Recent Advances In

Endodontic Surgery
Presented by-
Hena Rahman (JR-III)

INTRODUCTION

According to the strictest definition of the word surgery, most endodontic

treatment falls into the category of a surgical procedure, since removal of tissues,
such as vital pulp, necrotic debris, or dentin, is involved. However, as commonly
used, the term endodontic surgery refers to the removal of tissues other than the
contents of the root canal space to retain a tooth with pulpal and/or peri-apical
involvement.

Endodontic surgery encompasses surgical procedures performed to remove the

causative agents of radicular and peri-radicular disease and restore these tissues to
functional health.

With the recent advent of magnification and illumination, coupled with ultra-sonic
root end canal preparations and sealing with new retro-grade filling materials, the
success of surgical endodontic treatment will provide the answer to solving myriad
problems that were once considered hopeless. The expanded scope of surgical
endodontics includes apical curettage, apicoectomy, root end filling, root
resections, hemisections, replantation, transplantation, and guided tissue
regeneration, with more advances on the horizon. This gives the clinician a wide
range of choices in this conservative approach.

Microsurgery is defined as a surgical procedure on exceptionally small and

complex structures with an operating microscope. The microscope enables the
surgeon to assess pathological changes more precisely and to remove pathological
lesions with far greater precision, thus minimizing tissue damage during the
surgery. One of the most significant developments in the past decade in
endodontics has been the use of the operating microscope for surgical
endodontics . The medical disciplines (e.g. neurosurgery, ENT, and
ophthalmology) incorporated the microscope into practice 20 to 30 yr ahead of us.
It is now inconceivable that certain procedures in medicine would be performed
without the aid of the microscope.
The operating microscope provides important benefits for endodontic
microsurgery in the following ways:

Advantages and uses of operating microscope

 i. Visualization of surgical field
ii. Evaluation of surgical technique
iii. Use of fewer radiographs
iv. Patient education through video
v. Reports to referring dentists
vi. Reports to insurance companies
vii.Documentation for dental legal purposes
viii. Video libraries for teaching purposes
ix. Marketing the dental practice
x. Less occupational stress

INDICATIONS FOR ENDODONTIC SURGERY

1. Surgical Drainage
A. Necessity for drainage
1. Elimination of toxins
2. Alleviation of pain

2. Apical surgery
A. Irretrievable root canal fillings
1. Obviously inadequate filling
2. Apparently adequate filling

B. Calcified canals

C. Procedural errors
1. Instrument fragmentation.
2. Nonnegotiable ledging.
3. Over instrumentation and apical fracture.
4. Symptomatic overfilling.

D. Presence of dowels
E. Anatomic variations
F. Apical cyst
G. Biopsy
H. False indications.
1. Presence of an incompletely formed apex, making hermetic
sealing of the apex impossible.
 2. Marked overfilling.
3. Persistent pain.
4. Failure of previous treatment.
5. Extensive destruction of peri-apical tissue and bone involving
one third or more of the root apex.
6. Root apex that appears to be involved in a cystic condition.
7. Presence of crater shaped erosion of the root apex,
indicating destruction of apical cementum and dentin.
8. Inability to gain negative culture.
9. Internal resorption.
10. Extreme apical curvature.
11. Fracture of root apex with pulpal death.
3. Corrective surgery
A. Root anomalies
B. Perforating carious and resorptive defects
C. Periodontal-endodontal defects
 Guided tissue regeneration.
 Root resection, hemi section, bisection.
 Correction, radicular gingival groove.
4. Replacement surgery
A. Replant surgery
 Intentional.
 Post-traumatic.
B. Implant surgery
 Endodontic.
 Endosseous.

CONTRA-INDICATIONS TO ENDODONTIC SURGERY

1. Indiscriminate surgery.
2. Poor systemic health.
3. Psychological impact.
4. Local anatomic factors
 Short root length.
 Poor bony support.
 Site of surgery.

CLASSIFICATION OF ENDODONTIC SURGERY

It can be classified as follows:

1. Surgical drainage
 Incision
  Trephination (fistulative surgery)
2. Radicular surgery
A. Apical surgery.
 Curettage and biopsy (peri-radicular surgery).
 Apicoectomy.
 Retro filling.
B. Corrective surgery.
1. Perforative repair.
 Mechanical.
 Resorptive.
2. Periodontal repair.
 Guided tissue regeneration.
 Resection.
3. Replacement surgery.
A. Replant surgery
 Intentional
 Post traumatic.
B. Endosteal implants surgery.
 Endodontic
 Osseo-integrated (endosseous)

Implication of microsurgery in Endodontics

In medicine, incorporation of the concept of microsurgery began in the late
1950’s. The surgical operating microscope was used for the first time in
neurosurgery and ophthalmology in 1960. Precision is a key element in
endodontic microsurgery because of the restricted access to the surgical field.
The surgical operating microscope, which has long been a standard
instrument in medical surgery, provides the necessary illumination with a bright,
focused light and magnification upto 32x. This enhanced visibility allows the
surgeons to locate and treat anatomic variations such as partial or complete
isthmus, multiple foramina, C- shaped canals and apical root fractures. These
variations often cannot be treated by nonsurgical means.
Main advantages of microsurgical approach are small osteotomies, shallow
level, resected root surface under high magnification reveals anatomic details such
as isthumi, canal fins, lateral canals. Together with microscope, ultrasonic
instrument permit conservative coaxial root end preparations and precise retrofills.

The Differences between Traditional and Microsurgical Techniques in

Endodontic Surgery

Endodontic surgery is perceived as difficult because the surgeon must often

approximate the location of anatomical structures such as large blood vessels, the
mental foramen, and the maxillary sinus. Although the chances of damage to these
structures are minimal, traditional endodontic surgery does not have a positive
image in the dental profession because of its invasive nature and questionable
outcome. If we accept the premise that the success of endodontic surgery depends
on the removal of all necrotic tissue and complete sealing of the entire root canal
system, then the reasons for surgical failure by the traditional approach become
clear. Examination of failed clinical cases and extracted teeth by surgical operating
microscopes reveal that the surgeon cannot predictably locate, clean, and fill all
the complex apical ramifications with traditional surgical techniques. These
limitations can only be overcome with the use of the microscope with
magnification and illumination and the specificity of microsurgical instruments,
especially ultrasonic instruments.
Comparing Traditional and Modern Endodontic Microsurgery
Procedure Traditional Surgery Microsurgery

Identification of the apex Sometimes difficult Precise

Osteotomy Large (= > 10 mm) Small (= < 5mm)

Root surface inspection Imprecise Precise

Bevel angle Large (45 degrees) Small (< 10 degrees)

Isthumus identification Nearly impossible Customary

Retro preparation Approximate Precise

 Root end filling Imprecise Precise

Sutures 4 _ 0 silk 5_ 0, 6 _ 0 monofilament

Suture removal 7 days post-op 2–3 days post-op

Healing Success (over 1 40 – 90% 85 – 96.8%

yr)

Classification of Endodontic Microsurgical cases

Endodontic surgery can be classified as follows:-
1 Class A represents the absence of a periapical lesion, but unresolved
symptoms after nonsurgical approaches have been exhausted. The symptoms
are the only reason for the surgery.
2 Class B represents the presence of a small periapical lesion & no periodontal
pockets.
3 Class C represents the presence of a large periapical lesion progressing
coronally but without periodontal pockets.
4 Class D represents a clinical picture similar to class C with a periodontal
pocket
5 Class E classifies a periapical lesion with an endodontic and periodontal
communication but no root fracture
6 Class F represents a tooth with an apical lesion and complete denudement of
the buccal plate.
Classes A, B and C present no significant treatment problems and do not adversely
affect the successful treatment outcomes. Cases in the D, E, F categories present
serious difficulties. Although these cases are in the endodontic domain, proper and
successful treatment requires not only endodontic microsurgical techniques but
also current periodontal surgical techniques. (eg. the membrane barrier techniques)

PRESURGICAL PRECAUTIONS
Patient interview
The patient interview is an important part of the diagnostic work-up. The
interview give the surgeon the opportunity to develop thrust within the patient, to
assess the patient’s state of mind and physical conditions, most importantly to
establish a rapport with the patient. This is extremely important because most
surgeries are done under local anesthesia so the patient’s confidence in the surgeon
allays anxiety. The surgeon should also explain the microscope and microsurgical
methods. For most patients this is the first experience with a microscope,
therefore having it come within a few inches of the face can be intimidating.
Medical Evaluation
A systematic approach to determine the patient’s medical condition is
essential. Endodontic surgical procedures produce transient bacteremia, hence
antibiotics must be given prophylactically for patients with a history of rheumatic
fever, endocarditis, abnormal or damaged heart valves, organ transplants, or
placement of an implant prosthesis, such as a hip or knee replacement. It is
important that the patient be treated in consultation with the patient’s physician,
the most recent guidelines of the AHA should be observed.
Oral examination
The oral examination should be conducted in a systematic manner and in a specific
sequence. The patient’s complaint or complaints and chronologic history of the
problem should guide the line of inquiry to identify the etiology and source of the
problem. (e.g. Pain, swelling, reinforced pain such as earache and heaviness or
tightness of the jaws or muscles). An earache is usually indicative of radiating pain
from an infected ipsilateral mandibular molar tooth.
Extraoral swelling indicates that surgery should be postponed until the
swelling is reduced with oral antibiotics. If a sinus tract has developed, it should
be traced with a gutta-percha point. The tooth should be evaluated for its
periodontal integrity and for fractures. In cases designated class E or F, the
success of surgical endodontics becomes questionable.
 A vertical fracture can be detected clinically or radiographically or upon
elevation of the flap.
Radiographic evaluation
Anatomic deviations, fractures, periradicular pathosis, evidence of
traumatic injuries, root resorption, periodontal disease, changes in bone patterns
and the success or failure of prior endodontic therapy can be obtained from
radiographs. Atleast two periapical radiographs taken from different angles ie one
straight on and the other 250 to 300 mesially or distally are needed to ascertain root
length, long axis, morphology and proximity to the mental foramen, inferior
alveolar nerve bundle, or the antrum which allows the clinician to visualize the
three-dimensional space.
It is very important to view the radiograph systematically.

PREMEDICATION
The drugs used in endodontic practices before and after endodontic surgery
are:-
1 Anti-inflammatory analgesics:- It is recommended that the patient (average
weight of 150lbs) take ibuprofen (400 mg) just before surgery to minimize
the postsurgical inflammatory response. To minimize bleeding problems
during surgery the dose should not be taken sooner. With this regimen
most patients will not require narcotic pain medication.
2 Tranquilizers – sublingual triazolam taken 15-30 minutes before the surgery
relieves anxiety.
3 Antibiotics – patients in poor health must be premedicated in accordance
with the most recent AHA recommendations.
4 Antibacterial rinses - Reduces microflora with a 0.12% chlorhexidine
gluconate mouth rinse (eg:- peridex, perioguard) given the night before
surgery, the morning of surgery & 1 hr before surgery. Rinsing continued
after the surgery for 1 week reduces microorganisms in the oral cavity &
 promotes better healing.

LOCAL ANESTHESIA AND HEMOSTASIS

Adequate hemostasis is a prerequisite for microsurgery. For endodontic
microsurgery, effective hemostasis is essential because the bone crypt & resected
root surfaces have to be examined at high magnification.
Hemostasis in a surgical procedure can be considered in three phases
(1) presurgical
(2) surgical and
(3) post surgical.

Presurgical phase
Local Anesthesia – In surgical endodontics, local anesthesia has two prime
purposes (1) anesthesia and hemostatis. A good topical anesthetic ointment or
transoral lidocaine patch (eg: - Dentipatch) is left in place for a minimum of 2
minutes to take effect. The anesthetic solution of choice for endodontic surgery is
lidocaine 2% Hcl with 1:50,000 epinephrine. High concentration of 1:50,000
epinephrine is preferred for surgery, because it produces effective and lasting
vasoconstriction via the α-adrenergic receptors in the smooth muscle of the
arterioles. This prevents the anesthetic from being dissipate prematurily by the
microcirculation.
Epinephrine Connection – ideally for the purposes of endodontic surgery, an
adrenergic vasoconstrictor would be a pure & agonist. The predominant receptor
in the oral tissues is an α - receptor, and the number of collocated β - 2 receptors
is very small. Thus the drugs predominant effect in the oral mucosa, submucosa
and periodontium is that of vasoconstriction.
An aspirating syringe ensures that epinephrine is not accidentally injected
into the blood stream. Virtually the effects associated with epinephrine in dentistry
are dose – route dependent. The current recommended maximum doses of
epinephrine in local anesthetics are:

Epinephrine Maximum Mg ml # cartridges

Mg/ml parts/thousand
0.02 1:50,000 0.20 10 5.5
0.01 1:100,000 0.20 20 11
0.005 1:200,000 0.20 40 22

Clinical reasons for using 1:50,000 epinephrine

There was no correlation between the administration of epinephrine, blood
pressure and pulse rate during periapical surgery using 1:50,000 epinephrine. The
majority of patients had transitory, statistically insignificant increases in pulse rate
2 minutes after the injection. Pulse rates returned to normal within 4 minutes
Local anesthetic injection techniques
Inferior alveolar nerve block using the epinephrine – containing lidocaine
has been shown to reduce blood flow to the jaw by 90% along with buccal and
lingual infiltration to enhance the vasoconstrictive effect at the surgical site. What
ever the injection technique used for anesthesia, infiltration into the surgical site is
essential for hemostasis.
The infiltration sites for the anesthesia are in the loose connective tissue of
the alveolar mucosa near the root apices. As skeletal muscle has a predominance
of β -2 receptors, the injection of epinephrine into muscle will produce
vasodilation rather than vasoconstriction and therefore must be avoided. If the
anesthetic is injected in to the muscle, not only is hemostasis inadequate, but a
more rapid uptake of the anesthetic and vasoconstrictor occurs, increasing the
potential for substantial bleeding during surgery.
Rapid injection produces localized pooling of solution in the injected
tissues, resulting in delayed and limited diffusion into adjacent tissues, minimal
surface contact with microvascular and neural channels and less than optimal
hemostasis. The initial incision should be delayed for atleast 15 minutes after the
injection until the soft tissues through out surgical site have blanched.

Maxillary Anesthesia
1 Infiltration anesthesia in the mucobuccal fold over the apex of the root and
in the adjacent mesial and distal areas is the most effective anesthesia for
maxillary teeth. For surgery on anterior teeth, a supplemental nerve block
should be injected near the incisive foramen to block the nasopalatine
nerve. For surgery in the posterior quadrant, the anesthetic is injected near
the greater palatine foramen to block the greater palatine nerve. If a patient
has a large swelling in the cuspid and premolar region, an infraorbital block
injection can be very effective to attain profound anesthesia in this area.
The choice for the supplemental anesthetic is also a 2% lidocaine
Hydrochloride (eg: xylocaine) solution with 1:50,000 epinephrine
Mandibular Anesthesia – For surgery in the mandible a mandibular and long
buccal nerve block with a supplemental infiltration injection in the mucobuccal
fold and lingual mucosa in the apical area is the most effective method. One
carpule of 2% lidocaine HCl (ie, xylocaine) solution with 1:50,000 epinephrine is
also preferred with a 27 gauge, 11-inch needle in an aspirating syringe. After the
mandibular block, another carpule is injected in to the mucobuccal fold, mesial
and distal to the tooth. After 10 minutes, another infiltration injection of one-half
carpule is made into the lingual aspect of the tooth.

Hemostatic Control during Surgery

Local hemostasis can be achieved by the pressure technique of pressing
cotton pellets or gauze into the bone crypt for a few minutes. If the bleeding
persists, topical hemostats should be considered.
Topical Hemostats
The topical Hemostatic agents are:-
Mechanical Agents
Bone wax (Ethicon, Somerville, NJ)
Chemical agents
Epinephrine – saturated cotton pellets and other vasoconstrictors.
Ferric sulfate solution
Etiologic agents
Thrombin VSP (Throbostat, Thrombogen)
Absorbable Hemostatic agents
Intrinsic action
1) Gelfoam (The Up john Co., Kalamazoo, MI)
2) Absorbable collagen
3) Microfibrillar Collagen hemostats
Extrinsic action
1) Surgicel
Mechanical
1) Calcium Sulphate

Epinephrine pellets – Racellets are cotton pellets containing racemic epinephrine

HCl. Suggested by Grossman. The amount of epinephrine in each pellet varies
according to the number on the label. For example Racellet no.3 pellets contain an
average of 0.55 mg racemic epinephrine and Racellet no.2 pellets contain 0.2 mg.
Racellet no.2 pellets do not seem to change the pulse rate of patients when pressed
into the bone cavity for 4 minutes. This is plausible because topically applied
epinephrine causes immediate local vasoconstriction, thus there is minimal
absorption into the systemic circulation.
The following procedure is most effective to achieve local hemostasis
quickly during apical surgery:-
1 A small epinephrine – saturated cotton pellet is first placed in th bony crypt
and packed solidly against the lingual wall of the bony crypt.
 2 In quick succession, small sterile cotton pellets are packed in over the first
pellet, filling until the entire bone crypt.
3 Pressure is applied on these pellets and all but the last pellet is removed
after 2-4 minutes. At this time even the most persistent bleeding should
have stopped.
Ferric sulfate solution – Ferric sulfate (FS) is a hemostatic agent causing
hemostasis by agglutination of blood proteins from blood with both ferric and
sulfate ions and the acidic pH (0.21) of the solution occlude the capillary orifices.
FS affects hemostasis through a chemical reaction with blood. FS is an excellent
hemostatic agent on the buccal plate for small bleeders and is readily applied and
easily removed by the yellowish FS fluid turn into a dark brown or brown
coagulum immediately upon contact with epinephrine. The color differences are
useful for identification of the sources of any persistent bleeders. The
commercially available FS solutions are control – 50% FS, Monsel sol – 70% FS
& Stasis – 21% FS.
FS is known to be cytotoxic and to cause tissue necrosis, but systemic
absorption of FS solution is unlikely because the coagulum isolates it from the
vascular bed. FS has also been found to damage bone and to delay healing when
used in maximum amounts and when left in-situ. When the FS coagulum is
completely removed and the surgical site is thoroughly irrigated with saliva
immediately after hemostasis and before closure, there is no adverse reaction.
When there is a persistent bleeding despite of the epinephrine and cotton
pellet technique, FS solution is applied to the bone crypt. Brushing FS solution on
to the buccal surface around the bone crypt just before retrofilling ensures
hemostasis during this important procedure.

Calcium sulfate paste

It is not designed as topical hemostat. CS paste acts by mechanically blocking
blood vessels (i.e. tamponade effect). It’s a bone-inductive agent and is absorbed
by the body after 2 to 3 weeks. CS comes as a powder and a mixing solution,
which can be mixed to make a thick, pasty pellet the size of the osteotomy. After
placing the pellet into the bone, it is tamped down with a moist cotton pellet. CS
paste hardens quickly and the excess is removed, exposing the root apex for
further surgery. After the surgery, the Cs is left in the bone cavity, where it acts as
a barrier to the faster –growing soft tissue and potentially a matrix for the
osteoblasts. CS is an excellent agent for a large bone crypt that does not respond
to the other methods of hemostasis.

Other commercially available hemostats – Many other commercially available

topical hemostats are costlier effective and include bone wax, Thrombin, Gelfoam,
Collagen, Microfibrillar collagen, Hemostat (MCH), and surgical.
Calcium sulfate paste, boen wax and surgical achieve hemostasis through a
tamponade effect by mechanically blocking open vessels, whereas epinephrine
causes vasoconstriction by activating α adrenergic receptors. Gelfoam made of
animal skin gelatin acts intrinsically by promoting the disintegration of platelets
causing release of thromboplastin. Collagen is known to aggregate platelets,
which then release coagulation factors. These and plasma factors help form fibrin
and subsequently a clot. Thrombin is a protein that acts rapidly in an intrinsic
fashion, combining with fibrinogen to form blood clots. MCH is prepared from
bovine corium, which promotes rapid hemostasis by attracting platelets.

Post surgical Hemostasis

To avoid post surgical bleeding, it is important that hemostasis be
maintained after the flap is sutured. An ice cold, wet, sterilized gauze placed over
the suture helps stabilize the flap and control oozing of the blood from the surgical
sites. The gauze should be placed into the mucobuccal fold for about 1hr and an
ice pack should be applied to the cheek 10 minutes on, 5 minutes off, for 1 to 2
days.
 SOFT TISSUE MANAGEMENT
The soft tissue management consists of flap design, incision, elevation,
retraction, repositioning & suturing.
The two reasons for proper management of soft tissue when performing
endodontic surgery include:- to gain adequate access to the surgical site and to
ensure good post surgery healing. This can be achieved by proper flap designing
making precise incision, elevating and retracting the flap with minimum trauma to
the tissue and repositioning, suturing the flap precisely into its original position.
FLAP DESIGNS
The two major categories of flap designs are (1) Sulcular full thickness flap (or
full mucoperiosteal flap) and (2) mucogingival flap design (or limited
mucopperiosteal flap).

Design for sulcular full thickness flap

The flap design involves horizontal and vertical incisions. The horizontal incision
extends from the gingival sulcus, through the fibers of the periodontal ligament to
the crestal bone. The incision should pass through the mid-col area separating the
buccal and lingual papillae. The vertical incision should be firmly against cortical
bone between the root eminences, because the mucoperiosteum is thin over the
root eminence and tears easily. This design reflects the entire soft tissues, attached
gingival, midcol and mucosa overlying the cortical plate with the horizontal
incision being an intrasulcular incision. Thus provides the best access to all
surgical sites in the oral cavity and can be a triangular flap with one vertical
releasing incision or a rectangular flap with two vertical releasing incisions.
The rectangular design may be better for anterior teeth than the triangular
design because it provides better access to the root apex, especially when the root
is long. The rectangular design have the base of the flap as wide as the top which
follows the direction of the tissue fibers of blood vessels because less severity to
the fibers & allowing the sutured incisions to heal quickly with no scarring.
Earlier it was taught, the flap should be broader at the base to facilitate better
microvascular perfusion (ie Trapezoidal flap). In fact, the wider-based flap causes
delayed healing and unsightly scars because the incision cuts the fiber lines and
blood vessels obliquely rather than tracing them.
For posterior teeth the triangular design with one mesial vertical releasing incision
is recommended. For surgery on a mandibular first molar, the vertical releasing
incisions should be made distal or mesial of the first premolar .
In general whether it is the triangular or rectangular design, the sulcular full
thickness flap is preferred for most endodontic surgical cases.
Design for mucogingival flap:
The mucogingival flap design or limited mucoperiosteal flap design is most
suitable for crowned teeth, where there is an esthetic concern for open – crown
margins as a result of the surgery. The design calls for a scalloped incision in the
middle of the attached gingiva reflecting one half of he attached gingiva close to
the mucobuccal fold, leaving the remaining one half of the attached gingival intact
around the root and the sulcus. The angle of the incision in relation to the cortical
plate is 45 degrees, because this angle provides the widest cut surface allowing for
better adaptation once the flap is repositioned.
The mucogingival flap differs from Leubke – Ochsenbein design in that the
two vertical releasing incisions are parallel; they are wider at the base in the L – O
design. There is a significant difference in healing and potential scar formation.
The vertical incision of the mucogingival flap should be parallel. The junction
where the horizontal scalloped incision in the attached gingival meets the vertical
incision should be rounded to promote smoother and faster healing. Sharp 900
angled intersection makes healing slower and leaves a small, hard, knobby scar.
The purpose of the scalloped horizontal incision is to provide a guide for
the correct repositioning of the elevated flap for suturing which leaves a faint
unnoticeable scar in the attached gingiva.
Semilunar flap
Widely used in the past. Now rarely used because it does not allow for
adequate access to the surgical site and often leaves a noticeable scar.
FLAP ELEVATION
After giving horizontal and releasing incisions, the microperisteum is elevated and
reflected with a sharp elevator. The elevators P14S or P9 HM are placed
underneath the gingiva at the line angle. The mucoperiosteum is lifted away from
the alveolar bone by gently lifting the elevator toward the apex while it is under
the flap. The sharp wide end of the elevator is placed at a 45 degree angle to the
cortical bone surface; the mucoperiosteum peeling motion closely tracing the
cortical bone contours. The irregular surfaces of buccal cortical plates can easily
contribute to tearing or perforating the flap during the reflection. In addition to
shrinking, a traumatized flap will also swell, making it difficult to place it back to
its original position without additional trauma. A perforated or torn flap will be
difficult to suture. Moist gauze underneath the initially reflected flap helps by
gently pushing the gauze with an elevator to produce a smooth flap elevation
which have minimal bleeding.
FLAP RETRACTION
The retractor should be chosen for the specific purpose and to fit the anatomy of
the cortical plate. Retractors have narrow tips which are convex possessing
problems. Where the cortical bone protrudes the convex retractor is an unstable
anchor, because the only point of contact with the bone is the small area at the top
of the curve.
Retractors in Endodontic Microsurgery
KP retractors have wider (15mm) and thinner (0.5 mm) serrated working ends.
Some are concave & some are convex to accommodate the irregular contours of
the buccal plate. The serrated tips provide better anchorage on the bone and
prevent accidental slipping. The surfaces of the retractors are matted, so that the
light from the microscope is not reflected. KP – 1 retractor has a V shaped
working end to fit the bone eminences in the maxillary molar and mandibular
incisor regions. 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. The KP – 3 retractor tip has a slight convexity that is
well suited for the mandibular premolar and molar bone anatomy. Groove
technique overcomes the danger of being close to the mental foramen during
mandibular surgery.
Repositioning of the Flap
After surgical procedures the retracted tissue is carefully repositioned with tissue
forceps. After repositioning the flap, a chilled (with ice water), damp gauze pad
is placed firmly on the flap with finger pressure to remove accumulated blood and
fruits from underneath the flap. A clean, bloodless surgical site will aid in the
accurate repositioning of the flap. Flap shrinks during lengthy surgery, hence the
flap may have to be stretched for proper adaptation and first strategic suture is
placed into the free ends of the triangular or rectangular flap. Another suture is
placed just above the free ends to reduce the tension on the free ends. The third
strategic suture is a sling suture around the tooth centre to the flap. After the flap
has reassumed its original size, the remaining sutures can be placed.
SUTURE MATERIALS AND SUTURE TECHNIQUES
Silk sutures are braided and exhibit a wicking effect that accumulates bacterial
plaques. Also causes severe inflammation to the incision site. Synthetic
monofilament sutures, such as supra mid and monovicryl, have no wicking effect,
resulting in a better, more predictable postoperative outcome. The preferred suture
size is 5 – 0 or 6 – 0. Monofilament sutures have smoothness, flexibility as
compared to 4-0 silk sutures without the risk of causing inflammation. Resorbable
gut sutures are/not recommended, except when patient can’t return. Removal of
sutures is recommended within 48 hrs. Regardless of the suture materials, the
patient must keep the surgical site as clean as possible by frequent rinsing with
warm salt water and chlorhexidine to prevent any plaque accumulation after the
surgery.
Two simple suturing techniques are there:- interrupted and sling. The
vertical releasing incision is sutured with interrupted sutures; the interproximal
and sulcular incisions are sutured with sling sutures. In the sling-suturing
technique, the buccal gingival papilla is pierced with a 3/8 inch circle or straight
5-0 suture needle that is then brought through the interproximal space of the tooth.
The suture is then led around the lingual and interproximal aspects of the tooth to
go through the adjacent buccal papilla. The path is now reversed to arrive at the
first buccal papilla, where a knot is made to secure the suture.
The value of using a microscope with this procedure is marginal, because
the site for suturing is readily seen by with 3.5 x to 4.5 x telescopes. Suturing
under the microscope provides negligible added advantage, except when a 6-0 or
smaller sutures are used. The 6-0 sutures are generally used for crowned
maxillary anterior teeth where gingival esthetics and crown margins are always a
concern.
OSTEOTOMY
Osteotomy is the removal of the facial cortical plate to expose the root end. It
must be approached with a visualized 3-D image to ensure it is made exactly over
the root apices. The first step is to expose periapical radiographic images
perpendicular to the roots from two different horizontal angles. This is done to
ascertain the length and curvature of the roots, the position of the apices in relation
to the crown, and the number of roots. In addition, the proximity of each apex to
the apices of adjacent teeth, the mental foramen, the inferior alveolar nerve, and
the antrum can be ascertained. Once the flap has been raised, the clinician should
superimpose the visualized mental image gained from the radiographs and clinical
examination onto the cortical plate.
To locate the apex:-
 1) Mark the probable apex position on to the buccal plate using the radiograph
as a guide
2) Make a 1 mm deep indentation with a no.1 round, high speed bur and fill it
with a small amount of radioopaque material such as gutta-percha. A radio
graph exposed with this marker in place will show the marker in relation to
the root apex.
The microscope clearly distinguishes 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 probe. Root tip when cannot be distinguished,
methylene blue is used at the osteotomy site which stains the periodontal ligament.
The absence of a distinct periodontal ligament stain at mid magnification (10 x to
12X) indicates that the root tip has not yet been exposed.
Optimal Osteotomy size
Osteotomy should be as small as possible but just large enough to
manipulate ultrasonic tips freely within the bone crypt. Large size of the
osteotomy causes destruction of the buccal plate resulting in periodontic
endodontic communication. The large osteotomy causes slower and incomplete
healing period. Because the length of an ultrasonic tip is about 4 to 5 mm, leaving
just enough space to manipulate the ultrasonic tip and microinstruments within
its confines. A larger than 10 mm osteotomy was the norm with the previous
method. Under 10 x to 20 x magnification of the microscope, even a small
osteotomy looks huge. This magnified field forces the clinician to work in a small
space with small but precise movements resulting in a small osteotomy. This is
one of the true advantages of using the microscope in endodontic surgery.

Periradicular Curettage
Periradicular curettage does not eliminate the origin of the lesion it only relieves
the symptoms temporarily. The granualomatous soft tissue must be removed
completely before the apex is resected done by Columbia no.13 and no.14 curettes
or molt or Jaquette 34/35 curettes under medium magnification (10 x to 16 x)
Inspection of Resected Root Surface under the microscope
Once hemostasis is established in the bony crypt, the resected root surface
is stained with methylene blue and is examined carefully using a CX – 1
microexplorer, under 12 x to 25 x microscope magnification. The outline of the
anterior teeth demonstrate usually around outline, premolar and molar teeth
demonstrate an hourglass shape. Canal system appears elongated with more acute
bevels.
Another advantage of examining the resected root surface under the
microscope is the identification of the causes of endodontic failure. The most
frequent causes are missed canals, poor canal obturation and microfractures. The
most common failures of premicroscope endodontic surgery can be attributed to
misplaced amalgam retrofilling, apical microfractures with amalgam retrofillings
and lingual perforations of lingually positioned apices. Microleakage is the
common denomine underlying the failures in endodontics and endodontic surgery.
APICAL RESECTION
Apical resection is a root end resection or apicoectomy. Once the bone crypt is
free of granulation tissue and the root tip is clearly identified, 3 mm of the root tip
is resected perpendicular to the long axis of the root. This is done at low
magnification of 4 x to 8 x with the Lindemann bur in an Impact Air 45 handpiece
using copious water spray. Try to resect perpendicular to the long axis of the root,
especially with lingually inclined roots. The resected root surface is examined at
midmagnification (10 x to 12 x) for the presence of the periodontal ligament. This
is done to verify that the entire root tip has been removed. If the stained PDL is
visible only around the buccal aspect, the resection must be extended deeper
lingually.
Two important elements to consider with this procedure are
1) Extent of apical resection (apicoectomy)
2) Bevel Angle
Extent of Apicoectomy
The amount root tip to resect depends on the incidence of lateral canals and apical
ramifications at the root end. Using a computer system the roots of the Hess
models were resected, 1,2,3and 4 mm from the apex, counting the incidence of
lateral canals and apical ramifications at each level.
Only when 3 mm of the apex is resected are lateral canals reduced by 3 %.
Additional resection reduced the percentage insignificantly. A root resection of
3mm at a 0-degree level angle removes the majority of anatomic entities that are
potential causes of failure. Any remaining lateral canals are sealed during
retrograde filling of the canal. Therefore removing the apex beyond 3mm is of
marginal value and compromises a sound crown / root ratio.
Bevel Angle
Bevel helps the surgeon to view the apex so that it can be identified and
retroprepared. Early the bevel angle is 45 degrees. No biologic basis for this
practice existed. Bevel angle is used to 1) gain visual and operating access for
root tip /resection 2) place retrofilling materials and 3) Inspect. These reasons
were especially true for operating on lingually inclined roots eg:- mesiolingual
root of mandibular molars. Gilheany and colleagues found a positive correlation
between increasing bevel angles and increasing apical leakage. No bevels angle
thus would be best. The combination of the microscope, ultrasonic
retropreparation tips and micromirrors allows the apex to be prepared with
virtually no bevel. This is made possible by small, only 3 mm long ultrasonic tips,
which are offset by 90 degrees from the handle. Together with a small osteotomy
and bevels between 0 and 10 degrees, the minimal removal of both cortical plate
and the root apex are ensured. In this manner, surgical complications, such as the
unnecessary reduction of the crown to root ratio and creation of a periodontic
endodontic communication can be eliminated or minimized, thus preserving tooth
and bone structure promoting better healing.
 The root resection must be done perpendicular to the long axis of the root.
Resections not made at 90 degrees to the long axis result in an uneven or
incomplete resection of the apex. The buccal aspect is resected but the lingual part
is partially or not resected at all, leaving leaky lateral canals. Because the apices
of many teeth (especially maxillary anterior teeth) are tilted slightly lingually,
surgeons must approach the resection with this lingual inclination in mind. The
clinician should use a 10-degree bevel and tilt the patients head to the side, away
from the microscope, for optimal viewing of the apex.
ROOT END PREPARATION
It’s the fulfillment of biologic imperative with the hermetic sealing of any
actual or potentially noxious agent within the physical confines of the root.
Ideal retropreparation
It is a class I preparation alteast 3 mm into root dentin with walls parallel to and
coincident with the anatomic outline of the pulpal space.
The root end preparations did not often follow the long axis of the root,
rather it went off to the side, occasionally perforating the lingual aspect of the root
end. Often retrofillings were too large, covering most of the resected root surface
and too shallow, resulting in a dislodged apical seal.
Major errors of retropreparation
1. Retropreparation not placed down the long axis of the pulp canal
2. Retropreparation lacks sufficient retention form
3. Retropreparation lack proper (bucco – lingual) extension to assure adequate
seals
4. Retropreparation fails to include isthmus areas
5. Retropreparation weakens delicate apical dentin by unnecessary over
enlargement

ULTRASONIC APICAL PREPARATION

One of the advancements in endodontic surgery that allowed greater efficiency
was the adaptation of piezoelectric ultrasonics for root end preparations.
Ultrasonic tips are available in various configurations (Analytic Endo, Satelect/
Amadent Co. and Spartan / obtura co.) to accommodate virtually all access
situations. These microtips are very narrow in diameter ie about one tenth the size
of a conventional microhead handpiece.
The first ultrasonic tips for endodontics and endodontic surgery were the
CT tips made of stainless steel (SS) and designed by Dr. Gary Carrin 1990. In
1999 Kis tips were introduced which have cutting efficiency by coating the tip
with zirconium nitride, more convenient angles, and relocation of irrigation port.
The location of the ultrasonic irrigation shaft, delivers maximum irrigation volume
directly into the cutting site. Kis tips are different from CT tips in terms of shaft
angle, tip angle and length.
The advantages of ultrasonic tips over microhead burs are
1 Better access, especially in difficult to reach areas as the lingual apex.
2 More thorough debridement of tissue debris.
3 Conservative preparations tracing the long axis at a precise depth of 3 mm.
4 Precise isthmus preparations with parallel canal walls for better retention of
filling materials.
Ultrasonic Root End Preparation
This procedure is accomplished under the miscroscope at low-to-mid
magnifications (14 x 16x). a number of appropriate tips are preselected,
depending upon the location of each apex. The resected root surface then is
stained with methylene blue, which must be critically examined at high
magnification (16 x to 25 x) to see the microanatomy. Thirdly, at low
magnification (4 x to 6 x), the selected ultrasonic tip is positioned at the apex. It is
important at this stage that the tip is positioned parallel with the long axis of the
root. To accomplish this, the surgeon must examine the position of entire tooth at
low magnification (4 x), including the crown and root eminence and compare this
with the position of the ultrasonic tip. Failure to make this comparison will risk an
off-angle root end preparation or perforation. Fourth, the ultrasonic tip is activated
and the apical canal is retroprepared with copious water coolant to a depth of 3
mm. For effective cutting action, a light sweeping motion using short forward and
backward and up and down strokes can be done. A typical 3 mm retropreparation
should take less than 1 minute with kis tips. Preparation is inspected with a
micromirror at high magnification of 16 x to 25 x. A thorough inspection should
include the interior canal walls for remnants of gutta-percha, especially on the
difficult –to-reach facial wall and confirmation that the parallel walls are sharply
defined and smooth.
Micromirrors
One of the key instruments in microsurgery is the micromirror. The reflective
surface is made of either highly polished stainless steel or sapphire. The mirrors
are small enough to fit into an osteotomy measuring no larger than 4 to 5 mm in
diameter. Inspection of root ends cannot be performed thoroughly without the aid
of micromirrors.

INSPECTION OF THE ROOT END PREPARATION

The root end is best prepared at low to-mid magnification (8 x to 12 x). the
preparation must be inspected at high magnification (16 x to 25 x). The completed
preparation should be inspected for clean, sharply defined walls, anatomic
structures like accessory canals and microfracture.
Depth of the root end preparation
The optimal depth of the root end preparation should be 3 mm. The
incidence of lateral canals and apical examination in the natural apex have been
studied; & over 95% of these anatomic entities are found within the apical 3 mm.
Although a retropreparation deeper than 3 mm does not provide any greater
benefits, a retropreparation shorter than 3 mm may jeopardize the long-term
success of the apical seal.
COMPACTION OF GUTTA-PERCHA IN THE RETROPREPARED
CAVIY
The remnants of gutta-percha have to be compacted well to a 3 mm depth
with microcondensers. Many different type of micro condensers with different
handles are there, but their working tips are basically the same, with a 0.2 mm
diameter and a length. The retroprepared canals must be void of any gutta-percha
or debris for the final filling.
Retrogate filling materials are:-
- Amalgam
- Guttapercha
- Gold foil
- Titanium screws
- Glass ionomers
- Ketac silver
- Zinc oxide – eugenol
- Cavit
- Composite resins
- Polycarboxylate cement
- Poly HEMA
- Bone cements
- IRM
- Super EBA
- Mineral Trioxide Aggregate (MTA)
ISTHUMUS
In general sense it is a narrow strip of land connecting two larger lands . Isthmus is
a narrow connection between two root canals which usually contains pulp tissue.
The isthmus has been called a “corridor” by Green, a “lateral connection” by
Pineda and an “anastomosis” by Vertucci. In many teeth with a fused root there is
a weblike connection between two canals called an isthmus, which can be either
complete or incomplete. At 3 mm from the apex, isthmuses are often found to
merge two canals in one root. Thus isthmus is a part of a canal system and not a
separate entity; accordingly, it must be cleaned, shaped and retrosealed.
Isthmus frequency
The isthmus is most frequently observed between two root canals within one root.
Thus, the majority of posterior teeth contain an isthmus. At the 3-mm level from
the original apex, 90% of the mesiobuccal roots of maxillary first molars have an
isthmus, 30% of the maxillary and mandibular premolars, and over 80% of the
mesial roots of the mandibular first molars have one. This high incidence of
isthmuses in premolars and molars is an important consideration when performing
apical surgery. This is one of the reasons why apicoectomy alone, without root-
end preparation and/or root-end filling, especially in molar teeth, usually fails.
Importance of Finding and Treating the Isthmus
When an isthumus was present, these cases would eventually fail.
Isthumuses should be identified, prepared and properly sealed' The high incidence
of isthumi found during microsurgery was surprising and prompted an anatomic
investigation. The untreated isthumi are one of the main causes of treatment failure
of apical surgery, especially in the posterior teeth.

POSTOPERATIVE SEQUELAE
Surgical sequelae include pain, swelling, ecchymosis laceration, premature
separation of sutures, infection maxillary sinus perforation and transient
paresthesia. To minimize postsurgical sequelae, oral and written postoperative
instructions must be given to the patient and the person accompanying the patient.
Because of anxiety and nervousness, patients sometimes misunderstand or simply
do not remember the verbal instructions for this reason written instructions allay
confusion or further anxiety.
Pain
Pain is usually not a serious problem. Long-acting anesthetic agents such as
bupivacaine (ie mercaine) or etidocainel (ie, Duranest) can be injected
postoperatively in to the surgical site to control pain for a period of upto 8 hours.
Ibuprofen or acetaminophen regimen always ensures that any pain will be minimal
and transient. Rarely are narcotic analgesics required.
Hemorrhage
Postoperative haemorrhage is rare. To prevent it from occurring two 2 x 2 sterile
gauze pads are folded in half and moistened with chilled, sterile water. This pack
is placed over the sutured flap in the buccal fold and pressed by the surgeon with
moderate pressure for several minutes. The patient is provided an ice pack to
press lightly against the cheek or jaw for at least 30 minutes to constrict the cut
microvasculature, minimizes swelling and promotes initial coagulation.
Swelling
Swelling is a common surgical sequelae & is a major concern for the
patient. Patients must be informed that the surgical site and face may swell
regardless of the home care. Also, patients must be assured that the degree of
swelling is not an indication of the success or failure of the surgery or the severity
of the case. Intermittent application of ice packs, 10 minutes on an 5 minutes off,
for the first 2 days almost minimizes swelling.
Ecchymosis
Ecchymosis is the discoloration of facial and oral soft tissues because of the
extravasation and subsequent breakdown of blood in the intestinal subcutaneous
tissues. This is basically an esthetic problem. It is more prevalent in elderly
patients with capillary fragility and patients with fair skin. Frequently, ecchymosis
occurs below the surgical site because of gravity. The ecchymosis for the
maxillary premolar surgical site is found in the neck area. The patient should be
assured that the ecchymosis has no bearing on the success or severity of the case.
Paresthesia
When Paresthesia occurs, it is when the mental nerve presents near the second
premolar and first molar. Transient paresthesia may occur even if the surgical site
is far from the nerve. Inflammatory swelling of the surgical site may cause
temporary impingement on the mandibular nerve causing transient paresthesia. If
the nerve has not been severed, normal sensation generally returns within a few
weeks. Rarely, it may take a few months to regain normal sensation. The patient
should be assured of the probable return of sensation in the affected side.
Paresthesia some times can be permanent.
Maxillary sinus perforation
Perforation of the schneiderian membrane covering the sinuses may occur. If
perforation of the sinus occurs, utmost care should be taken to prevent any
material from entering the sinus.
The patient should be instructed to elevate the head during the night. Prophylactic
antibiotic therapy with augmentin 500 mg every 6 hours along with Sudafed for 1
week should be prescribed. The patient should return for a postsurgical checkup
in 1 week.