardiovascular and hematological
should answer all questions patiently and in disorders are some of the more common condi¬
terms the individual can understand. When the tions that require consultation with the patient’s
patient understands the need for the surgery and physician.
agrees to it, an informed consent form is pre¬ Because endodontic surgery produces a tran¬
sented for signature. The interview gives the sur¬ sient bacteremia, antibiotics must be given pro-
25
BOX 3-1 Recommended Prophylactic Regimen for Dental, Oral, and Upper Respiratory
Procedures in High-Risk Patients*
1. Standard regimen: If the patient is allergic to ampicillin, amoxicillin, or
Amoxicillin penicillin and cannot take oral medications, the regimen is:
Adults: 2 g orally (PO) 1 hour before procedure Clindamycin
Children: 50 mg/kg PO 1 hour before procedure Adults: 300 mg IV 30 minutes before procedure;
then 150 mg IV or PO 6 hours after initial dose
If the patient cannot take oral medications, the regimen is:
Children: 10 mg/kg 6 hours after initial dose
Adults: 2 g intramuscularly (IM) or intravenously (IV)
3. Regimen for high-risk patients who are not candidates
Children: 50 mg/kg IM or IV 30 minutes before
for the standard regimen:
procedure
Ampicillin, gentamicin, and amoxicillin
2. Regimen for patients allergic to amoxicillin or
Adults: Ampicillin (2 g) plus gentamicin (1.5 mg/kg,
penicillin:
not to exceed 80 mg) IM or IV 30 minutes before
Clindamycin
procedure; then amoxicillin 1.5 g PO 6 hours after
Adults: 600 mg PO 1 hour before procedure
initial dose (as an alternative, the parenteral regimen
Children: 20 mg/kg PO 1 hour before procedure
may be repeated 8 hours after initial dose)
Cephalexin or cefadroxil
Children: Ampicillin (50 mg/kg) plus gentamicin
Adults: 2 g
(2 mg/kg); then half the initial dose 6 hours later.
NOTE: Amoxicillin is not recommended for use as
Azithromycin or clarithromycin
the initial dose; it can be used as the follow-up dose
Adults: 500 mg
(25 mg/kg)
4. Regimen for high-risk patients allergic to ampicillin,
If the patient cannot take oral medications, the regimen is: amoxicillin, or penicillin:
Ampicillin Vancomycin
Adults: 2 g IM or IV 30 minutes before procedure; Adults: 1 g IV given over the course of 1 hour just
then 1 g IM or IV (or amoxicillin 1.5 g PO) 6 hours before procedure; no repeat dose necessary
after initial dose Children: 20 mg/kg then half the initial dose 6 hours
Children: 50 mg/kg IM or IV 30 minutes before later; the total pediatric dose should not exceed the
procedure; then 25 mg/kg IM or IV 6 hours later total adult dose (5).
*Patients at high risk include those with prosthetic heart valves.
phylactically for patients with a history of rheu¬ it is important to listen carefully and to gather the
matic fever, endocarditis, abnormal or damaged relevant information from a patient who usually
heart valves, organ transplantation, or placement has no medical or dental training.
of an implant prosthesis such as a hip joint or Pain and swelling are the symptoms that most
knee replacement. It is important that the patient often prompt a patient to seek endodontic treat¬
be treated in consultation with the primary physi¬ ment. The patient may report persistent pain, and
cian and that the recent guidelines for prophylaxis many complain of referred pain such as an ear¬
established by the American Heart Association ache or heaviness or tightness of the jaw or mus¬
(AHA), presented in Box 3-1, are observed. cles. An earache usually indicates a problem with
Determining the patient’s medical problems an infected ipsilateral mandibular molar tooth.
and preparing the patient properly are simply a Extraoral swelling or cellulitis alters the con¬
matter of practicing good medicine. It gains the tour of the patient's face. In such cases surgery
patient’s confidence and thereby makes the pro¬ should be postponed until the swelling has been
cedure easier for the patient and the surgeon. resolved through administration of antibiotics.
Surgery should not be attempted while an ag¬
gressive, large, hard swelling is present.
ORAL EVALUATION Intraoral inflammation and local mucosal
The oral examination should be conducted in a swelling change the color and contour of the mu¬
systematic manner that follows a specific se¬ cosa over the root surface. If swelling is present, it
quence. The patient’s complaint and the chrono¬ should be palpated to determine its character. A
logical history of the problem should guide the soft, fluctuant swelling indicates a local acute ab¬
line of inquiry to identify the etiology and source scess that requires incision and drainage. If a fis¬
of the problem. As with the medical examination, tulous tract or sinus tract has developed in the
Chapter 3 Patient Evaluation and Premedication 27
Fig. 3-1 A, Fistulous tract between tooth #5 and tooth #6. Fig. 3-2 A, Tooth root has a halo appearance, strongly sug¬
B, Gutta-percha point clearly identifies the origin of the tract at gesting a fracture. B, A vertical fracture along the buccal aspect
tooth #5. of the root was identified upon elevation of the flap. The tooth
is unsalvageable.
mucosa, a gutta-percha point is gently inserted Vertical fractures are difficult to detect clinically
along the tract until it meets resistance. A radi¬ and radiographically unless the fracture is com¬
ograph taken at the point of resistance can iden¬ plete and an instrument can be wedged into the
tify the origin of the fistula. This procedure is es¬ space. On a radiograph, a halo-shaped radiolu-
sential for identifying the correct tooth because cency around the root that is accompanied by a
the exit of the fistula may be away from its origin, deep, wide probable space most often indicates
as shown in Fig. 3-1. that the root is fractured (Fig. 3-2). If the clinical
The tooth should be checked for fractures, and conditions are inconclusive and the tooth might be
its periodontal condition should be assessed. saved, exploratory surgery should be considered.
Pocket depth, tooth mobility, and radiographical
findings are important criteria for determining if
endodontic surgery can be performed. If severe RADIOGRAPHIC EVALUATION
periodontal defects exist that must be taken into The radiograph is still one of the most important
account during surgery, the patient must be in¬ diagnostic aids, and valuable information can be
formed. Failure to inform the patient of factors obtained from a radiograph in the evaluation for
that might compromise the outcome of the periapical surgery. Anatomical deviations, frac¬
surgery allows unrealistic expectations to de¬ tures, periradicular pathosis, evidence of trau¬
velop. For example, when the surrounding corti¬ matic injury, root resorption, periodontal disease,
cal bone is of poor quality and the tooth demon¬ changes in bone patterns, and the success or fail¬
strates mobility (i.e., Class E and Class F lesions), ure of endodontic therapy are some of the salient
the success of endodontic surgery becomes less points that can be determined by radiographs.
predictable. Comparison of previous and current radiographs
Fig. 3-3 Radiograph showing the apices of the second premo¬

lar and the first molar and their proximity to the inferior alveo¬
lar nerve bundle and mental foramen. Apical surgery on the
second premolar must be approached with utmost caution be¬
cause it is closest to the mental foramen.
Fig. 3-4 A, and B, Diagram showing the systematic examination of a radiograph before
surgery, including such features as the apical curvature, the length of the roots, and the prox¬
imity of the roots to the inferior alveolar canal and mental foramen. From Beer/Baumann/Kim:
Color atlas of dental medicine: Endodontology, New York, 2000, Thieme Verlag Stuttgart.
can determine whether an area of periradicular It is important to view the radiographs system¬
pathosis is new or recurrent or has enlarged, in¬ atically. A diagram showing such a system is pre¬
dicating the need for periradicular surgery. sented in Fig. 3-4.
At least two radiographs taken from different One of the radiographs is a normal frontal
angles are needed to ascertain root length and view; the other is taken 25 to 30 degrees mesially
morphology and root proximity to the mental or distally. The following factors are determined:
foramen and inferior alveolar nerve bundle
(Fig. 3-3). Two radiographs are absolutely nec¬ • Approximate root length
essary when surgery is done near the mental • Number of roots and their configuration
foramen. The surgeon must translate the two- (e.g., fused or separate)
dimensional information from the radiographs • Degree of root curvature
into a three-dimensional image to determine • Size and type of lesion (e.g., Class B, Class C)
the correct position of the roots and their rela¬ • Position of surrounding structures (e.g.,
tionship to important proximal anatomical mental foramen, sinus) and their proximity
structures. In most cases a definitive decision to the root apex
for either endodontic surgery or nonsurgical • Distance from the root apex to the inferior
endodontic therapy can be made after consid¬ alveolar nerve bundle
ering the radiographic evidence in three-di¬ • Distance between root tips, especially in an¬
mensional space. terior teeth
Chapter 3 Patient Evaluation and Premedication 29
As mentioned before, the surgeon must be able infection after surgery is amoxicillin (500 mg
to translate the two-dimensional radiographic four times a day for 1 week) for patients who are
images into three-dimensional real space. This not allergic to penicillin. For patients who are
skill develops after years of comparing radi¬ allergic to penicillin, clindamycin (300 mg four
ographs with the clinical picture after the flap has times a day for 1 week) can be used in place of
been raised. Not only must surgeons be good sur¬ amoxicillin.
geons; more importantly, they must become ex¬ • Antibacterial rinses: To reduce oral microflora,
cellent diagnosticians. the patient should be instructed to rinse with a
0.12% chlorhexidine gluconate mouth rinse the
night before, the morning of, and 30 minutes
PREOPERATIVE MEDICATIONS before surgery. Continuing the rinsing proce¬
Except for tranquilizers, which should be used se¬ dure for at least 1 week after surgery reduces
lectively, the drugs listed below are common in the population of microorganisms in the oral
medical and dental practice. cavity and promotes better healing.
• Antiinflammatory agents: The patient should

take ibuprofen (800 mg) immediately before SUGGESTED READINGS
surgery to ameliorate the inflammatory re¬ American Heart Association, Council on Dental Therapeu¬
sponse; the medication should not be taken tics: Prevention of bacterial endocarditis: a statement for
earlier than this because bleeding problems dental professionals, J Am Dent Assoc 122:87-92, 1991.
Becker DE: Drug interactions in dental practice: a summary
could arise during surgery. The patient should
of facts and controversies, Compend Cont Educ Dent
continue this dose of ibuprofen for 48 hours af¬ 15:1228-1244, 1994.
ter surgery to prevent or reduce pain and Dionne RA, Phero JC, editors: Management of pain and an¬
swelling. Most patients who follow this regimen xiety in dental practice, New York, 1991, Elsevier.
do not require narcotic pain medication. Hargreaves KM, Troullos E, Dionne R: Pharmacological ra¬
• Tranquilizers: If a patient is very anxious about tionale for the treatment of acute pain, Dent Clin North
Am 31:675-694, 1987.
the surgery, Valium (5 mg) taken before surgery
Hersh EV: Local anesthetics in dentistry: clinical considera¬
provides relief. tions, drug interactions and novel formations, Compend
• Antibiotics: Patients in poor health, those who Cont Educ Dent 14:1020-1028, 1993.
have advanced diabetes mellitus or heart valve Jackson D, Moore P, Hargreaves KM: Preoperative non¬
problems, and those with implanted prosthetic steroidal antiinflammatory drugs for the prevention of
postoperative pain, J Am Dent Assoc 119:641-647,1989.
devices must be given prophylactic medica¬
Malamed SF: The management of pain and anxiety. In Co¬
tions according to the recent AHA recommen¬ hen S, Burn RC, editors: Pathways of the pulp, ed 7, St
dations (see Box 3-1) with an appropriate an¬ Louis, 1998, Mosby.
tibiotic selected in consultation with the Wahl MJ: Myths of dental-induced endocarditis, Arch Intern
primary physician. The drug of choice for local Med 154:137-144, 1994.
V *
'
MICROSURGICAL INSTRUMENTS
KEY CONCEPTS able, and without such instruments endodontic

• Some microsurgical instruments are miniatur¬ surgery under high magnification is nearly impos¬
ized versions of standard surgical instruments, sible. Traditional surgical instruments are simply
but many more were designed exclusively for too large for working at magnifications of X10 to
work under the microscope. X25. Surgical endodontics owes a great debt
• A15C blade works well for most tasks, but a mi¬ to Dr. Gary Carr, the designer and manufacturer of
croblade is useful when the interproximal the first generation of microinstruments for
spaces are very tight. endodontics.
• Micromirrors are key instruments in endodon¬ Some microsurgical instruments are miniatur¬
tic surgery. ized versions of traditional surgical instruments,
• Micropluggers with a 0.2-mm diameter tip and but many more are specifically designed for the
different bent angles are necessary for retrofill- precision needs of endodontic microsurgery, in¬
ing procedures. cluding ultrasonic tips, the Stropko irrigator/drier,
• The Impact Air 45 handpiece with the H 161 and an array of pluggers, cement carriers, and
Lindemann bone cutting bur is the instrument micromirrors.
of choice for osteotomy. The instrument setup described in this chap¬
• 5-0 or 6-0 monofilament suture has replaced ter is the endodontic microsurgical instrument
braided 4-0 silk suture as the suture material of set used in the Department of Endodontics at
choice; sutures are removed within 48 hours of the University of Pennsylvania School of Dental
surgery. Medicine. Fig. 4-1 shows various instrument
• KP retractors (1 through 4), which have a thin¬ categories.
ner blade and a wider mouth than conven¬
tional retractors, were specifically designed for
endodontic microsurgery. EXAMINATION INSTRUMENTS
• Use of the Stropko drier ensures drying of retro- The examination instruments include the mirror,
prepared cavities. periodontal probe, explorer, and microexplorer
• KiS ultrasonic tips (1 through 6) are the mi¬ (see Fig. 4-1, 1). These instruments are shown at
crotips of choice because they are coated with higher magnification in Fig. 4-2.
zirconium nitride for smooth, efficient cutting The dental mirror, periodontal probe, and en¬
of the dentin; they have an irrigation port close dodontic explorer are standard instruments in
to the cutting tip; and they are available in a va¬ endodontic practice. Only the microexplorer is
riety of angles. specifically designed for microsurgery. It has a
2-mm tip bent at 90 degrees on one end and
The operation microscope is not a “high tech” 130 degrees on the other. The short tip makes it
instrument. It has been used in medicine for more particularly easy to maneuver inside the small
than half a century. Several dentists tried to use the bone crypt. This instrument is extremely useful
operation microscope around 1960, about the for looking for the exact site of a leak on the re¬
same time it began to be used in neurosurgery and sected root surface and for distinguishing a frac¬
ophthalmological surgery. It was not used in en¬ ture line or canal from an insignificant craze line.
dodontic surgery until recently, however, primarily In Fig. 4-3 the tip of the microexplorer points to
because no dental microinstruments were avail¬ the origin of a leak on a resected root surface.
31
Fig. 4-1 Endodontic microsurgical instrument setup used in the Fig. 4-4 Incision and elevation instruments.
Department of Endodontics at the University of Pennsylvania
School of Dental Medicine. The objects are grouped as follows:
1, Examination instruments; 2, incision and elevation instru¬
ments; 3, curettage instruments; 4, inspection instruments;
5, retrofilling carrier and plugging instruments; 6, miscellaneous
instruments; 7, osteotomy instruments; S, suturing instruments;
9, tissue removal instruments; 10, tissue retraction instruments.
Fig. 4-5 15C blade in use.
INCISION AND ELEVATION

Fig. 4-2 Examination instruments.
INSTRUMENT
Instruments used for incision and elevation in¬
clude a 15C blade and handle and soft tissue or
periosteal elevators (Figs. 4-4, 4-5). The ideal
scalpel blade for microsurgery is a 15C blade,
which is small enough to manage the interproxi-
mal papilla but large enough to make a vertical re¬
leasing incision in one stroke (Fig. 4-5). Micro¬
blades are useful when the interproximal spaces
are very tight (Fig. 4-6). The soft tissue elevators are
designed to elevate the gingiva and tissue from the
underlying cortical bone with minimum trauma to
the tissue. As shown in Fig. 4-7, one end of the in¬
strument has a thin, sharp, triangular beak and the
other end has a sharp, rounded beak that varies in
size. Unlike the periosteal elevators used in peri¬
Fig. 4-3 The tip of the microexplorer can be used to search for
a leak in a root end filling, to distinguish a canal or craze line
odontics, this new design incorporates thin, sharp
from a microfracture line, and to point to the origin of a leak edges and points that allow the soft tissues to be el¬
for explanation and documentation purposes (x!6). evated from the bone cleanly and completely.
Chapter 4 Microsurgical Instruments 33
F'g 4-6 Microblades are used when the interproximal spaces

Fig. 4-8 Curettage instruments. Specially designed minicurettes
are very tight.
(top five). Minimolten curettes (bottom two).
Fig. 4-7 Enlarged view of tips of soft tissue elevators (Fig. 4-4, Fig. 4-9 Enlarged view of the tips of minijacquettes and mini¬
middle and bottom). endodontic curettes used on the lingual wall or periodontal
ligament.
CURETTAGE INSTRUMENTS
Curettage instruments (Fig. 4-1,3 and Fig. 4-8) in¬
clude a minijacquette 34/35 scaler, a Columbia
13-14, and minimolten and miniendodontic
curettes. Curettage generally is not a microsurgi¬
cal procedure because any periodontal curette
can be used for that purpose. The exception is
curettage of the lingual wall or periodontal liga¬
ment, which requires miniaturized curettes. Mini-
jacquettes and miniendodontic curettes (Fig. 4-9)
were designed especially for this purpose.
INSPECTION INSTRUMENTS
Fig. 4-10 Micromirrors with sapphire surfaces (center) and
Fig. 4-10 shows four micromirrors of two types
stainless steel surfaces (top and bottom with blue handles).
(also see Fig. 4-1, 4). Two of the mirrors (Fig.
4-10, two in the center) are made of stainless steel.
The micromirrors with blue handles (Fig. 4-10, top
Fig. 4-11 Stainless steel surface micromirrors. Round (3 mm in Fig. 4-12 Round micromirror reflecting the entire surface of the
diameter) and modified rectangular; size comparison with reg- resected root of a maxillary anterior root,
ular dental mirror.
Fig. 4-13 Retrofilling carriers. One has a straight blade; the Fig. 4-14 Magnified view of blades of retrofilling carriers
other has a 45-degree angled blade for hard to reach areas. shown in Fig. 4-13.
Fig. 4-15 Magnified view of ball burnisher end of retrofilling Fig. 4-16 Retrofilling material (SuperEBA) is carried to the retro-
carriers shown in Fig. 4-13. preparation with the flat surface of the retrofilling carrier and
condensed with the ball burnisher end of the carrier.
and bottom) have scratch-free sapphire mirror sur¬

faces. Fig. 4-11 shows two stainless steel micromir¬
rors, one round, one rectangular, next to a regular
dental mirror for size comparison. Micromirrors
are available in many different shapes, but the two
shown in Fig. 4-11 have proved most useful.
An important feature of the mirror neck is flex¬
ibility. The necessity of this is demonstrated in
Fig. 4-12, which shows a round micromirror po¬
sitioned at a 45-degree angle to the resected root
to reflect the entire root surface. Without the abil¬
ity to bend the micromirror neck to accommo¬
date the angle, the resected root surface could
not be viewed clearly or completely. Fig. 4-17 Micropluggers with different bends and angles.
RETROFILLING CARRIER AND

PLUGGING INSTRUMENTS
Fig. 4-13 shows two retrofilling carriers (also see
Fig. 4-2, 5). Each has a 0.5-mm diameter ball on
one end and a 1-mm wide blade on the other.
One blade is in line with the handle, and the
other is offset at 45 degrees (Fig. 4-14). The flat
surface is designed to carry retrofilling material
to the retropreparation, and the ball end is de¬
signed for packing the material into the prepara¬
tion (Fig. 4-15). Use of the carrier for this purpose
is shown in Fig. 4-16.
Fig. 4-17 shows six micropluggers, all of which
have ball ends ranging from 0.2 to 0.5 mm in di¬ Fig. 4-18 Straight-handled micropluggers, one with a 90-degree
ameter on one end. Two of the instruments have tip and one with a 65-degree tip. The 90-degree tip is for univer¬
a 90-degree and a 65-degree tip with a straight sal use; the 65-degree tip is useful for the lingual apex.
handle (Fig. 4-18). Two angled microplugger tips
are offset by 65 degrees, one left and one right for
left and right molar surgeries (Fig. 4-19). All mi¬
croplugger tips are 3 mm long and 0.2 or 0.5 mm
in diameter. Micropluggers are shown in working
position in Fig. 4-20.
MISCELLANEOUS INSTRUMENTS
A number of miscellaneous instruments are used
in endodontic microsurgery (see Fig. 4-1, 6). A
large ball burnisher (Fig. 4-21, top) and a bone file
(Fig. 4-21, bottom) are used to smooth the bone
and root surface, to mold bone augmenting ma¬
terial, such as calcium sulfate, to the bone con¬
tours. A minirongeur is used to remove granula¬
tion tissue from a lesion. The beaks of these Fig. 4-19 Double-angled microplugger tips for posterior roots.
rongeurs (Fig. 4-22) are miniaturized to fit into the
hard to reach areas deep inside the bone crypt.
Fig. 4-20 A and B, Micropluggers in working position, here condensing Super EBA into a retro-
prepared cavity. From Beer/Baumann/Kim: Color atlas of dental medicine: Endodontology, New York,
2000, Thieme Verlag Stuttgart.
OSTEOTOMY INSTRUMENTS
The Impact Air 45 handpiece (Fig. 4-23 and Fig.
4-1,7) is designed to direct water onto the cutting
surface by channeling it along the surface of the
bur while the air is ejected through the back of
the handpiece. This reduces the chance of em¬
physema and pyemia and creates less splatter
than a conventional handpiece. The handpiece’s
45-degree angled head makes it easier to work in
difficult-to-reach areas.
The H 161 Lindemann bone cutting bur has
fewer flutes than conventional burs, resulting in
less clogging and frictional heat and more effi¬
Fig. 4-21 Miscellaneous instruments used in endodontic mi¬ cient cutting.
crosurgery. Top, Large ball for facilitating condensation of large
areas of calcium sulfate. Middle, Minirongeur for removing
granulation tissue from the bone crypt. Bottom, Double-ended
SUTURING INSTRUMENTS
bone file for smoothing rough edges.
The Laschal microscissors, or any small-beaked
scissors, and the Castroviejo needle holder are
used to manage 5-0 or 6-0 synthetic sutures (Fig.
4-24 and Fig. 4-1, 8). We recommend these two in¬
struments because standard large-beaked scis¬
sors do not cut well enough and are too large in a
microsurgical environment. Other needle holders
also are too large for microsurgery. The smaller,
more delicate Castroviejo needle holder may re¬
quire some adjustment at first but will reward the
surgeon with greater ease in delicate and difficult
suturing. Before the advent of microsurgery, 4-0
silk sutures were the standard for endodontic
surgery, but they are no longer recommended.
Because silk sutures are braided and thick,
Fig. 4-22 Miniaturized rongeur beaks shown in Fig. 4-21. These
plaque, food debris, and bacteria readily accumu¬
thin beaks are ideal for removing tissue from small osteotomy late on them, resulting in secondary inflamma¬
sites. tion in the suture site.
Fig 4-23 Osteotomy instrument. The impact Air 45 handpiece Fig. 4-25 Tissue retraction instruments. Top to bottom, KP 1, KP
is designed to irrigate the surgical site while ejecting air from 2, KP 3, and KP 4 retractors,
the back of the handpiece, eliminating water splatter.
Fig. 4-24 Suturing instruments. Top, Castroviejo needle holder. Fig. 4-26 Retractor tips magnified for comparison with the
Bottom, Laschal microscissors. commonly used endodontic retractor (far right).
To prevent this inflammation and associated tractor with the same features as the others but
delayed healing, 5-0 and 6-0 monofilament su¬ has the standard 10-mm width. The KP retractor
tures of nylon or polypropylene are now used. tips are modeled on the concavities and convex¬
Similarly, suture needles with a triangular cross ities of the cortical bone plate. Fig. 4-26 shows a
section for easy penetration of the tissue and l/z magnification of the retractor tips for compari¬
and 3/8 curvatures are recommended. son with an endodontic retractor.
Using an endodontic retractor on a convex or
flat bone surface is difficult (Fig. 4-27, A). The con¬
TISSUE RETRACTION INSTRUMENTS tact with the bone is limited to a very small area;
The new retractors developed for microsurgery in contrast, the KP 1 retractor fits the convex con¬
eliminate many deficiencies of previous retrac¬ tour of the bone (Fig. 4-27, B). Limited contact
tors. The Kim/Pecora (KP) 1, 2, and 3 retractors surface is also a problem when an endodontic re¬
have wider mouths than conventional retractors tractor is used in the mandibular anterior region
(15 mm compared with 10 mm) and are 0.5 mm because of the convexity of the bone and the
thinner (Fig. 4-25 and Fig. 4-1,10). Their serrated shape of the retractor tip (Fig. 4-28, A). The KP 2
ends anchor the retractors securely onto the retractor (Fig. 4-28, B) is designed for use with the
bone. The KP 4 retractor is a small, all-purpose re¬ convex bone contours of the mandibular anterior
A B
Fig. 4-27 A, Endodontic retractor is difficult to use on a convex bone. B, The KP 1 retractor fol¬
lows the contour of the bone.
A B
Fig. 4-28 A, Endodontic retractor is difficult to use on a convex bone of the mandibular anterior
region. B, KP 2 retractor follows the convex contour of the mandibular bone for perfect retraction.
bone. The full contact of the retractor tip with the eter micro tips (Ultradent Co.). It is easy to use
bone provides a secure, stable hold, eliminating and highly effective for irrigating and drying
sudden or creeping slippage that results in trau¬ retropreparations, as shown in Fig. 4-30. It sup¬
matized tissue, swelling, and painful healing. It plants the use of paper points to dry the prepa¬
also eliminates interference and interruption dur¬ ration, which is tedious and time-consuming
ing the surgery and assistant fatigue. Many re¬ and provides no certainty that the preparation
tractors are available on the dental market, but is completely dry.
only the KP retractors are designed especially for • Ultrasonic units and tips: Ultrasonic units cre¬
endodontic surgery; other types do not provide a ate vibrations in the range of 30 to 40 kHz by
secure hold during flap retraction. exciting quartz or ceramic piezoelectric crystals
In addition to the items on the tray, the follow¬ in the handpiece. The energy created is carried
ing equipment and instruments are essential for to the ultrasonic tip, producing forward and
microsurgery: backward vibrations in a single plane. Continu¬
ous irrigation along the cutting tip cools the
• Stropko irrigator/drier: This simple but most surface and maximizes debridement and
useful device (Fig. 4-29) fits on a standard cleaning. The three most widely used ultra¬
air/water syringe and uses blunt 0.5-mm diam¬ sonic units are the EMS Miniendo (Analytic
Fig. 4-29 Stropko irrigator/drier with Ultradent microtip. Fig. 4-31 Ultrasonic units. Left, EMS Miniendo (Analytic Endo).
Center, Spartan (Spartan/Obtura). Right, P-5 (Satelec).
Fig. 4-30 Use of the Stropko irrigator/drier to dry prepared Fig. 4 -32 Original ultrasonic Carr tips. Left to right, CT 1, CT 2,
cavities (x10). CT 3, CT 4, and CT 5.
Endo), the Spartan (Spartan/Obtura) and the

P-5 (Satelec) (Fig. 4-31).
Surgical ultrasonic tips, first designed by Dr.

Gary Carr, are known as Carr tips, or CTs. They are
V4 mm in diameter and about V10 the size of a
conventional microhead handpiece. The original
CTs (1-5) are shown in Fig. 4-32. The CT 1 and
CT 5 have the same design except that the CT 5 is
more sharply pointed (Fig. 4-33, center). The
hook-shaped tip, known as a back-action or CK
tip, is very effective for cleaning the buccal wall
of a canal (Fig. 4-33, right). The CT 1 and CT 5 tips
are used mainly for maxillary and mandibular Fig. 4 -33 Enlarged view of ultrasonic tips. Left, CT 1. Center, CT
anterior teeth (Fig. 4-34). The CT 2 and CT 3 have 5. Right, Back-action (or CK).
a double angle to facilitate work in posterior teeth
(Fig. 4-35). CTs are made of stainless steel and
Fig. 4-34 CT 1 for in use in maxillary anterior teeth. Fig. 4-36 KiS tips. Left two tips, KiS 3 and KiS 4; middle two, KiS 1
and KiS 2; right two tips, KiS 5 and KiS 6.
have not been altered since their introduction

more than a decade ago. However, surgeons are
now familiar with ultrasonic retropreparation
and want improved tips, such as better cutting
tips and those with a more efficient irrigation
port. In 1999 Spartan/Obtura introduced a new
type of ultrasonic tip.
The Kim Surgical (KiS) ultrasonic tip is the
next generation of microsurgical tips. It is coated
with zirconium nitride and has an irrigation port
near the tip rather than in the shaft (as with CTs).
The KiS tips are shown in Fig. 4-36. The enlarged
view of a KiS tip, which has a 3-mm cutting tip,
is shown in Fig. 4-37. These advanced tips cut
faster and smoother and cause fewer microfrac¬
tures because of the improved positioning of the
irrigation port (Fig. 4-38). The KiS 1 tip, which
has an 80-degree angled tip and is 0.24 mm in di¬
ameter, is designed for the mandibular anterior
teeth and premolars (Fig. 4-39). The KiS 2 tip has
a wider diameter tip and is designed for wider
apex teeth (e.g., maxillary anteriors) (Fig. 4-40).
The KiS 3 tip (Fig. 4-41) is designed for hard to
reach posterior teeth. It has a double bend and a
75-degree angled tip for use in the maxillary left
side or the mandibular right side. The KiS 4 tip is
F'g 4-35 A, CT 2 and CT 3 have double angles, which facilitate
similar to the KiS 3 except that the tip angle is
use in posterior teeth. B, CT 3 is used in mandibular molar
roots. 110 degrees, to reach the lingual apex of molar
roots. The KiS 5 tip is the counterpart of the KiS 3
for the maxillary right side and the mandibular
left side (Fig. 4-42). The KiS 6 tip is the counter¬
part of the KiS 4 tip.
Fig. 4 -37 Enlarged view of KiS 1 tip, which is 3 mm long and

0.24 mm in diameter and has an 80-degree angle. The tip is
coated with zirconium nitride for smooth, efficient cutting of
dentin.
Fig. 4-38 A, KiS 4 tip showing irrigation port near tip. B, Water shooting from irrigation port,
bathing the tip.
Fig. 4-39 A, The KiS 1 tip is designed for use in anterior teeth. The tip is in position for retro-
preparation of the mandibular anterior tooth. B, Enlarged view of the tip touching the canal
orifice in the resected root surface.
A B
Fig. 4-40 A, KiS 2 tip, which has a larger diameter than the KiS 1 tip, in position to retroprepare
the larger maxillary anterior tooth apex. B, Enlarged view of A.
Fig. 4-41 A, Double-angled KiS 3 tip in position to retroprepare the mesiobuccal root of the
maxillary left first molar. B, Enlarged view of A.
F ig. 4 42 A, Double-angled KiS 5 tip in position to retroprepare the mesial root of the
mandibular left first molar. B, Enlarged view of A.
BOX 4" 1 Manufacturers of Microsurgical

Instruments
(A \F RAI Ml( KOSURGICAf INSTRUMENTS
An al ytic f in do
Uuf'riedy
Ifart/.di & Son
Ul'f RASONIC UNITS AND TIPS

Spartan/Obtura tKiS tips)
Analytic l.ndo (Cl tips)
Satelec/Amadent Manufactures its own brand of tips)
DENTAL CART
A dental cart specifically designed for endodontics
and endodontic microsurgery by Spartan/Obtura
is shown in J ig. 4-43. The cart is a compact, all in
one unit with the essentials built in. it has a tank
for sterilized water (an important feature), highl¬
and low-speed handpiece ports, an ultrasonic unit,
and a Stropko irrigator/drier. This cart is an impor¬ Fig. 4-43 Dental cart designed especially for endodontics and
tant piece of equipment for a modern micro¬ microsurgery by Spartan/Obtura. It has high- and low-speed
surgery practice. Box 4-1 presents a list of manu¬ handpiece hookups, an ultrasonic unit, a Stropko irrigator/drier,
facturers of microsurgical instruments. and a tank for sterilized water.
.
'
USE OF THE SURGICAL
MICROSCOPE
KEY CONCEPTS 5-1). When a fiberoptic headlamp system is added
• Greater visual acuity with the surgical micro¬ to the armamentarium, light is projected coaxial
scope’s wide range of magnifications and bright with the line of sight into the surgical field; en¬
illumination allows for a higher success rate. dodontic procedures, both surgical and nonsur-
• The medical disciplines (e.g., neurosurgery; ear, gical, can be performed with less eyestrain and fa¬
nose, and throat [ENT]; and ophthalmology) in¬ tigue (Fig. 5-2).
corporated the surgical microscope into prac¬ Surgeons who have used surgical telescopes
tice 30 years ago; dentistry is 20 years behind. and surgical headlamps have benefited from the
• An assistant observation scope attached to the increased magnification and illumination. These
main scope reduces the maneuverability of the telescopes and loupes provide magnification
surgical microscope and the effectiveness of ranging from X2 to X6. However, the problem
the assistant. with magnification instruments attached to the
• The minimum requirements for endodontic head is that even moderate movements of the
microsurgery are five-step magnification, a head result in total visual dislocation and loss of
light source carried by a fiberoptic cable, and a the visual field, especially at higher magnifica¬
180-degree inclinable binocular. tions. Efficient use of these visual aids requires a
• The important features of an endodontic sur¬ steady head and only incremental movements, a
gical microscope are optics, maneuverability, difficult habit to acquire. The surgical microscope,
stability, and modularity. in contrast, is much easier to use, especially with
• Documentation by means of a video camera at¬ low to midrange magnification (X3 to X16).
tached to the microscope is valuable for com¬ The most useful overall magnification range is
municating with referring dentists and for X3 to X30. The low magnifications (X3 to X8)
teaching patients and students. produce a wider field of view and high focal
• A basic surgical microscope for dentistry depth; this keeps the field in focus despite mod¬
should have the following configuration: X 12.5 erate movements. This range therefore is useful
eyepieces with reticule for orientation within the surgical field and for
• 200- or 250-mm objective lens alignment of instrument tips. The midrange mag¬
• 180-degree inclinable binocular nifications (X10 to X16) provide moderate focal
• Five-step manual magnification changer or depth. In endodontics these are the “working”
power zoom magnification changer magnifications; they provide reasonably large
• Fiberoptic illumination system magnification for all microsurgical procedures
• Audiovisual accessories (e.g., video camera) and a moderately deep field, which keeps the
field in focus despite small movements. The high
One of the more significant developments in magnifications (X20 to X30) are used only for in¬
surgical endodontics in recent years has been the spection of fine detail, such as a resected root sur¬
incorporation of the surgical microscope. Most face. At these magnifications the focal depth is
dentists have had clinical experience with loupes shallow, and the field moves out of focus with
and surgical headlamps or conventional surgical even slight movements.
telescopes, which are commonly available in a va¬ The photographs in Fig. 5-3 show SuperEBA
riety of configurations and magnifications (Fig. retrofillings in both roots of a mandibular right
45
• Video recordings of the procedure can be used

for patient teaching.
• Communication with referring dentists and in¬
surance companies can be improved.
• Video libraries can be madqvfor teaching pro¬
grams. Video recordings of different surgical
procedures and techniques can be effective
teaching tools.
• Occupational stress can be reduced. Use of a
surgical microscope requires erect posture;
also, the clinical environment is less stressful
when clinicians can see what they are doing
rather than guessing.
Fig. 5-1 Surgical telescopes or loupes.
It is important to understand how the surgical
microscope works. The four major areas dis¬
cussed here are magnification, illumination, ac¬
cessories, and documentation.
Magnification
Magnification is determined by the power of the
eyepiece, the focal length of the binoculars, the
magnification change factor, and the focal length
of the objective lens. Fig. 5-4 presents a surgical
microscope and a diagram of each component,
showing how magnification is calculated.
Eyepieces
Eyepieces play an important role in magnifica¬
tion. Together with the focal length and magnifi¬
Fig. 5-2 Surgeon using a surgical headlamp and telescopes. cation change factors, they provide the desired
magnification of an object. Eyepieces generally
are available in powers of X6.3, X10, X 12.5, X16,
and X20 (Fig. 5-5). The viewing side of an eye¬
first molar at increasing magnification. These pic¬ piece has a rubber cup, which is turned down if
tures clearly demonstrate the benefits of en¬ the surgeon wears eyeglasses. Eyepieces also
hanced magnification and illumination. Cer¬ have adjustable diopter settings from -5 to +5.
tainly, if a task can be seen better, it can be An eyepiece with a reticule field can be substi¬
performed more accurately. Endodontic surgery tuted for a conventional eyepiece and can prove
is no exception. an invaluable aid for alignment during videotap¬
The surgical microscope can provide impor¬ ing and 35-mm photography.
tant benefits in clinical practice in the following
ways: Binoculars
The function of the binoculars is to project an in¬

• The surgical field can be inspected at high mag¬ termediate image into the focal plane of the eye¬
nification so that minute details of anatomical pieces. The interpupillary distance is set by ad¬
structures (e.g., the lateral canal apex) can be justing the distance between the two eyepieces.
identified and managed. Once the diopter setting and interpupillary dis¬
• Surgical techniques can be evaluated. tance adjustments have been made, they should
• Fewer or no radiographs may be needed dur¬ not need to be changed unless the microscope is
ing surgery because the surgeon can inspect used by a surgeon with different optical require¬
the apex or apices directly. ments. Binoculars often come in different focal
Chapter 5 Use of the Surgical Microscope 47
Fig. 5-3 A, X4 magnification of tooth #30 showing SuperEBA retrofill in mesiobuccal, mesi-
olingual, and distal canals. B, At X8 magnification the distal and mesial roots are in the field of
view. C, At X10 magnification the distal roots are almost out of view. D, At Xl6 magnification
only the distal root is not visible. E, At X20 magnification details of the resected root surface of
the mesial apex can be seen. F, At X26 magnification fine details are visible.
f lube
Mtotal
f objective
Kepler telescope
Tube with eyepieces
■ f tube = focal length of the tube
A f objective = focal length of
the objective
y = factor of the
Galilean changer magnification changer
Magnification changer M eyepieces = magnification of
the eyepiece
cool light
Loupe
Objective
Fig. 5-4 A, Surgical microscope. B, Diagram of the microscope. The basic components are the
binocular with eyepiece, magnification changer, objective lens, and illumination system. Calcu¬
lation of magnification is given at right.
Fig. 5-5 Eyepieces: X10, X12.5, X16, and X20 magnification. Fig- 5-6 Inclinable binocular.
lengths. When choosing binocular focal lengths, Magnification Changers

it is important to remember that the longer the Magnification changers, located in the head of
focal length, the greater the magnification. Binoc¬ the microscope, are available as three- or five-
ulars are available either as straight, inclined, or step manual changers or power zoom changers
inclinable. Straight binoculars are orientated par¬ (Fig. 5-7). Power zoom changers avoid the mo¬
allel to the optical axis of the microscope, mentary visual disruption or jump common to
whereas inclined binocular tubes are offset at a three- or five-step manual changers. Magnifica¬
45-degree angle. Inclinable binoculars (Fig. 5-6) tion changer functions in power zoom micro¬
are adjustable for positions up to and sometimes scopes are controlled either by manual knobs at
beyond 180 degrees. the side of the microscope near the objective lens
The inclinable binocular is the most useful for or by foot control.
endodontic surgery. It allows the surgeon to look Magnification of an image with a microscope
directly at the maxillary and mandibular arches depends on many factors. Charts that explain
and has all the advantages of the other binocu¬ magnification as it relates to eyepiece power,
lars with the additional advantage of postural binocular focal length, magnification factors, and
comfort and flexibility. objective lenses are shown in Box 5-1. They con-
Fig. 5-7 Magnification changer dial. Fig. 5-8 Objective lenses. Focal lengths range from TOO to
400 mm.
tings must be set individually. The microscope

BOX 5-1 Calculating Total Magnification
should be parfocalled once a month to keep it
The equation for calculating total magnification is properly focused for even subtly changing eye¬
Mt = ft/fo X Me X Mc sight. Parfocaling prevents unnecessary eye fa¬
tigue and strain.
where:
Mt = Total magnification Objective Lens
ft = Focal length of the binocular tube
f0 = Focal length of the objective lens The focal length of the objective lens determines
Me = Magnification of the eyepiece the distance between the lens and the surgical
Mc = Magnification factor held. A variety of objective lenses are available with
focal lengths ranging from 100 to 400 mm (Fig.
5-8). A 175-mm lens focuses at about 7 inches,
a 200-mm lens focuses at about 8 inches, and
tain information that can help the surgeon select a 400-mm lens focuses at about 16 inches. The
the appropriate optical components. They also 200-mm objective lens is recommended for en¬
explain magnification as it relates to depth of dodontic microsurgery because this distance pro¬
field and field of view. vides adequate room between the surgical held
and the objective lens for surgical instruments and
Focusing Knob constitutes a comfortable working distance.
The surgical microscope is focused much like a
laboratory microscope. The manual focusing Optimum Configurations for Endodontic
knob, which usually is located on the side of the Microsurgery
microscope housing, changes the distance be¬ Considering the factors just described, a typical
tween the microscope and the surgical field. surgical microscope package should have x 12.5
eyepieces with a reticule, 200- or 250-mm objec¬
Parfocalization tive lens, 180-degree inclinable binoculars, a five-
Parfocaling is the process of setting the operator- step manual magnification changer or a power
specific focus for the entire range of magnifica¬ zoom magnihcation changer. This conhguration
tions. To parfocal a microscope, a flat object, such creates a comfortably working range of about
as a dollar bill or dull copper penny, is placed un¬ 8 inches from the patient at a magnification
der the microscope and focused at the highest range of x3 to x26 (with a 200-mm objective
magnification. The left eye/right eye diopter set¬ lens). The power zoom feature permits smooth
tings are unique to each person and should be transition between magnihcations.
written down, especially if the microscope is Once its advantages have been recognized, the
shared. In this case each surgeon’s diopter set¬ surgical microscope becomes as indispensable
Fig. 5-10 Fiberoptic cable light system.
objective lens, through the magnification changer

lenses, and through the binoculars to the eyes as
two separate optical beams. The separation of the
image beams produces the stereoscopic effect
necessary for depth perception. Another popular
illumination system is the fiberoptic system,
Fig. 5-9 Path of light from a light source using a cross sectional which is widely used by ophthalmologists. It is a
view of a five-step manual microscope. cold light source in which the light of the quartz
halogen bulb is focused onto the end of the
fiberoptic cable. This system also provides an ex¬
cellent light source for the needs of the microen-
in endodontic practice as the high-speed hand- dodontic surgeon (Fig. 5-10).
piece and the radiograph. The surgeon should
use the most maneuverable, flexible, and “user Beam Sputter
friendly” microscope with add-on options so A beam splitter (Fig. 5-11, A) can be inserted in
that procedures can be performed comfortably the optical pathway of the microscope. The
and efficiently. The following features should be beam splitter supplies light to direct the image
considered, in addition to the basics, to achieve to a camera or an auxiliary observation tube (Fig.
an extremely maneuverable microscope: mo¬ 5-11, B). Because the beam splitter divides each
torized zoom, angled and rotating optics, and beam path separately, up to two accessories can
a free-float magnetic clutch system, which be added (Fig. 5-11, Q. Depending on the split
facilitates resistance-free balancing and hands¬ ratio, most of the light is available for the sur¬
free locking of the microscope’s position. geon. The beam splitter is essential for docu¬
mentation. Recently, a microscope with a built-
Illumination in video camera became available. This is a
Fig. 5-9 shows the path that light takes as it travels wonderful development because a beam splitter
through the microscope (a 100-W halogen bulb is expensive.
was used as the light source). The intensity of the
light is controlled by a rheostat, and the lamp is Light Sources
cooled by a fan. The light is reflected through a Two light source systems are commonly avail¬
condensing lens to a series of prisms and then able—the xenon bulb and the quartz halogen
through the objective lens to the surgical field. bulb in the fiberoptic light system. The xenon
The microscope in the illustration has a light field bulb is brighter and produces light almost com¬
width of 50 mm. As the light illuminates the sur¬ parable to daylight. It has a color temperature of
gical field, the image is transmitted through the 5600° K and produces a true color picture. The
Fig- 5 11 A, Beam splitter. B, Beam splitter with a 35-mm camera, photographic adapters, and
video camera attached. C, Light pathways of a beam splitter.
halogen light has a color temperature of 3200° K

and produces a yellow picture. For 35-mm pho¬
tographs, xenon light needs daylight film, whereas
the halogen light uses tungsten film. Illumination
of the surgical microscope is coaxial with the line
of sight.
Accessories
Many accessories are available for the surgical
microscope. Pistol grip or bicycle-style handles
(Fig. 5-12) can be attached to the bottom of the
microscope to facilitate movement of the micro¬
scope during surgery. Either of these two types is
required for maneuverability. Fig. 5-12 Pistol grip and bicyde-style handles.
Also available are observer tubes for assistants.
The reasoning is that the assistants must see what
the surgeon sees so they can assist at the same difference. In endodontic surgery the patient is
magnification. In the medical and surgical fields under local anesthesia and usually moves during
this is done routinely with an assistant doctor who the procedure. In this situation using observer
is being trained. In these settings, patients are un¬ tubes for assistants would create more problems
der general anesthesia and patient movements than it would solve. For endodontic microsurgery,
are not a problem. Endodontic surgery, however, an independent monitor showing what the mi¬
is not neurosurgery, and there is a fundamental croscope “sees” is a more practical solution.
camera that can be used for both 35-mm color

slides and video tapes or prints.
A video print of the completed case can be in¬
cluded with the final radiograph and report to the
referring dentist and kept as a yisual record (Fig.
5-13). Video prints are the most productive com¬
munication tools between the surgeon and the
referring dentist. They are 4X6 iriches in size
and, if desired, different images can be digitized
during the surgery and later recorded on a single
print. Video printers can readily be connected to
a video cassette recorder or the video camera on
the microscope.
Fig. 5-13 Video print of a surgical procedure.
Documentation
As mentioned previously, documentation is an im¬
portant benefit of using the surgical microscope.
The function of the photographic and video The system requirements for documentation (e.g.,
adapters is to attach the 35-mm and video cam¬ video adapter, video camera, video printer) were
eras to the beam splitter, which directs the image discussed earlier in this chapter. The three pur¬
for photographic and video documentation poses of documentation are to communicate with
adapters (see Fig. 5-11, B and Q. Photographic the referring dentist, to educate patients and stu¬
and video adapters also provide the necessary fo¬ dents, and to maintain the required legal docu¬
cal length so that the cameras record an image mentation for each case.
with the same magnification and field of view as For the better treatment of the patient, the spe¬
that seen by the surgeon. Because the 35-mm cialist and the referring dentist must be in close
camera receives only part of the available light communication. In dentistry, especially in en¬
and because color photographic film is relatively dodontics, this communication has involved pri¬
light insensitive, the microscope’s light usually marily the radiograph and the telephone. Adding
must be supplemented by adding a strobe over color video prints of the procedure is a welcome
the objective lens. Although several strobes are development. The referring dentist can see im¬
available, achieving a good 35-mm picture of the portant parts of the procedure, which, for in¬
surgical field has been problematic so far. Recent stance, may illustrate why previous endodontic
advances in digital cameras allow connection to treatment failed.
the microscope without strobe lights and pro¬ We have been educating our future dentists
duce excellent pictures (see Chapter 15). and physicians through lectures, hands-on prac¬
Unlike 35-mm color film, video cameras are tice on models, and actual demonstration of sur¬
extremely light sensitive and do not require sup¬ gical cases. However, using this method alone has
plemental light. Many different video cameras its drawbacks. It is time consuming and makes it
are available, and they generally are capable of impossible to teach everything there is to learn,
capturing about 340 lines of resolution. The reso¬ especially the rarer but more confounding prob¬
lution of the video camera should be matched to lems. By documenting every case on videotape
the recording capability of the video cassette through the microscope, students now have a
recorder and the resolution of the monitor. For large library of real-time surgeries of all kinds
example, an S-VHS format, which records more showing many procedures and techniques. This
than 400 lines of resolution, provides a better has been the single most important development
match for a 340-line camera than a standard VHS of using the microscope for teaching purposes.
format, which records only 230 lines. A video
monitor that can display 420 lines of horizontal
resolution is a good match for a 340-line camera DENTAL MICROSCOPES
and S-VHS video cassette recorder. The major microscope manufacturers, Global,
In the very near future dental surgeons may JedMed, Leica, Moller, and Seiler and Zeiss offer
need perhaps only a high-resolution digital video the microscopes described in this chapter. These
Fig. 5-14 A, OPMI Pro Magis surgical microscope for den¬

tistry. B, Fine focusing knob and zoom magnification changer
are housed inside the bicycle handle. C, By pushing any one of
the three buttons, the microscope head can be moved freely in
any direction. This magnetic, free-float system provides ex¬
ceptional maneuverability and stability of the microscope.
B C
microscopes are essentially otolaryngology (ENT) At the time of this writing, several micro¬
microscopes with minor modifications, if any, for scopes have made a giant step forward in that
the needs of dentistry. Although these microscopes direction. The OPMI Pro Magis dental micro¬
serve the dentist’s needs reasonably well, there are scope by Zeiss (Fig. 5-14, A) is equipped with a
fundamental differences between ENT procedures 180-degree inclinable binocular, motorized
and endodontic microsurgical techniques. The zoom, spot illumination “target” light, zoom/fo¬
ENT surgeon can immobilize the patient’s head, cus function integrated into a conveniently ac¬
whereas the dentist cannot. Therefore a highly ma¬ cessible handle (Fig. 5-14, B), angular and ro¬
neuverable microscope that easily follows a mov¬ tating optics, and a free-float magnetic clutch
ing surgical field is a necessity in dentistry. release system for exceptional maneuverability
purchase of a microscope must be considered a

long-term investment in the practice.
The features of an endodontic microscope
should include (1) excellent optics, (2) mechani¬
cal stability, (3) maneuverability, and (4) modu¬
larity. The most important aspect, the quality of
the optics, is very difficult to assess. Fortunately,
most microscopes on the U.S. market have excel¬
lent optics. Currently microscopic optics are
made in Brazil (Seiler), Germany (Kaps, Leica,
Moller, and Zeiss), Japan (Nikon, Olympus), and
the United States (Global).
Mechanical stability is the second most impor¬
Fig. 5-15 Artist's rendition of the free-float OPMI Pro Magis tant criterion in selecting a microscope. Because
surgical microscope. the microscope must be repositioned many times
during a procedure to accommodate changes in
the patient’s head position, it is important that the
(Fig. 5-14, C). This high-end microscope incor¬ microscope stop moving immediately after being
porates the magnetic clutch technology specif¬ repositioned. The stability of microscopes varies
ically to accommodate the needs of the dentist. greatly. The microscope should not drift, and the
For example, by pushing one of six buttons (see arm should not “bounce” after being moved. To
Fig. 5-14, C), the microscope head can be ro¬ test for mechanical stability, the dentist can gently
tated resistance free (free floating) in any direc¬ tap the end of the arm of the microscope when it
tion (Fig. 5-15). Once the reticule is at the tar¬ is fully extended. In a good microscope, superior
get, the button is released and the microscope suspension and balance mechanisms prevent the
is instantly fixed at that position. Furthermore, arm from moving or bouncing in response to po¬
with a 180-degree binocular and angled optics, sition adjustments.
surgery in the mandibular molar region is much Maneuverability of the microscope is essential
easier because the angle between the binocular because a patient’s head moves frequently, either
and the objective lens is now only 45 degrees in¬ to adjust position or because of involuntary mus¬
stead of the standard 90 degrees. cle activity. The microscope head has to be light
Global has produced a six-step magnification for almost effortless maneuverability. For this
microscope, which is one additional step from the reason it is not advisable to add an assistant
conventional five-step. Most recently Zeiss has of¬ scope or any other large or heavy accessories.
fered an entry level, five-step manual microscope Because a microscope is a life-time investment,
called OPMI Pico, which has a 180-degree inclin¬ modularity, or adaptability, is an important factor.
able binocular. As the surgical microscope be¬ The requirements for the microscope will change
comes a standard piece of equipment in dentistry, with the user’s needs, and other sophisticated fea¬
manufacturers will continue to incorporate fea¬ tures can be added as experience dictates. For in¬
tures that make a truly dental microscope. stance, manual magnification can be changed to
an automatic zoom function. Some microscopes
Selecting an Endodontic Microscope are fully modular, whereas others are limited in
A surgical microscope is a major piece of equip¬ this respect. It therefore is important to check
ment that will have a great impact on the dental with the manufacturers about the modularity of
practice. It is costly, and its integration into the the microscope before it is purchased.
practice requires many changes in instrumenta¬
tion and procedures. Also, the surgeon and staff
must learn new handling and assisting require¬ MISCONCEPTIONS ABOUT SURGICAL
ments. Finally, the quality of the optics, the engi¬ MICROSCOPES
neering of the components, and the choice of op¬ The introduction of any new tool or equipment, if
tions will greatly affect the long-term visual and it is designed to change the field significantly, has
physical well-being and comfort of the user. The always led to misconceptions and misinterpreta-
microsurgeon uses all magnifications (low,

BOX 5-1 Use of Magnification in Stages
midrange, and high), depending on the particu¬
of Endodontic Microsurgery
lar needs at a point.
MAGNIFICATION STAGE OF SURGERY
Low (X3 to X8) Orientation Access to the Surgical Field
Alignment of surgical tips
The microscope does not improve access to the
Midrange (x 10 to x 16) Surgical procedures,
retropreparations surgical field. If access is limited for traditional
High (X16 to X30) Inspection and observation surgery, it will also be limited when the micro¬
of fine details scope is placed between the surgeon and the sur¬
gical field. However, the microscope creates a
much better view of the surgical field by appro¬
priate magnification and high-focused illumina¬
tions. Following are some of the misconceptions tion. Because vision is enhanced so dramatically,
about surgical microscopes, which we hope to cases can be treated with a higher degree of con¬
clarify. fidence and accuracy.
Magnification Procedures Appropriate for Use

The frequently asked question, “How powerful of a Microscope
is your microscope?” really addresses the issue A surgical procedure involves many small steps,
of usable power. Usable power is the maximum and although the microscope is essential in en¬
object magnification that can be used in a given dodontic surgery, certain steps are just as easily
clinical situation relative to depth and size of and well done without the microscope. These
field. Increasing the magnification decreases may be considered macroscopic steps. In gen¬
the depth of field and narrows its size. The ap¬ eral, the beginning and the end of endodontic
propriate question is, “How usable is the maxi¬ surgery are macroscopic steps. For example, ad¬
mum power?” Experience suggests that magni¬ ministering a local anesthetic and reflecting and
fication above X30 is of little value in periapical suturing soft tissue flaps are not procedures that
surgery because the slightest movement by the require high magnification. Although the micro¬
patient, sometimes even simple breathing, scope could be used at low magnification, little is
throws the field out of view and out of focus. gained in these applications. Only when 6-0 or 7-
The surgeon must repeatedly recenter and refo¬ 0 sutures are used on a mucogingival flap of a
cus the microscope, wasting time and creating crowned anterior tooth is the use of the micro¬
unnecessary eye fatigue and not really adding scope at low magnification suggested for esthetic
to the visibility of the surgical site. Thus the be¬ reasons. The surgical microscope is recom¬
lief that the greater the magnification, the better mended primarily for osteotomy, curettage, api-
or more useful the microscope is a misconcep¬ coectomy, inspection of a resected root surface,
tion. Box 5-1 shows the uses of different magni¬ apical preparation, retrofilling, examination of
fications at different stages of surgery. A skillful the surgical site, and documentation.
■
\\
' V
*
POSITIONING FOR SURGERY
KEY CONCEPTS ASSISTANT'S POSITION AND

• The occlusal plane of the patient should be INSTRUMENT DELIVERY SYSTEM
parallel to the floor for mandibular surgery A well-designed microsurgery may use two den¬
and perpendicular to the floor for maxillary tal assistants. The first assistant is primarily re¬
surgery. sponsible for suctioning and retraction and usu¬
• The patient is positioned slightly below the mi¬ ally sits opposite the surgeon. The second
croscope head for maxillary surgery and assistant passes instruments and usually stands.
slightly above for mandibular surgery. This assistant is positioned next to the surgeon’s
• The surgeon should use an adjustable surgeon’s dominant side to facilitate instrument passing. If
stool with armrests. a front delivery system is used, the second assis¬
• For maximum comfort and better access to tant can be positioned across from the surgeon
molar surgical sites, the patient should turn on and may pass instruments from the tray over the
the side rather than turning the head without patient. The second assistant is also in charge of
turning on the side. video recording. When micromirrors are used to
• Lateral extrusion and mandibular protrusion inspect the surgical site at high magnification, the
are useful for achieving better access to the second assistant may help with retraction to ex¬
maxillary molars and the mandibular molars, pedite the inspection.
respectively. Good communication is essential between the
surgeon and the assistants. The first assistant
must let the surgeon know if he or she does not
ARMAMENTARIUM have good visual access to the surgical field or if
Surgical microscope the surgical site has drifted from the center of the
4S- Surgeon’s chair with armrests (JedMed Co. and television monitor. For these reasons the televi¬
Global Co.) sion monitor must be positioned for easy obser¬
4S- Small pillows made of buckwheat hulls or mem¬ vation by the first assistant (i.e., slightly right of
ory foam (Brookstone Co. and Crescent Co.) the patient).
The microscope eyepiece should also be
Since the introduction of the surgical micro¬ equipped with a reticule. The surgeon must learn
scope to medicine in the 1960s, each division of to position the target site (e.g., the apex) at the
medicine has had to approach the issue of operat¬ center of the reticule so that the target can be po¬
ing positions from the unique perspective of its sitioned at the center of the television monitor.
own specialty. Endodontics is no exception. The When the surgical site has drifted off center, the
most appropriate position for an endodontic sur¬ first assistant must prompt the surgeon to “cen¬
geon is determined by a combination of factors: ter,” a short, neutral word that does not alarm the
the patient’s head and body positions, the position patient. The surgical team should be mindful that
of the dental chair, the microscope’s position, and patients are acutely aware of everything that is
the assistant’s position. The dynamics of each of going on, and the team must refrain from mak¬
these positions must be thoroughly understood to ing statements or movements that would cause
arrive at operating positions that are comfortable undue concern or anxiety. Continuous, calm
for the patient, the surgeon, and the assistant. communication between the team members
57
F'g 6-1 View of surgery performed by a right-handed surgeon. Fig 6-2 View of a patient readied for surgery. A travel pillow
Note the surgeon's and assistant's armrests and comfortable filled with buckwheat hulls is an excellent support for the neck
posture. A television monitor is placed on the surgeon's right and head.
side for easy viewing by the assistant.
ensures a smooth, efficient procedure and serves

to reassure the patient.
SURGEON S POSITION
The surgeon should use an adjustable surgeon’s
stool with armrests (Fig. 6-1). The thighs should
be parallel to the floor so that the large muscle
groups are at rest. Specially designed surgical
stools with arm supports can provide comfort,
stabilize the arm and hand, and minimize
fatigue.
A right-handed surgeon is positioned on the
right side of the dental chair in all situations (see Fig. 6-3 Keeping the head turned more than slightly for a pro¬
Fig. 6-1). A left-handed surgeon should face the longed period may cause torquing of the neck muscles. This
position should be avoided.
patient’s left side. (Chapter 5 discusses a specially
configured dental microscope for additional
comfort and efficiency.)
of the head. The occlusal plane of the patient
should be parallel to the floor for mandibular
PATIENTS POSITION surgery and perpendicular to the floor for maxil¬
Every effort should be made to ensure that the lary surgery. The head should be comfortably
patient will be comfortable during surgery. This centered or turned slightly toward or away from
is especially important if the surgery will take the surgeon.
longer than 45 minutes. Using a small, ergonom¬ Turning the head more than slightly for a pro¬
ically correct pillow in addition to or instead of longed period may cause torquing of the neck
the headrest provides the proper head support. muscles (Fig. 6-3), which can be avoided by hav¬
Such pillows may be filled with buckwheat hulls ing the patient lie on the side (Fig. 6-4). This po¬
or may be made of the newer memory foams, sition usually is necessary for surgery in the pos¬
which return to their original shape (Fig. 6-2). terior regions. The patient can lie on the right side
The important thing is that the pillow be ex¬ for surgery on the left side and vice versa. Again,
tremely pliable and mold readily to the contours the patient’s comfort is exceedingly important
Chapter 6 Positioning for Surgery 59
Fig. 6-4 For the patient's and surgeon's comfort, the patient lies
on the side during posterior surgery.
because smooth, expeditious surgery depends on

the patient’s cooperation.
JAW MANIPULATION AND ACCESS

FOR POSTERIOR TEETH
In addition to the patient’s position in the chair,
the position of the jaws plays a very important
Fig. 6-5 Lateral extrusion gains another 'k inch of space for
role in achieving access to the surgical site in pos¬
maxillary molar surgery; in some cases this makes the differ¬
terior teeth. As part of the oral evaluation, the ence between sufficient and insufficient access. A, Normal oc¬
surgeon should determine how wide the patient clusion. B, Lateral extrusion.
can open the mouth and if access is sufficient for
surgery. If the patient can shift the lower jaw to
the left or right (lateral extrusion) and hold it
there, access to the molar area is improved (Fig. scope and the operating field. The chair is
6-5). For example, for surgery on a maxillary mo¬ adjusted twice. The first adjustment is made to
lar the cheek can be retracted an additional create the necessary clearance between the
1 inch if the mandible is shifted to the same side. objective lens and the patient’s mouth (e.g.,
Patients can easily be taught to extrude the 8 inches for a microscope with a 200-mm objec¬
mandible laterally before maxillary molar tive lens). Usually this puts the chair at the low¬
surgery. Having the patient protrude the est level or close to it. In this position the surgeon,
mandible (mandibular protrusion) so that the when sitting upright, can see the patient’s mouth
edges of the maxillary and mandibular anterior through the binoculars without straining. Once
teeth meet also can help create better access to the surgeon has assumed an ergonomically cor¬
the mandibular molar region (Fig. 6-6). rect position and has determined the correct po¬
sition for the microscope, minor corresponding
adjustments can be made in the patient’s chair
DENTAL CHAIR POSITION position.
The dental chair should be maneuvered into a The patient generally is positioned slightly be¬
position that ensures maximum comfort for the low the microscope head for maxillary surgery
surgeon. By manipulating the chair’s height and and slightly above it for mandibular surgery.
back position, the surgeon allows for sufficient These positions present the surgeon with a view
space for the legs and space between the micro- of the teeth from the apices toward the crowns.
Fig. 6-7 Operating position for the maxillary anterior region.
Fig 6-6 Mandibular protrusion provides greater access for

mandibular molar surgery. A, Normal occlusion. B, Mandibular better access (see Fig. 6-5, B and Fig. 6-6, B). The
protrusion. image of the surgical region is brought to the cen¬
ter of the video monitor so that the assistant can
observe the procedure, and video images are cen¬
ADJUSTING THE OPERATING POSITION tered for documentation purposes.
Adjustment of the operating position begins with SPECIFIC OPERATING POSITIONS
the surgeon sitting comfortably with both arms
The following section outlines the proper posi¬
on the armrests (see Fig. 6-1). At this point the
dental chair is at its lowest level in a reclined po¬ tioning for maxillary and mandibular proce¬
dures.
sition. The patient’s head or body is adjusted ac¬
cording to the surgical area (e.g., for posterior A. Operating Positions for the Maxilla
surgery the patient should lie on the side, as 1. Anterior position (Fig. 6-7)
shown in Fig. 6-4). Next, the microscope is a. The occlusal plane is at a 45-degree an¬
brought to within 10 inches of the patient’s gle to the floor.
mouth and set at the lowest magnification. The b. The patient is looking straight ahead.
small bright ring that appears on the patient’s c. The microscope is angled down the axial
mouth must be sharply focused by adjusting the plane of the roots.
height of the microscope; this determines the ap¬ d. The dental chair position or the surgical
proximate clearing distance between the micro¬ site is low in relation to the microscope.
scope and the surgical site. The surgeon can now 2. Left posterior position (Fig. 6-8)
adjust the dental chair and the height of the mi¬ a. The occlusal plane is perpendicular to
croscope to accommodate the surgeon’s position. the floor.
Fine adjustments are made for specific regions, b. The patient is facing slightly to the right
such as maxillary or mandibular areas, and if for premolar surgery and turns onto the
necessary the patient manipulates the jaw for right side for molar surgery (see Fig. 6-4).
Chapter 6 Positioning for Surgery 61
Fig. 6-8 Operating position for the maxillary left posterior Fig. 6-9 Operating position for the maxillary right posterior
region. region.
c. The microscope is angled down the axial

plane of the roots.
d. The dental chair position or the surgical
site is low in relation to the microscope.
3. Right posterior position (Fig. 6-9)
a. Occlusal plane is perpendicular to the
floor.
b. The patient is facing slightly to the left
for premolar and turns onto the left side
for molar surgery.
c. Microscope is angled down the axial
plane of the roots.
d. The dental chair position or the surgical
site is low in relationship to the micro¬ Fig. 6-10 Operating position for the mandibular anterior
scope. region.
B. Operating Positions for the Mandible
1. Anterior position (Fig. 6-10)
a. The occlusal plane is parallel to the floor. b. The patient is lying on the right side
b. The patient is looking straight ahead. with the head turned up slightly.
c. The microscope is angled up the axial c. The microscope is angled up the axial
plane of the roots. plane of the roots.
d. The dental chair position or the surgical d. The dental chair position or the surgical
site is slightly high in relation to the mi¬ site is low in relation to the microscope.
croscope. 3. Right posterior position (Fig. 6-12)
2. Left posterior position (Fig. 6-11) a. The occlusal plane is parallel to the
a. The occlusal plane is parallel to the floor. floor.
Fig. 6-12 Operation position for the mandibular right poste¬

rior region.
b. The patient's head is turned slightly.

c. The microscope is angled up the axial
plane of the roots.
d. The dental chair position or the surgi¬
cal site is low in relation to the micro¬
scope.
Fig. 6-11 Operating position for the mandibular left posterior The first assistant sits and the second assistant
region. stands for these procedures.
ANESTHESIA AND HEMOSTASIS
KEY CONCEPTS guessing at anatomical landmarks and struc¬

• Effective hemostasis is a prerequisite for mi¬ tures. Effective hemostasis is absolutely essential
crosurgery. for endodontic microsurgery because the bone
• Profound anesthesia is essential for effective crypts and resected root surfaces must be exam¬
hemostasis. ined at high magnification with the microscope.
• Lidocaine (2%) with 1: 50,000 epinephrine is If continuous bleeding obscures the view, the en¬
the anesthetic of choice. tire purpose of microsurgery is negated. Hemo¬
• Both buccal and lingual or palatal injections static control can be divided into preoperative,
are required to achieve profound anesthesia intraoperative, and postoperative phases.
and effective hemostasis.
• Epinephrine pellets used alone or in conjunc¬
tion with a ferric sulfate-soaked cotton pellet PREOPERATIVE PHASE
are effective topical hemostats when applied in
Administration of a Local Anesthetic
the bone crypt with light pressure. In nonsurgical endodontic procedures, anes¬
• True epinephrine allergy is extremely rare. thetizing the affected area is the prime objective
• Attempts to improve hemostasis by injecting of local anesthesia. In surgical endodontics,
into soft or osseous tissues after the incision however, local anesthesia has two prime pur¬
has been made are ineffectual because power¬ poses: anesthesia and hemostasis. Profound
ful vasodilators at the incision site override the anesthesia of the surgical site is essential for the
effect of the vasoconstrictor. patient’s comfort and the working efficiency of
• Surgeons must understand the normal clotting the surgeon. Preparing the patient for the anes¬
mechanism and normal clotting time of hu¬ thesia is an important pretreatment procedure,
man blood; it takes several minutes for blood one that can significantly reduce the patient’s
to begin clotting. anxiety.
Reassurance that everything will be done to
keep the patient as comfortable as possible is the
ARMAMENTARIUM first step. Next, a good topical anesthetic oint¬
Aspirating syringe and short and long needles ment or epinephrine patch is left in place for a
43-Mandibular surgery: 27-gauge needles (1 and minimum of 1 or 2 minutes. Then a generous
1% inch) amount of a vasoconstrictor containing a local
4S-Maxillary surgery: 30-gauge needles (1 inch) anesthetic should be injected to ensure profound
j&-2% Lidocaine with 1:50,000 epinephrine anes¬ anesthesia throughout the surgery. Reluctance to
thetic solution use an anesthetic agent with a sufficiently high
^ Microforceps epinephrine content can result in harm to the pa¬
Epinephrine pellets (Racellets) tient and added difficulties for the surgeon be¬
Ferric sulfate solution (Cutrol or Stasis) cause the anesthesia may not be profound
enough and the hemostasis may not be sufficient
Adequate hemostasis is a prerequisite for mi¬ for the duration of the procedure. An inade¬
crosurgery. In the past achieving effective hemo¬ quately anesthetized patient produces consider¬
stasis was a challenge. Many endodontic sur¬ ably more endogenous catecholamine in re¬
geons performed surgery in a pool of blood, sponse to discomfort than is contained in the
63
anesthetic solution, and inadequate hemostasis

leads to a prolonged, difficult to control proce¬
dure.
Unless severe, a cardiovascular disorder does
not automatically contraindicate the use of anes¬
thetics containing epinephrine. Consultation
with the primary physician should clarify this is¬
sue and allay any concerns the patient might
have. Some patients may state that they are “al¬
lergic to Novocain” or that they had heart palpi¬
tations after a procedure in which an epineph¬ Fig. 7-1 Diagram of epinephrine-induced vasoconstriction in
an arteriole. E, Epinephrine.
rine-containing anesthetic was used. They may
therefore request that such an anesthetic not be
used. Although the patient’s concern should be
acknowledged, it is nonetheless strongly recom¬
mended that the surgery be done only if anes¬
thetics containing a vasoconstrictor can be used.
The patient should be informed of the reason for
this choice, and the patient’s physician should be
consulted before surgery to ensure that no unex¬
pected complications arise because of an un¬
known health factor.
The anesthetic solution of choice for en¬
dodontic surgery is lidocaine 2% HC1 with
1:50,000 epinephrine. This high concentration of F'g 7-2 In the oral mucosa 95% of the receptors are a-recep-
epinephrine is preferred for surgery because it tors, which respond to activation by vasoconstriction.
produces effective, lasting vasoconstriction via
the a-adrenergic receptors in the smooth muscle
of the arterioles. This prevents the anesthetic pure a-agonist. Fortunately, the predominant re¬
from being washed out prematurely by the mi¬ ceptor in the oral tissues is an a-receptor, and the
crocirculation. number of colocated (3-2 receptors is very small.
Thus the drug’s predominant effect in the oral
Epinephrine
mucosa, submucosa, and periodontium is vaso¬
Epinephrine binds a-1, a-2, (3-1, and (3-2 adren¬ constriction (Fig. 7-2).
ergic receptors. Epinephrine causes vasocon¬ A source of enduring controversy in dentistry is
striction by stimulating the membrane-bound a- the potential of epinephrine for causing systemic
receptors on vascular smooth muscle (Fig. 7-1). effects when used in relatively small amounts for
The a-1 receptors are adjacent to sympathetic local anesthesia. It has been shown that epineph¬
nerves that innervate blood vessels. The a-2 re¬ rine given submucosally elicits little or no re¬
ceptors are distributed throughout the vascular sponse from the cardiovascular system. However,
system and are generally bound by circulating when an identical dose is injected directly into the
catecholamines. When epinephrine binds to the blood supply, the heart rate and stroke volume,
3-1 adrenergic receptors in the heart muscle, the and therefore cardiac output, increase. Simulta¬
heart rate, cardiac contractility, and peripheral neous p-receptor activation causes mean the ar¬
resistance increase. When the drug binds to (3-2 terial blood pressure to decrease, lowering pe¬
adrenergic receptors in the peripheral vascula¬ ripheral resistance through vasodilation of
ture, vasodilation results. The (3-2 receptors are skeletal muscle. To avoid such an occurrence, an
prevalent in blood vessels that supply skeletal aspirating syringe should be used at all times to
muscle and certain viscera but are relatively rare ensure that epinephrine is not injected into the
in mucous membranes, oral tissues, and skin. bloodstream accidentally. Virtually all adverse ef¬
Ideally, for the purposes of endodontic micro¬ fects associated with epinephrine are dose and
surgery, an adrenergic vasoconstrictor would be a route dependent. A high dose injected into the
Chapter 7 Anesthesia and Hemostasis 65
infiltration to enhance the vasoconstrictive effect

Table 7-1 Dosage of Epinephrine for Local
at the surgical site. Whatever the injection tech¬
Anesthesia
nique used for anesthesia, infiltration into the
Epinephrine Maximum Dosage
surgical site is always required for hemostasis.
CONCENTRATION mg/ml mg ml CARTRIDGES Adequate hemostasis can be achieved by in¬
1:50,000 0.02 0.2 10 5V> jecting a vasoconstrictor-containing anesthetic
1:100,000 0.01 0.2 20 11 (e.g., 2% lidocaine solution with 1:50,000 epi¬
1:200,000 0.005 0.2 40 22 nephrine) into the submucosal tissues at the sur¬
gical sites 15 minutes before the first incision is
made. Attempts to improve hemostasis by inject¬
bloodstream can be fatal. The current recom¬ ing into soft or osseous tissues after the incision
mended maximum dosages of epinephrine in lo¬ has been made are a thankless task because pow¬
cal anesthetics are shown in Table 7-1. erful vasodilating neuropeptides at the incision
site override any vasoconstrictor effect.
Clinical Reasons for Using The infiltration sites for the anesthesia are in
High-Concentration Epinephrine the loose connective tissue of the alveolar mu¬
For effective hemostasis, the epinephrine con¬ cosa near the root apices. Injection into the
centration must be greater than 1:100,000. The deeper supraperiosteal tissues over the basal
vasoconstricting effect of 1:100,000 epinephrine bone, rather than the alveolar bone, may not pro¬
is insufficient for a bloodless field, meaning the vide hemostatic control in the surgical site but
surgeon must stop the procedure repeatedly to may instead deposit anesthetic into the skeletal
control bleeding. This is not only frustrating, it is muscle. Because skeletal muscle has a predomi¬
also time-consuming. Buckley and coworkers nance of (3-2 receptors, injection of epinephrine
provided strong evidence of the need for the in such sites produces vasodilation rather than
higher concentration in a clinical study of 10 pa¬ vasoconstriction and therefore should be
tients who required bilateral posterior segment avoided. If the anesthetic is injected into the
periodontal flap surgery. Almost twice as much muscle, not only is hemostasis inadequate, but a
blood loss occurred when patients were anes¬ more rapid uptake of the anesthetic and vaso¬
thetized with 1:100,000 epinephrine as with constrictor occurs, increasing the potential for
1:50,000 epinephrine. These investigators further substantial bleeding.
observed that the reduced blood loss with Anesthesia should be deposited into numer¬
1:50,000 epinephrine kept the surgical site drier, ous infiltration sites to ensure distribution of the
reducing the operating time. Postoperative he¬ solution throughout the entire surgical field. The
mostasis also was better. rate of injection should be no faster than 1 or 2
In our study using a clinic population, no cor¬ ml per minute. Rapid injection produces local¬
relation was found between the administration of ized pooling of solution in the injected tissues, re¬
1:50,000 epinephrine and the blood pressure and sulting in delayed and limited diffusion into ad¬
pulse readings during periapical surgery. Most jacent tissues, minimal surface contact with
patients had transitory, statistically insignificant microvascular and neural channels, and less than
increases in the pulse rate 2 minutes after the optimal hemostasis. The initial incision should
injection. The rate returned to normal within be delayed for at least 15 minutes after the injec¬
4 minutes. tion, until the soft tissues throughout the surgi¬
cal site have blanched.
Injection Techniques
It is essential that the injection procedure result Maxillary Anesthesia
in profound and prolonged anesthesia and max¬ Infiltration anesthesia in the mucobuccal fold
imum hemostasis. Unlike anesthesia, hemostasis over the apex of the root and in the adjacent api¬
cannot be established effectively by injection into cal mesial and distal areas is the most effective
sites other than the surgical site. Although an in¬ anesthesia for maxillary teeth. In addition, for
ferior alveolar nerve block has been shown to re¬ surgery on anterior teeth, a supplemental nerve
duce blood flow to the ipsilateral side of the jaw, block should be injected near the incisive fora¬
this must be supplemented with buccal or lingual men to block the nasopalatine nerve (Fig. 7-3, A).
rine solution is injected into the apical area of the

tooth, and half a carpule (0.9 ml) is injected into
the adjacent apical areas. An aspirating syringe
with a 30-gauge, 1-inch needle is used to prevent
the anesthetic solution from being injected into
a blood vessel. The high concentration of vaso¬
constrictor in the anesthetic solution given in
stages provides not only profound anesthesia but
also effective hemostasis. Ten minutes after the
initial infiltration, about half a carpule (0.9 ml) is
injected into the palate. Because most people
find a palatal injection painful, the patient should
be told that it will cause discomfort. To make this
injection less painful, the surgeon can deposit a
small amount of anesthetic into the palate and
then wait approximately 5 minutes before inject¬
ing the remainder very slowly. The second palatal
injection should be considerably less painful.
Mandibular Anesthesia
For surgery in the mandible, a mandibular and
buccal nerve block with a supplemental infiltra¬
tion injection into the mucobuccal fold and lin¬
gual mucosa in the apical area is the most effec¬
tive method of achieving anesthesia (Fig. 7-4).
Fig. 7-3 A, For the maxillary anterior region, one carpule of a One carpule of 2% lidocaine with 1:50,000 epi¬
lidocaine-epinephrine solution (2% lidocaine with 1:50,000 epi¬ nephrine is also preferred for the mandibular
nephrine) is injected at the apex of the tooth (shaded area), fol¬
block, which is administered with a 27-gauge,
lowed by half a carpule each mesial and distal to the apex. Half
a carpule then is injected into the palate over the apex. The
1%-inch needle in an aspirating syringe. After in¬
anesthetic must be administered at least 15 minutes before jection of the mandibular block, another carpule
surgery begins. B, For the maxillary posterior region, the same is injected into the mucobuccal fold, mesial and
dosage is used. Because the palatal injection usually is very distal to the tooth. After 10 minutes half a carpule
painful, a small drop is injected initially at the apex of the palatal
is injected into the lingual aspect of the tooth.
root as a preanesthetic. After 1 or 2 minutes half a carpule is in¬
If the patient is highly anxious, the surgeon
jected slowly and steadily. This makes the palatal injection less
painful. may consider using nitrous oxide inhalation se¬
dation in conjunction with a local anesthetic.
This ensures greater patient comfort and coop¬
For surgery in the posterior quadrant, the anes¬ eration.
thetic is injected near the greater palatine fora¬
men to block the greater palatine nerve (Fig. 7-3,
B). If the patient has a large swelling in the cus¬ INTRAOPERATIVE PHASE
pid and premolar region, an inferior-orbital block Effective hemostasis is critically important dur¬
injection can be very effective for attaining com¬ ing endodontic microsurgery because uncon¬
plete and profound anesthesia in this area. The trolled bleeding in the surgical site obscures the
drug of choice for the supplemental anesthetic is anatomical landmarks guiding the surgeon. It
also a 2% lidocaine solution with 1:50,000 epi¬ therefore is not surprising that one of the most
nephrine. frequently asked questions about endodontic mi¬
The sequence and dosage of the injections are crosurgery is how to effectively manage bleeding
as follows: The anesthesia is best injected in three in the osteotomy site and inside the bone crypt.
intervals, beginning about 15 minutes before the As mentioned earlier, effective hemostasis begins
surgery. After application of the topical anesthe¬ with the right local anesthetic, and profound lo¬
sia, a full carpule (1.8 ml) of lidocaine-epineph¬ cal anesthesia is a prerequisite to good hemosta-
BOX 7-1 Topical Hemostatic Agents

MECHANICAL AGENTS
Bone Wax (Ethicon, Somerville, NJ)
Calcium sulfate
CHEMICAL AGENTS
Epinephrine
Ferric sulfate
BIOLOGICAL AGENTS
Thrombin USP (Thrombostat, Thrombogen)
ABSORBABLE HEMOSTATIC AGENTS

Intrinsic Action
Gelfoam (Upjohn Co., Kalamazoo, MI)
Absorbable collagen
Microfibrillar Collagen Hemostats
Extrinsic Action
Surgicel (Johnson & Johnson, New Brunswick, NJ)
Mechanical Action
Calcium Sulfate Surgiplast (Classlmplant, Rome, Italy)
epinephrine, and Racellet #2 pellets contain 0.2

mg. It has been shown that Racellet #2 pellets
did not change the patient’s pulse rate when
Fig. 7-4 A, In the mandibular anterior region, one carpule of a pressed into the bone cavity for 4 minutes. This
lidocaine-epinephrine solution (2% lidocaine with 1:50,000 epi¬ result is plausible because topically applied epi¬
nephrine) is injected as a mandibular block, followed by half a nephrine causes immediate local vasoconstric¬
carpule at the apex and half a carpule each mesial and distal to
tion with only minimal absorption into the sys¬
the apex. Haifa carpule then is injected lingually. The anesthetic
must be administered at least 15 minutes before surgery begins.
temic circulation.
B, In the mandibular posterior region, the dosage and route of Other brands of hemostatic cotton pellets with
the injection are the same. epinephrine are Epidri pellets, which contain an
average of 1.9 mg of racemic epinephrine, and
Radri pellets, which have a combination of vaso¬
sis. The next challenge is to control minor local constrictor and astringent. Each Radri pellet con¬
bleeding. Local hemostasis can be achieved by tains an average of 0.45 mg of racemic epineph¬
the pressure technique, that is, by pressing cot¬ rine and 1.85 mg of zinc phenolsulfonate.
ton pellets or gauze into the bone crypt for a few For achieving local hemostasis quickly during
minutes. However, if the bleeding persists, topi¬ apical surgery, we have found the following pro¬
cal hemostatic agents should be considered. cedure most effective: A small epinephrine pellet
is placed in the bone cavity and packed solidly
Topical Hemostatic Agents against the osteotomy wall. In quick succession,
Many types of topical hemostatic agents are small, sterile cotton pellets are packed one by one
available. Those listed in Box 7-1 are broadly clas¬ over the first pellet, filling the entire bone crypt
sified by their mode of action. (Fig. 7-6). Pressure is applied to these pellets for 2
to 4 minutes. After this interval, all but the epi¬
Epinephrine Pellets nephrine pellet are removed, one by one (Fig.
Racellets are cotton pellets containing racemic 7-7). This technique should stop even the most
epinephrine (Fig. 7-5). The amount of epineph¬ persistent bleeding. Care should be taken to leave
rine in each pellet varies according to the num¬ the epinephrine pellet inside the osteotomy to
ber on the label. For example, Racellet #3 pel¬ avoid reopening the ruptured vessels. The combi¬
lets contain an average of 0.55 mg of racemic nation of epinephrine and pressure has a syner-
Fig. 7-6 Epinephrine pellet technique for hemostasis. A Racel-

let pellet is placed in the bone crypt, and sterile cotton pellets
are placed on top of it. These pellets must be pressed in hard
with a blunt instrument, such as the back of the mirror handle,
for 2 to 4 minutes. The cotton pellets are removed one by one,
but the epinephrine pellet is left in place. Ultrasonic retro-
preparation can be started if there is no bleeding in the bone
crypt.
sis through a chemical reaction with blood. Ferric

sulfate is an excellent surface hemostatic agent
on the buccal plate for small and slow bleeders.
It is easily applied and easily removed by irriga¬
tion. The pale yellow FS fluid turns into a dark
brown or greenish brown coagulum immediately
F'g 7-5 Racellet, an epinephrine-containing cotton pellet.
upon contact with blood and epinephrine. The
color differences are useful for identifying the
source of persistent bleeders. Many FS solutions
gistic effect that results in profound vasoconstric¬ are available, including Cutrol (50% FS), Monsel
tion in the bone crypt. As described at the begin¬ Sol (70% FS), and Stasis (21% FS).
ning of this chapter, epinephrine causes local FS is known to be cytotoxic and to cause tissue
vasoconstriction by acting on the a-1 receptors in necrosis, but systemic absorption of ferric sulfate
the membranes of the blood vessels, and the pres¬ is unlikely because the coagulum isolates it from
sure augments this hemostatic potential. Of the vascular bed. FS has also been found to dam¬
course, the epinephrine pellet is removed before age bone and to delay healing when used in max¬
the final irrigation and closure of the surgical site. imum amounts and when left in situ. However,
This epinephrine pellet technique is the most ef¬ when the FS coagulum is completely removed
ficient and economic technique for hemostatic and the surgical site is thoroughly irrigated with
management in the bone crypt. saline before closure, no adverse reactions occur.
Because the epinephrine pellet technique is very
Ferric Sulfate
effective in bone crypt management, we do not use
Another chemical agent used in hemostasis is FS for this purpose; rather I use it exclusively for
ferric sulfate (FS). Ferric sulfate or ferric subsul¬ bone surface hemostasis, for small bleeders
fate is a hemostatic agent that has long been used around the osteotomy on the buccal plate (Fig.
in restorative dentistry. Although its mechanism 7-8). Brushing FS onto the buccal surface around
is still unclear, agglutination of blood proteins re¬ the bone crypt just before retrofilling ensures he¬
sults from the reaction of blood with both ferric mostasis during this important procedure.
and sulfate ions and the acidic pH (0.21) of the
solution. The agglutinated proteins form plugs Calcium Sulfate
that occlude the capillary orifices. Unlike other Hemihydrate medical-grade calcium sulfate (CS)
hemostatic agents, therefore, FS effects hemosta- was not designed to be a topical hemostatic sub-
Fig. 7-9 Calcium sulfate (CS) is mixed and molded into a pellet
the size of the bone crypt (left)- The CS pellet is immediately
packed into the crypt with a moist cotton pellet (right).
Fig. 7-7 After 3 minutes, cotton pellets are removed, leaving

the epinephrine pellet in place. Ultrasonic retropreparation can
begin in the absence of bleeding in the bone crypt.
Fig. 7-10 A curette is used to carve the hardened calcium sul¬

fate (left), exposing the resected root surface (right). The re¬
sorbable calcium sulfate is left in the crypt.
Surgicel. These agents are not any more effective

than the ones described earlier, but they are con¬
Fig. 7-8 Stasis, a 21% ferric sulfate solution. Ferric sulfate solu¬ siderably more costly. Fig. 7-11 presents the main
tions are available in many concentrations. point of action in the hemostasis cascade. Cal¬
cium sulfate, Bone Wax, and Surgicel achieve he¬
mostasis through a tamponade effect by me¬
stance; it initially was developed as a bone-in¬ chanically blocking open vessels, whereas
ductive agent. However, CS serves well as a topi¬ epinephrine causes vasoconstriction by activat¬
cal hemostatic agent by mechanically blocking ing a-adrenergic receptors. Gelfoam, made of an¬
open vessels. It is resorbed by the body after 2 to imal skin gelatin, acts intrinsically by promoting
3 weeks. CS is supplied as a powder with a mix¬ the disintegration of platelets, causing a subse¬
ing solution, and the two can be used to make a quent release of thromboplastin. Collagen is
pellet the size of the osteotomy. After the pellet is known to aggregate platelets, which release coag¬
placed into the bone, it is tamped down with a ulation factors. Those factors, with plasma fac¬
moist cotton pellet (Fig. 7-9). The excess is re¬ tors, help form fibrin and subsequently a clot.
moved, exposing the root apex for further surgery Thrombin is a protein that acts rapidly in an in¬
(Fig. 7-10). The CS pellet is left in the bone cavity, trinsic fashion, combining with fibrinogen to
where it acts as a barrier to the faster growing soft form blood clots. One product worth mentioning
tissue and may aid bone regeneration by provid¬ is Microfibrillar Collagen Hemostats (MCH). It is
ing a matrix for the osteoblasts. prepared from bovine corium, which promotes
rapid hemostasis by attracting platelets.
Other Hemostatic Agents
Epinephrine pellets, ferric sulfate, and calcium
sulfate are inexpensive and provide excellent lo¬ HEMOSTATIC TECHNIQUE IN
cal hemostasis during surgery, but many other ENDODONTIC MICROSURGERY
topical hemostatic agents are available, including The first and most important step in achieving
thrombin, absorbable collagen, Bone Wax, good hemostasis is obtaining effective local anes¬
Gelfoam, Microfibrillar Collagen Hemostats, and thesia. If the anesthesia is profound, achieving
Epinephrine
Calcium Sulfate
Vascular Injury -►Vasoconstriction
Local Anesthetic
Bone Wax 1: 50,000 Epinephrine
Platelet Adherence -Collagen

Ferric Sulfate
Epinephrine Pellets
j Platelet Aggregation
-
Small Large
Intrinsic and Platelet Plug Osteotomy Osteotomy
Extrinsic nathwav
Thrombus -»-j Thrombin
Ferric Sulfate Calcium Sulfate
Fibrin Split Products
Fig. 7-11 Summary of events in hemostasis and the action of Fig. 7-12 Recommended hemostatic techniques for endodon¬
topical hemostatic agents: Calcium sulfate, Bone Wax, and Sur- tic microsurgery.
gicel block the vascular opening, acting as a tamponade,
whereas epinephrine causes vasoconstriction. Celfoam and col¬
lagen work on platelet hemostatic function and platelet adher¬
ence, respectively.
SUGGESTED READINGS
Benoit PW, Hunt LM: Comparison of a microcrystalline col¬
lagen preparation and gelatin foam in extraction wounds,
local hemostasis during surgery is a simple task. Oral Surg Oral Med Oral Pathol 34:1079-1083, 1976.
The recommended steps are (Fig. 7-12): Besner E: Systemic effects of racemic epinephrine when ap¬
plied to the bone cavity during periapical surgery, Va
• Administer the local anesthetic; use 2% lido- Dent] 49(5):9-12, 1972.
caine with 1:50,000 epinephrine. Buckley JA, Ciancio SG, McMullen JA: Efficacy of epineph¬
• Use epinephrine pellets for additional hemo¬ rine concentration on local anesthesia during periodon¬
tal surgery, J Periodon tol 55:653-657, 1984.
static control in the osteotomy.
Evans BE: Local hemostatic agents, NY J Dent 47:109-114,
• Apply ferric sulfate for osteotomies smaller 1977.
than 5 mm. Guralnick WC, Berg L: Gelfoam in oral surgery: a report of
• Apply calcium sulfate for osteotomies larger 250 cases, Oral Surg Oral Med Oral Pathol 1:632-639,
than 5 mm. 1984.
Gutmann JL: Parameters of achieving quality anesthesia and
hemostasis in surgical endodontics, Anesth Pain Control
Dent 2:223-226, 1993.
POSTOPERATIVE PHASE Gutmann JL, Harrison JW: Surgical endodontics, St Louis,
To achieve good postoperative hemostasis, it is 1994, Ishiyaku EuroAmerica.
imperative to maintain hemostasis after the flap Haasch GC, Gerstein H, Austin BP: Effect of two hemostatic
has been sutured. A wet, sterilized gauze placed agents on osseous healing, / Endodont 15:310-314, 1989.
Hecht A, App AR: Blood loss during gingivectomy using
over the sutures helps stabilize the flap and con¬
two different anesthesia techniques, /Periodontol 45:9,
trols oozing of blood from the surgical sites. The 1974.
gauze should be kept in the mucobuccal fold for Hunt LM, Benoit PW: Evaluation of microcrystalline colla¬
about 1 hour, and an ice pack should be applied gen preparation in extraction wounds, / Oral Surg34:407-
to the cheek (15 minutes on, 30 minutes off) for 414, 1976.
Ibarrola JL et al: Osseous reaction to three hemostatic
1 or 2 days. The patient must be forewarned of a
agents, J Endodont 11:75-83,1985.
possible rebound hemorrhage from the surgical Jastak JT, Yagiela JA: Vasoconstrictors and local anesthesia: a
site even hours after the operation. If this oc¬ review and rationale for use, /ADA 107:623-630, 1983.
curs, the patient should place a wet tea bag on Jeansonne BG, Boggs WS, Lemon RR: Ferric sulfate hemo¬
the surgical site and gently apply an ice pack to stasis: effect on osseous wound healing. II. With curettage
the affected cheek. The tannic acid in the tea, and irrigation, J Endodont 19(4):174-176, 1993.
Kim S, Rethnam S: Hemostasis in endodontic microsurgery,
along with gentle pressure and peripheral vaso¬ DCNA 41 (3):499-511, 1997.
constriction by the ice pack, should stop the Kim S et al: Effects of local anesthetics on pulpal blood flow
bleeding. in dogs, JDent Res 63:650-652, 1984.
Knoll-Kohler E et al: Changes in plasma epinephrine con¬ Olson RAJ, Roberts DL, Osbon DB: A comparative study of
centration after dental infiltration anesthesia with differ¬ polylactic acid, Gelfoam, and Surgicel in healing extrac¬
ent doses of epinephrine, / Dent Res 68(6):1097-1101, tion sites, Oral Surg Oral Med Oral Pathol 53:441-449,
1989. 1982.
Lemon RR, Steele PJ, Jeansonne BG: Ferric sulfate hemo¬ Selden HS: Bone Wax as an effective hemostat in periapical
stasis: effect on osseous wound healing. I. Left in situ surgery, Oral Surg Oral Med Oral Pathol 29(2):262-264,
for maximum exposure, / Endodont 19(4):170-173, 1970.
1993. Yagiela JA: Vasoconstrictor agents for local anesthesia, Anes¬
Milam SB, Giovannitti JA: Local anesthetics in dental prac¬ thesia Progress 42:116-120, 1995.
tice, Dent Clin North Am 28(3) :493-508, 1984.
.
1
'
SOFT TISSUE MANAGEMENT:
FLAP DESIGNS, RETRACTION,
AND SUTURING
KEY CONCEPTS ARMAMENTARIUM

• The sulcular full-thickness flap is the design of 45- KP 1, 2, 3, and 4 retractors
choice for endodontic microsurgery. 45- Miniblade, 15C Bard-Parker blade
• For aesthetic reasons the mucogingival flap is 45- Tissue elevators (P 14S or P 9HM [G. Hartzell &
suitable for crowned anterior teeth. Son])
• The scalloped horizontal incision of the 45- 5-0 and 6-0 Jackson sutures (/ and % circle
mucogingival flap provides a guide for correct needles)
repositioning of the flap. 45- Castroviejo needle holder
• The semilunar flap has been found useful for 45- Laschal microscissors
incision and drainage only. 45- Microforceps
• The rectangular flap design is more suitable for
anterior teeth. The free and attached gingiva, the mucosa, the
• The triangular flap design with vertical releas¬ muscles, the periodontal ligament, and the peri¬
ing incision at the mesial aspect of the flap is osteum make up the soft tissues in the mouth.
more suitable for posterior teeth. The two primary reasons for properly managing
• For either sulcular full-thickness or mucogin¬ these tissues during endodontic microsurgery are
gival flaps, the base of the flap should be to gain adequate access to the surgical site and to
as wide as the top so that the incision does ensure good postoperative healing. To achieve
not bisect tissue fibers and blood vessels. No these goals the surgeon must have the knowledge
scientific or sound clinical evidence supports to choose the proper flap design and the skills to
the theory that the flap should be wider at make a precise incision, to elevate and retract the
the base to facilitate better microvascular flap with minimum trauma to the tissue, and to
perfusion. reposition and suture the flap precisely into its
• Newly developed KP retractors are designed original position.
specifically for endodontic microsurgery.
• The groove technique eliminates retraction dif¬
ficulties with posterior teeth. FLAP DESIGNS
• 5-0 Synthetic monofilament sutures promote Sulcular Full-Thickness Flap
faster healing and produce fewer scars. The sulcular full-thickness flap requires both
• Interrupted suturing and sling suturing are the horizontal and vertical incisions. The horizontal
suturing techniques used most often in en¬ incision extends from the gingival sulcus
dodontic surgery. through the fibers of the periodontal ligament
• The value of suturing under the microscope is to the crestal bone. The incision should pass
debatable except when 6-0 or 7-0 sutures are through the midcol area separating the buccal
used. and lingual papillae. The vertical incision should
73
be deep and made between the root eminences tremely limited space in that area. For this rea¬
because the mucosa is thin over the root emi¬ son the triangular design with one mesial verti¬
nence and tears easily. cal releasing incision is preferred for posterior
This flap design provides the best access to all teeth (Fig. 8-3).
surgical sites in the oral cavity and can be either a For surgery on a first molar of the mandible,
triangular flap with one vertical releasing incision the vertical releasing incisions should be made
or a rectangular flap with two vertical releasing distal or mesial to the first premolar. There are
incisions (Fig. 8-1). two important reasons for positioning the releas¬
The rectangular design may be better for ante¬ ing incision this far anterior; first, it avoids the
rior teeth than the triangular design because it mental foramen, which usually is located around
provides better access to the root apex, especially the apex of the second premolar; second, the
when the root is long (Fig. 8-2). When the rectan¬ muscle attachment at the second premolar, when
gular design is used, the base of the flap should be severed, heals slowly and poorly.
as wide as the top so that the incision follows the In general, whether triangular or rectangular,
direction of the tissue fibers and blood vessels. In the sulcular full-thickness flap is preferred for
this way fewer fibers and blood vessels are severed, most endodontic surgery (Fig. 8-4). Clinical pic¬
and the sutured incisions heal quickly and are tures of a sulcular flap, the incision, and elevation
hardly noticeable when healed. This is also true for of the flap are presented in Fig. 8-5.
the vertical releasing incision of the triangular flap.
Although some believe that the flap should be
wider at the base to facilitate better microvascular
perfusion (i.e., trapezoidal flap design), no scien¬
tific or sound clinical evidence exists to support
this theory. In fact, the wider-based flap results in
delayed healing and unsightly scars because the
incision cuts the fiber lines and blood vessels
obliquely rather than following them.
For posterior teeth the distal vertical releasing
incision provides no advantage, but rather
causes suturing problems because of the ex¬
F'g 8-2 Sulcular flap with two releasing incisions (rectangular

flap design).
Fig. 8-1 Diagram of a sulcular flap. The shaded tooth is the Fig. 8-3 Sulcular flap with one releasing incision (triangular flap
problem tooth. The solid line alone represents the incision line design).
for a triangular flap; the dotted line with the solid line repre¬
sents the incision line for a rectangular flap.
Chapter 8 Soft Tissue Management: Flap Designs, Retraction, and Suturing 75
Mucogingival Flap
The mucogingival flap is most suitable for
crowned teeth when open crown margins after
surgery are an esthetic concern. This type of flap
calls for a scalloped incision in the middle of the
attached gingiva (Fig. 8-6). The angle of the inci¬
sion in relation to the cortical plate is 45 degrees
because this angle provides the widest cut sur¬
face, allowing for better adaptation when the flap
is repositioned. The attached gingiva around the
crown margin remains intact, guaranteeing
preservation of the existing esthetics (Fig. 8-7).
Mesial or mesial and distal vertical releasing
incisions permit adequate access to the surgical
site without violating the integrity of the attached
gingiva around the tooth or crown (Fig. 8-8).
When two vertical releasing incisions are made,
the flap is widely mislabeled as the Luebke- Fig. 8-4 Sagittal view of a sulcular full-thickness flap. Note
Ochsenbein design. However, this mucogingival that no attached gingiva remains around the neck of the
flap differs from that design in that the two verti- crown.
Fig. 8-5 A, Maxillary anterior region before the incision is made. B, Sulcular full-thickness
rectangular flap incisions. C, Elevation of the gingiva. D, A rectangular flap provides wide sur¬
gical access.
Fig. 8-8 Mucogingival flap with two releasing incisions. This

type of flap is used when opening of the gingival margin around
the crown after healing is likely.
cal releasing incisions are made parallel in the

mucogingival flap, whereas in the Luebke-
Ochsenbein flap they are wider at the base. This
may seem a minor difference, but it actually is a
significant one.
As with the sulcular full-thickness flap, the
vertical incision of the mucogingival flap should
be straight up and down, following the fiber
Fig. 8-6 Diagram of a mucogingival flap. The horizontal scal¬ lines in the mucosa, which progress almost
loped line in the middle of the attached gingiva is the incision straight vertically following the root. When two
line. The line near the mucosa is the mucogingival line, which is
releasing incision are made, they should be par¬
the demarcation between the gingiva and the mucosa.
allel to each other throughout (see Fig. 8-8). The
junction, where the horizontal scalloped inci¬
sion in the attached gingiva meets the vertical
incision, should be rounded to promote
smoother and faster healing. When this junc¬
tion is made at a sharp, 90-degree angle, it heals
very slowly and leaves a small, hard, knobby
scar.
The purpose of the scalloped horizontal inci¬
sion is to provide a guide for correct reposition¬
ing of the elevated flap for suturing (Fig. 8-9).
Therefore it is important to scallop the incision
correctly, following the gingival margin precisely.
A scalloped incision may at first leave a faint scar
in the attached gingiva, but within a few months
the scar is hardly noticeable (Fig. 8-10).
Semilunar Flap
The semilunar flap was widely used in the past.
Although it is not now advocated for most proce¬
Fig. 8-7 Sagittal view of the mucogingival flap showing the re¬ dures, it may be useful in certain cases, such as
maining attached gingiva above the crown. A 45-degree inci¬ for emergency incision and drainage (Fig. 8-11).
sion angle is used to maximize microvascular perfusion. The semilunar flap does not facilitate adequate
Fig. 8-9 A, Clinical picture of the horizontal scalloped incision

made for a mucogingival flap. B, Elevation of the flap shows
good access to the surgical site. From Beer/Baumann/Kim:
Color atlas of dental medicine: Endodontology, New York, 2000,
Thieme Verlag Stuttgart
Fig. 8-10 A, Wide, canine to canine mucogingival flap for surgery

access to the surgical site, and upon healing it on several teeth. This flap design provides unhindered access to all
leaves a noticeable scar. anterior apices. B, The case in A at the 6-month checkup. Only a
faint line is present where the incision was made.
INCISION
For a full-thickness flap, the vertical releasing
incision begins at the line angle of the tooth (Fig.
8-12) and must cut through the attached gingiva,
mucosa, and periosteum in one stroke if possible.
A 15C Bard-Parker blade is used to make this in¬
cision efficiently and to follow the fiber lines in
the mucosa precisely (Fig. 8-13). The base of the
flap should be as wide as the top so that most of
the blood vessels, which are also distributed ver¬
tically along the fiber lines, can adequately per¬
fuse the flap. For the sulcular incision the gingival
margin must be incised fully and carefully, fol¬
lowing the contours of the margin. Fig. 8-11 Semilunar incision, which should not be used in en¬
The interproximal papillae must be cut sharply dodontic surgery. A mucosal scar, which is esthetically unaccept¬
toward the lingual extension, following the root able, remains.
Fig. 8-12 All vertical incisions, regardless of the flap design, Fig. 8-14 Miniblades and a 15C Bard-Parker blade.
must start at the line angle and follow the fiber line, straight up
coronally.
Fig. 8-13 Incision is made with a 15C Bard-Parker blade. Fig. 8-15 Newly designed tissue elevators. The elevator blades
are sharp for effective tissue cutting, and the different shapes
are needed to follow the contours of the buccal bone.
contour. Failure to follow the tooth neck contour

closely causes blunting of the papillae after heal¬
ing, which raises esthetic concerns, especially in fleeted with a sharp elevator. The elevator (P 14S
the anterior region. Miniblades (e.g., Beaver or P 9HM, made by G. Hartzell & Son, or similar
blades) are recommended for this purpose be¬ ones) (Fig. 8-15) is placed at or beneath the gin¬
cause their size permits a more precise incision giva at the line angle, and the gingiva is separated
in the tight interproximal spaces (Fig. 8-14). How¬ from the alveolar bone by gently “walking” the el¬
ever, the miniblade is too small for the vertical re¬ evator toward the apex. The sharp, wide end of
leasing incision; the 15C Bard-Parker blade is bet¬ the elevator is placed at a 45-degree angle to the
ter choice for this incision. cortical bone surface, and the gingiva and mu¬
cosa are reflected apically with a slow, firm, con¬
trolled peeling motion, closely following the corti¬
FLAP ELEVATION cal bone contours (Fig. 8-16).
After the incisions have been made, the perios¬ The surfaces of the buccal cortical plates in
teum and overlying gingiva are elevated and re¬ both the maxilla and the mandible are not flat
B
A
Fig. 8-16 Tissue reflection with a rectangular flap. Careful

but firm elevation at the line angle (A) is followed by total el¬
C evation (B) and retraction (C) of the flap; an apical fenestra¬
tion is clearly visible.
and smooth; rather, they have many irregulari¬ does not affect the reattachment and healing of
ties, including bone eminences, concavities, and the soft tissues in any significant manner. In
fenestrations. If not negotiated carefully, these ir¬ fact, complete removal of the periosteum pro¬
regularities can easily contribute to tearing or vides a bloodless surgical field, a critical advan¬
perforation of the tissues during the reflection. tage in microsurgery.
Elevating the flap with sudden or uncontrolled
force (e.g., accidental slippage) damages the tis¬
sue, and great care should be taken to avoid this. FLAP RETRACTION
A flap normally shrinks a bit while separated Flap retraction, usually done by an assistant, can
from the bone. A traumatized flap, in addition to be the most vexing problem because an improp¬
shrinking, swells; this makes it extremely difficult erly retracted flap interferes with a clear view of
to handle and to return to its original position and access to the operating site. In most instances
without additional trauma. A perforated or torn frequent slippage and repositioning of the retrac¬
flap also is difficult to suture. Careful surgeons tor causes tearing and traumatization of the re¬
therefore are cautious and patient during flap el¬ tracted tissue, resulting in swelling. This slipping
evation; they may place a piece of gauze beneath and repositioning also disturb the surgeon’s con¬
the initially reflected flap and gently push at the centration, compromising the smooth execution
gauze with an elevator for smooth flap elevation. of the surgery. It is even more of a problem during
It is also necessary to reflect the periosteum microsurgery because the microscope may need
completely to minimize bleeding during to be readjusted, which prolongs the procedure.
surgery. Some advocate that the periosteum not Retractors are among the most important in¬
be elevated even though it causes bleeding, struments for apical surgery. Properly designed
whereas others believe that the periosteum and used, they improve access to the surgical field,
should be removed completely. Clinical obser¬ prevent tissue trauma, and facilitate efficient exe¬
vation suggests that removing the periosteum cution of the surgery. A retractor should be chosen
Fig. 8-17 Several types of retractors are available on the dental Fig. 8-19 Contour-specific KP retractors.
market. None of these convex-tip retractors effectively meets the
endodontic surgeon's needs.
Fig. 8-18 A convex-tip retractor shows minimal contact with

the bone eminence in the maxillary anterior region.
for a specific purpose and to fit the anatomy of the

cortical plate. None of the standard retractors
available today satisfy this need (Fig. 8-17). They
are too narrow at the tip, causing the retracted tis¬
sue to overhang into the surgical site, hindering
access. Also, all retractor tips are convex. Where Fig. 8-20 A, Comparison of the KP 1, 2, and 3 retractor tips
the cortical bone protrudes, the convex retractor with the convex tip of an endodontic retractor (right). The KP
is an unstable anchor because the only point of retractors are wider, thinner, and serrated and are contoured to
the maxillary and mandibular buccal plates. B, Magnified view
contact with the bone is the small area at the top of
of the serrated ends of two KP retractors.
the curve (Fig. 8-18).
They have wider (15 mm) and thinner (0.5 mm)

RETRACTORS FOR ENDODONTIC serrated working ends than standard retractors.
MICROSURGERY Some are concave and some are convex, to ac¬
Kim-Pecora (KP) retractors (Fig. 8-19) were de¬ commodate the irregular contours of the buccal
signed specifically for endodontic microsurgery. plate (Fig. 8-20, A). The serrated tips provide bet-
Fig. 8-21 KP 1 retractor in the maxillary molar region. Fig. 8 -23 KP 3 retractor in the mandibular premolar region.
eminences in the maxillary molar and mandibu¬

lar incisor regions (Fig. 8-21). The KP 2 retractor
has a slight concavity in the center and is curved
gently inward to accommodate the slight bone
eminences found in the maxillary canine region
(Fig. 8-22). The KP 3 retractor tip has a slight con¬
vexity that is well suited to the mandibular pre¬
molar and molar bone anatomy (Fig. 8-23).
These instruments have greatly eased the as¬
sistant’s job of retracting and therefore have re¬
sulted in less fatigue, less tissue trauma, and a
shorter operating time. However, even with these
stable retractors, apicoectomy on a mandibular
premolar or molar brings the blade frighteningly
close to the mental foramen. This danger has
been overcome by a simple procedure, the groove
technique for tissue retraction.
Groove Technique for Tissue Retraction

To eliminate retraction difficulties, we have devel¬
oped an alternative approach. A 15-mm, shallow,
horizontal groove is cut into the water-cooled
bone with a Lindemann bur. The groove is made
beyond the apex for molar surgery and above the
mental foramen for premolar surgery to allow
space for the osteotomy and subsequent apicoec¬
Fig. 8 -22 A, KP 2 retractor provides wider access to the surgi¬
cal site and follows the bone contour. B, KP 2 retractor in the
tomy. This groove permits secure anchoring of the
maxillary canine region. serrated retractor tip (KP 2 or 3) and secure,
steady retraction of the flap. This technique is es¬
pecially useful when operating in the mandibular
ter anchorage on the bone and prevent accidental molar region and near the mental foramen.
slipping (Fig. 8-20,15). The surfaces of the retrac¬
tors are matte so that the light from the micro¬ Management of the Mental Foramen
scope is not reflected. The working end In molar or premolar surgery the vertical releas¬
of the KP 1 retractor is V shaped to fit the bone ing incision must extend close to the mental
foramen. This poses a real danger of damage to initial vertical incision is made halfway toward
the mental nerve. A careful radiographical exam¬ the apex of the first premolar root, and then the
ination before surgery is essential for identifying horizontal incision is made. This allows the flap
the position of the mental foramen (see Chapter to be elevated gently and the mental foramen to
3). With the position of the foramen in mind, the be located visually. With the foramen identified,
the final vertical incision is made to full length
(Fig. 8-24).
For premolar and molar surgery a groove is
made under the microscope just coronal to the
mental foramen (Fig. 8-25, A). A KP 2 or 3 re¬
tractor is positioned firmly in the groove, and
the surgery is continued (Fig. 8-25, B). For mo¬
lar teeth the groove is made just distal to the
foramen, and a serrated retractor is used to pro¬
tect the foramen if it is close to the mesial apex.
The groove not only creates a firm anchoring
place for the retractor but also protects the
mental foramen from accidental slippage and
damage by an instrument.
REPOSITIONING OF THE FLAP

Upon completion of the surgery, the retracted
tissue is carefully repositioned with tissue for¬
ceps. It is not uncommon for a novice to suture
the flap in the wrong position; therefore care
should be taken to confirm the proper position
before suturing. After repositioning the flap, a
damp gauze pad is firmly placed on the flap
with finger pressure to removed accumulated
Fig. 8-24 Mental nerve bundle exiting the foramen. (x6.) blood and fluids from beneath the flap. A clean,
Fig. 8-25 Groove technique for tissue retraction. A, A groove is placed just coronal to the men¬
tal foramen. B, KP 3 retractor is placed in the groove to protect the mental foramen from dam¬
age during the surgery.
bloodless surgical site aids accurate reposition¬ tooth (Fig. 8-28, A). The suture is led around the
ing of the flap. Because the flap shrinks during lingual and interproximal aspects of the tooth
surgery, especially if the surgery is prolonged, it and passed through the buccal papilla. The path
may need to be stretched for proper adaptation is now reversed to arrive at the first buccal
and first be sutured at strategic points. The first papilla, where a knot is made to secure the su¬
strategic suture is placed into the free end (or ture (Fig. 8-28, B to D).
ends) of the triangular or rectangular flap. An¬ The value of using a microscope for this proce¬
other suture is placed just above the free ends dure is debatable because the suturing sites are
to reduce the tension on them. The third strate¬ easily seen with the naked eye. Suturing under
gic suture is a sling suture placed around the the microscope provides negligible added advan¬
tooth central to the flap. After the flap has reas¬ tage except when 6-0 or smaller sutures are used.
sumed its original size, the remaining sutures The 6-0 sutures are used for crowned maxillary
can be placed. anterior teeth and when opening of the margins
is a concern.
A variety of suture materials are available on
SUTURING the market today, and although silk is still the
There are many ways of suturing and many most widely used, newer synthetic sutures are
types of sutures. We recommend two simple quite good. In fact, synthetic sutures produce
techniques: interrupted suturing (Fig. 8-26) and better postoperative results because less plaque
sling suturing (Fig. 8-27 and Fig. 8-28). Usually accumulates on the smooth surface of the syn¬
the interrupted suture technique is used for the thetic sutures than on the twisted silk strands,
vertical releasing incision, and the sling suture resulting in less inflammation (Fig. 8-29). Re¬
technique is used for the interproximal and sul- sorbable gut sutures are not recommended un¬
cular incisions. In the sling suture technique, the less the patient cannot return for suture re¬
buccogingival papilla is pierced with a % circle moval. In the past sutures were removed 4 to 7
or straight 5-0 suture needle, which is then days after surgery. In view of new research find¬
brought through the interproximal space of the ings, however, suture removal is recommended
within 48 hours (see Chapter 15). Regardless of
the suture material used, the patient must keep
the surgical site as clean as possible by rinsing
frequently with warm saltwater or chlorhexidine
to prevent plaque accumulation.
Fig. 8-26 Interrupted suture technique is used for a vertical re¬ Fig. 8 -27 Diagram of the sling suture technique, which is most
widely used and most convenient for interproximal sutures.
leasing incision.
Fig. 8-28 A, After suturing the buccogingival papilla (1), the needle is taken through the inter-
proximal space of a tooth and exits from the lingual side (2). B, The suture is then brought around
the lingual aspect of the tooth, passed through the interproximal space on the other side of the
tooth, and passed through the second buccal papilla (3). C, The suture is reversed through the in¬
terproximal space (3), around the lingual of the tooth (4), and through the interproximal space.
D, The suture is secured with a knot at the first buccal papilla (6).
Gutmann JL, Harrison JW: Surgical endodontics, St. Louis,

1994, Ishiyaku EuroAmerica.
Harrison JW: Healing of surgical wounds in oral muco-
periosteal tissues, J Endodont 17:401-408, 1991.
Harrison JW, Jurosky KA: Wound healing in the tissue of the
periodontium following periradicular surgery. I, The in¬
cision wound, / Endodont 17:425-435, 1991.
Harrison JW, Jurosky KA: Wound healing in the tissue of the
periodontium following periradicular surgery: II, The dis-
sectional wound, / Endodont 17:544-552, 1991.
Harrison JW, Jurosky KA: Wound healing in the tissue of
the periodontium following periradicular surgery. Ill,
The osseous excisional wound, / Endodont 18:76-81,
1992.
Lang NR Lo H: The relationship between the width of kera¬
Fig. 8-29 A 5-0 Supramid Jackson suture made of synthetic ny¬
tinized gingiva and gingival health, / Periodontol 43:623-
lon and monofilament. The smooth surface retards plaque accu¬
627, 1972.
mulation, resulting in less inflammation and faster healing.
Levine HL, Stahl SS: Repair following periodontal flap
surgery with the retention of gingival fibers, / Periodon¬
tol 43:98-103, 1972.
SUGGESTED READINGS
Peters LB, Wesselink PR: Soft tissue management in en¬
Carr GB: Surgical endodontics. In Cohen S, Burn RC, editors: dodontic surgery, Dent Clin North Am 41:513-528, 1997.
Pathways of the pulp, ed 7, St Louis, 1998, Mosby. Selvig KA, Torabinejad M: Wound healing after muco-
Cutright DE, Hunsunk EE: Microcirculation of the perioral periosteal surgery in the cat, /Endodont 22:507-515,1996.
regions in the Macaca rhesus. I, Oral Surg 29:776-785, Wood DL et al: Alveolar crest reduction following full- and
1970. partial-thickness flaps, J Periodontol 43:141-144, 1972.
OSTEOTOMY AND APICAL
ROOT RESECTION
KEY CONCEPTS mental foramen, the mandibular nerve, and si¬

• An osteotomy should be just large enough to nus space can be ascertained (Fig. 9-1). Sur¬
accommodate the ultrasonic tip, but no larger geons with limited experience may find it help¬
than 4 mm in diameter. ful to carefully examine a model skull before
• An osteotomy should be prepared at the lowest each surgery to provide a clear mental image of
magnification (e.g., X4). the anatomical relationships of these structures
• Bevel angles should be shallow, from 0 to 10 and to review the osteotomy procedure (Fig.
degrees. 9-2). Once the flap has been raised, the mental
• Apical root resections should be 3 mm in length image of the radiographs should be superim¬
and should be made perpendicular to the long posed onto the cortical plate.
axis of the root. If the surgeon is unsure of the exact location
• Apical curettage addresses only the symptoms of the apex, the following procedure provides a
of pathology, not the cause. way to determine the location: using the radi¬
ograph as a guide, the surgeon marks the proba¬
ble apex position on the buccal plate. Next, a
ARMAMENTARIUM small indentation made with a #1 round high¬
45-Lindemann bur speed bur is filled with a small amount of ra¬
45-Impact Air 45 handpiece dioopaque material, such as gutta percha. A ra¬
45-Micromirrors diograph taken with this marker in place will
45-Microexplorers show the marker in relation to the root apex.
45-Curettes: Columbia, Molten, Mini-jacquets Once the surgeon is sure of the exact location of
45-Stropko irrigator/drier the apex, the cortical bone is removed slowly and
45-Ultradent microtips carefully with copious water spray under low
45-Methylene blue stain magnification (X4 to X6). This procedure is dis¬
cussed in greater detail in the next section of this
chapter. The H 161 Lindemann bone cutter and
OSTEOTOMY the Impact Air 45 handpiece are best suited for
An osteotomy, which entails the removal of the creating an osteotomy. The bone cutter bur is
cortical plate to expose the root end, must be specially designed to remove the bone while
approached deliberately and carefully, so that minimizing the frictional heat. It has fewer flutes
the osteotomy is made exactly onto the apices. than conventional burs, which results in less
The first step is to take radiographs perpendicu¬ clogging and more efficient cutting. The advan¬
lar to the roots from two different angles with tage of the Impact Air 45 handpiece is that water
which to ascertain the length of the roots, the is directed along the bur shaft, while air is ejected
curvature of the roots, the position of the apices out of the back of the handpiece (Fig. 9-3). This
in relation to the cusp tips, and the number of creates less splatter than conventional hand-
roots. Finally, the proximity of the apices to pieces and decreases the chance of emphysema
apices of adjacent teeth, the proximity of the and pyemia.
85
Distinction between Bone and Root Tip

The purpose of using the microscope for making
the osteotomy is to clearly distinguish the root tip
from the surrounding bone. The root has a
darker, yellowish color and is hard, whereas the
bone is white, soft, and bleeds when scraped with
a probe. When the root tip cannot be distin¬
guished from its surroundings, the osteotomy site
is stained with methylene blue, which preferen¬
tially stains the periodontal ligament (see Chap¬
ter 10). The absence of a distinct PDL stain at
medium magnification (X10 to X12) indicates
that the root tip has not yet been exposed. Since
F'g 9-1 A radiograph showing the position of the inferior alve¬ the tip of the root is very small in relation to the
olar nerve in relation to the apices of #30 must be taken before osteotomy, the surgeon must be very observant
incision and osteotomy. for even the smallest irregularity in the bone,
which is usually the root tip. The advantage of us¬
ing the microscope for this procedure is the min¬
imal removal of healthy bone structure. This
more conservative osteotomy generally results in
faster healing and as a result, greater patient
comfort. Fig. 9-4 shows four stages of creating an
osteotomy under the microscope. The main rea¬
son for using the microscope at this stage is to
identify the root tip and thus to minimize the un¬
necessary removal of cortical bone. This proce¬
dure perfectly illustrates the main principle of
microsurgery: the complete removal of pathology
with minimum removal of or damage to healthy
tissue structures.
Clinical Situations for Endodontic

Fig 9-2 An examination of the skull, especially of the tooth po¬ Microsurgery
sition in the jaw in relation to a significant anatomical structure,
can be very helpful, even to the experienced surgeon. The three most common clinical situations for
endodontic microsurgery are the following:
1. An intact cortical plate with a very small or
no periapical lesion.
2. An intact cortical plate with a distinct peri¬
apical lesion.
3. A fenestration through the cortical plate
leading to the apex.
The first two cases fall into Classes A, B, and C
of apical surgery, while the third case reflects
Classes D, E, and F (see Chapter 1).
Intact Cortical Plate without

a Radiographic Periapical Lesion
Surgery is generally not performed if a periapical
lesion does not appear on the radiograph. An ex¬
Fig- 9-3 An Impact Air 45 handpiece. ception is a patient with undiminished discom-
Chapter 9 Osteotomy and Apical Root Resection 87
Fig. 9-4 A, A small osteotomy and root tip are barely visible at x2. B, At X16, the root tip and
the bone can be distinguished from each other. C, At xtO, the root tip with gutta percha filling
is clearly visible. D, At X16, the details of the resected root surface can be seen, even without
staining.
fort after endodontic treatment or a tooth with large because of difficulty in identifying the root
procedural errors that cannot be corrected with¬ apex. As described in the previous section, the
out surgery. Another exception is a medullary preparation of angulation radiographs and a ra¬
bone lesion that does not appear on radiographs. dioopaque marker along with methylene blue
Only when the lesion encroaches on the inner staining are essential aids for accurately deter¬
wall of the cortical bone will a radiolucency ap¬ mining the position of the apices and for making
pear. A surgeon should not assume that a nega¬ a conservative osteotomy. The root length and
tive radiograph indicates the absence of pathol¬ position of the root tip in relation to the cusp tip
ogy. This is especially true for mandibular molars, and to the adjacent roots should be ascertained
where the cortical bone ridge widens as it pro¬ radiographically before making the osteotomy
ceeds proximally. In most cases, persistent dis¬ (see Fig. 9-1).
comfort, sensitivity to percussion, and palpation
Intact Cortical Plate with a Periapical Lesion
are equally important indicators of periapical
pathology. The intact cortical plate with a periapical lesion
From a surgical standpoint, the mandibular is the most common situation in surgical en¬
molar region is the most challenging because the dodontics. In many cases, a probe will penetrate
surgeon must be certain of the exact location of through the thinned cortical bone to the lesion.
the apex. A good analogy is a diver descending to This thin cortical plate is removed with a mini¬
a target through muddy waters. It is not uncom¬ rongeur or with curettes. Subsequently, the
mon for an osteotomy to become excessively boundary of the lesion is defined with an Impact
Air 45 handpiece and copious water coolant, and

the soft tissue is removed. Occasionally, the corti¬
cal plate overlying the lesion is thick and appears
to be intact. Puncturing the bone with a Linde-
mann bur in an Impact Air 45 handpiece will pro¬
vide an important landmark from which the os¬
teotomy can be carefully enlarged. The size of the
lesion is always larger than it appears on the ra¬
diograph. This phenomenon is a result of the fact
that the lesion begins in the medullary bone and
progresses to the cortical bone, where the dam¬
age is therefore smaller.
Fenestration through the Cortical Fig. 9-5 Comparison of osteotomies made with standard sur¬
Plate Leading to the Apex gical instruments (left) and microsurgical instruments [right,
If the fistula exists directly over the affected root, xlO). The new techniques result in a significantly smaller os¬
teotomy.
the procedure is a simple one. The osteotomy
can be performed quickly and precisely by fol¬
lowing the fistulous tract and extending the os¬
teotomy to the appropriate size to expose the le¬ trasonic tips freely within the bone crypt.” Since
sion and provide access for the retropreparation. the length of an ultrasonic tip is 3 mm, the ideal
However, in many situations fistulas do not exit diameter of an osteotomy is about 4 mm, leav¬
at the locus of the pathology but near an adja¬ ing just enough space to manipulate the ultra¬
cent tooth. In this case, to avoid excess removal sonic tip and microinstruments within its
of healthy bone, careful measurements are nec¬ confines (Fig. 9-6, A). The ideal size of an os¬
essary to prepare the osteotomy directly onto teotomy is also illustrated in this clinical picture
the root. (Fig. 9-6, B).
As a corrective treatment for apical lesions,
Optimal Osteotomy Size periradicular curettage alone does not elimi¬
The size of an osteotomy depends primarily on nate the origin of the lesion—it only temporar¬
the size of the instruments. Traditional en¬ ily eliminates the symptoms (Fig. 9-7). However,
dodontic surgery uses relatively large instru¬ periradicular curettage is an important part of
ments; consequently, the size of the osteotomy the procedure. The diseased tissue must be re¬
will be large—approximately 10 mm in diameter moved completely before the apex is resected
to allow the surgeon to view and treat the apices and the remaining canal orifices are cleaned
with a conventional mirror and a micro hand- and obturated.
piece. The removal of so much healthy buccal Once the lesion and the root tip are exposed,
plate has a cost: healing is always slower and of¬ Columbia #13 and #14 curettes and Molten or Ja-
ten painful, and incomplete healing often causes quette 34/35 curettes are used to completely re¬
postoperative complications. The microsurgical move the granulation tissue under medium mag¬
technique, in contrast, uses significantly smaller nification (X10 to X16). Larger curettes, such as a
instruments, resulting in a smaller osteotomy, 33L spoon excavator or a #86 Lucas bone curette,
less healthy tissue damage, faster healing, and are too large and do not efficiently remove gran¬
fewer complications. This difference is illustrated ulomatous or cystic tissue from small and
in Fig. 9-5. medium-size bone crypts. These curettes are
The microscope has also changed percep¬ most suitable for the enucleation of large lesions.
tions. Since even a small osteotomy looks large Because of its gradual curve, the Columbia #13
at higher magnifications (x 8 to X16), there is a and #14 curettes allow access to the lingual as¬
tendency to want to make the osteotomy even pect of the root, which is the hardest area to
smaller. With the availability of microsurgical reach. The Jaquette 34/35 scaler allows efficient
instruments, the new size criteria for an os¬ removal of tissue from the junction of the bone
teotomy is “just large enough to manipulate ul- crypt and the root.
Fig. 9-7 Schematic drawing that illustrates periapical curettage

with a Molten curette.
the bone wall and pressure is applied to peel

away the lesion. Once the lesion is dislodged, the
walls of the bone crypt are scraped clean with a
Molten curette. The lingual aspect of the root is
the most difficult to reach; consequently it is dif¬
ficult to remove the granulation tissue com¬
pletely, although a Columbia #14 curette has
demonstrated effective removal of lingual granu¬
lation tissue. When thorough cleaning of the lin¬
gual area is too difficult, the apicoectomy may be
performed first to provide additional space for
continued periradicular curettage. In addition to
Fig. 9-6 A, The ideal osteotomy is no larger than 4 mm in di¬
ameter to accommodate the 3-mm long ultrasonic tip in the
inspection with a microscope, continued bleed¬
bone crypt. B, An apical preparation shown at x6. The os¬ ing is a good indication that not all granulation
teotomy is small but large enough to accommodate the ultra¬ tissue has been removed. Bleeding will cease only
sonic tip. after all tissue has been removed and the crypt
has been irrigated thoroughly with isotonic
saline. Any minor bleeding from the crypt can
The granulation tissue is richly vascularized now be controlled easily with the methods de¬
and therefore hemorrhages profusely when it is scribed in the section on hemostasis. Bone crypt
disturbed. Controlling the bleeding at this point management is completed when all the granula¬
is an enormous task. Because of the mobilized tion tissue is removed and hemostasis has been
vasodilating inflammatory mediators in the tis¬ established.
sue, the injection of epinephrine containing
anesthetic (1:50,000) directly into the lesion will
only be marginally effective. The granulation tis¬ APICAL ROOT RESECTION
sue must be removed as quickly and completely Root end resection is a straightforward proce¬
as possible. To remove the lesion quickly and dure. When the bone crypt is free of granulation
completely, a concave curette is placed against tissue and the root tip is clearly identified, 3 mm
Lateral
Canal 40 % 86 % 93 %
<PE3Wf<EWDO
Fig. 9-9 Decreasing occurrence of lateral canals and apical

ramifications as apical resections in 1-mm increments progress
coronally. Apical resections at 3 mm are most effective for elim¬
inating the majority of anatomical structures.
removed. If the PDL is not clearly visible as a

complete circle around the root surface, a meth¬
ylene blue stain helps identify the membrane
(see methylene blue technique in the section on
distinction between the bone and root tip) (Fig.
9-8, A, B). If the stained PDL is visible only around
the buccal aspect, the resection must be ex¬
tended deeper lingually.
There are two important elements to consider
with this procedure: how much root tip should be
resected and at what angle should it be resected?
Extent of Apical Resection

Determining how much root tip to resect de¬
pends on the incidence of lateral canals and api¬
cal ramifications at the root end. The authors ex¬
amined this question by using the Hess model of
root anatomy. Using a computer system, the au¬
Fig. 9-8 A, Direct microscopic view (x4) of a resected root
thors resected the roots of the Hess models 1, 2, 3,
stained with methylene blue; the PDL around the root apex is
clearly shown. B, Micromirror view of the resected root surface
and 4 mm from the apex, counting the incidence
stained with methylene blue. Notice the stained PDL as an un¬ of lateral canals and apical ramifications at each
broken circle around the root end. level. The following diagram illustrates the results
(Fig. 9-9).
The results of this study revealed that resecting
of the root tip is resected perpendicular to the 1 mm off the apex reduces 52% of the apical ram¬
long axis of the root. This is most effectively done ifications and 40% of the lateral canals; resecting
at low magnification (X4 to X8) with the Linde- 2 mm reduces these apical structures by 78% and
mann bur in an Impact Air 45 handpiece using 86%, respectively. When 3 mm of the apex is re¬
copious water spray. The only caveat here for the sected, lateral canals are reduced by 93%, and
surgeon is to be certain to resect at a right angle apical ramifications are reduced by 98%. Addi¬
to the root axis, especially with lingually inclined tional resection does not significantly reduce the
roots. Following the resection, the root surface is percentage. This study shows that a root resec¬
examined at medium magnification (X10 to X12) tion of 3 mm at a 0-degree bevel angle removes
for the presence of the periodontal ligament. This the majority of anatomical entities, which are po¬
is done to verify that the entire root tip has been tential causes of failure. Any remaining apical
Fig. 9-10 Apical resections must be performed perpendicular to Fig. 9-11 A large osteotomy and a steeply angled bevel per¬
the long axis of the roots. Section level #1 and #2 result in in¬ formed with the traditional surgical technique. This case failed
complete root resection. Only section level #3 eliminates all ac¬ because of a periodontic-endodontic communication and in¬
cessory canals. (From Beer/Baumann/Kim: Color atlas of dental adequate filling of the elongated canal.
medicine: Endodontology, New York, 2000, Thieme Verlag Stuttgart)
ramifications and lateral canals are sealed during reason for such acute bevel angles in the pre-mi¬
retrograde filling of the canal, which extends 3 crosurgery days was for the surgeon to gain visual
mm coronally (see the section on retrofilling). Re¬ and operating access to the root tip for resection,
moving the apex beyond 3 mm is of marginal placement of retrofilling materials, and inspec¬
value, but it compromises a sound crown-root ra¬ tion. This was especially true for lingually inclined
tio and is therefore not advised. The resection, or roots (e.g., the mesiolingual root of mandibular
bevel angle, should be made perpendicular to the molars). In the process, the mesiobuccal root sur¬
long axis of the root (i.e., as close to 0 degrees as face was significantly reduced, often causing
possible). The reasons for a 0-degree bevel angle periodontic-endodontic communications and
are discussed in the next section. eventual tooth loss.
The surgical operation microscope and micro-
Bevel Angle surgical instruments changed all that by provid¬
The root resection must be performed perpen¬ ing the visual and operating access that result in
dicular to the long axis of the root. Ignoring this minimal bone and root removal. The size of the
rule is the most frequent mistake in apical resec¬ operation access is now dictated by anatomical
tion. Resections not made at 90 degrees to the conditions rather than the size of the instru¬
long axis result in an uneven or incomplete re¬ ments. An apicoectomy with a minimal bevel an¬
section of the apex. The buccal aspect is resected, gle provides three important advantages:
but the lingual part is partially resected or not re¬ 1. It minimizes the removal of the buccal
sected at all, leaving leaky lateral canals. As plate, resulting in a more stable tooth and
shown in Fig. 9-10, resecting along lines #1 and faster healing of the osteotomy.
#2 misses some lateral canals and apical ramifi¬ 2. It exposes fewer dentinal tubules, thus pre¬
cations. When the resection follows line #3 (i.e., venting excess leakage and contamination.
perpendicular to the long axis of the root), 98% of 3. It prevents a potential endodontic-peri¬
the apical ramifications and 93% of the lateral odontic communication.
canals are removed. Since the apices of many
teeth, especially maxillary anterior teeth, are Many surgeries fail because of a large os¬
tilted slightly lingually, surgeons must approach teotomy and an acute bevel angle with resultant
the resection with this lingual inclination in endodontic-periodontic communications (Fig.
mind. 9-11). Although a 0-degree bevel angle is ideal, it
Even until recently, a bevel angle of 45 degrees is not possible in some situations, (e.g., the mesi¬
could be found in textbook illustrations and was olingual root of the mandibular first molar). In
taught in dental schools. There was no biological such a case, to see and work on the apex, the sur¬
or clinical imperative for this practice; the only geon should use a 10-degree bevel and tilt the
Fig. 9-12 Ideal 3-mm root resection perpendicular to the long

axis of the root (From Beer/Baumann/Kim: Color atlas of dental
medicine: Endodontology, New York, 2000, Thieme Verlag Stuttgart)
Fig. 9-13 Many bevel angles result in failed surgery. Line #3 is

the correct angle for beveling.
patient’s head to the side, away from the micro¬

scope. Fig. 9-12 illustrates the ideal root resec¬
tion with a minimal bevel angle. Fig. 9-13 illus¬ Fig. 9-14 A, The ideal 0- to 10-degree bevel angles used in mi¬
trates various bevel angles and the resultant crosurgery. B, The 45-degree or steeper bevel angles advocated
resected root surfaces. Resection line #1 only in traditional surgery. This steep bevel angle is biologically un¬
desirable and structurally destructive. (From Beer/Baumann/Kim:
“shaves” off the buccal aspect of the root, leav¬
Color atlas of dental medicine: Endodontology, New York, 2000,
ing the lingually located apex untouched. Line #2 Thieme Verlag Stuttgart.)
is similar to line #1 with an even sharper bevel
angle. Line #4 resects both apices, but the acute
45-degree bevel angle should be avoided. Only extracted molar tooth, the ideal bevel angle of all
line #3 bisects both apices with a 10-degree shal¬ three roots is illustrated in Fig. 9-15. Microsurgi-
low bevel angle. The resection prognosis along cal techniques provide optimal effectiveness
lines #1 and #2 is poor because of the unat¬ without sacrificing root structure and buccal cor¬
tended lingual apex. Line #4 also has a poor tical plate.
prognosis because of the excessive removal of
buccal root surface and the loss of buccal plate. Wide Lingual Root Extensions
As a comparison, the 10-degree bevel and a Many roots, especially those of maxillary premo¬
45-degree bevel are illustrated in Fig. 9-14. On an lars and the mesial roots of mandibular molars,
Fig. 9-17 Drying the root with paper points is inexact and in¬
complete.
examination is difficult without the superior illu¬

mination and magnification of the microscope.
With extreme lingual anatomy, observing the lin¬
gual border of the resected root end is difficult,
even at high magnification. In this case, the root
surface should be stained with methylene blue
and reexamined at medium magnification (X10
Fig. 9-15 Bevel angles of 0 to 10 degrees illustrated on an ex¬ to X12). The stained PDL should clearly identify
tracted tooth model. Healthy cortical bone and root removal is
the most lingual aspect of the root.
minimized while the majority of the apical delta is removed.
Cleaning and Drying

the Apical Preparation
Before the introduction of the Stropko irriga¬
tor/drier, it was difficult to clean the apical prepa¬
ration of blood and tissue debris. The best
method was cutting a small section of a sterile
absorbent paper point and bending it to fit it into
the apical preparation (Fig. 9-17). The Stropko
device permits the controlled introduction of air,
water, or saline into the apical preparation, so
that it can be rinsed and dried easily and effec¬
tively (Fig. 9-18). To decrease the risk of air em¬
bolism, the existing pressure in the air and water
lines leading to the syringe should be reduced to
less than 10 psi. When microscopic amounts of
Fig. 9-16 Long buccal-lingual extension of the root, which is water are left in the line, an atomized droplet of
common in premolars and mesial roots of molars. water may be deposited in the preparation al¬
though the air button is pressed. The use of two
Stropko irrigators/dryers (one with rinse and dry
extend rather deep lingually (Fig. 9-16). A fre¬ and one with only drying capability) eliminates
quent cause of surgical failure in these teeth is a this minor problem and adds versatility and pre¬
root resection that does not extend deeply cision to the surgical armamentarium.
enough, thus leaving the lingual aspect of the The irrigator/drier also easily replaces the
root unresected. Because of the angle and the re¬ standard three-way tip on most air/water
cessed position of the lingual aspect of the root, syringes and accepts most Luer-Loc needle
croorganisms and their toxins, the removal of the

diseased periapical tissues by periradicular curet¬
tage eliminates only the effect of the leakage, not
the cause. Elimination of the periradicular lesion
alone will result in the recurrence of the lesion.
Initially, there may be a cessation of symptoms
and a radiographic improvement, but this is only
temporary.
As the initial healing surge plateaus, the slower
but persistent pathology prevails, and the case
will fail again. The problems are caused by a leaky
root filling or an untreated accessory canal or
isthmus. Apical surgery therefore entails not just
the removal of the diseased tissue or the root tip,
but most importantly, the retrofilling and reseal¬
ing of the root canal system. If the entire root
canal system could be cleaned and hermetically
sealed every time, the endodontic success rate
would be 100%, and endodontic surgery would
not be required. In reality, however, the complex¬
ity of the root canal system, especially in the api¬
cal region, prevents a 100% success rate for con¬
ventional endodontic therapy. Therefore, when
treating such failures surgically, periradicular
curettage must be followed by a root end resec¬
tion and retrograde filling to prevent repeated
failures.
SUGGESTED READINGS
Arens DE, Adam WR, DeCastro RA: Endodontic surgery,
Fig. 9-T8 A, Drying the root end with the Stropko drier is con¬ Philadelphia, 1981, Harper & Row.
trolled and reliable (X16). B, Schematic drawing, which illus¬ Bender IB, Seltzer S: Roentgenographic and direct observa¬
trates the Stropko drier in action at the resected root surface. tion of experimental lesions in bone. I, J Am Dent Assoc
62:153-160, 1961.
Bender IB, Seltzer S: Roentgenographic and direct observa¬
tion of experimental lesions in bone. II, J Am Dent Assoc
attachments. For example, it is compatible with
62:708-716, 1961.
Ultradent tips of various designs with small to
Carr GB: Surgical Endodontics. In Cohen S, Burn RC, editors:
large orifices, Monojet endodontic irrigating nee¬ Pathways of the pulp, ed 7, St Louis, 1998, Mosby.
dles of various gauges that can be bent or modi¬ Friedman S: Retrograde approaches in endodontic therapy,
fied to any desired configuration, Monojet 27 Endodont Dent Traumatol 7:97-107, 1991.
gauge needles, and Maxiprobe 30 gauge needles. Gilheany PA, Figdor D, Tyas MI: Apical dentin permeability
and microleakage associated with root end resection and
Apical Curettage versus Apical retrograde filling, J Endodont 20:22-26, 1994.
Kim S: Principles of endodontic microsurgery, Dent Clin
Curettage with Root Resection
North Am 41:481-497, 1997.
Since the major cause of periapical lesions is a Kim S, Rethnam S: Hemostasis in endodontic microsurgery,
leaky apical seal with attendant egress of mi¬ Dent Clin North Am 41:499-511,1997.
THE RESECTED ROOT
SURFACE AND ISTHMUS
KEY CONCEPTS sected root surface closely (Fig. 10-1). After the
• The resected root surface is dried with root resection and removal of granulation and
Stropko irrigator/drier and stained with other tissues from the bone crypt, local hemo¬
methylene blue to accent anatomical and stasis must be established first. The resected
pathological details of the root canal system. root surface is then examined carefully at high
Anatomical details include isthmi, fins, and magnification (X16 to X25) with a CX-1 mi¬
lateral and accessory canals. Pathological de¬ croexplorer (Fig. 10-2). To accent the anatomi¬
tails include microfractures, perforations, and cal structures, the resected root surface is
leaky fillings. stained with a cotton swab soaked in methylene
• After staining with methylene blue, the blue. After removal of the excess stain with a
anatomical and pathological details of the re¬ saline solution, the periodontal membrane and
sected root surface are examined at high mag¬ leaky areas are clearly defined by the blue stain.
nification (X16 to X25). Frequently seen anatomical details are isthmi,
• Roots of posterior teeth have the most isthmi. C-shaped canals, accessory canals, canal fins,
• More isthmi are found in the mesial roots than apical microfractures, and leaky canals with par¬
in the distal roots of mandibular molars. tial seals of gutta-percha. The outline of the re¬
• The mesiobuccal root of a maxillary molar has sected root defined by the blue-stained peri¬
more isthmi than the other two roots. odontal ligament (PDL) varies significantly with
• Untreated isthmi frequently cause treatments to tooth type; anterior teeth generally have a round
fail; therefore they must be identified, cleaned, outline, whereas premolars and molars are
shaped, and filled as carefully as the root canals. shaped like a peanut shell (Fig. 10-3). The canal
system also varies with tooth type, bevel angle,
and length of resection.
ARMAMENTARIUM Examining the resected root surface of a previ¬
45- Microexplorers ously treated tooth at high magnifications (X16
45-Micromirrors to X25) also helps the surgeon determine the ad¬
4k Methylene blue stain equacy of the root canal filling and thus the pos¬
4k- Stropko irrigator/drier sible causes of the patient’s problem. Poor mar¬
45-Ultrasonic tips: Kim Surgical tips and Carr ginal adaptation of canal fillings is a frequent
tips (CT) cause for problems with endodontics and
endodontic surgeries. Figs. 10-4 to 10-7 show
the more important problems encountered after
INSPECTION OF THE RESECTED endodontic microsurgery and ways they can
ROOT SURFACE be identified. Shown in Fig. 10-4 are two gutta¬
One of the most important benefits of using a percha fillings with an area of microleakage be¬
microscope during endodontic surgery is that it tween them. A calcified canal always appears as
gives the surgeon the ability to inspect the re¬ a dot when stained with methylene blue (see
95
Fig. 10-1 Inspection of the resected root surface with a mi¬

cromirror positioned at 45 degrees in the bone crypt.
Fig. 10-2 Microexplorer examining a previously unidentified Fig. 10-3 A, Resected root surface of the maxillary first pre¬
orifice on the resected root surface (XI6). molar before methylene blue staining. B, Staining clearly re¬
veals the PDL as an ovoid ring around the resected root sur¬
face of the periodontal ligament. The palatal canal orifice was
also identified.
Fig. 10-5). Fig. 10-6 shows multiple canals instead

of a single foramen. Each of the canals has to be
prepared and obturated. Amalgam retrofillings
are often associated with the microfractures as Contrary to current thought, one or two leaky
shown in Fig. 10-7. The frequency with which apices are not the cause for all failed traditional
these problems are encountered during retreat¬ endodontic surgeries; the cause encompasses all
ment microsurgeries indicates that careful exam¬ the problems just mentioned (see Figs. 10-4 to
ination of the resected root surface at high 10-7). Ironically, many common pathological
magnifications is one of the most important pro¬ conditions that traditional endodontic surgeries
cedures in endodontic microsurgery. Only when are supposed to cure are never actually identified
the defects, whether they are anatomical or iatro¬ in the patient, because they cannot be seen with¬
genic defects, are identified can they be treated. out great magnification.
Chapter 10 The Resected Root Surface and Isthmus 97
Fig. 10-4 Methylene blue staining showing microleakage be¬

tween two gutta-percha fillings.
Fig. 10-7 Microfractures associated with large amalgam retro-

fillings are easily detected using methylene blue stain.
Fig. 10-5 Totally calcified canal, which always looks like a small
dot on a resected root surface when stained with methylene blue.
Fig. 10-8 Using a microapplicator to apply methylene blue to a

dried resected root surface.
because most are truly microscopic. Methylene

Fig. 10-6 Methylene blue stain identifying all canal orifices. This blue staining is an easy and the most effective
root has four apices. means of identifying these features. Methylene
blue stains the PDL, faulty adaptations of retro¬
grade fillings, microfractures, and anatomical ab¬
Methylene Blue Staining normalities of the root surface (see Figs. 10-4 to
Traditional endodontic surgery techniques leave 10-7). Because these features are critically impor¬
many apices untreated and many microfractures tant during microsurgery, staining the resected
or isthmi unidentified (defects that are noticed root surface is an essential diagnostic procedure.
only when they are relatively large). Even at high Methylene blue is applied to the dry resected
magnifications the features can be overlooked root surface with a microapplicator tip (Fig. 10-8).
Fig. 10-9 Clinical photograph (X26) clearly showing an isth¬

mus in the mesial root of a mandibular first molar. Usually the
isthmus is not identified (or filled) when traditional surgical tech¬
niques are used.
After a few seconds the root and the bone crypt are
rinsed with isotonic saline to remove the excess
stain and then dried with a Stropko irrigator/drier
(see Chapter 9).
The stained area can then be examined under
the microscope (X10 to X12). If the entire root tip
has been resected, the PDL appears as an unbro¬
Fig. 10-10 A, Complete isthmus is shown on the mesiobuccal
ken line around the root surface (see Fig. 10-3, B). root of the maxillary first molar. The surface is stained with
A partial line indicates that only part of the root methylene blue stain (X26). B, Partial isthmus (preparation is
has been resected. If no definable line can be the same as in A).
seen, it probably means that only the bone, and
not the root, has been stained. The staining also
helps to distinguish craze lines from microfrac¬ as other canal spaces. Although the current en¬
tures; microfractures stain, but craze lines do not. dodontic techniques of cleaning, shaping, and
The presence of a microfracture can also be con¬ filling the canals have improved significantly
firmed with a microexplorer. If the explorer tip through the use of many new instruments, clean¬
catches, it is a fracture; if it does not, it is a craze ing and shaping the isthmus in the canal system
line. with nonsurgical methods is still problematic.
Development
THE ISTHMUS The embryonic origin of an isthmus is the ep¬
An isthmus is a narrow connection between two ithelial root sheath. In teeth with single roots, the
root canals and usually contains pulp tissue (Fig. inner cells of the root sheath that are next to the
10-9). The isthmus has been called a corridor dental pulp differentiate into odontoblasts and
by Green (1973), a lateral connection by Pineda start secreting dentin matrix. As this matrix be¬
(1973), and an anastomosis by Vertucci (1984). gins to mineralize, the epithelial root sheath cells
In many cases, a tooth with a fused root has a secrete a thin layer of cementum on the newly
weblike connection between two canals; the con¬ formed dentin structure. The cells then continue
nection is called the isthmus, and it is either com¬ to form dentin and cementum while breaks oc¬
plete or partial (Fig. 10-10). Isthmi are often cur within the root sheath epithelium.
found connecting two canals in one root 3 mm Degeneration of the root sheath epithelial
from the apex. Thus the isthmus is a part of the cells allows mesenchymal cells or ectomes-
canal system and not a separate entity. As such it enchymal cells to migrate into the broken areas
must be cleaned, shaped, and filled as thoroughly and differentiate to form cementoids, which
fills the gaps. Cementum production continues

as the tooth erupts into the oral cavity and until
root formation is complete. Occasionally, de¬
fects in the root sheath interfere with dentin
formation, consequently cementum is not de¬
posited in the area. This condition leads to the
development of lateral and accessory canals,
which is commonly observed in the apical third
of the root.
However, in teeth with multiple roots and roots
with multiple canals, another mechanism takes
place. The mechanism of root formation is simi¬
lar to the formation of a single root trunk in all ar¬
eas except in the cervical area, which is where the
root divides. The area where the tooth divides is
known as the furcation zone. Tonguelike projec¬
tions of the epithelial root sheath develop and
proliferate until they make contact with other
Fig. 10-11 Different types of isthmi. Type 1, Incomplete isthmus;
projections, which allows fusion to take place. type 2, complete isthmus between two canals; type 3, complete
The epithelial projections continue to proliferate isthmus between two short canals; type 4, complete or incom¬
and divide. The original large opening forms two, plete isthmus connecting three or more canals; type 5, two to
three, or four openings, which eventually become three canal openings with no visible connection after meth¬
the orifices. As teeth with multiple roots continue ylene blue staining.
to grow, defects develop just as they do in normal

teeth with single roots. Defects are more com¬
mon in teeth with multiple roots because the which is an incomplete isthmus, is a barely
tonguelike projections of the epithelial root traceable communication line between two
sheath do not completely fuse with each other, canals. Type 2 is a definite connection between
resulting in the formation of lateral or accessory the two main canals. This type of isthmus is a
canals in the furcation area. An isthmus is formed complete isthmus and can exist as a straight line
when an individual root projection is unable to between two canals or as a C-shaped connec¬
close itself off. Therefore the approximation of tion. Type 3 is a complete but very short con¬
the root projections can fuse completely and nection between two canals and sometimes
form one root with other root canal systems, looks like a single elongated canal. Type 4 can be
which occurs in the distobuccal root of maxillary either complete or incomplete but connects
molars. Alternatively, partial fusion results in the three or more canals instead of two. Incomplete
formation of two root canals with an isthmus be¬ isthmi connecting three canals in a C-shape are
tween them, which occurs in the mesial root of also included in this category. Type 5 isthmi in¬
the mandibular first molar. No fusion causes the clude two or three canal openings on an elon¬
formation of a large, ribbon-shaped canal that gated ovoid root surface and do not have any
forms an isthmus throughout the entire root, visible connections, even after they are stained.
which is a common finding in the distal root of The dilemma with a root surface of this type is
the mandibular first molars and maxillary second whether to treat it as though the canals were
molars. connected by an isthmus or to treat the canal
orifices only. It is thought that the absolute ab¬
Characteristics sence of any visible staining between canals ex¬
Examination of many resected root surfaces amined at high magnification (X16 to X25) in¬
during endodontic microsurgery and careful in dicates the absence of an isthmus, and therefore
vitro microscope examinations of resected root only the canal orifices should be treated. How¬
surfaces of extracted human teeth reveal many ever, in some cases, seemingly separate canal
different isthmus forms. A diagram illustrating orifices are found to be connected microscopi¬
these characteristics is shown in Fig. 10-11. Type 1, cally when examined under SEM; therefore
1 00 Color Atlas of Microsurgery in Endodontics
Complete Partial Total
Percentage of Isthmus
100
90 Maxillary
80 Mandibular
£70
to 60
§50
X 40
to 30
20 Total
10
0
r mm m 0M
2 3 4 5 6
Partial
Complete
Level from Apex (mm) Percentage of Isthmus %
Fig. 10-12 Results of study showing high numbers (more than Fig. 10-13 The isthmus frequency in maxillary and mandibular
45%) of complete and partial isthmi between 3 and 4 mm from premolars is almost 30%.
the apices of the mesiobuccal roots of maxillary first molars. (From
Beer/Baumann/Kim: Color atlas of dental medicine: Endodontology,
New York, 2000, Thieme Verlag Stuttgart.)
some endodontic surgeons treat this microscopic

connection as an isthmus. Because of the lack of
controlled clinical study results regarding the heal¬
ing outcome of treated versus untreated micro¬
scopic connections between apical canals, the is¬
sue of whether to treat them remains unresolved.
Frequency
The frequency with which isthmi are found in
maxillary and mandibular anterior teeth is rela¬ Fig. 10-14 High incidence (70% to 80%) of isthmi at the 3- to
4-mm level on the mesial roots of mandibular first molars.
tively low (15%). In the maxillary premolar
group, the frequency with which isthmi are
found increases as the resections are made in a
more coronal direction. For example, the inci¬ Percentage of Isthmus
dence ranges from 16% in a 1-mm resection to
52% in a resection 6 mm from the apex. This
variability is not the same in mandibular pre¬
molars, which have an incidence of approxi¬
mately 30% starting 2 mm from the apex. In the
maxillary first molar, 60% of the mesiobuccal
roots have two canals. In a 1994 study, Weller,
Niemczyk, and Kim randomly selected 50 maxil¬
lary first molar mesiobuccal roots of extracted
teeth, cut them into 1-mm cross-sections begin¬
ning at the apex, and examined them magnified Fig. 10-15 Low incidence (15%) of isthmi on the distal roots of
mandibular first molars.
(X25). Two types of isthmi were found; a com¬
plete (type 2) and an incomplete (type 1), and
the incidence of these isthmi (a combination of
types 1 and 2) accounted for more than 45% of level. In the mesial root of the mandibular first
those found 3 mm from the apex and for ap¬ molar, approximately 80% of the sections from
proximately 50% 4 mm from the apex (Fig. 10- the 3- to 4-mm level contain isthmi (Fig. 10-14).
12). Fig. 10-13 shows nearly 30% of both arches By contrast only 15% of the distal roots have
in premolars had an isthmus at the 3- to 4-mm isthmi at the 3-mm level (Fig. 10-15).
Chapter 10 The Resected Root Surface and Isthmus 1 01
Fig. 10-16 A, Mandibular first molar one year after apical surgery. Swelling and pain recurred.
Radiograph shows two, round amalgam retrofillings in the mesial root with a PAR. B, High mag¬
nification of isthmus retropreparation with an ultrasonic instrument. Because isthmus had not
been treated initially, the problem recurred. C, Retrofilling of isthmus in B, with SuperEBA at
high magnification (X16). Note elongated retrofilling covering two apices and connecting isth¬
mus. D, Radiograph immediately after surgery and 1 year after surgery, which shows complete
healing.
Clinical Significance isthmus correctly with the traditional large

The high number of isthmi found during micro¬ instruments.
surgery was a surprising finding that prompted
an anatomical investigation. The results of the Preparation with Ultrasonic Tips
study agreed with clinical observations and cor¬ As pointed out previously, preparing an isthmus
roborated the opinion that untreated isthmi are using a bur is almost impossible. Ultrasonic
one of the main causes of surgical treatment preparation of the isthmus requires a more care¬
failure. Fig. 10-16 shows one of many cases sup¬ ful and delicate approach because the isthmus
porting the view that the higher numbers of is located in the thin portion of the root, which
isthmi found in the mesial roots of mandibular can easily be perforated or stripped. An ultra¬
molars appear to be the cause of the greater sonic tip with a diameter of less than 0.3 mm is
number of failed mesial surgical retrofillings ideal for treating an isthmus without causing
versus the distal roots. The identification of ex¬ perforation or stripping the root.
isting isthmi is therefore extremely important Occasionally, a dental surgeon encounters an
for the success of the endodontic therapy, but incomplete isthmus (Fig. 10-17, A). In this case,
equally important is that the isthmus be treated providing a guideline for the ultrasonic tip by
under the microscope with ultrasonic tech¬ creating a shallow groove, or tracking groove,
niques and microinstruments. Because of its along the isthmus line with a microexplorer is
size and location, it is impossible to prepare an helpful (Fig. 10-17, B). The ultrasonic tip is first
Fig. 10-17 A, Incomplete isthmus. B, Microexplorer making a tracking groove along the
incomplete isthmus. C, KiS tip being used to prepared isthmus (3 mm deep and 2 mm wide).
D, Magnified view (X16) of a prepared isthmus. Notice sharp outline and uniform depth
3 mm into canal space.
activated without water coolant to make the mus is carefully inspected at a high magnifica¬
tracking groove connecting the two canals, tion (x 16 to X25) for a sharp wall definition and
which are usually oriented from buccal to lin¬ a smooth preparation (Fig. 10-17, D).
gual. The groove can be produced quickly by
gently guiding the tip along the isthmus. Before Importance of Locating and Treating
preparing the isthmus to the full depth, the the Isthmus
tracking groove should be examined with mag¬ The dental isthmus was not mentioned in dental
nification (X12 to X16) for correct positioning. textbooks or published journals until 1983, when
Once the correct position is verified, the isthmus Cambruzzi and Marshall published an article on
is fully prepared with a water-cooled KiS-1 tip* isthmi in a Canadian dental journal. The article
(Fig. 10-17, Q. The length of the active portion predated the evolution of apical surgery and was
of the tip is 3 mm with a 0.2-mm diameter therefore ignored. Evidence of a treated and
width, and the entire tip length must be used to retrofilled isthmus is virtually absent from the
prepare the isthmus. Before retrofilling, the isth- dental literature. The accepted radiographical
“look” after apical surgery and amalgam retrofill¬
* We are currently testing a prototype of the new KiS blades, which
ing was the previously mentioned radioopaque
performed very well during isthmus preparations. The idea of using BB-gun appearance at the apex (Fig. 10-18). Den¬
a blade rather than a tip developed after frequently encountering tal professionals who consider a hermetic seal at
difficulties with isthmus preparations in posterior roots because
the apex to be the goal of the surgery have man¬
they were difficult to access and were found in long buccolingual
roots (i.e., long isthmi). The blades make isthmus preparation easier aged poorly in the many cases in which an isth¬
and eliminate the need for a tracking groove. mus was present.
Fig. 10-18 A, Radiograph showing two small, round amalgam

retrofillings at apices of a mesial root; "BB-gun" fillings. B, Amal¬
gam retrofilling "floats" on the orifice because it is too large in
relation to the root width.
The nonmicrosurgical traditional techniques

can neither identify nor treat the isthmus. There¬
fore management of the isthmus is solely the do¬
main of the endodontic microsurgeon, which
has been confirmed by the clinical evidence in
the previous sections. Many different types of
isthmi exist (see Fig. 10-11). Surgeons must con¬
sider the possible presence of an isthmus before
surgery and should be prepared to encounter
and treat any of its various types during the
surgery. In posterior teeth the natural unresected
root apices are frequently round (Fig. 10-19) but
after the 3-mm resection, they assume the shape
of a peanut shell and show evidence of having an
isthmus (Fig. 10-20). To be certain of microsur-
gical success, surgeons should familiarize them¬
selves with each of the isthmus types and their
characteristic signs. If every isthmus were prop¬
erly treated and filled, endodontic surgery out¬
comes would be greatly improved and many oth¬ Fig. 10-20 After resecting 3 mm, an isthmus can be found in
erwise unsalvageable teeth could be maintained the elongated, peanut-shell shape root surface in the majority of
as functional members of the dentition. The roots, especially those of posterior teeth.
advantage of the microsurgical technique is that Hsu YY, Kim S: The resected root surface: the issue of canal
the isthmus can be identified using the micro¬ isthmi, Dent Clin North Am 41:529-540, 1997.
scope and micromirrors and managed with con¬ Pineda F: Roentgenographic investigation of the mesiobuc-
cal root of the maxillary first molar, Oral Surg 36:253,
fidence using ultrasonic instruments.
1973.
Vertucci FJ: Root canal anatomy of the human permanent
SUGGESTED READINGS
teeth, Oral Surg 58:589-599, 1984.
Cambruzzi JV, Marshall FJ: Molar endodontic surgery, J Can Weller RN, Niemczyk SP, Kim S: Incidence and position of
Dent Assoc 1:61-66, 1983. the canal isthmus. I. Mesiobuccal rooPof the maxillary
Green D: Double canals in single roots, Oral Surg35:689-696, first molar, JEndodont 21:380-383, 1995.
1973.
RETROPREPARATION
KEY CONCEPTS primarily limited by the lack of physical access to

• Microsurgical retropreparation techniques re¬ the root apices. The standard dental instruments
quire the practiced use of ultrasonic tips and (e.g., microhandpieces) were too large to perform
micromirrors under the microscope. an ideal class I preparation along the long axis of
• Retropreparations are made 3 mm deep with the root, unless the osteotomy was large enough
ultrasonic tips. to accommodate the head of the microhandpiece
• Ultrasonic tips are used in a light, sweeping freely inside the bone crypt. For this reason the os¬
motion—short forward/backward and upward/ teotomy was always large and frequently en¬
downward strokes result in effective cutting croached on the coronal border of the alveolar
action. bone, often resulting in a periodontic-endodontic
• Retropreparation begins with aligning a se¬ communication. In the endodontic community,
lected ultrasonic tip along the root prominence many approaches were proposed to overcome the
on the buccal plate under low magnification problem, such as performing class I preparations
(X4) to ensure that the preparation follows the at a 45-degree bevel angle to the long axis of the
long axis of the root. root and performing vertical or transverse root slot
• Once the ultrasonic tip is aligned, the prepara¬ preparations. These approaches were considered
tion can be carried out under magnification successful; an amalgam filling placed at the apex
(xlOto X12). had a satisfactory round radiographical appear¬
• Final inspection of the retroprepared cavity un¬ ance (Fig. 11-1). However, seldom did the prepa¬
der high magnification (X20 to X24) is neces¬ rations fully prepare the apical canals and rarely
sary to ensure complete removal of gutta-per¬ did the fillings seal the canals. In fact, the root end
cha from the canal. preparations did not follow the long axis of the
root (Fig. 11-2, A). Rather, they veered off to the
side and frequently perforated the lingual aspect
ARMAMENTARIUM the root end, a situation that was common in
45-Ultrasonic tips; Kim surgical (KiS) tips or Carr preparations made at a 45-degree angle (Fig. 11-2,
tips (CTs) B,C). In animal experiments the traditional surgi¬
45-Ultrasonic units: Spartan, Satelec, and Miniendo cal techniques always resulted in lingual perfora¬
45-Micromirrors: round and rectangular tion or near perforation and accumulation of in¬
4S- Microcondensers flammatory cells in the perforation site (Fig. 11-3).
45- Microexplorers In addition, the retrofillings were too large and
covered most of the resected root surface; they
were also too shallow, which caused the fillings to
TRADITIONAL RETROPREPARATION become dislodged (and become “floating” apical
TECHNIQUE seals) (Fig. 11-4).
The objective of the root end preparation is to The use of the surgical operation microscope
clean and shape the apical canal so that the filling with targeted illumination and magnification and
material placed into the root end obturates the re¬ the development of microsurgical techniques have
maining root canals, providing a hermetic apical allowed dental surgeons to overcome the inade¬
seal. In the past, although root end preparation quacies and difficulties associated with traditional
methods varied according to tooth type, they were techniques. A perfect class I preparation can be
105
Fig. 11-1 A, "Floating" large amalgam filling placed using a traditional retrofilling technique in
the maxillary molar. B, Two amalgam retrofillings in MB and ML apices, which are placed at the
wrong angle, neglecting an isthmus. Both cases failed.
Fig. 11-2 A, Bur retropreparation, which too fre¬

quently results in apical perforation or near perfora¬
tion because of difficulty aligning bur with canal di¬
rection. B, Bur retropreparation with a 45-degree
bevel angle on a root. This method was practiced in
traditional apical surgeries before the introduction of
C
microsurgery. C, Scanning electron microscope pho¬
tograph of a tooth prepared with a bur, not following
the canal, resulting in leakage. (Courtesy C. Carr,
Chula Vista, Calif.)
made with a small (usually 4 to 5 mm in diameter) size so that the tip can be manipulated freely in the
osteotomy. bone crypt. Thus an osteotomy does not need to
As discussed in the previous chapter, the size of be larger than 4 to 5 mm in diameter. Fig. 11-5
the osteotomy depends strictly on the size of the shows the various sizes of three retropreparation
ultrasonic tips; an additional 1 mm is added to the instruments: an ultrasonic tip, a microhandpiece,
Chapter 11 Retropreparation 107
Fig. 11-3 A, H & E-stained dog premolar with a SuperEBA retrofilling prepared with a bur. This
micrograph shows lingual perforation. B, Lingual perforation site shown in A showing bone
loss and a large collection of inflammatory cells.
A B
Fig. 11-4 The mandibular first molar before (A) and after (B) amalgam retrofilling. Notice the
large amalgam retrofilling, which is many times larger than the actual retropreparation.
Fig. 11-5 Three generations of retropreparation instruments.

Top to bottom: a high-speed handpiece, a microhandpiece, and
an ultrasonic tip. Notice the successively smaller cutting ends.
Fig. 11-6 Diagram of ultrasonic retropreparation. Notice that

the ultrasonic cutting tip is aligned with the long axis of the root.
(From Beer/Baumann/Kim: Color atlas of dental medicine: En¬
dodontology, New York, 2000, Thieme Verlag Stuttgart.)
Fig. 11-7 A, Ultrasonic unit designed for endodontic micro¬

and a small round bur in a high-speed handpiece.
surgery by Spartan/Obtura Co. This unit is used for microen¬
The difference in sizes is quite evident; it is obvi¬ dodontics and microsurgery. B, Enlarged view of ultrasonic
ous why surgeons could not make precise root handpiece and tip.
preparations and had to use large osteotomies
when using the larger instruments. Procedures us¬
ing the ultrasonic units result in much better ac¬ (Fig. 11-6). Ultrasonic units create vibrations
cess to the teeth and greatly improved endodon¬ ranging from 30 to 40 kHz by exciting the quartz
tic retropreparations. A preliminary study shows or ceramic electric crystals that are located in the
that ultrasonic procedures are 96% more success¬ handpiece (Fig. 11-7). The energy is carried to the
ful than the traditional surgical procedures. Many ultrasonic tip, and single-plane forward-back-
traditional endodontic surgery approaches are ward vibrations are created. Continuous irrigation
compromises or more or less educated guesses along the tip prevents buildup of frictional heat at
and should be abandoned because microsurgical the cutting surface and maximizes debridement
instruments and techniques have been perfected. and cleaning efforts. Copious irrigation is essen¬
tial in ultrasonic root end preparation so that the
Ultrasonic Units and Tips root tissue does not become heated and result in
One of the most significant advancements in en¬ microfractures.
dodontic surgery is the successful use of the Piezo Ultrasonic tips are available in various config¬
ultrasonic instrument for root end preparations urations (Analytic Endo, Satelec/Amadent Co.,
Fig. 11-9 Comparison of the CT (top) and the new KiS tip (bot¬
tom). The CT is shorter and more angled than the KiS tip.
Fig. 11-8 Enlarged views of ultrasonic tip and microhandpiece.

Note size differences among the 3 mm-tip, the bur, and the
microhead.
and Spartan/Obtura Co.) for almost all situations

(see Chapter 4), allowing surgeons to use proper
preparation angles and conservative osteotomy
sizes. Specially designed tips cut smoothly with Fig. 11-10 The KiS tip is coated with zirconium nitride for
smooth and efficient cutting.
relatively little chatter when the tips are activated
against the dentinal walls of the apical prepara¬
tion. Most importantly, the tips are only ^-mm in
diameter, about one tenth the size of a conven¬
tional microhead handpiece (Fig. 11-8). and KiS tips; the CTs are shorter and more an¬
The first ultrasonic tips for endodontics and gled than KiS tips.
endodontic surgery were the CTs that were first The KiS tips are made of the same metal and
available in early 1990 (see Chapter 4). These have the same physical characteristics as the CPR
tips were a true innovation at the time, and they tips that are used for post removal in retreatment
were the beginning of the fundamental change endodontics. The KiS tips are coated with zirco¬
in endodontic surgery that occurred in the nium nitride, which provides strength and sur¬
1990s. During the past decade, microsurgery face roughness (Fig. 11-10). As a result, they cut
and microsurgical instruments have evolved to significantly faster and more smoothly but leave
accommodate new endodontic needs. Regard¬ a slightly rougher dentin surface than other tips,
less, even with the improvements, endodontic which provides a more adherent surface for the
surgeons still hoped for instruments with bet¬ filling material. The location of the irrigation port,
ter cutting capabilities and many different an¬ which is on the tip rather than on the shaft, al¬
gle tips so that they could have better access to lows it to irrigate directly into the cutting site (Fig.
difficult-to-reach areas. The new KiS tips, which 11-11). The improved cutting and irrigation char¬
have been on the market since 1999, have ad¬ acteristics of the KiS tips reduce the risk of mi¬
dressed these needs. Figure 11-9 shows the CTs crofractures. KiS tips also have different shaft
design, and tip specificity. Tip specificity refers to

the fact that most tips work best with the unit for
which they were designed (e.g, KiS tips that are
designed for the Spartan unit).
The following is a list of ultrasonic tips and
their suggested areas of use:
• Anterior teeth: KiS 1 and 2 tips N

• Premolars: KiS 1 and 2 tips or KiS 3, 4, 5, and 6
tips (depending on access space)
• Molars: KiS 3, 4, 5, and 6 tips
Fig. 11-11 The irrigation port of the KiS tip is very close to the • Isthmi (wide): KiS 2 tip
tip's cutting end, providing complete cooling during cutting. • Isthmi (narrow): KiS 1, 3, and 6 tips
Ultrasonic Root End Preparation

angles, tip angles, and lengths than CTs. KiS 1 and The ultrasonic root end preparation procedure is
2 tips are used in the same situations as CTs 1 and carried out under the microscope at low to middle
5; they are used for anterior and premolar teeth. magnifications (X4 to X16). Numerous appropri¬
The KiS 2 tip is thicker than the KiS 1 tip and is ate tips are selected for the particular tooth to be
designed to treat larger apices. KiS 3 and 4 tips are treated. For example, one of the KiS 3,4, 5, or 6 tips
double angled, with 75-degree and 110-degree is chosen to treat the mesiobuccal root of a maxil¬
angled tips; they are used for maxillary right and lary first molar or the mesiodistal roots of the
mandibular left posterior teeth. The KiS 3 tip is mandibular first molar for an easy approach to the
used for the buccal root, whereas the KiS 4 tip is apex. The KiS 1 and 2 tips are the preferred ultra¬
used for the deeper lingual root. KiS 5 and 6 tips sonic tips for treating anterior and premolar teeth.
are used for the maxillary left side and the The resected root surface is stained with meth¬
mandibular right side and have the same config¬ ylene blue and thoroughly examined at high
uration as KiS 3 and 4 tips. The KiS tips do not magnification (X16 to X25) to visualize the par¬
have the deficiencies of the CTs, and the features ticular microscopic anatomical details, such as
needed for microsurgery are better. The KiS tips isthmi and accessory canals, being considered for
work best with the Spartan Piezo ultrasonic unit. preparation (see Chapter 10).
Ultrasonic tips are better than microhead burs Using low magnification (X4 to X6), the se¬
for many reasons. Ultrasonic tips provide the fol¬ lected ultrasonic tip is positioned at the apex. Be¬
lowing advantages: cause the tip must be aligned with the long axis of
the root, the surgeon must examine the position
• Better access to surgical areas, especially diffi-
of the entire tooth, including the crown and root
cult-to-reach areas (e.g., lingual apices)
eminence, at low magnification (X4) and com¬
• Ultrasonic cleansing of tissue debris
pare it to the position of the ultrasonic tip. Failure
• Conservative preparations that follow the canal
to confirm that the ultrasonic tip is positioned at
anatomy to a precise depth of 3 mm
the correct angle is likely to result in an incorrectly
• Ultra precise isthmus preparations
angled root end preparation or a root end perfo¬
• Parallel canal walls preparation for better re¬
ration. Confirming the tip’s position is one of the
tention of filling materials
few times during surgery that low magnification
Ultrasonic retropreparation is still evolving, is essential for preventing a procedural error.
but some facts have been established. Using the The ultrasonic tip is activated, and the apical
smallest tips producing the least chatter and canal is retroprepared with copious amounts of
making apical preparations in the widest part of water coolant to a depth of 3 mm. After activation
the root are the safest techniques because they the tip should be placed at the most apical open¬
reduce the risk of microfractures and craze lines ing of the canal and gently guided deeper into the
in the apical dentin. canal as it ablates the dentin. Unlike a bur, the ul¬
From a mechanical perspective, ultrasonic trasonic tip needs space around it to function
performance is most affected by amplitude, tip properly, and its cutting mechanism functions
Fig. IT-12 Micromirror view of retroprepared canal with ultra¬ Fig. 11-13 Two most useful micromirrors in microsurgery:
sonic tips. Note smooth and well-defined walls required for small round and rectangular shapes with pointed tips.
good retention of retrofilling material.
through vibration, not pressure. An ultrasonic tip

that is pressed into a canal is unable to vibrate
and therefore unable to cut. Pressing too hard on
the tip also decreases the ultrasonic energy and
may damage the Piezo electric crystals in the
handpiece. A light, sweeping motion with short
forward/backward and upward/downward
strokes is essential for effective cutting action and
tip preservation. Depending on the canal config¬
uration, a typical 3-mm retropreparation should
take less than 1 minute using KiS tips.
After the retropreparation is completed, the
prepared cavity is inspected with a micromirror
at a high magnification (X16 to X25) (Fig. 11-12).
At this point, maintaining hemostasis is very im¬
portant (see Chapter 7). A thorough inspection
is performed and should include examination
of each of the interior canal walls for any rem¬
nants of gutta-percha, especially on the difficult -
to-reach facial wall, and verify that the parallel
walls are sharply defined and smooth, which re¬
sults in superior retrofilling adaptation and
retention. Fig. 11-14 Retrocavities that were perfectly prepared using an
ultrasonic tip (X24). Note well-defined class I preparation of the
Importance of Micromirrors two apices, which are approximately 0.3 mm.
One of the key instruments in microsurgery is the
micromirror (Fig. 11-13). The reflective surface is
made of highly polished stainless steel or sapphire. mirror was too large to fit into even a large os¬
The mirrors are small enough to fit comfortably teotomy. Although the microscope’s inclinable
into an osteotomy that is 4 to 5 mm in diameter. binoculars provide a viewing range from 0 to 180
Inspection of root ends, regardless of whether they degrees, it is usually not sufficient for examining
are prepared, cannot be carried out without the the entire root end. The anatomy of the root sur¬
aid of micromirrors. In fact, before the introduc¬ face is reflected in the micromirror into the view¬
tion of micromirrors, it was impossible to see an ing range of the surgical operation microscope be¬
apical preparation because the standard mouth fore and after the retropreparation (Fig. 11-14).
Micromirrors have an optical grade finish and

are bent at 45 degrees. They are available in vari¬
ous sizes and shapes from many manufacturers,
including the Hartzell and Son Co., Analytic
Endo, Hu-Friedy, and ledmed. The mirrors are
made in basically two shapes: round and rectan¬
gular, with small variations. The mirror type and
size that are used are dictated by tooth type and
osteotomy size. For example, a small round mir¬
ror with a diameter of 3 mm is useful for round
resected root surfaces, such as those found in an¬
terior teeth. The rectangular type is the most
widely used because the resected root surfaces of
premolars and mesial roots of molars are long Fig. 11 -15 Gutta-percha is thermoplasticized by an activated
ultrasonic tip. No cutting noise is heard, and retropreparation
buccolingually. Both mirror types are shown in
is simple.
Fig. 11-13.
Micromirrors have flexible handles that can be
bent out of the microscope’s sight path, a very im¬
portant feature of a micromirror. The miniatur¬
ized mirrors easily fit into very small bone crypts
for examination of retropreparations and are es¬
sential for the following procedures:
• Differentiation of the root end from the bone

(X8 to X10)
• Identification of the causes of treatment fail¬
ures (X16 to X25)
• Examination of the resected root surface (x 16
to X25)
• Inspection of the retropreparation (X16 to
X25) (see Figs. 11-10, 11-11, and 11-15)
• Examination of the retrofilling (X16 to X25) Fig. 11-16 Complete ultrasonic preparation of an isthmus
(X20). This view shows well-defined walls and smooth, clean
(see Chapter 12)
surfaces. The prepared cavity is ready for retrofilling material.
Management of Gutta-Percha
in Retroprepared Cavity maining gutta-percha or other filling material left
As the ultrasonic unit is activated, gutta-percha on the canal wall hinders the formation of a solid
is thermoplastisized and comes out of the prepa¬ retrofilling seal. In numerous failed surgical treat¬
ration in long strings (Fig. 11-15). After the retro- ments it was noted that root filling material was
preparation is complete, the gutta-percha re¬ left on the facial wall just coronal to the beveled
maining at the base of the preparation is surface of the root. In these cases the new “seal”
recondensed with a small, ^-mm microplugger, was less than ^-mm deep before meeting with
which should provide a smooth, flat base against remnant, loose gutta-percha fill.
which the retrofilling material can be placed.
The most difficult area to reach and therefore Inspection of Root End Preparation
the most often neglected is the facial wall of the To see the root end with an appropriate depth of
canal. Special care should be taken to remove any field, it is best prepared at low to middle magnifi¬
remaining gutta-percha from the facial walls of cation (X8 to X12); however, the preparation must
the molar canals with KiS 3, 4, 5, or 6 tips or to be inspected at high magnification (X16 to X25).
condense it coronally with a microplugger to Fig. 11-16 shows a high-magnification inspection
leave a clean, 3-mm deep retropreparation that reflected in a micromirror. Retropreparations can
resembles a class I cavity preparation. Any re- also be inspected directly, but this rarely occurs,
Fig. 11-17 Traditional method of drying retroprepared cavities- Fig. 11-18 New and completely reliable method of drying retro-
using a paper point. (From Beer/Baumann/Kim: Color atlas of prepared cavities-using a Stropko irrigator/drier with a microtip.
dental medicine: Endodontology, New York, 2000, Thieme Verlag (From Beer/Baumann/Kim: Color atlas of dental medicine: En¬
Stuttgart.) dodontology, New York, 2000, Thieme Verlag Stuttgart.)
especially when the bevel is shallow as it is in a found within the apical 3-mm level. To study the
microsurgery. In addition to examining the com¬ proper depth of the retropreparation, the ex-
pleted preparation to ensure that it has clean, tracted-tooth model was examined during an ex¬
sharply defined walls, it should also be examined periment with a scanning electron microscope
a final time for important anatomical structures, (SEM). In this in vitro experiment, extracted hu¬
such as accessory canals and microfractures, that man teeth were used to place root end fillings of
might have escaped detection during the initial amalgam, SuperEBA, and IRM after 3-mm root
inspection. resections. After filling, teeth were bathed in
saliva-like medium for one month. Beginning at
Drying the Retropreparation the root tip, each tooth was then sectioned at
The apical preparation can easily be rinsed and 1-mm intervals. The sections, specifically the
dried with the Stropko irrigator/drier before junctions between the filling materials and the
placement of an apical filling. With the introduc¬ dentinal walls, were examined under a SEM. A
tion of the surgical operation microscope and mi¬ wide gap measuring 10 to 15 |xm was consistently
cromirrors, careful examination of the cleaned found at the 1-mm level. The gap became nar¬
and dried apical preparation often revealed resid¬ rower at 2 mm, and at 3 mm the filling material
ual blood and debris. The debris and moisture and dentin walls were tightly adapted. These ob¬
were sufficient to prevent the formation of an ad¬ servations were the same regardless of filling ma¬
equate apical seal and frequently caused the terial used. Results of this in vitro study strongly
surgery to fail. At that time, a paper point was the suggest that a root end preparation should ex¬
only means of drying the retroprepared canal; in tend at least 3 mm into the canals to ensure an
retrospect, it was highly inadequate (Fig. 11-17). effective apical seal. Although a retropreparation
Today, the Stropko instrument allows reliable and deeper than 3 mm does not provide any greater
successful irrigation and drying of a prepared benefit, a retropreparation shorter than 3 mm se¬
canal (Fig. 11-18). riously jeopardizes the long-term success of the
apical seal. Fig. 11-19 illustrates the management
Depth of Root End Preparation of the apical 6 mm; a root resection and a retro-
Currently, no consensus exists in the endodontic filling of 3 mm each are essential to ensure an ad¬
community on the optimal depth of the root end equate root apex seal.
preparation. Depths of 1, 2, 3, and 4 mm are be¬
ing discussed and studied. Using the Hess model, Sequence of Retropreparation Procedures
the incidence of lateral canals and apical ramifi¬ After a 3-mm root section is removed, the resected
cations in the natural apex has been studied; root surface is dried with the Stropko irrigator/drier
more than 95% of these anatomical entities are perpendicular to the long axis of the root. Total
ultrasonic tip is selected, and the surgical area is

magnified by the lowest magnification (X4). At
this low magnification the entire surgical area,
including the root and tip, is visible, which is ex¬
tremely important because the ultrasonic tip
must be exactly aligned with the long axis of the
root to prevent perforation or an incorrectly an¬
gled preparation. After confirmatidn of the cor¬
rect alignment, the ultrasonic unit is activated
and the retropreparation begins at x 12 to X16.
SUGGESTED READINGS
Abdal AK, Retief DH, Jamison HC: The apical seal via the ret-
rosurgical approach II. An evaluation of retrofilling ma¬
terials, OralSurg 4:213-218, 1982.
Carr GB: Common errors in periradicular surgery, Endodont
Rep 8:12, 1993.
Carr GB: Ultrasonic root end preparation, Dent Clin North
Am 41:541-554, 1997.
Gilheany PA, Figdor D, Tyas MJ: Apical dentin permeability
Fig. 11-19 Diagram of principles involving retropreparations
and microleakage associated with root end resection and
and retrofillings: 3-mm apical root resection, bevel of 0 or less
retrograde filling, JEndodont 20:22-26, 1994.
than 10 degrees, and 3-mm deep retropreparation and retro-
Jou Y, Pertl C: Is there a best retrograde filling material? Dent
filling. This microsurgical technique provides a seal 6 mm from
Clin North Am 41:555-561, 1997.
the original apex, thus sealing all accessory or lateral canals
King KT et al.: Longitudinal evaluation of the seal of en¬
found in the apical delta.
dodontic retrofillings, / Endodont 16:307-310, 1990.
Nicholls E: Retrograde filling of root canal, Oral Surg 15:463-
473,1962.
hemostasis in and around the bone crypt is very O’Connor RP, Hutter JW, Roahen JO: Leakage of amalgam
important at this stage because numerous in¬ and SuperEBA root-end filling using two preparation
techniques and surgical microscopy, / Endodont 21:74-
spections of the resected root surface are neces¬ 78, 1995.
sary. The resected root surface is stained with Oynick J, Oynick T: A study of a new material for retrograde
methylene blue using a micro tip (Ultradent Co.). fillings, J Endodont 4:203-206, 1978.
After a few seconds the methylene blue is Rubinstein R, Kim S: Short-term observation of the results
washed away thoroughly with isotonic saline. of endodontic surgery with the use of a surgical opera¬
tion microscope and SuperEBA as root-end filling mate¬
The redried resected surface is reflected in a mi¬
rial, J Endodont 25:43-48, 1999.
cromirror and inspected carefully (X16 to X25) Torabinejad M et al: Physical and chemical properties of a
for anatomical details such as isthmi, fins, mi¬ new root-end filling materials, J Endodont 21:349-353,
crofractures, or untreated canals. An appropriate 1995.
RETROFILLING MATERIALS
AND TECHNIQUES
KEY CONCEPTS • They are bactericidal or bacteriostatic.
• No ideal retrofilling material exists. • They adhere to the tooth.
• Retrofilling procedures are carried out under • They are dimensionally stable.
magnification (X10 to X16). • They are readily available and easy to handle.
• Super ethoxybenzoic acid (SuperEBA) is a rein¬ • They do not stain teeth or periradicular tissue.
forced zinc oxide-eugenol (ZOE) cement. Clin¬ • They are noncorrosive.
ical and histological evaluations show that it • They are resistant to dissolution.
provides a good retrofilling seal. • They are electrochemically inactive.
• Of all retrofilling materials tested, periapical tis¬ • They promote cementogenesis.
sue has the best response to mineral trioxide • They are easy to use.
aggregate (MTA). • They are radiopaque.
• Irrigating the bone crypt after MTA placement re¬
sults in dissolution of the material from the cavity. The purpose of filling the apex is to hermet¬
• Maintaining complete hemostasis in and ically seal it so that no bacteria or bacterial byprod¬
around the bone crypt is especially important ucts can enter or leave from the canal. Thus the
when using MTA as a retrofilling material. ideal filling materials should completely adhere to
• Amalgam is no longer used as a retrofilling ma¬ dentinal walls for the long term. They should also
terial in microsurgery. maintain their structural integrity after setting and
not dissolve or corrode during contact with body
Endodontic microsurgery has advanced to such fluids, which amalgam does. In addition, ideal
a level of sophistication and precision that the de¬ retrofilling materials should at least be bacteriosta¬
mand for creating the ideal retrograde filling ma¬ tic and preferably bactericidal. Because bone re¬
terial is even greater than before. Although this generation is one of the most important factors in
goal is as elusive as ever, several compounds are healing lesions, retrofilling materials should also
now available that satisfy at least some of the de¬ promote cementum formation, which provides a
mands. The retrofilling material must provide an natural barrier to bacteria and their toxic byprod¬
apical seal that inhibits the leakage of residual irri¬ ucts. Of all the desired characteristics, a lack of tox¬
tants from the root canal into the periradicular tis¬ icity and an excellent sealing ability are the two
sues. It is a well-known fact that the apical seal is most important qualities.
the single most important factor affecting success Endodontists use a guideline for “required”
in surgical endodontics. Other important charac¬ filling radiopacity (based on amalgam, which is
teristics are discussed in the following section. highly opaque) that was established many years
ago. The newer materials on the market are less
opaque, but their degree of radiopacity is nei¬
PROPERTIES OF IDEAL ther an indicator of the density nor the quality
RETROFILLING MATERIALS of the filling. Nor is radiopacity important
Ideal retrograde filling materials have the follow¬ in terms of the biological interactions between
ing characteristics: the materials and tissues. In endodontics, ra¬
diopacity, or at least some degree of radio¬
• They are well tolerated by periapical tissues. pacity, is important only in that it provides
115
BOX 12-1 Retrograde Filling Materials Thus other materials, especially SuperEBA and
IRM, are slowly replacing amalgam. Most re¬
• Amalgam
cently, MTA has shown promise as a retrofilling
• Gutta-percha
material. Histological examination of the tissue
• Gold foil
• Titanium screws response to MTA showed a superior bone re¬
• Glass ionomers sponse, a result not seen with other retrograde
• Ketac silver filling materials (Fig. 12-2).
• ZOE Only the retrofilling materials thht are accept¬
• Cavit
able to the authors are discussed in this chapter.
• Composite resins
• Polycarboxylate cement Amalgam is not discussed because its less than
• Bone cement ideal properties and potentially toxic effects have
• Intermediate restorative material (IRM) been confirmed in numerous publications. The
• SuperEBA materials discussed are the ones used the most
• MTA
often: reinforced ZOE cements such as SuperEBA,
IRM, and MTA.
Zinc Oxide-Eugenol Cements

information about whether and how com¬ As early as 1962, Nicholls showed a preference for
pletely the roots are filled; other than this it has ZOE cement over amalgam. The original ZOE ce¬
no purpose. ments were weak and took a long time to set.
For practical purposes, retrofilling materials When used as a retrograde filling, the cement
should be readily available, be reasonably easy to tended to be absorbed over time because of its
manipulate, have a manageable working time, high water solubility.
and be acceptably priced. If the materials are too When ZOE cement is in contact with water or
difficult to use, the intended results are difficult tissue fluids, it is hydrolyzed into zinc hydroxide
to achieve. If the materials are difficult to get and and eugenol. The eugenol continues to be re¬
excessively priced, the added effort and expense moved by leaching until all the original zinc
make them impractical for use by many clini¬ eugenolate is converted into zinc hydroxide. The
cians. Thus the ideal properties of a retrofilling free eugenol may have several undesirable ef¬
material should satisfy biological, physical, prac¬ fects depending on its concentration. Eugenol
tical, and economic criteria. can competitively inhibit prostaglandin syn¬
thetase by preventing the biosynthesis of cy¬
clooxygenase. Eugenol inhibits sensory nerve
RETROFILLING MATERIALS activity, inhibits mitochondrial respiration,
Throughout dental history, a wide variety of ma¬ eliminates a range of native oral microorgan¬
terials has been used for retrograde fillings. Box isms, and can be an allergen. ZOE cements were
12-1 lists of some of the materials that have been modified in an attempt to resolve some of these
or are currently being used. problems.
Although a plethora of materials exists, none
currently fulfill all or most of the ideal properties Intermediate Restorative Material
of retrograde filling materials. IRM is a modified ZOE cement that was rein¬
Amalgam has been the most popular and forced by the addition of polymethacrylate (20%
widely used retrograde filling material during by weight) to the powder. The reinforcement has
the last century. It is easy to manipulate, readily eliminated the problem of absorbability, and
available, well tolerated by tissues, radiopaque, IRM has a milder reaction than unmodified ZOE
and initially acceptable as a seal. However, its cement. In a tissue tolerance study, it was found
disadvantages are numerous: it sets slowly, is di¬ that IRM elicited little or no inflammatory effects
mensionally unstable, scatters, causes leakage, after 90 days, which led to the conclusion that
releases mercury into the tissues, corrodes and the oral tissues were just as tolerant of IRM as
percolates over time, results in tattoos on over- they were of any other retrograde filling material.
lying tissues, and causes microfractures in the IRM was found to be relatively biocompatible
roots (Fig. 12-1). and is frequently used for endodontic retrograde
Chapter 12 Retrofilling Materials and Techniques 117
Fig. 12-1 A, Amalgam tattoo resulting from an amalgam retrofilling, a serious esthetic con¬
cern for patients with a high lip line. B, Radiograph of an amalgam retrofilling. Notice irregular
and splattered appearance of filling. C, Large amalgam filling, relative to resected root surface,
causes microfractures. D, Magnified (X20) view of a failed surgery that shows microfractures
around the large amalgam retrofilling.
filling procedures. In a retrospective study, IRM gam, it was not significantly different from IRM.
was found to have a statistically significant However, the addition of hydroxyapatite to
higher success rate as a restorative material than IRM increased its disintegration rate, which is
amalgam. a disadvantage if the modified IRM is used as
In an attempt to further improve IRM as a a retrograde filling material. Its disintegration
retrograde filling material, hydroxyapatite was allows leakage of potential irritants from the
added because of its biocompatibility with root canal into the periapical tissues. Unmodi¬
bone. Although it was shown that the addition fied IRM has not been shown to disintegrate,
of 10% and 20% of hydroxyapatite to IRM thus making it a very suitable retrograde filling
produced a significantly better seal than amal¬ material.
Fig. 12-3 Photomicrograph of a root apex of a canine treated

with fluorochrome. Fine collagen fibers connect SuperEBA (yel¬
low) and surrounding fibrous encapsulation.
Staident, Middlesex, England) contains 60%

zinc oxide, 34% silicone dioxide, and 6% natural
resin in the powder component and 62.5%
ethoxybenzoic acid and 37.5% eugenol in the
liquid. In the United States the most similar for¬
mulation is Bosworth’s SuperEBA cement,
which has the same contents except that the sil¬
icone dioxide is replaced by 37% alumina, mak¬
ing the cement stronger. Bosworth’s SuperEBA
has only been available since 1981.
Stailine SuperEBA has a neutral pH and low sol¬
ubility. It is radiopaque and hence facilitates the ra¬
diographic checkup. Ethoxybenzoic acid is the
strongest and least soluble of all ZOE formulations.
It yields high compressive and tensional strengths.
Tissue tolerance studies show that the Super¬
EBA and eugenol cements produce similarly
Fig. 12-2 A, Photomicrograph of a dogtooth apex retrofilled mild reactions. It has been demonstrated in
with MTA 15 weeks after surgery. Notice new, thick bone
vitro that ethoxybenzoic acid cement produces
around apex. (Courtesy M. Torabinejad, Loma Linda, Calif.)
B, Photomicrograph of a dog root apex injected with fluo¬ a tight seal compared with amalgam, glass
rochrome to detect bone formation. Notice bonelike structure ionomer cement, and hot-burnished gutta¬
abutting elongated MTA filling. percha. Leakage studies demonstrated that
SuperEBA allowed significantly less leakage
than amalgam.
Super Ethoxybenzoic Acid Oynick and Oynick (1978) reported that Super¬
SuperEBA is a modified form of ZOE cement EBA is unresorbable and radiopaque. Histologi¬
with ethoxybenzoic acid cement. Ethoxyben¬ cal evaluation of one specimen showed collagen
zoic acid was developed in an attempt to alter fibers growing over the material and into cracks,
the setting time and increase the strength of despite a chronic inflammatory reaction, which
basic ZOE cements. The cement was modified is considered normal in the presence of a foreign
by the partial substitution of eugenol liquid for body (Fig. 12-3).
orthoethoxybenzoic acid and the addition of SuperEBA cement adapts very well to canal
fused quartz or aluminum oxide (alumina) walls compared with amalgam, which appears
to the powder. Stailine SuperEBA (Stailine, to be well condensed but seems to have poor
Chapter 12 Retrofitting Materials and Techniques 119
Fig. 12-5 Prepared cavity ready to receive retrofilling. Notice

hemostasis in and around bone crypt.
ness, and for complete elimination of gutta¬

percha, especially on the buccal canal wall. At
this stage, complete hemostasis should be es¬
tablished in the bone crypt. Small bleeders on
the buccal plate around the bone crypt should
be treated with a small dab of ferric sulfate. Sur¬
face hemostasis is important because an un¬
controlled bleeder from the bone surface fre¬
Fig. 12-4 A, Preoperative radiograph of tooth #30. Mesial
quently flows into the retroprepared cavity,
roots have a PAR. B, SuperEBA retrofilling by microsurgical tech¬
nique. Notice radiopacity of SuperEBA, which is similar to that of
causing unnecessary delays because the cavity
gutta-percha. must be dried and blood-contaminated filling
material removed (Fig. 12-5). As emphasized in
Chapter 7, attention to detail is critical at this
adaptation. However, SuperEBA can be a diffi¬ stage because it is the last phase of the surgery.
cult material to manipulate because the setting The vasoconstrictor effects of the anesthetic are
time is short and greatly affected by humidity. rapidly being washed out by the reestablishing
The material tends to adhere to all surfaces, circulation thus creating a situation in which
and it may be difficult to place and condense. timing is critical.
Currently, little data are available regarding
the most effective method of manipulating Preparation and Placement of Intermediate
SuperEBA to achieve the best seal. Restorative Material
In summary, SuperEBA is well tolerated by IRM is easy to handle. A thicker mix than usual
tissues, fast setting, polishable, dimensionally is placed into the prepared cavity using a
stable, and provides the best apical seals. The carrier and is packed with a microball bur¬
disadvantages of SuperEBA are that it is diffi¬ nisher under magnification (X16). Micro¬
cult to manipulate, sensitive to temperature condensers are used for a deep condensation.
and humidity, and only moderately radiopaque IRM has physical properties that are similar
(Fig. 12-4). to SuperEBA; zinc oxide is the main ingredi¬
ent. Therefore IRM is a good alternative to
Preparation of Periapical Area SuperEBA.
for Retrofilling
The retroprepared apex is checked under mag¬ Preparation and Placement of SuperEBA
nification (X16) for possible missed anatomical SuperEBA is rather difficult to mix and to han¬
structures, such as accessory canals, for dry- dle. The liquid and the powder are mixed in a
vealed burnishing the SuperEBA without pol¬

ishing provides a better seal, the surface should
be reexamined under high magnification to ver¬
ify that it was not broken during polish¬
ing (Fig. 12-7, F). Fig. 12-8 is a radiographical
view of a tooth treated by endodontic micro¬
surgery using Super EBA as retrofilling material.
The filling replaced the insufficient amalgam
filling.
Mineral Trioxide Aggregate

Recently, the experimental substance MTA was
suggested for use as a potential retrograde filling
Fig. 12-6 SuperEBA cement: liquid and powder on glass slab. material. MTA powder consists of fine hy¬
Proper mixing of material requires practice. drophilic particles; the primary compounds are
tricalcium silicate, tricalcium aluminate, trical¬
cium oxide, and silicate oxide. In addition, MTA
contains small amounts of other mineral oxides
1:4 ratio (Fig. 12-6). The powder is mixed into that are responsible for its chemical and physical
the liquid slowly in small increments. When the properties. Bismuth oxide powder has been
mixture is thick but still shiny, additional pow¬ added to make the aggregate radiopaque. Elec¬
der should be added. Once the rolled SuperEBA tron probe microanalysis of MTA powder shows
mixture loses its shine, and the tip does not that calcium and phosphorous are the main ions
droop when picked up by an ethoxybenzoic present. Because MTA has a high pH, like that of
acid carrier, the mixture has the right consis¬ calcium hydroxide cement, it is possible that us¬
tency (Fig. 12-7, A). It takes approximately 3 to 4 ing it as a retrograde filling material may induce
minutes to prepare SuperEBA, and the surgeon hard tissue formation.
has only about 2 minutes to place and con¬ Investigations have revealed that the sealing
dense the filling, depending on the humidity ability of MTA is superior to that of amalgam or
level. Therefore the retropreparation should be SuperEBA and is not adversely affected by blood
completed before the SuperEBA mix is ready. contamination. Investigations also revealed that
The small portion of the rolled mixture is picked when MTA comes into contact with periradicular
up and placed directly into the dried, retropre- tissue, it forms fibrous connective tissue and ce-
pared cavity (Fig. 12-7, B and Q. The procedure mentum and causes only low levels of inflamma¬
is performed under middle magnification (x 10) tion. The regeneration of new cementum over
with sufficient focal depth. The SuperEBA MTA is a unique phenomenon that has not been
is then packed with the microball burnisher observed during investigations of other root end
on the other end of the carrier (Fig. 12-7, D). fillings (Fig. 12-9). The University of Pennsylvania
Microcondensers of appropriate sizes are then tested MTA in an animal model and found that
used for deep condensation. For example, new bone grew into the MTA, confirming the
a thin preparation in a molar root is treated published results. The mechanism for the forma¬
with a thin microcondenser that is less than tion of cementum over MTA is unclear, but it may
0.3 mm in diameter, whereas a larger prepara¬ activate cementoblasts and cause them to pro¬
tion in a central incisor is treated with 0.5-mm duce a matrix for cementum formation. This
diameter microcondensers. Placement and process might be caused by its sealing ability, its
packing are repeated two to three times, and ex¬ high pH, or the release of substances that activate
cess SuperEBA is carved out using excavators. cementoblasts to lay down a matrix for cemento-
The resected root surface may be polished us¬ genesis.
ing a fine diamond bur under copious amounts Using MTA has many advantages; it is the least
of water spray to create an esthetic finish (Fig. toxic of all the filling materials, has excellent
12-7, E). In view of a recent report that re¬ biocompatibility with surrounding tissues, is
Chapter 12 Retrofitting Materials and Techniques 121
Fig. 12-7 A, A properly mixed and rolled SuperEBA mixture has no shine, and the tip does not
droop when picked up by an ethoxybenzoic acid carrier. B, A small portion of rolled SuperEBA is
picked up and placed directly into the retroprepared cavity. C, SuperEBA is pushed into the cavity.
D, A microball burnisher is used to compact the SuperEBA E, Excess material is gently polished.
F, The SuperEBA surface is examined carefully under middle to high magnification (X16 to X24) for
the last time for any defects or overlooked anatomical details. (From Beer/Baumann/Kim: Color
atlas of dental medicine: Endodontology, New York, 2000, Thieme Verlag Stuttgart)
itself or any instrument. Therefore it cannot be

transported to the cavity using a normal cement
carrier but has to be carried with a messing gun,
amalgam carrier, or another specially designed
carrier (Fig. 12-10, B). After the MTA is placed
into the retropreparation, microball burnishers
and micro-pluggers are used to gently condense
Fig. 12-8 Retreatment of a failed amalgam retrofilling. Using
microsurgical techniques and a SuperEBA retrofilling results in
it (Fig. 12-10, Q. The condensation force is
a similar radiopacity but a different retrofilling appearance. approximately one tenth of the force used for
condensing SuperEBA because normal conden¬
sation pressure pushes the loosely bound ag¬
gregate out of the canal. A small, moist cotton
pellet is used to gently clean the resected sur¬
face and to remove any excess MTA from the
cavity (Fig. 12-10, D). Finally, the retrofilled area
is reexamined under magnification (X16) (Fig.
12-10, E).
Cold-Burnished Gutta-Percha
Although gutta-percha has been used success¬
fully for obturating the root canal system, it is
not recommended as a retrograde filling mate¬
rial. The existing gutta-percha filling, which is
not exposed after resection, should not be left
as the only canal seal (Fig. 12-11). A dye pene¬
Fig. 12-9 Photomicrograph taken 5 months after placement of tration study found that cold-burnished gutta¬
an MTA retrofilling in a monkey, which shows a band of new percha provided a better seal than amalgam or
cementum surrounding MTA, biologically sealing apex. (Cour¬ heat-burnished gutta-percha. However, a sub¬
tesy M. Torabinejad, Loma Linda, Calif.) sequent study demonstrated that although
cold-burnished gutta-percha provided an excel¬
lent seal for the first 3 weeks, leakage increased
after 1 month, 2 months, and 3 months. The
hydrophilic, and is reasonably radiopaque. Its leakage may have been caused by the dissolu¬
disadvantages are that it is difficult to manipulate tion of the sealer in the samples. It is relatively
and has a very long setting time. easy to avoid this high potential for failure. Re¬
moving 3 mm of the existing gutta-percha and
Mineral Trioxide Aggregate placing a retrograde filling of SuperEBA, IRM, or
Placement Technique MTA eliminates the problem. It is highly recom¬
The cavity preparation for MTA placement is mended to take this extra step even if the old
the same as for SuperEBA with two exceptions. gutta-percha filling at the root end appears
First, the cavity should be packed with a sterile adequate.
cotton pellet or similar materials, exposing only
the resected root surface, to prevent pieces of Current State of Retrofilling Materials
the MTA from falling into the bone crypt. Sec¬ With the development of endodontic micro¬
ond, the bone crypt cannot be irrigated after surgery, a renewed interest in searching for an
MTA placement, or it may be washed out of the ideal retrofilling material has developed. In the
retropreparation. To prepare the MTA, a small early 1990s, SuperEBA quickly replaced amalgam
amount of liquid and powder are mixed to putty as a retrofilling material, which was no longer fa¬
consistency (Fig. 12-10, A). Because the MTA vored because of its toxic mercury content. Be¬
mixture is a loose granular aggregate, similar to cause IRM is so similar to SuperEBA, it was ac¬
concrete cement, it does not stick very well to cepted as a good substitute for the material.
Chapter 12 Retrofilling Materials and Techniques 123
Fig. 12-10 A, MTA is mixed to putty consistency. B, Place¬

ment of MTA with messing gun into the retroprepared cav¬
ity under magnification (X16). C, Packing MTA with a ball
burnisher. D, A moist cotton pellet is used to gently wipe off
excess cement. E, Final examination of MTA filling under
magnification (X16) to ensure that the seal is good.
Fig. 12-11 After root resection, exposed gutta-percha undergoes

cold burnishing instead of retropreparation and subsequent filling.
Example shown is magnified (X20).
Unfortunately SuperEBA was difficult to mix Gartner AH, Dorn SO: Advances in endodontic surgery, Dent
into the proper consistency. MTA, which is also Clin North Am 36:357-378, 1992.
somewhat difficult to handle but promotes supe¬ King KT et al: Longitudinal evaluation of the seal of en¬
dodontic retrograde fillings, JEndodont 16:307-310,1990.
rior bone healing according to clinical and histo¬
Luomanen M, Tuompo H: Study of titanium screws on ret¬
logical studies, is now used. The new bone growth rograde fillings using bacteria and dye, Scand J Dent Res
into the MTA shown in Figs. 12-2 and 12-9 clearly 93:555-559, 1985.
indicates that MTA is superior to SuperEBA, Nicholls E: Retrograde filling of root canal, Oral Surg 15:463-
which shows no such bone regeneration near the 473, 1962.
O’Connor RP, Hutter JW, Roahen JO: Leakage of amalgam
retrofilling. Because of the bone healing around
and SuperEBA root-end fillings using two preparation
the root apices, the most important criteria for techniques and surgical microscopy, J Endodont 21:74-
treatment success, MTA may be the best material 78, 1995.
on the market today. Owadally ID et al: The sealing ability of IRM with the addi¬
tion of hydroxyapatite as a retrograde root filling, En¬
dodont Dent Traumatol 9:211-215, 1993.
SUGGESTED READINGS
Oynick J, Oynick T: A study of a new material for retrograde
Blackman R, Gross M, Seltzer S: An evaluation of the bio¬ fillings, / Endodont 4:203-206, 1978.
compatibility of a glass ionomer-silver cement in rat con¬ Szeremeta-Browar TL, Van Cura JE, Zaki AE: A comparison
nective tissue, JEndodont 15:76-79, 1989. of the sealing properties of different retrograde tech¬
Bondra DL, Hartwell GR, MacPherson MG: Leakage in vitro niques: an autoradiographic study, / Oral Surg 59:82-87,
with IRM, high copper amalgam and EBA cement as ret¬ 1985.
rograde filling materials, JEndodont 15:157-160, 1989. Torabinejad M et al: Effects of contamination of dye leakage
Cook D, Taylor P: Tissue reactions to improved zinc oxide- of root-end filling materials, JEndodont 20:159-163,1994.
eugenol cements, JDent Child 40:199-207, 1973. Torabinejad M et al: Investigation of MTA for root-end fill-
Dorn SO, Gartner AH: /Endodont 8:391-393, 1990. ingin dogs./Ehdodorcf 21:603-608, 1995.
Forte SG et al: Microleakage of SuperEBA with and without Torabinejad M et al: Physical and chemical properties of a
finishing as determined by the fluid filtration method, new root-end filling material, J Endodont 21:349-353,
/0£ 24:12, 799-801, 1998. 1995.
TOOTH REPLANTATION
Samuel Kratchman, contributing author
KEY CONCEPTS
der himself is a replantation patient. The proce¬
• Tooth replantation is not a new procedure; it dure was performed twice on the same tooth, the
has been performed for more than 50 years. second time about 10 years ago. Dr. Bender says,
• Tooth replantation should be a part of every the tooth is “rock solid” and asymptomatic.
surgeon’s repertoire. This anecdotal evidence, as well as the seem¬
• Case selection is the most important aspect of ingly high success rates of the studies listed in
tooth replantation. Table 13-1, generally proves the viability of tooth
• Root resorption can be minimized by avoiding replantation, even when earlier and less sophisti¬
contamination of the root surface and extrac¬ cated techniques were used. Fortunately, most re¬
tion socket during surgery and by keeping the plantations are successful, but both success rates
extraoral time to 15 minutes or less. and techniques vary considerably. The studies in
• Ankylosis can be prevented by maintaining Table 13-1 fall into the mean of success rates.
the tooth in physiological occlusion without Given that the procedures in these studies
splinting. Observance of biological principles were performed without the aid of the surgical
has virtually eliminated tooth resorption and microscope or Hanks Balanced Salt Solution
ankylosis. (HBSS), replantation would seem to be even
• The advantages of tooth replantation outweigh more reliable today. In my clinical experience
the disadvantages. with 86 replantations, only two failed after 4
years, and those because of fracture. None of the
teeth showed radiographic evidence of ankylosis
ARMAMENTARIUM
or resorption.
45-Surgical microscope In the past Dr. Grossman also had said that,
45* Universal forceps “Tooth replantation should be thought of as a
45- Hanks Balanced Salt Solution (Bio Whittaker, procedure of last resort.” This attitude seems to
Walkersville, Md.) persist in dentistry even today. In medicine, sur¬
46- Emesis basin geons are reattaching or reimplanting acciden¬
45*Super EBA cement or MTA cement tally severed appendages daily; fingers, toes,
45-Microsurgical instruments even hands and feet are successfully reattached
In 1966 Dr. Louis I. Grossman defined replan¬ through neurovascular surgery in hospitals all
tation as “the purposeful removal of a tooth and over the United States. Considering that reat¬
its almost immediate replacement, with the ob¬ tachment of severed appendages is vastly more
ject of obturating the canals apically while the complex and often must be done after the
tooth is out of its socket.” Tooth replantation, or nerves, bones, and tissues have sustained con¬
simply “replantation,” is not a new procedure. It siderable damage, why should those in dentistry
was performed even earlier than the 1950s, when find it so inconceivable to remove a tooth, repair
Dr. Grossman, who recalled his patients 2 to 11 it, and reimplant it? Objections to replantation
years after replantation, reported a success rate arise from a lack of understanding of biology, es¬
of 80%. pecially of the viability of the periodontal liga¬
A study by Dr. I.B. Bender, begun in 1971, ment, and from the long-standing belief that ex¬
showed a success rate similar to that of Dr. Gross- tracted teeth belong in the wastebasket. Nothing
man even after recalls of up to 22 years. Dr. Ben¬ could be farther from the truth.
125
Table 13-1 Success Rates for Tooth Replantation

NUMBER SUCCESS
STUDY OFTEETH FOLLOW-UP RATE
Grossman 45 2-11 yr 80%
(1966)
Kingsbury 151 3 yr 95%
Wisenbaugh,
and Koenig
(1971)
Bender 31 1 day-22 yr 80.6%
and Rossman
(1993)
Fig. 13-1 In the past the extracted tooth was held by the
roots in a moistened gauze square; however, this caused
resorption.
Before 1990 the replantation technique was
not based on recognition of the role of the
healthy periodontal ligament (PDL) in prevent¬
ing ankylosis and resorption and of the impor¬
tance of keeping PDL cells alive during the pro¬
cedure. At that time, the extracted tooth was held
by the roots in a wet gauze square; the extraction
socket was irrigated or curetted; retropreparation
was done with a full-size handpiece without
magnification; retrofilling was done with amal¬
gam; and the replanted tooth was immobilized
with a fixed splint (Figs. 13-1 and 13-2). No em¬
phasis was placed on the duration of the proce¬
dure because there was no awareness of the PDL
cell population. Given current knowledge, it is
amazing that so many teeth survived this proce¬
dure and remained functional for so long. Fig. 13-2 New retrofilling materials have replaced the amalgam
It must be noted, however, that most of the re¬ retrofillings used in the past.
planted teeth in the Grossman and Bender stud¬

ies, as well as other studies, showed ankylosis
and varying degrees of resorption, even though socket is not touched; and the replanted tooth is
they remained functional. In fact, in a lecture Dr. not splinted. Recent histological analysis of re¬
Grossman gave in the mid-1980s at Columbia plantations done in animals with the new tech¬
University School of Dental Medicine, he showed niques showed only small areas of microankylo¬
20 replantation cases after 20-year recall visits; sis, whereas teeth treated by the old techniques
all teeth were still functional after 20 years. Al¬ showed total ankylosis and rampant root resorp¬
though all 20 teeth also had ankylosis and exten¬ tion. My clinical experience with the new replan¬
sive resorption, they were clinically successful for tation techniques confirms that the old tech¬
that long. This is astounding considering that niques contributed to ankylosis and resorption. Of
most dental restorations are not expected to last 86 replantation cases done by the new technique
20 years. in my private practice, none showed ankylosis or
The modern replantation technique is based on resorption after 4 to 10 years.
biological concepts and the importance of main¬ The replantation procedure was viable even
taining the viability of the PDL. Therefore the du¬ with the old techniques, but the new techniques,
ration of the procedure is limited by the length of which practically eliminate ankylosis and re¬
time the PDL cells are viable ex situ; the extraction sorption, make tooth replantation not only a vi-
Chapter 13 Tooth Replantation 127
Fig. 13 3 External oblique ridge (outlined in red) on a cadaver Fig. 13-5 Proximity of teeth to anatomical features. The
mandible. mandibular premolar is near the mental foramen, and the
mandibular molars are close to the inferior alveolar nerve.
/’V)
• Second Molar Inclined more / u- i not be that difficult, but gaining access to the sec¬
Lingually than First Molar _jk 1 ond molar root apices is extremely difficult if not
• First Molar Root Apices M7 ■ / impossible (Fig. 13-4). Even if access can be
usually Close to the Cortical | d: gained, aligning the osteotomy and retroprepa-
Bone rgSmif 1/ ration on the lingually inclined apices close to the
• Need to Drill through More
Bone to Locate Apices towards
-fW mandibular canal could create more complica¬
tions than expected.
Second Molar
Anatomical Limitations
The apices of mandibular bicuspids often ap¬
Fig. 13-4 Rationale for replantation: the mandible ramps to¬
ward the second molar, which is inclined more lingually than pear radiographically to be right on top of the
the first molar. mental foramen, and the mandibular molar
roots are extremely close to the inferior alveolar
nerve (Fig. 13-5). If a surgical approach might
able but also a biologically sound technique. The seriously infringe on the nerve or the sinus,
most difficult aspect of tooth replantation is per¬ tooth replantation may be a safer option. Al¬
suading the patient and the referring dentist that though skilled microsurgeons can manage these
the procedure will be successful. situations, less experienced clinicians may opt
for replantation.
INDICATIONS FOR REPLANTATION Perforation in Inaccessible Areas

Difficult Access A perforation of the buccal surface of the palatal
The categorization “difficult access” applies to root that occurs during postpreparation of a max¬
such examples as the mandibular second molars, illary bicuspid is essentially out of reach by any
where gaining access to the apices of the roots treatment means. An attempt to repair the perfo¬
through a surgical approach is extremely difficult. ration surgically would result in the loss of
Because of the external oblique ridge, the bone of healthy buccal bone to gain access to the buccal
the mandible widens behind the first molar (Fig. root and then to loss of a large portion of the buc¬
13-3). Also, the roots of the mandibular second cal root to gain access to the perforation site on
molars incline more lingually than do those of the palatal root. The amount of healthy bone and
the first molars. For these reasons, gaining access root destroyed to reach the actual problem can¬
to the root apices of mandibular first molars may not be justified (Fig. 13-6).
unsuccessful (e.g., the patient has persistent

pain, fistulae reappear, swelling recurs, or le¬
sions persist), replantation is the only alterna¬
Perforation in Buccal tive to extraction of the tooth (Fig. 13-7). In this
Aspect of Palatal Root sense only is replantation the choice of last re¬
sort. Most often the earlier endodontic proce¬
dures and surgery did not identify a problem
Amalgam critical to the success of the treatment, such as a
missed canal or a perforation. After the tooth
Fig. 13-6 Perforation in the buccal aspect of the palatal root has been extracted, it can be examined quickly
of an endodontically treated maxillary bicuspid. An apicoec- under high magnification (X16 to X26) and
tomy would result in a poor crown to root ratio and excessive from all aspects. Usually the cause of the prob¬
bone loss. lem can be readily identified and corrected. An
undetected microfracture often is the cause of
the failed surgery even if the surgical micro¬
scope was used.
Contraindications in Replantation
Just as surgical cases are evaluated, the feasibil¬
ity and prognosis of extraction and replantation
must be determined.
A tooth with severely dilacerated roots and
much interseptal bone is not a good candidate
for replantation. Not only would the extraction
be difficult, but most likely the curved roots and
surrounding bone would be damaged. Similarly,
if the tooth were already compromised peri-
odontally, showing moderate mobility, replanta¬
Fig. 13-7 Good candidate for replantation: the tooth has had tion would be less likely to succeed. Case selec¬
endodontic therapy, retreatment, and apicoectomy, yet a fistula
tion is crucial; a healthy periodontium is a
has reappeared.
prerequisite for long-term success. The restora-
bility of the tooth also should be considered. If
not enough structure exists for a buildup and
Patient Limitations crown or a permanent restoration, replantation
Handicapped, medically compromised, and is not indicated.
geriatric patients often do not have the phys¬
ical or mental stamina to endure endodontic
microsurgery. These procedures are done using REPLANTATION TECHNIQUES
local anesthesia, and they demand the patient’s Case Selection
complete cooperation: the head must be held As mentioned previously, case selection is perhaps
completely still for the duration of the proce¬ the most crucial aspect of replantation. The most
dure to provide a stable field under the micro¬ sensitive part of the procedure is removing the
scope, and the mouth must be kept open the tooth atraumatically and in one piece. The ideal
entire time. This is fatiguing even for younger, replantation candidate has a conical shape and
healthy patients. Replantation does not make usually fused roots and no furcation (Fig. 13-8).
such demands on the patient and therefore is a Such a tooth is easy to extract and replant.
good alternative treatment option. The advantages of replantation compared with
a more lengthy surgical technique are (1) replan¬
Failed Retreatment tation is less complicated, and (2) with proper
When conventional endodontic therapy, en¬ case selection and removal of the tooth in one
dodontic retreatment, and apical surgery are piece, the remainder of the procedure is simple
Premedication
Whether every patient should be given antibiotics
before a surgical procedure is a matter of debate. If
the procedure is complicated, time-consuming,
and involves a long osseous preparation, antibi¬
otics are recommended. Although replantation
procedures tend to be much shorter and less com¬
plicated, there is still a chance of bacterial contam¬
ination of the tooth or socket. Often the patient is
premedicated with a broad-spectrum antibiotic
such as amoxicillin (500 mg three times a day). In
addition, every patient is instructed to rinse with
chlorhexidine (A ounce twice a day) and to take a
nonsteroidal antiinflammatory medication (e.g.,
ibuprofen, 600 mg every 4 to 6 hours).
The patient should begin taking the antibiotics
and using the mouth rinse the day before the pro¬
cedure; this ensures a sufficient blood level of the
antibiotic and a significant reduction in the bacte¬
rial content of the oral cavity at the time of the re¬
plantation procedure. The patient takes the first
dose of the antiinflammatory agent just before the
procedure so that it can block some of the inflam¬
matory response and the resultant pain from the
outset. Although the affected tooth commonly is
very tender and sometimes painful to percussion
and chewing for 4 to 5 days, narcotics are rarely
needed.
Anesthesia
Local infiltration and posterosuperior alveolar
block anesthesia are indicated for maxillary teeth;
inferior alveolar, lingual, and long buccal blocks
are indicated for mandibular teeth. Adjunct tech¬
niques can be used to fully anesthetize the area
(see Chapter 7).
Extraction
Fig. 13-8 This mandibular second molar is a good candidate When extracting the tooth, the surgeon must take
for replantation. A, Roots are fused, which makes removal easy. great care to keep the forceps off the cementum;
B, Replantation with SuperEBA fill. C, At the 6-month recall visit, this is one of the most critical aspects of the pro¬
healing is complete.
cedure. The beaks of the forceps must remain on
the crown of the tooth above the cementoenamel
junction (CEI). This is contrary to normal extrac¬
and straightforward. The key to replantation suc¬ tion procedures, in which the emphasis is on get¬
cess is speed and organization. Everything that ting the best grip and leverage for expeditiously
could possibly be needed must be readied in ad¬ removing and disposing of the tooth. In contrast,
vance. Before the extraction the team should re¬ the emphasis in replantation is on keeping the
hearse the surgical steps so that once the tooth periodontal ligament as intact as possible. To en¬
has been removed, the procedure can be carried sure that, the forceps must not be allowed to slip
out efficiently and in minimum time. below the CEI (Fig. 13-9).
Fig. 13-10 Typical setup for replantation. The tooth is held

above an emesis basin filled with Hank's Balanced Salt
Solution.
in a buccal to lingual or mesial to distal direction,

which gently expands the bone plates. Elevators
should not be used because the edge of an ele¬
vator on the root surface would certainly dam¬
age the cementum and the PDL. By slowly and
gently “rocking” the tooth, the surgeon can grad¬
ually loosen it and eventually lift it out of the
socket. This is a procedure that can be neither
Fig. 13-9 A, Correct forceps placement on extracted teeth: the
rushed nor muscled; the surgeon must be pa¬
beaks are secured above the cementoenamel junction to pre¬
serve the periodontal ligament. Note the rubber band wound
tient and use the tactile sense to determine when
around the forceps handle to secure the tooth. B, Incorrect the tooth is “ready.” The point where the tooth
positioning of forceps on the cementum, which results in in¬ begins to lift is a good moment to recheck
jury to periodontal ligament cells. quickly with the team that everything has been
prepared, before the tooth is lifted out com¬
pletely. Some teeth lift out readily, whereas oth¬
Once the tooth has been removed, a simple but ers may take as long as 20 minutes.
effective means of preventing the beaks from slip¬
ping is to place a rubber band around the handles Extraoral Duration
of the forceps, which applies a constant pressure The tooth’s extraoral time should be kept to 10 to
on the tooth. The rubber band also prevents a 15 minutes. While the tooth is out of the mouth,
too-tight grip and possible fracture of the tooth or, it should be bathed frequently in HBSS (Fig.
on the other extreme, a loosened grip and acci¬ 13-10). HBSS is a well-known tissue culture
dental dropping of the tooth. Of the cases that medium that has all the necessary elements for
have failed because of resorption predominantly culturing cells; therefore it can maintain the via¬
on the cervical portion of the tooth, it is suspected bility of the PDL for some time. In preparation
that the beaks of the forceps may have slipped for replantation, the HBSS is poured into a stain¬
down onto the root surface, denuding it of impor¬ less steel emesis basin. After extraction, the tooth
tant PDL cells. is held firmly by forceps and immersed in the
HBSS to bathe the PDL. The tooth then is lifted
Maintaining the Viability just above the basin so that the extraoral api-
of the Periodontal Ligament coectomy and retrograde filling can be done.
With the forceps beaks securely fastened above During this procedure the tooth should be
the CEJ, the tooth is slowly and passively luxated dipped frequently in the HBSS to prevent desic-
cation of the PDL, and the entire procedure

should not last longer than 15 minutes.
The apicoectomy and retrofilling procedure
should be done with a microhandpiece rather
than with ultrasonic tips because the ultrasonic
work takes longer. Also, with the tooth in hand
the osteotomy is not an issue, and keeping the
retropreparations within the canal spaces
should not be a problem with straight-line ac¬
cess to the apices.
Extraction Socket Management

Upon extraction of a tooth, the apical gran¬
uloma or cyst sometimes comes out attached
Fig. 13-11 This replanted tooth is stabilized with a perio-pak.
to the root. In such cases nothing should Splinting is not recommended because it most likely promotes
be done to the extraction site at all. If granula¬ ankylosis.
tion tissue appears to remain in the socket, it
is best to leave it; the healing process gradu¬
ally resorbs the tissue. The extraction socket
should never be curetted. If the surgeon wishes Stabilization
to remove the granulation tissue, a thin, ta¬ After the tooth has been returned to its socket,
pered, metal or plastic aspirator can be used the buccal and lingual bone plates are com¬
for that purpose, as long as the instrument pressed manually. The patient then bites down
does not touch the walls. However, this pro¬ on a wood stick for a few minutes to help stabi¬
cedure carries a risk: accidentally touching lize the tooth. Most often the tooth literally
the walls of the extraction site could greatly “pops” back into the socket, with surprisingly
increase the chance of replacement resorp¬ little mobility once it is reseated. The tooth
tion and eventual failure. This is a judgment should not be splinted because the splint can
call for the surgeon. Our experience has shown harbor bacteria, delay healing, and promote
that the body deals quite effectively with replacement resorption by preventing phys¬
granulation tissue once the cause has been iological mobility. If stabilizing the tooth is
eliminated. truly necessary, we recommend the following
two methods, which allow for physiological
Apicoectomy and Retrofilling Procedures mobility:
After extraction the tooth is held under the mi¬
croscope for examination at X24 magnification. • Perio-pak can help stabilize the tooth but can
The apicoectomy is performed at X16 magnifica¬ also trap bacteria, therefore it should
tion with a crosscut fissure bur in a high-speed not be left in place longer than 1 week (Fig.
handpiece. A retrograde preparation is then 13-11).
made, usually with a small bur (e.g., #330 carbide • Monofilament sutures can be placed diagonally
bur). Throughout the procedure, the tooth is fre¬ over the occlusal surface of the tooth for stabi¬
quently dipped in the HBSS. If the root end is thin lization. Silk sutures should not be used be¬
and has an unusual anatomy, such as a C-shaped cause they collect food particles and plaque
canal or a thin isthmus, an ultrasonic instrument and hinder the healing process.
should be used for the retrograde preparation (an
exception to the usual recommendation that a Postoperative Instructions
microhandpiece be used). The root end prepara¬ The patient should be informed that the tooth will
tion is then dried, and a retrograde filling is be painful for a few days and tender for a couple of
placed. Finally, the apical tip is reexamined un¬ weeks. The patient should make every effort to
der the microscope to ensure a complete seal of chew on the other side and to eat a softer diet for
the apices. about 3 days after the replantation procedure.
CAUSES OF REPLANTATION FAILURE These teeth are unsalvageable and must be

As with any dental procedure, some replantations permanently removed.
do fail. Most failures occur during the first year • Fortunately most replantations are success¬
and can be due to several factors: ful. Box 13-1 lists do’s and don’ts that summa¬
rize the essential replantation procedures. If
• The known causes of failure are (1) contamina¬ these guidelines are followed assiduously, re¬
tion during the replanting procedure that re¬ planted teeth should reattach to the socket
sults in root resorption and (2) an undetected readily and should not develop ankylosis or
root fracture that may result in several chronic resorption.
symptoms such as fistula formation, a persis¬
tent lesion, and swelling and pain. The following cases are a representative sam¬
• On rare occasions a replanted tooth shows ple of the replantation cases in our files. They
symptoms such as those mentioned above were chosen because they illustrate the most
without a fracture or any other explanation. common reasons for choosing replantation.
BOX 13-1 Replantation Do’s and Don’ts
DO'S • Limit the out of socket time to 15 minutes or less.

• Extract the tooth gently by rocking it back and forth. • Replant the tooth and allow for physiological
• Examine the extracted tooth at X24 magnification for occlusion.
microfractures.
• Secure the extracted tooth with a forceps and rubber DON'TS
band. • Do not touch the root surfaces or the socket walls.
• Bathe the tooth frequently in Hank’s Balanced Salt • Do not curet the extraction socket.
Solution (HBSS). • Do not exceed the 15-minute limit for out of socket
• Clean and fill the apical canal system at time.
midmagnification. • Do not splint the tooth.
CASE 1
The mandibular first molar with extremely poor tooth ex situ with SuperEBA retrofillings and to re
access shown in Fig. 13-12 developed a fistulous plant it. A 4-year recall visit showed complete heal
tract with a PAR. The tooth had been treated twice ing, and the tooth was asymptomatic.
by endodontists. The choice was made to treat this
CASE 3
Endodontic treatment of this maxillary first molar 4 months later with swelling and pain (D). It was
was performed poorly, with a broken file tip decided to perform extraoral repair and replanta¬
lodged at the mesiobuccal apex, and the tooth tion. Examination of the extracted tooth under the
had become symptomatic with swelling (Fig. microscope revealed that the mesiobuccal apex
13-14, A). Retreatment was completed without dif¬ had a perforation. This root was resected more
ficulty, although the broken file tip could not coronally to remove the section with the perfora¬
be removed (B). When the symptoms persisted, tion (E), and all apices were reprepared at mid¬
the mesiobuccal root was treated surgically and magnification and obturated with SuperEBA
the canal was retrofilled with SuperEBA (C). The retrofillings. One year after the procedure, the
symptoms subsided initially but resurfaced tooth was symptom free (F).
CASE 4
The tooth in Fig. 13-15 had been treated en- showed that the canal was C-shaped with leakage
dodontically 4 years previously. The tooth sud¬ in the center, which was the cause of the problem
denly became painful, keeping the patient awake (C and D). The canal was recleaned and refilled
all night (A). Apical surgery was ruled out be¬ with SuperEBA (E), and the tooth was reimplanted
cause the tooth was positioned too posteriorly. in the socket (F). A 6-year recall visit found the area
Instead, the tooth was extracted (B), treated ex- completely healed and the tooth firm, asympto¬
traorally, and replanted. Examination of the apex matic, and fully functioning (C).
If the tooth is properly handled during re¬ Dryden JA: Tooth replantation, The Compendium of Contin¬
plantation, there is no better dental implant. uing Education 10(1) :23-27, 1989.
With today’s techniques and knowledge of cell Grossman LI: Replantation of teeth: a clinical evaluation,
JADA 104:633-636, 1966.
culture, the decision whether to do replantation Kim S: Ligament injection: a physiological explanation of its
is an easy one. Replantation is a reliable, suc¬ efficacy, JOE 12(10):486-491, 1986.x.
cessful procedure and should be in every clini¬ Kingsbury BC, Weisenbaught JM: Tooth replantation of
cian’s repertoire. mandibular molars and premolars, / Am Dent Assoc
83:1053-1057, 1971. '
Koenig KH, Nguyen NT, Barkhordar RA: Tooth replantation:
SUGGESTED READINGS
a report of 192 cases, Gen Dent 36:327-331, 1988.
Andreasen JO: Relationship between cell damage in the Lindeberg RW, Girardi AF, Troxell JB: Tooth replantation:
periodontal ligament after replantation and subsequent management in contraindicated cases, Compend Cont
development of root resorption: a time-related study in Educ 7 (4) :248-258, 1986.
monkeys, Acta Odontol Scand 39:15-25,1981. Ross WJ: Tooth replantation: an alternative, Comp Cont Educ
Bender IB, Rossman LE: Tooth replantation of endodonti- 6(101:735-739, 1985.
cally treated teeth, Oral Surg Oral Med Oral Pathol Simon JHS, Kimura JT: Maintenance of alveolar bone by the
76(5):623-630, 1993. tooth replantation of roots, Oral Surg Oral Med Oral
Berude JA et al: Resorption after physiological and rigid Pathol 37(61:936-945, 1974.
splinting of replanted permanent incisors in monkeys,
JEndodont 14(12):592-600,1988.
SURGICAL SEQUELAE
AND COMPLICATIONS
KEY CONCEPTS Pain

• Mild pain and swelling are to be expected after Except for mandibular molar surgery, in which
surgery, especially on molar teeth. the osteotomy is made deep into the medullary
• Postoperative instructions should be given to bone, pain usually is not a serious problem.
the patient and to the caretaker verbally and in Long-acting anesthetic agents such as bupiva-
writing. caine (Marcaine) or etidocaine (Duranest) can be
• Occasionally ecchymosis occurs in fair-skinned injected into the surgical site after the procedure
patients; this is no indication of the outcome of to control pain for up to 8 hours. In recent years
the surgery. the understanding of pain and its management
• Swelling and inflammation can cause transient have seen a diametric change. The current ap¬
paresthesia in the mandibular posterior region proach for both long-term and short-term pain
even if the nerve is not damaged. The paresthe¬ relief is to provide the patient with pain medica¬
sia usually reverses within a few days to several tion immediately after treatment, before any pain
weeks. is felt. For example, antiinflammatory agents
• Sinus infringement, if treated promptly, poses such as ibuprofen (800 mg) may be taken just be¬
no serious problem. fore surgery. For some patients or for some surgi¬
• In rare cases uncontrollable swelling occurs; cal procedures, analgesics such as Percodan or
this must be treated immediately in the hospi¬ other narcotics may be needed to block the for¬
tal with intravenous antibiotics. mation of prostaglandins, which stimulate the
• Serious postoperative sequelae are rare. sensory nerve endings, which in turn stimulate
release of other substances, causing a pain cas¬
cade. This approach has been tested with great
SURGICAL SEQUELAE success in clinical trials on patients undergoing
Surgical sequelae include pain, swelling, ecchy¬ third molar extraction. The results of this study
mosis, laceration, premature separation of su¬ confirmed that blocking the pain response before
tures, infection, maxillary sinus infection, and it begins results in a much shorter or even no
transient paresthesia. A member of the office postoperative pain episode.
staff should call the day after surgery to check on Because postoperative pain normally is most
the patient’s condition. Immediately after the severe the night of and the day after surgery, the
surgery the patient and the person accompany¬ patient should continue the pain medication
ing the patient should be given both oral and through the second day. Usually over-the-
written postoperative instructions. Through counter drugs such as Extra Strength Tylenol or
anxiety and nervousness, patients sometimes ibuprofen (800 mg) are sufficient.
misunderstand or simply forget oral instruc¬
tions. Although postoperative symptoms usually Hemorrhage
are mild, they sometimes can cause patients un¬ Postoperative hemorrhage is rare. It can be pre¬
necessary confusion and anxiety. vented in the following way: two 2 x 2-inch sterile
137
gauze pads are folded in half and moistened

with sterile water. This pack is placed over the
sutured flap, and an ice bag is held on the cheek
or jaw with light pressure for at least 30 minutes
to collapse the cut microvasculature in the soft
tissue and to promote initial coagulation. After
removal of the ice pack, the surgical site is ex¬
amined for bleeding. The patient should remain
in the office until bleeding has stopped com¬
pletely. The patient may then be discharged with
an ice bag or a chemical cold pack to be held on
the cheek or jaw.
Light oozing of blood from the surgical site
during the first hours after surgery is normal. Fig. 14-1 Patient with ecchymosis. This condition usually oc¬
The patient should be informed of this before curs in fair-skinned women who have a history of bruising eas¬
leaving the office. In rare cases a patient may ily. The patient should be reassured that the ecchymosis is not
experience postoperative hemorrhage after re¬ a complication of the surgery.
turning home. Undue anxiety or even panic can
be avoided by careful postoperative instruction.
The patient should apply a dampened 2X2-
inch gauze pad to the surgical area with mod¬ Ecchymosis
erate pressure for 10 minutes. Sometimes Ecchymosis is the discoloration of facial and oral
bleeding cannot be stopped by pressure alone. soft tissues caused by extravasation and subse¬
Tea contains a hemostatic agent, tannic acid, quent breakdown of blood in the subcutaneous tis¬
and a wet tea bag may be used with light pres¬ sues (Fig. 14-1). This is basically an esthetic prob¬
sure instead of the gauze pad to produce he¬ lem. It is more common in fair-skinned patients
mostasis. and in elderly patients with fragile capillaries, but it
If the bleeding cannot be stopped with these can also occur in people with darker complexions.
measures, the patient should return to the dental Ecchymosis often occurs distant from the sur¬
office immediately. Resuturing the site and ap¬ gical site. For example, the surgical site may be a
plying pressure hemostasis should solve this maxillary premolar, but the ecchymosis may be
problem. This type of hemorrhage usually does found in the ipsilateral neck area. The patient
not occur unless the patient has hemophilia or is should be reassured that the ecchymosis has no
taking medication that prevents blood clotting. bearing on the success or severity of the case. It
This information should be in the patient’s med¬ is merely the deposition of blood from the
ical history, and the physician should be con¬ surgery in the interstitial tissue spaces and will
sulted before surgery so that the patient’s medi¬ resorb as would a bruise.
cines can be changed if possible.
Paresthesia
Swelling Paresthesia is the abnormal sensation of burning,
Swelling is a common surgical sequela and the pricking, itching, or numbness produced by im¬
one that causes the patient the greatest concern. pingement, handling, laceration, or severance of
For this reason the patient must be informed a nerve. The nerve most often affected is the infe¬
that the surgical site or the face may swell re¬ rior alveolar nerve after mandibular periradicu-
gardless of home care. The patient also must be lar surgery near the second premolar and first
reassured that the degree of swelling is not an molar. Transient paresthesia may occur even if
indication of the success or failure of the surgery the surgical site is far from the nerve.
or of the severity of the case. Intermittent appli¬ Inflammatory swelling of the manipulated tis¬
cation of ice (30 minutes on, 30 minutes off for sues may cause impingement on the mandibular
the first 2 days) may alleviate the swelling to a nerve, resulting in transient ipsilateral paresthe¬
great extent. sia. If the nerve has not been severed, normal
Chapter 14 Surgical Sequelae and Complications 139
Fig. 14-3 This excessive swelling occurred after surgery on a

mandibular molar. In such cases treatment with intravenous an¬
tibiotics may be required.
not to blow the nose and should be instructed to

elevate the head during the night. Prophylactic
antibiotic therapy with Keflex (500 mg four times
a day for 1 week) should be prescribed, and the
Fig. 14 2 Patient who had surgery in the maxillary quadrant with use of Sudafed and other anticongestants should
a sinus complication. (Courtesy C. Watzek.) be recommended. The patient should return for a
postoperative checkup in 1 week.
Lacerations
sensation generally returns in approximately 4 Lacerations may occur in the lips and oral soft tis¬
weeks. In rare cases, however, it may take a few sues during surgery. In posterior surgery espe¬
months to regain normal sensation. The patient cially, the lips often are overstretched, producing
should be reassured that sensation eventually lacerations in the commissures. This can be ame¬
will return in the affected side. liorated by applying a thin film of petroleum jelly
to the lips, especially in the corners. Careless ele¬
vation of the mucoperiosteal flap may cause lac¬
COMPLICATIONS erations or even perforations in the flap. The flap
Maxillary Sinus Infringement may also be lacerated if the retractor is not kept
Perforation of the Schneiderian membrane that on the osseous tissue. Lacerations can be pre¬
covers the sinuses and infringement of the max¬ vented by gentle, careful handling of the oral tis¬
illary sinus occurs in some cases of maxillary pos¬ sues and by remaining alert to this problem dur¬
terior surgery (Fig. 14-2). When infringement of ing the surgical procedure.
the sinus occurs, utmost care must be taken to
prevent any material from entering the sinus. The Serious Infection
perforation should be covered with iodoform Only rarely does a patient develop a serious facial
gauze strips or a cotton pellet tied to a suture un¬ infection. If the patient reports that the throat is
til the surgical procedure has been completed. If closing or that the pain is continuous and severe
the patient has a normal sinus and does not suf¬ or reports other symptoms beyond the norm, the
fer from rhinitis or sinusitis, coaptation and su¬ patient should be referred immediately to the
turing of the flap are sufficient for stimulating emergency department of a hospital. The patient
normal healing and preventing formation of an most likely will require intravenous antibiotic
oroantral fistula. The patient should be cautioned therapy to contain the infection (Fig. 14-3).
SUGGESTED READINGS Jackson D, Moore P, Hargreaves KM: Preoperative non¬

Arens DE: Surgical endodontics. In Cohen S, Burns RC, ed¬ steroidal antiinflammatory drugs for the prevention
itors: Pathways of the pulp, ed 3, St Louis, 1984, Mosby. of postoperative pain, J Am Dent Assoc 119:641-647,
Carr GB: Surgical endodontics. In Cohen S, Burns RC, ed¬ 1989.
itors: Pathways of the pulp, ed 7, St Louis, 1998, Mosby. Kim S, Rethnam S: Hemostasis in endodontic microsurgery,
Gutmann JL, Harrison JW: Surgical endodontics, St Louis, Dent Clin North Am 41:499-511, 199/.
1994, Ishiyaku EuroAmerica. Watzek G, Bernhart T, Ulm C: Complications of sinus perfo¬
Hargreaves KM, Troullos E, Dionne R: Pharmacological ra¬ ration and their management in endodontics, Dent Clin
tionale for the treatment of acute pain, Dent Clin North North Am 41:563-583, 1997. ^
Am 31:675-694, 1987.
SELECTED CASES AND SUCCESS
OF MICROSURGERY
KEY CONCEPTS
• Postoperative sequelae were significantly re¬
• Of endodontic cases that did not involve a pe¬
duced with microsurgery.
riodontal pathologic condition, 96.8% healed
completely within 1 year. This chapter presents three cases treated with the
• The size of the lesion is directly related to the techniques and instruments introduced in this
length of time required for healing. book. For illustration purposes, pictures were
• Undetected microfractures are common causes taken through the microscope at varying magni¬
of surgical failure. fications. Generally, the working magnification
• The average postoperative healing period is ap¬ range is X12 to X16, and the inspection range is
proximately 7 months. X24 to X26. This pictorial essay is intended to as¬
• Microsurgical techniques showed greater clin¬ sist the reader in applying the contents of the
ical success 1 year after surgery. book to real clinical situations.
CASE 1
Tooth #7 had been treated by the Sargenti (Fig. 15-4 at X12). A CK back-action tip was acti¬
method, was retreated and obturated with gutta¬ vated, and a microplugger was used to condense
percha and sealer (Fig. 15-1). The retreatment the gutta-percha coronally, making the retropre¬
also failed, and a fistula persisted; the radi- pared cavity 3 mm deep with smooth, parallel
ographical size of the lesion was 1.5 cm in cir¬ walls. The finished preparation was viewed di¬
cumference. Fig. 15-2 shows the fenestrated buc¬ rectly at X20 magnification under the microscope
cal plate and a large periapical lesion at X8 (Fig. 15-5). The lingual wall was now free of filling
magnification. The periapical lesion was scraped remnants; this is the best attainable view through
out with a #13-14 Columbia curette, and the re¬ a microscope without a micromirror. In contrast,
moved tissue was sent for biopsy. The exposed Fig. 15-6 shows the finished retropreparation re¬
root apex was carefully examined at X10 magni¬ flected in a micromirror at X26 magnification.
fication, and it was noted that the root had been Well-mixed SuperEBA was placed in the prepara¬
overfilled with gutta-percha (Fig. 15-3). An api- tion (Fig. 15-7 at X16) and condensed with a mi¬
coectomy was performed perpendicular to the croplugger (Fig. 15-8). Additional SuperEBA was
long axis of the root with a Lindemann bone cut¬ placed and condensed firmly with the ball bur¬
ter in an Impact Air 45 handpiece. This resection nisher end of the microplugger (Fig. 15-9 at X16).
technique is the standard for all cases reported Excess SuperEBA was roughly carved from the
here. The resected root apex was examined and margins with a #13-14 Columbia curette (Fig.
prepared with a CT 5 tip on a Spartan ultrasonic 15-10), and the filling was polished with a #30
unit. The retroprepared cavity reflected in a mi¬ fluted F9 finishing bur (Fig. 15-11 at X12). Fig.
cromirror showed that gutta-percha was still 15-12 shows the completed retrofilling at
present on the labial wall of the prepared canal X12 and x20 magnification. A postoperative
Continued
141
CASE 1-tout'd
radiograph taken immediately after the surgery later (Fig. 15-13). Flowever, the tooth was asymp¬
shows the lesion as larger and more radiolucent tomatic, and the recall radiographs showed
than before the surgery, suggesting a possible a significant reduction in the size of the lesion
through-and-through communication 9 months (Fig. 15-14).
Fig. 15-3
Fig. 15-1
Fig. 15-4
■Mb
f
*
**
; *
• /
>
► * P
Fig. 15-2 Fig. 15-5

Chapter 15 Selected Cases and Success of Microsurgery 143
Fig. 15-6 Fig. 15-7
Fig. 15-8 Fig. 15-9
Continued
Comments
Note the detailed retropreparation using the ul¬ cause histological examination of polished root
trasonic technique and a smooth transition from apices showed that it results in greater micro¬
the gutta-percha filling to the SuperEBA filling scopic root resorption than with simply carving
with a similar radiopacity. We have since elimi¬ away the excess cement. The biopsy results indi¬
nated the polishing of the retrofilling material be¬ cated a dental granuloma.
CASE 2
Endodontic therapy on tooth #10 followed by inter¬ polished (Fig. 15-23). Next, an amalgam overfill in the
nal repair of a perforation with amalgam 10 years lateral lesion, appearing as a small, dark mark near
earlier had failed. Radiographs revealed lateral and the coronal margin of the buccal plate, was replaced
periapical lesions with a deep periodontal pocket (Fig. 15-24 at X16). Because the amalgam could not
connecting to the lateral lesion (Fig. 15-15). After lo¬ be penetrated by ultrasonication, a #1 round bur
cal anesthesia was obtained using 2% lidocaine with was used to remove it (Fig. 15-25). The prepared per¬
1:50,000 epinephrine, a flap was elevated. The buc¬ foration was filled with SuperEBA (Fig. 15-26, A),
cal bone over the periapical lesion was found to be packed (Fig. 15-26, B), condensed (Fig. 15-26, C), and
very thin and could easily be penetrated with a mi¬ polished (Fig. 15-26, D). The repaired perforation was
croexplorer CX 1 (Fig. 15-16). A small osteotomy was examined at the highest magnification to ensure a
made around the apex, and apical granulation tis¬ complete seal (Fig. 15-26, £). Fig. 15-27 shows both
sue was removed with a #13-14 Columbia curette surgical sites at low magnification (x8). A 5-mm
and Jaquette 34/35 curettes. Fig. 15-17 shows the wide band of healthy bone separates the two lesions,
root apex at X16 magnification after complete curet¬ as shown in the postoperative radiograph (Fig. 15-
tage, revealing a gutta-percha filling beyond the 28). Fig. 15-29 shows complete healing of the apical
apex. An apicoedomy with a 0-degree bevel after a and lateral lesions within 6 months and elimination
3-mm apical resection is shown in Fig. 15-18. The of the lateral periodontal pocket. Fig. 15-30 shows
resected root surface of this tooth can be seen in Fig. minimal to no scarring from the surgery and bio¬
15-19. The apex was retroprepared with a CT 5 ul¬ logical reorganization of soft tissues around the
trasonic tip on a Spartan ultrasonic unit (Fig. 15-20). tooth, maintaining the esthetics of the area.
Close examination of the retroprepared canal in a
micromirror showed remnants of gutta-percha on
the labial wall (Fig. 15-21). These were compacted
with a microplugger, creating a smooth, 3-mm
retropreparation (Fig. 15-22). SuperEBA retrofilling
material was placed and packed, and the surface was
Fig. 15-15 Fig. 15-17
Continued
CASE 2-cont'd
Fig. 15-20 Fig. 15-21
Fig. 15-22 Fig. 15-23

CASE 2-cont d
Fig. 15-26
Continued
Comments was unknown until the flap was raised and the
The case reflects the difficulties presented by a perforation became evident. In such a case, the
combined lesion from apical pathology and surgeon must be prepared to treat the problem
root perforation. The origin of the root lesion immediately.
Chapter 15 Selected Cases and Success of Microsurgery 1 49
The endodontics, post placement, and restoration percha in the cavity, especially on the buccal wall
on tooth #30 were performed by a general den¬ (Fig. 15-37). Some debris was found on the buccal
tist. The patient had clinical symptoms, and radi¬ wall, requiring ultrasonication of the wall with a
ographic examination showed a periapical lesion CK back-action tip (Fig. 15-38). The final examina¬
with a probable post perforation (Fig. 15-31). A 4 tion of the retropreparation was done at x8 mag¬
X 4-mm osteotomy was created, and a #13-14 nification using a micromirror; the reflected view
Columbia curette was used to remove the granu¬ is clearly shown in Fig. 15-39. Note the size of the
lation tissue from the bone crypt at X16 magnifi¬ osteotomy in comparison to the micromirror,
cation (Fig. 15-32). The apical 3 mm was resected which has a diameter of 3 mm. Fig. 15-40 shows
in the standard manner. Fig. 15-33 shows a direct the micromirror view of the retropreparation at
view of the resected root surface at X16 magnifi¬ the highest magnification (x26). SuperEBA is
cation; the root is long buccolingually and has an mixed to filling consistency, placed in the retro-
isthmus connecting the two apices. Fig. 15-34 prepared cavity (Fig. 15-41), and condensed with a
shows a CT 5 ultrasonic tip in the lingual canal ball burnisher (Fig. 15-42). Fig. 15-43 shows the
before activation. This tip was also used to pre¬ micromirror view of the SuperEBA retrofilling at
pare the isthmus and the apices (Fig. 15-35). The X20 magnification; note the isthmus connecting
apical preparation was dried with the Stropko ir¬ the buccal and lingual canals. Fig. 15-44 is the im¬
rigator/drier (Fig. 15-36), and the prepared isth¬ mediate postoperative radiograph. The 1-year
mus and apices were closely examined at Xl6 postoperative radiograph (Fig. 15-45) shows sig¬
magnification for remaining debris or gutta¬ nificant healing.
Fig. 15-31 Fig. 15-33
Fig. 15-32 Fig. 15-34
Continued
CASE 3-cont'd
Fig. 15-35 Fig. 15-36
• *
Fig. 15-37 Fig. 15-38
Fig. 15-39 Fig. 15-40

Comments 2. Anesthesia was obtained using 2% lido-

The surgical microscope was essential for treat¬ caine with 1:50,000 epinephrine. Then a
ing the lingual apex of this molar successfully. 15C blade was used to create a mucogingi-
Making a small osteotomy and treating the val flap with two vertical releasing incisions
isthmus with ultrasonic instruments were the (Fig. 15-47). ,v
key points in the successful treatment of this 3. A scalloped incision was made in the at¬
case. tached gingiva about 2 mm apical to the
margin of the crown of the anterior teeth.
Care was taken to round out the corners
OUTLINE OF THE MICROSURGICAL to avoid 90-degree incision intersections,
PROCEDURE which do not heal well. Care was also taken
The procedure described below involves a rou¬ to make the incision on a bias, at 45 degrees
tine case without any special conditions or com¬ apical to the cortical bone, to provide
plications. It is presented here because most sur¬ the maximum surface area for revascular¬
gical cases fall into this category. ization during the healing phase (see
Fig. 15-47).
1. Tooth #9 was still symptomatic, especially to
palpation at the apex, after twice having been
treated endodontically. A preoperative radi¬
ograph showed no significant pathologic
condition except a slight overfilling of the
canal (Fig. 15-46).
Fig. 15-46 Fig. 15-47

4. The flap was elevated carefully with a con¬ 5. The flap was reflected and retracted high with
trolled peeling movement using specially de¬ a KP 2 retractor (Fig. 15-50).
signed tissue elevators (see Chapter 4) (Figs. 6. An osteotomy was made at the apex (Fig.
15-48 and 15-49). 15-51) with a Lindemann bone cutter in an
Impact Air 45 handpiece using copious water
coolant. Fig. 15-52 shows a completed os¬
teotomy at X5 magnification.
Fig. 15-48 Fig. 15-50
Fig. 15-49 Fig. 15-51

7. Hemostasis within the osteotomy was 8. The resected root surface was dried with the
achieved by the epinephrine pellet technique. Stropko irrigator/drier (Fig. 15-54). The re¬
Buccal plate hemostasis was achieved by dab¬ sected root surface then was stained with
bing the cortical plate with a cotton pellet methylene blue under low magnification
soaked with a small amount of ferric sulfate so¬ (Fig. 15-55).
lution (Stasis) (Fig. 15-53), which was rinsed
away quickly after application.
Fig. 15-52 Fig. 15-54
Fig. 15-53 Fig. 15-55

9. A higher magnification (X16) was used to in¬ 11. Fig. 15-58 shows as a reflection in a mi¬
spect the resected root surface, and a lingual cromirror the resected root surface at X24
fracture was found (Fig. 15-56). The apex was magnification. The gutta-percha filling ap¬
resected by another 2 mm in an attempt to pears as a pink dot except for a leaky lingual
get beyond the fracture and save the tooth. spot, which was the extension of the mi¬
10. The resected root surface was reexamined crofracture. A KiS 2 tip was activated to re¬
carefully at high magnification (X24). Fig. move the old filling and to retroprepare the
15-57 shows the ideal osteotomy size at canal (Fig. 15-59).
midmagnification.
Fig. 15-57 Fig. 15-59

12. At X16 magnification the prepared apical

cavity was condensed with a microcondenser
(Figs. 15-60 and 15-61). Fig. 15-62 shows a re¬
flection in a micromirror of a microcon¬
denser deep in the retroprepared cavity. Fig.
15-63 shows a resected root surface and a
prepared cavity at X14 magnification; note
the clean, sharply defined walls of the retro-
prepared cavity.
Fig. 15-60 Fig. 15-62
Fig. 15-61 Fig. 15-63

13. A well-mixed MTA filling was placed near croball end of the retrofilling carrier (Fig.
the cavity with an amalgam carrier (Fig. 15-67). The excess MTA was removed with a
15-64). A retrofilling carrier blade was use curette, and the resected root surface was
to move the MTA into the cavity. This was cleaned with a moist cotton pellet (Fig.
followed by condensing with a microplug- 15-68). A view of the cleaned, resected root
ger (Figs. 15-65 and 15-66). Additional MTA surface X20 magnification shows the MTA
was plugged into the cavity with the mi- filling at the center (Fig. 15-69).
Fig. 15-64 Fig. 15-66
Fig. 15-65 Fig. 15-67

14. The flap was repositioned at low magnifica¬ 15-72 shows the sutured distal flap corner at
tion using specially designed tissue forceps midmagnification. The vertical incision, the
(Fig. 15-70), and the distal corner of the flap two corners, and the center were sutured
was sutured first with a 5-0 monofilament with 5-0 suture. The remainder was sutured
synthetic suture (Jackson) (Fig. 15-71). Fig. with a 6-0 monofilament synthetic Jackson
Fig. 15-70
Fig. 15-68
Fig. 15-71
■#
Fig. 15-69 Fig. 15-72

Chapter 15 Selected Cases and Success of Microsurgery 1 59
suture (Fig. 15-73). Figs. 15-74 to 15-76 show 15. The patient returned for suture removal 48
large magnifications of the mesial corner, hours later. To ease this potentially painful
the distal corner, and the center of the flap. experience, a dentin patch impregnated with
Note the well-adapted flap created by the lidocaine was placed over the sutures for 10
45-degree incision bias. minutes (Fig. 15-77). Fig. 15-78 shows the re¬
moval of the patch and the blanched tissue
underneath, indicating that the lidocaine
was effective. Microscissors were used to re¬
move the sutures (Fig. 15-79).
Fig. 15-73
Fig. 15-76
Fig. 15-74 Fig. 15-77
Fig. 15-75 Fig. 15-78

16. Figs. 15-80 to 15-83 show the incision line 17. Figs. 15-84 to 15-87 show that 1 week after su¬
from the mesial corner to the distal corner 48 ture removal, the incision sites have healed
hours after surgery. Even at this early stage completely and are almost scar free. Fig.
reattachment has taken place, and the 15-81 can be compared with Fig. 15-84
wound is free of the inflammation often (48 hours versus 1 week after surgery), as can
found with sulk sutures.
Fig. 15-79 Fig. 15-82
Fig. 15-80 Fig. 15-83
Fig. 15-81 Fig. 15-84

Fig. 15-88
Comments
The cause of the problem was a lingual apical
fracture, therefore the second retreatment did not
succeed. The photographic documentation of the
case was done with a NIKON digital camera at¬
tached to a Zeiss OPMI-Pro Magis microscope,
demonstrating that photographic documenta¬
tion is now possible for everyone.
SUCCESS RATE FOR MICROSURGERY

Is the microsurgical technique more successful?
This is an important and appropriate question.
To answer it, we had to run a well-controlled clin¬
ical study using the techniques described in this
book. The results were published in the Journal
of Endodontics in January, 1999. To summarize
the results: Cases were selected with endodontic
Fig. 15-87 lesions only. Periodontal complications (e.g.,
pocket depth greater than 5 mm) were not in¬
cluded in the study. Specifically, only Class A, B,
Fig. 15-80 with Fig. 15-85; Fig. 15-82 with Fig. and C cases were included (see Chapter 1). Ante¬
15-86; and Fig. 15-83 with Fig. 15-87. Fig. rior, premolar, and molar teeth were used in
15-88 is an immediate postoperative radi¬ equal numbers, and all canals were retrofilled
ograph showing the apical MTA filling in line with SuperEBA. Clinical and radiographic exam¬
with the canal. inations were done every 3 months for 1 year.
Fig. 15-89 A, Mandibular first premolar, an anterior abutment of a three-unit bridge, that was
treated microsurgically. B, Healing was complete within 6 months.
Fig. 15-90 Mandibular second molar with reasonable access. A, Immediately after surgery.
B, Healing was complete within 3 months.
The study produced several important findings: The results of this clinical study have con¬
(1) Most healing takes place by 7.1 months, indi¬ firmed that microsurgical techniques show
cating that the usual 6-month recall is too short; greater clinical success at the 1-year recall visit
(2) the larger the lesion, the slower the healing, in¬ and that postoperative sequelae are signifi¬
dicating a direct correlation between the size of the cantly reduced.
lesion and the time required for healing; (3) com¬
plete healing, defined as reconstitution of the lam¬ SUGGESTED READING
ina dura and healing by scar, occurred in 96.8% of Rubinstein R, Kim S: Short-term observation of the results
the cases; (4) failed cases could be attributed to un¬ of endodontic surgery with the use of a surgical opera¬
detected fractures. tion microscope and SuperEBA as root end filling mate¬
Fig. 15-89 is an example of a mandibular pre¬ rial, ] Endodont 25:43-48, 1999.
molar case, and Fig. 15-90 is an example of a
mandibular second molar case.
INDEX
163
164 Index
A Apicoectomy—cont’d
Access, difficult, replantation and, 127 procedural error and, 18
Adrenergic receptor, epinephrine and, 64 replantation and, 131
Allergy, patient history and, 25 retractors for, 81
Aluminum oxide, super ethoxybenzoic acid surgical microscope for, 55
and, 118 Azithromycin, prophylactic regimen with, 26b
Amalgam
controversy over use of, 5 B A
properties of, as retrofilling material, 116 Bacteremia, endodontic surgery and, 25

American Heart Association, prophylaxis guide¬ Bacteriostasis, retrofilling materials and, 115
lines from, 26 Ball burnisher, description of, 35
Amoxicillin Barb-Parker blade, flap incision with, 77
endodontic surgery and, 29 Beam splitter, surgical microscope and, 50
premedication with, prior to replantation, 129 Beaver blade, flap incision with, 78
prophylactic regimen with, 26b Bender, Dr. I. B., 125
Ampicillin, prophylactic regimen with, 26b Bevel angle, root resection and, 91-92
Analgesic drugs, pain following endodontic Binoculars
surgery treated with, 137 inclinable, 48
Anastomosis, definition of, 98 surgical microscope and, 46-48
Anesthesia, 63-71 Bismuth oxide powder, mineral trioxide aggre¬
infiltration sites for, 65 gate preparation and, 120
intraoperative phase of, 66-69 Bleeding, following endodontic surgery,
local, administration of, 63-64 137-138
mandibular, 66 Blood pressure, effect of epinephrine on, 64, 65
maxillary, 65-66 Blunderbuss apex, microsurgery for, 15
pain following endodontic surgery treated Bone, root tip distinguished from, 86
with, 137 Bone crypt
preoperative phase of, 63-66 hemostasis and, 114
for replantation, 129 management of, 89
Ankylosis, replantation and, 126 vasoconstriction in, 68
Antibiotic drugs Bone cutter bur, osteotomy and, 85
bacteremia prevented with, 25 Bone file, description of, 35
endodontic surgery and, 29 Bone Wax, hemostasis with, 69
premedication with, prior to replantation, Buccal canal wall, retrofilling of, 119
529 Buccal plate, thickness of, microsurgery con¬
Anticongestant drugs, sinus infection treated traindications and, 19
with, 139 Buccal surface, perforation of, replantation and,
Antiinflammatory drugs, endodontic surgery 127
and, 29 Bupivacaine, pain following endodontic surgery
Anxiety, patient treated with, 137
anesthesia and, 63 Bur, ultrasonic tip compared to, 110
prior to surgery, 25
Apex C
filling of, materials for, 115 C-shaped canal, microsurgery for, 5
of mandibular bicuspid, replantation and, Calcification, microsurgery for, 15
127 Calcium sulfate, hemostasis with, 68-69
radiography for location of, 85 Canal
resection of, 2 accessory, inspection of, 95
retrofilling of, 119 apical
Apical leakage, endodontic surgery failure preparation of, 105
and, 15 retropreparation of, 110
Apical preparation, surgical microscope for, 55 buccal, retrofilling of, 119
Apical root resection, 85-94 C-shaped
Apical seal, insufficient, causes of, 18 inspection of, 95
Apicoectomy microsurgery for, 5, 15
bevel angle in, 91-92 lateral, root resection and, 90
granulated tissue removal and, 89 leaky, inspection of, 95
Index 165
Canal—cont’d Dental chair, position in, in endodontic

multiple, isthmus formation and, 99 surgery, 59
retrofilling and resealing of, 94 Dentin, formation of, isthmus creation and, 99
S-shaped, microsurgery for, 15 Diabetes mellitus, surgery contraindicated
Canal fins, inspection of, 95 by, 25
Cardiovascular disorder Documentation, surgical microscope for, 52, 55
anesthesia and, 64
surgery contraindicated by, 25 E
Cardiovascular system, effect of epinephrine Ecchymosis, following endodontic surgery, 137,
on, 64 138
Carr tip, description of, 39-40 Ectomesenchymal cell, isthmus formation
Castroviejo needle holder, 36, 37 and, 98
Catecholamine, anesthesia and, 63 Elevation, instruments for, 32-33
Cefadroxil, prophylactic regimen with, 26b Elevator, flap elevation and, 78-79
CEJ. see Cementoenamel junction Endocarditis, prophylactic treatment and, 26
Cementoenamel junction, 129 Endodontic surgery, see also Microsurgery
Cementoid, formation of, isthmus creation and, anesthesia in, 63-71
98-99 assistant’s position in, 57
Cementum for broken instrument, 18
formation of, retrofilling materials and, 115 categories of, 1
mineral trioxide aggregate and formation of, changes in techniques in, 3
120 complications from, 139
production of, isthmus formation and, 98-99 contraindications to, 25
replantation technique and, 129-130 exploratory, 18
Cephalexin, prophylactic regimen with, 26b hemostasis in, 63-71
Chlorhexidine, premedication with, prior to nerve irritation from, 138-139
replantation, 129 patient evaluation prior to, 25-29
Chlorhexidine gluconate mouth rinse, patient management and, 23
endodontic surgery and, 29 patient premedication prior to, 25-29
Chronic inflammatory reaction, super ethoxy- position of patient in, 58-59
benzoic acid as cause of, 118 position of surgeon in, 58
Clairthromycin, prophylactic regimen with, 26b positioning for, 57-62
Clindamycin, prophylactic regimen with, 26b postponement of, 20
Collagen, absorbable, hemostasis with, 69 problems in, 1-2, 20-23
Condenser, microsurgery and, 6 clinical cases of, 2
Contamination, replantation failure caused by, procedural errors in, 15-18
132 replantation after failure of, 128
Corridor, definition of, 98 replantation compared to, 128-129
Cortical plate, intact, microsurgery on, 86-88 sequelae of, 137-140
CS. see Calcium sulfate traditional versus modern, 6-7
Curettage Endodontics, see also Endodontic surgery
apical, 94 classification of surgical cases in, 8-10
instruments for, 33 current state of, 1
periradicular, 88 failure of, microsurgery following, 14-15
surgical microscope for, 55 microsurgery compared to, 1-12
Curette Epinephrine, 64-65
microsurgery and, 6 anesthesia with, 63
miniendodontic, description of, 33 dosages of, 651
types of, for microsurgery, 88 high-concentration, 65
pellet for, 67-68
D racemic, 67
Dental assistant vasodilation and, 89
in endodontic surgery, 57 Epithelial cell, isthmus formation and, 98
positioning of, 57-58 Epithelial root sheath, isthmus formation
role of, in endodontic surgery, 57 and, 98
Dental cart, description of, 43 Ethoxybenzoic acid, retrofilling material and, 118
166 Index
Etidocaine, pain following endodontic surgery GTR. see Guided tissue regeneration
treated with, 137 Guided bone regeneration, 5
Eugenol Guided tissue regeneration, description of, 5
properties of, 116 Gutta-percha
zinc oxide-eugenol cement converted into, cold-burnished, 122
116 retropreparation and, 112
Evaluation, patient, 25-29
Explorer, endodontic surgery and use of, 31 H A
Extraction, replantation and, 129-130 H 161 Lindemann bone cutting bur, 36

Extraction socket, management of, during Halogen bulb, surgical microscope and, 50-51
replantation, 131 Hanks Balanced Salt Solution, 125, 130
Extrusion, surgery for, 1 HBSS. see Hanks Balanced Salt Solution
Eyepiece Headlamp, surgical, 45
position of, in endodontic surgery, 57 Heart valve, damaged, prophylactic treatment
surgical microscope and, 46 and, 26
Hematological disorder, surgery contraindi¬
F cated by, 25
Ferric sulfate Hemisection, surgery for, 1
bleeding stopped with, 119 Hemorrhage, following endodontic surgery,
hemostasis with, 68 137-138
Fiberoptic headlamp system, surgical micro¬ Hemostasis, 63-71
scope and, 45 agents for, 67
Fiberoptic light system, surgical microscope case study example of, 154
and, 50-51 importance of, 66
Fibrous connective tissue, mineral trioxide lidocaine for, 65
aggregate and formation of, 120 postoperative phase of surgery and, 70
Filling, see also Retrofilling retrofilling and, 119
incomplete, causes of, 18 retropreparation and, 114
retrograde, methylene blue for staining of, 97 Hydroxyapatite, retrofilling material and, 117
Fistula, identification of, 27
Fistulation, microsurgery for treatment of, 13 I
Flap Ibuprofen
case study example of creation of, 153 endodontic surgery and, 29
design of, 73-77 pain following endodontic surgery treated
elevation of, 78-79 with, 137
Luebke-Ochsenbein, 75-76 premedication with, prior to replantation,
mucogingival, 75-76 129
rectangular, 74 Ice pack
repositioning of, 82-83 hemostasis with, 138
retraction of, 79-80 postoperative phase of surgery and, 70
semilunar, 76-77 Illumination
sulcular full-thickness, 73-74 microsurgery and, 6
trapezoidal, 74 surgical microscope and, 50
triangular, 74 Impact Air 45 handpiece, 88
Focusing knob, surgical microscope and, 49 osteotomy and, 85
Forceps Incision
replantation technique and, 129-130 case study example of, 152-153
tissue, 82 flap techniques and, 77-78
FS. see Ferric sulfate instruments for, 32-33
Furcation zone, 99 for mucogingival flap, 75-76
for sulcular full-thickness flap, 73-74
G Infection
Gelfoam, hemostasis with, 69 facial, following endodontic surgery, 139
Gentamicin, prophylactic regimen with, 26b following endodontic surgery, 137, 139
Gingiva, soft tissue comprised of, 73 Inflammation
Groove technique of tissue retraction, 81 intraoral, endodontic treatment and, 26
Grossman, Dr. Louis I., 125 super ethoxybenzoic acid as cause of, 118
Index 167
Injection Lesion—cont’d
palatal, 66 periapical
techniques for, 65-66 causes of, 94
Inspection, instruments for, 33-35 microsurgery on, 87-88
Instrument size of, microsurgery and, 13
broken, 17 Lidocaine
endodontic surgery for, 18 anesthesia with, 66
curettage, 33 hemostasis with, 65
elevation, 32-33 Lidocaine 2% hydrochloride, anesthesia
examination, 31-32 with, 64
incision, 32-33 Ligament, periodontal, see Periodontal ligament
inspection, 33-35 Light, sources of, in surgical microscope, 50-51
microsurgery and, 6 Lindemann bone cutting bur, 36, 88
microsurgical, 31-45 Lingual mucosa, anesthesia injection into, 66
osteotomy, 36 Luebke-Ochsenbein flap, 75-76
plugging, 35
retrofilling, 35 M
surgical, miniaturization of, 5 Magnification
suturing, 36-37 changers for, 49-50
tissue retraction, 37-43 determination of, in surgical microscope, 46
Intermediate restorative material microsurgery and, 6
preparation of, 119 range of, in surgical microscope, 45
properties of, as retrofilling material, 116-117 surgical microscope and, 55
IRM. see Intermediate restorative material Mandible
Isthmus, 98-104 anesthesia for, 66
characteristics of, 99-100 endodontic surgical operating position for,
clinical significance of, 101 61-62
frequency of, 100 flap design for surgery on, 74
incomplete, 99 protrusion of, endodontic surgery access
origin of, 98 and, 49
partial, microsurgery for, 5 Maneuverability, endodontic microscope selec¬
resected root and, 95-104 tion and, 54
treatment of, 101-104 Maxilla
types of, 99-100 anesthesia for, 65-66
ultrasonic tip used on, 110 endodontic surgical operating position
for, 60
J Maxillary sinus, microsurgery contraindications
law, manipulation of, in endodontic surgery, 59 and, 19-20
loint replacement, prophylactic treatment Maxillary sinus infection, following endodontic
and, 26 surgery, 137, 139
MCH. see Microfibrillar Collagen Hemostats
K Mechanical stability, endodontic microscope
Keflex, sinus infection treated with, 139 selection and, 54
Kim-Pecora retractor, description of, 37-38, Medication
80-81 anticoagulant, endodontic surgery postpone¬
Kim surgical ultrasonic tip, 40-43 ment and, 20
KiS ultrasonic tip, description of, 109-110 preoperative, 29
KP retractor, see Kim-Pecora retractor Membrane barrier technique, 5, 8
Mental foramen
L correct use of retractor and, 81
Laceration, following endodontic surgery, 137, management of, 81-82
139 radiography for location of, 85
Laschal microscissors, 36, 37 Mesenchymal cell, isthmus formation and, 98
Lateral connection, definition of, 98 Messing gun, retrofilling and, 122
Lesion Methylene blue
apical, causes of, 20 resected root inspection with, 95-98
bone, microsurgery and, 87 resected root surface stained with, 114
168 Index
Methylene blue—cont’d Microsurgery—cont’d

root tip distinguished with, 86 classification of cases of, 8-10
staining with, 97-98 clinical situations for, 86-88
Microball burnisher, super ethoxybenzoic acid contraindications for, 18-20
packed with, 120 curette types used in, 88
Microblade, description of, 32-33 definition of, 3-5, 7
Microcondenser, super ethoxybenzoic acid endodontics compared to, 1-12
retrohlling and, 120 essential instruments for, If
Microexplorer hemostasis in, 63-71
endodontic surgery and use of, 31 techniques for, 69-70
microfracture inspection and, 98 indications for, 13-18
Microfibrillar Collagen Hemostats, hemostasis on intact cortical plate, 86-88
with, 69 postponement of, 20
Microfracture problems in, 20-23
amalgam associated with, 116 procedural errors in, 15-18
amalgam retrohlling associated with, 96 retractors for, 80-82
apical, inspection of, 95 retropreparation in, 105-114
methylene blue for staining of, 97 sequelae of, 137-140
ultrasonic tip and, 109 success of, 10
Microhandpiece, ultrasonic tip compared to, success rate of, 161-162
108-109 surgical microscope configuration in, 49-50
Microinstrument, development of, 5 triad of, 6
Micromirror Microsurgical instrument, see Instrument,
description of, 33-34 microsurgical
importance of, 111-112 Mineral trioxide aggregate, 120-122
microsurgery and, 7f advantages of, 120
Microplugger case study of use of, 157
description of, 35 development of, 5
microsurgery and, 7/ preparation of, 122
Microscope Miniblade, hap incision with, 78
dental, 52-54 Miniendodontic curette, description of, 33
endodontic, selection of, 54 Minijacquette, description of, 33
operating, history of, 31 Minirongeur, description of, 35
operation, description of, 3 Mirror, see also Micromirror
for osteotomy, 86 endodontic surgery and use of, 31
scanning electron, retropreparation inspec¬ microsurgery and, 6
tion with, 113 Modularity, endodontic microscope selection
surgical and, 54
benefits of, 46 Molar
documentation with, 52 mandibular, microsurgery and, 87
illumination in, 50 mandibular hrst
magnification changers in, 49-50 hap design for surgery on, 74
magnification in, 46, 55 isthmus formation in, 99
magnification range of, 45 replantation of, 127, 132
misconceptions about, 54-55 retrohlling in, 107/
parts of, 46-49 mandibular second
photographic and video adapters for, 52 case study of microsurgery on, 162
proper use of, 55 microsurgery contraindications and, 19
sources of light in, 50-51 replantation of, 127, 133
use of, 45-56 mandibullar second, microsurgery con¬
Microscopy, surgical, patient reaction to, 25 traindications and, 19
Microsurgery, see also Endodontic surgery maxillary hrst, replantation of, 134
advantages of, 7 maxillary second, isthmus formation in, 99
anesthesia in, 63-71 ultrasonic tip used on, 110
case selection for, 13-23 Monitor, position of, in endodontic surgery, 57
case studies of, 141-162 Mouth rinse, endodontic surgery and, 29
Index 169
MTA. see Mineral trioxide aggregate Paper point, retropreparation drying with, 113
Mucobuccal fold, anesthesia injection into, 66 Paresthesia, following endodontic surgery, 137,
Muco gingival flap, 75-76 138
Mucosa Parfocalization, surgical microscope and, 49
epinephrine as vasoconstrictor in, 64 Patient
soft tissue comprised of, 73 anesthesia for, 63-64
Multiple foramina, microsurgery for, 5 evaluation of, 25-29
Muscle, soft tissue comprised of, 73 geriatric, replantation contraindicated for,
Myocardial infarction, endodontic surgery post¬ 128
ponement and, 20 handicapped, replantation contraindicated
for, 128
N health of, microsurgery contraindications
Nerve and, 20
inferior alveolar, 138 interview of, 25
mandibular, 138 limitations of, replantation and, 128
radiography for location of, 85 oral evaluation of, 26-27
mental, tissue retraction and, 82 position of, in endodontic surgery, 57-58
nasopalatine, as anesthesia site, 65 premedication of, 25-29
Neurovascular bundle, microsurgery con¬ Patient management, endodontic surgery
traindications and, 19 and, 23
Nitrous oxide, anesthesia supplemented with, 66 PDL. see Periodontal ligament
Nylon, suturing with, 83 Penicillin, prophylactic regimen with, 26b
Perforation, replantation and, 127
O Periapical area, retrofilling of, 119
Objective lens, surgical microscope and, 49 Periapical radiolucency
Observer tube, surgical microscope and, 51 case study of, 14
Occupational stress, surgical microscope microsurgery for treatment of, 13
and, 46 Perio-Pack, tooth stabilization with, 131
Operating position, endodontic surgery and, Periodontal defect, microsurgery contraindica¬
60-62 tions and, 20
OPMI Pico dental microscope, 54 Periodontal ligament
OPMI Pro Magis dental microscope, 53 inspection of, 95
Optics, endodontic microscope selection methylene blue for staining of, 97
and, 54 role of, in replantation, 126
Oral evaluation soft tissue comprised of, 73
endodontic surgery and, 59 viability of, 126
patient, 26-27 during replantation, 130
radiography for, 27-29 Periodontal pocket, microsurgery contraindica¬
Organ transplantation, prophylactic treatment tions and, 19
and, 26 Periodontal probe, endodontic surgery and use
Orthoethoxybenzoic acid, super ethoxybenzoic of, 31
acid and, 118 Periodontium
Osteotomy, 85-94 epinephrine as vasoconstrictor in, 64
case study example of, 155 replantation and, 128
instruments for, 36 Periosteum
microscope for, 86 reflection of, 79
microsurgery and, 6 soft tissue comprised of, 73
optimal size for, 88-89 Photographic adapter, surgical microscope
size of, 106-108 and, 52
surgical microscope for, 55 Piezo ultrasonic instrument, 108
Plugger, microsurgery and, 6
P Plugging, instruments for, 35
Pain Post and crown restoration, case study of, 15
continuous, microsurgery for treatment of, 13 Post restoration, cost of, 23
endodontic treatment and, 26 Pregnancy, endodontic surgery postponement
following endodontic surgery, 137 and, 20
170 Index
Premedication Retractor
patient, 25-29 description of, 37
for replantation, 129 flap retraction with, 79-80
Probe, endodontic surgery and use of, 31 Kim-Pecora, 80-81
Prosthesis implantation, prophylactic treatment for microsurgery, 80-82
and, 26 Retreatment \\
Pulp stones, microsurgery for, 15 causes of, 1
Pulse, effect of epinephrine on, 65 replantation after failure of, 128
Retrofilling. see also Filling
Q amalgam, microfracture associated with, 96
Quartz, fused, super ethoxybenzoic acid isthmus formation and, 101
and, 118 materials for, 5, 115-124
Quartz halogen bulb, surgical microscope and, current state of, 122-124
50-51 replantation and, 131
surgical microscope for, 55
R techniques for, 115-124
Racellet, anesthesia with, 68 traditional techniques for, 105
Radiation therapy, endodontic surgery post¬ Retrofitting, instruments for, 35
ponement and, 20 Retropreparation, 105-114
Radiography bur, 106/
eccentric-angle, microsurgery and, 13 case study of, 144
oral evaluation with, 27-29 depth of, 113
osteotomy and, 85 drying of, 113
two-dimensional, 28 inspection of, 112-113
Radiolucency, periapical, microsurgery for sequence of procedures in, 113-114
treatment of, 13 traditional techniques for, 105-114
Radiopacity ultrasonic, evolution of, 110
mineral trioxide aggregate and, 120 ultrasound techniques for, success rate
retrofilling materials and, 115 of, 108
super ethoxybenzoic acid and, 118 Rheostat, surgical microscope and, 50
Reinforced zinc oxide eugenol cement, descrip¬ Rheumatic fever, prophylactic treatment
tion of, 5 and, 26
Replantation, 125-136 Root
advantages of, 128-129 abnormalities in surface of, methylene blue
anesthesia for, 129 for staining of, 97
case selection for, 128-129 amputation of, surgery for, 1
case studies of, 132-135 apical, resection of, 89-94
causes of failure of, 132 curvature of, osteotomy and, 85
contraindications for, 128 extension of, microsurgery and, 92-93
definition of, 125 fracture of, replantation failure caused by, 132
difficult access and, 127 length of
historical technique of, 126 osteotomy and, 85
indications for, 127-128 radiography for location of, 85
objections to, 125 multiple, isthmus formation and, 99
patient limitations and, 128 perforation of, case study of, 15
periodontal ligament viability during, 130 preparation of, for microsurgery, 105
postoperative instructions following, 131 resection of, 85-94
premedication for, 129 examination of, 99
success rate of, 1261 inspection of, 95-98
surgery for, 1 isthmus and, 95-104
techniques for, 128-131 tortuous, microsurgery for, 15
tooth stabilization after, 131 Root apex, flap design for surgery on, 74
Resection, of apical root, 89-94 Root canal
Resin, super ethoxybenzoic acid and, 118 failure to sterilize, microsurgery following, 14
Resorption, replantation and, 126 retrofilling and resealing of, 94
Index 171
Root canal system, complexity of, 20-23 SuperEBA. see Super ethoxybenzoic acid
Root end, preparation of Surgery
depth of, 113 causes of failure in, 15-18
inspection of, 112-113 changes in techniques in, 3
ultrasonic unit used for, 110-111 endodontic [see Endodontic surgery)
Root fracture exploratory, 18
case study of, 15 instruments for, miniaturization of, 5
microsurgery for, 5 molar, clinical case of, 2
surgery for, 1 positioning for, 57-62
Root sheath, isthmus formation and, 98 postponement of, 20
Root surface, inspection of, surgical microscope Surgical blade, flap incision with, 77-78
for, 55 Surgical microscope, see Microscope, surgical
Root tip Surgicel, hemostasis with, 69
bone distinguished from, 86 Suture
resection of, 90-91 monofilament, tooth stabilization with, 131
premature separation of, following endodon¬
S tic surgery, 137
Scalpel, description of, 32 synthetic, 83
Scanning electron microscope, retropreparation types of, 36-37
inspection with, 113 Suturing
Schneiderian membrane, perforation of, 139 case study of, 158-160
SEM. see Scanning electron microscope description of, 83-84
Semilunar flap, 76-77 instruments for, 36-37
Silicone dioxide, super ethoxybenzoic acid and, interrupted, 83
118 sling, 83
Silk, suturing with, 83 Swelling
Sinus, infringement on, endodontic surgery endodontic treatment and, 26
and, 139 following endodontic surgery, 137, 138
Sinus space, radiography for location of, 85 microsurgery for treatment of, 13
Socket, management of, during replantation,
131 T
Socket implant, fractured tooth and, 5 Tannic acid, hemostasis and, 138
Soft tissue, management of, 73-84 Tea bag, hemostasis produced by, 138
Spaghetti phenomenon, example of, 17/ Telescope, surgical, 45
Spartan Piezo ultrasonic unit, 110 Television monitor, position of, in endodontic
Stability, mechanical, endodontic microscope surgery, 57
selection and, 54 Thrombin, hemostasis with, 69
Stabilization, replantation and, 131 Through-and-through defect, example of, 17/
Stress, occupational, surgical microscope Tissue
and, 46 fibrous connective, mineral trioxide aggre¬
Stropko irrigator/drier gate and formation of, 120
description of, 38-39 granulated, removal of, 89
development of, 5 granulation, replantation and, 131
resected root inspection and, 95 reflection of, 79
retropreparation drying with, 113 retraction of
root resection and, 93-94 instruments for, 37-43
Submucosa, epinephrine as vasoconstrictor retraction of, groove technique for, 81
in, 64 soft, management of, 73-84
Sudafed, sinus infection treated with, 139 super ethoxybenzoic acid tolerance of, 118
Sulcular full-thickness flap, 73-74 Tooth
Super ethoxybenzoic acid anterior, ultrasonic tip used on, 110
advantages of, 119 extraction of, in replantation, 129-130
disadvantages of, 119 fractured, extraction of, 5
preparation of, 119-120 mandibular anterior, isthmus frequency in,
properties of, as retrofilling material, 100
118-119 mandibular bicuspid, replantation of, 127
172 Index
Tooth—cont’d U
mandibular first molar Ultrasonic tip, 18
replantation of, 132 advantages of, 110
retrofilling in, 107/ description of, 38-39
mandibular premolar isthmus location and treatment with,
case study of microsurgery on, 162 101-104
isthmus frequency in, 100 Kim, 40-43
mandibular second molar microhandpiece compared to, 108-109
case study of microsurgery on, 162 microsurgery and, 6, If
replantation of, 127, 133 types of, 108-110
maxillary anterior, isthmus frequency in, Ultrasonic unit
100 description of, 38-39
maxillary first molar types of, 108-110
isthmus frequency in, 100 Ultrasound, retropreparation with, success rate
replantation of, 134 of, 108
maxillary premolar, isthmus frequency in,
100 V
mobility of, microsurgery contraindications Vancomycin, prophylactic regimen with, 26b
and, 19 Vasoconstriction
molar, ultrasonic tip used on, 110 anesthesia and, 63
number nine, case study of microsurgery on, bone crypt and, 68
152-161 causes of, 64
number seven, case study of microsurgery Vasodilation, granulation tissue removal and, 89
on, 141-144 Video adapter, surgical microscope and, 52
number ten, case study of microsurgery on, Video camera, surgical microscope and, 52
145-149 Video recording, with surgical microscope, 46
number thirty, case study of microsurgery on,
149-152 X
with post restoration, 23 Xenon bulb, surgical microscope and, 50
premolar, ultrasonic tip used on, 110
replantation of (see Replantation) Z
Tooth fracture, identification of, 27 Zinc hydroxide, zinc oxide-eugenol cement
Tracking groove, isthmus location and treat¬ converted into, 116
ment with, 101-102 Zinc oxide, super ethoxybenzoic acid and, 118
Tranquilizer drugs, endodontic surgery Zinc oxide-eugenol cement, properties of, as
and, 29 retrofilling material, 116
Transplantation, surgery for, 1 Zirconium nitride, ultrasonic tip coated with, 109
*
.
• UlRAfty
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W.B. SAUNDERS COMPANY ISBN 0-7216-4851-7
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Dentistry 9 780721 648514

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SYNGCUK KIM, DDS, PhD

GABRIELE PECORA, MD, DDS RICHARD A. RUBINSTEIN, DDS, MS

W.B. SAUNDERS COMPANY

Editor-in-Chief: John Schrefer

COLOR ATLAS OF MICROSURGERY IN ENDODONTICS ISBN 0-7216-4851-7

Copyright © 2001 by W.B. Saunders Company

Printed in the United States of America

Last digit is the print number: 987654321

T hroughout the history of endodontics,

1 Comparison of Traditional and Microsurgery

Fig. 1-1 Presurgical radiograph of tooth #30 with a large PAR

Fig. 1-2 X8 magnification of the apices of the extracted tooth

CAUSES OF FAILURE WITH

CHANGES IN SURGICAL TECHNIQUES

DEFINITION OF MICROSURGERY for the first time in neurosurgery and ophthal¬

F'g 1-9 A microfracture caused the failure of this amalgam

Fig. 1-10 The triad of endodontic microsurgery—magnification,

Fig. 1-11 Composite picture of the most popular operation mi¬

Fig. 1-12 Essential microinstruments for endodontic micro¬

Fig. 1-13 A microsurgery team performing apical microsurgery

PROCEDURE TRADITIONAL SURGERY MICROSURGERY

Identification of the apex Difficult Precise

COMPARISON OF TRADITIONAL Microsurgery’s main advantages are easy iden¬

the canal. This will be discussed more in later

Fig. 1-17 Class A tooth-there is no periapical lesion, but the

SUCCESS OF ENDODONTIC Dahlin C, Linde A, Gottlow J et al: Healing of bone defects by

Fig 2-1 Failed endodontic therapy (left)- Surgery was not

Fig. 2-2 A, A preoperative radiograph showing a through-and-through defect requiring the

Failure of Previous Endodontic Therapy CASE 1

After nonsurgical retreatment, the tooth remains

After endodontic therapy, a periapical rarefac¬

Fig 2-4 The radiograph of this maxillary anterior tooth shows

Fig 2-6 A, Tooth #14 with a broken instrument at the MB

during the subsequent post restoration. It takes

*Patients at high risk include those with prosthetic heart valves.

Fig. 3-3 Radiograph showing the apices of the second premo¬

• Antiinflammatory agents: The patient should

KEY CONCEPTS able, and without such instruments endodontic

Fig. 4-5 15C blade in use.

INCISION AND ELEVATION

F'g 4-6 Microblades are used when the interproximal spaces

and bottom) have scratch-free sapphire mirror sur¬

RETROFILLING CARRIER AND

Endo), the Spartan (Spartan/Obtura) and the

Surgical ultrasonic tips, first designed by Dr.

have not been altered since their introduction

Fig. 4 -37 Enlarged view of KiS 1 tip, which is 3 mm long and

BOX 4" 1 Manufacturers of Microsurgical

Ul'f RASONIC UNITS AND TIPS

• Video recordings of the procedure can be used

The function of the binoculars is to project an in¬

lengths. When choosing binocular focal lengths, Magnification Changers

tings must be set individually. The microscope

Fig. 5-10 Fiberoptic cable light system.

objective lens, through the magnification changer

halogen light has a color temperature of 3200° K

camera that can be used for both 35-mm color

Fig. 5-14 A, OPMI Pro Magis surgical microscope for den¬

purchase of a microscope must be considered a

microsurgeon uses all magnifications (low,

Magnification Procedures Appropriate for Use

KEY CONCEPTS ASSISTANT'S POSITION AND