Cirugía Endodontica

Review Article
Modern Endodontic Surgery Concepts and Practice:

A Review
Syngcuk Kim, DDS, PhD, MD(hon), and Samuel Kratchman, DMD
Abstract
Endodontic surgery has now evolved into endodontic
microsurgery. By using state-of-the-art equipment,
instruments and materials that match biological con-
T he classic view that endodontic surgery is a last resort is based on past experience
with accompanying unsuitable surgical instruments, inadequate vision, frequent
postoperative complications, and failures that often resulted in extraction of the tooth.
cepts with clinical practice, we believe that micro- As a result, the surgical approach to endodontic therapy, or surgical endodontics, was
surgical approaches produce predictable outcomes in taught with minimum enthusiasm at dental schools and was practiced by very few in
the healing of lesions of endodontic origin. In this private practices. Stated simply, endodontic surgery was not considered to be important
review we attempted to provide the most current within the endodontist’s domain.
concepts, techniques, instruments and materials with Fortunately, this changed when the microscope, microinstruments, ultrasonic
the aim of demonstrating how far we have come. Our tips, and more biologically acceptable root-end filling materials were introduced in the
ultimate goal is to assertively teach the future gen- last decade (Fig. 1). The concurrent development of better techniques has resulted in
eration of graduate students and also train our col- greater understanding of the apical anatomy, greater treatment success and a more
leagues to incorporate these techniques and con- favorable patient response. These developments marked the beginning of the endodon-
cepts into everyday practice. (J Endod 2006;32: tic microsurgery era that began in the 1990s. The purpose of this review is to illustrate
601– 623) the advancements in techniques and theories and, to provide a contemporary perspec-
tive of endodontic microsurgery today and how it can be used to improve patient care.
Key Words
Apical surgery, endodontic surgery, microsurgery, MTA,
The Differences between Traditional and Microsurgical
ultrasonic retropreparation
Techniques in Endodontic Surgery
Endodontic surgery is perceived as difficult because the surgeon must often ap-
proximate the location of anatomical structures such as large blood vessels, the mental
From the Department of Endodontics, School of Dental foramen, and the maxillary sinus. Although the chances of damage to these structures
Medicine, University of Pennsylvania, Philadelphia, Pennsylva- are minimal, traditional endodontic surgery does not have a positive image in the dental
nia. profession because of its invasive nature and questionable outcome (1, 2). If we accept
Address requests for reprint to Syngcuk Kim, DDS, PhD, the premise that the success of endodontic surgery depends on the removal of all
MD, Louis I. Grossman Professor and Chair, Director, Micro-
scope Training Center, Department of Endodontics, School of necrotic tissue and complete sealing of the entire root canal system, then the reasons for
Dental Medicine, University of Pennsylvania, Philadelphia, PA surgical failure by the traditional approach become clear. Examination of failed clinical
19008. E-mail address: [email protected]. cases and extracted teeth by surgical operating microscopes reveal that the surgeon
0099-2399/$0 - see front matter cannot predictably locate, clean, and fill all the complex apical ramifications with
Copyright © 2006 by the American Association of
Endodontists.
traditional surgical techniques. These limitations can only be overcome with the use of
doi:10.1016/j.joen.2005.12.010 the microscope with magnification and illumination and the specificity of microsurgical
instruments, especially ultrasonic instruments. Table 1 shows the primary differences
between the traditional and microscopic approach to endodontic surgery.
Endodontic microsurgery, as it is now called, combines the magnification and
illumination provided by the microscope with the proper use of new microinstruments
(1–5). Endodontic microsurgery can be performed with precision and predictability
and eliminates the assumptions inherent in traditional surgical approaches.
The advantages of microsurgery include easier identification of root apices,
smaller osteotomies and shallower resection angles that conserve cortical bone and
root length. In addition, a resected root surface under high magnification and illumi-
nation readily reveals anatomical details such as isthmuses, canal fins, microfractures,
and lateral canals. Combined with the microscope, the ultrasonic instrument permits
conservative, coaxial root-end preparations and precise root-end fillings that satisfy the
requirements for mechanical and biological principles of endodontic surgery (1, 5).
Periapical Lesions: Can Complete Healing Occur with Nonsurgical

Endodontic Procedures Alone?
The success of endodontic therapy ranges from 53 to 98% when performed the
first time (6 – 8), while that for retreatment cases with periapical lesion is lower (9, 10).
The histological status of a periapical lesion shown as a radiolucent lesion on a radio-
JOE — Volume 32, Number 7, July 2006 Modern Endodontic Surgery Concepts and Practice 601
Review Article
Figure 1. Pictoral representation of endodontic microsurgery. From top center clockwise: micromirrors, isthmus, ultrasonic KiS tip, KiS tip positioned for root-end
preparation, radiograph of resected apex, and MTA root-end filled apices.
graph, is unknown to the clinicians at the time of treatment (Fig. 2). The surgical endodontic therapy (11, 12, 15). Only a subsequent surgical
lesion can be a granuloma or a cyst. It is a well-accepted fact that a intervention will result in healing of such a lesion. Thus, from a purely
granuloma heals after endodontic therapy. However, there has been a pathological point of view, approximately 10% of all periapical lesions
long-standing debate among dentists as to whether periapical cysts heal require surgery in addition to endodontic treatment. In addition, failed
after endodontic therapy (11, 12). Endodontists are of the opinion that re-treatment cases because of apical transportation or procedural er-
cystic lesions heal after complete endodontic therapy. Oral surgeons rors, often the result of using NiTi rotary files, are in many cases, best
hold the opposing view, that such lesions do not heal and have to be treated by surgical endodontics, especially if they have post restorations
removed surgically. The truth may actually lie somewhere in between. (Fig. 3). Further, the complexity of the canal anatomy does not allow
Nair’s (13) meticulous serial sections of human periapical lesions 100% success in nonsurgical endodontic therapy, even if the cysts are
showed that overall 52% of the lesions (n ⫽ 256) were epithelialized, pocket cysts (Fig. 2). Considering these situations one may wonder why
but only 15% were actually periapical cysts (Fig. 2) (14, 15). Periapical so few surgeries were performed and why surgery was not taught more
cysts can be differentiated into true cysts, which have a completely assertively in the specialty training programs. Fortunately, with the ad-
enclosed lumina, and pocket cysts that are open to the root canal (13, vent of microsurgery, the approach to the management of periapical
15). It is the prevailing opinion that pocket cysts heal after endodontic lesions is changing. Teaching the use of the magnification is now an
therapy (13, 16, 17), but true periapical cysts may not heal after non- accreditation requirement of the ADA for endodontic specialty pro-
grams. As a result, more private specialty practices have incorporated
TABLE 1. Differences between traditional and microsurgical approaches
Traditional Microsurgery
1. Osteotomy size Approx. 8–10 mm 3–4 mm
2. Bevel angle degree 45–65 degrees 0–10 degrees
3. Inspection of resected none always
root surface
4. Isthmus identification impossible always
& treatment
5. Root-end preparation seldom inside always within
canal canal
6. Root-end preparation bur ultrasonic tips
instrument
7. Root-end filling amalgam MTA*
material
8. Sutures 4 ⫻ 0 silk 5 ⫻ 0, 6 ⫻ 0
monofilament
9. Suture removal 7 days post-op 2–3 days post-op
10. Healing Success (over 40–90% 85–96.8%
Figure 2. According to Nair (11, 12), 15% of all periapical radiolucencies are
1 yr)
some type of cyst. The radiograph shown does not correspond to the histological
*Other materials such as SuperEBA are also being used. For details see section on root-end filling. section, but illustrates the relationship in general.
602 Kim and Kratchman JOE — Volume 32, Number 7, July 2006
Review Article
4. At higher magnification the osteotomy can be made small (3-4
mm) and this results in faster healing and less postoperative
discomfort.
5. Surgical techniques can be evaluated, e.g. whether the granulo-
matous tissue was completely removed from the bone crypt.
6. Occupational and physical stress is reduced since using the mi-
croscope requires an erect posture. More importantly, the clini-
cal environment is less stressful when clinicians can clearly see
the operating field (Fig. 4).
7. The number of radiographs may be reduced or may be eliminated
because the surgeon can inspect the apex or apices directly and
precisely.
8. Video recordings or digital camera recordings of procedures can
be used effectively for education of patients and students.
9. Communication with the referring dentists is improved
significantly.
Given these clinical as well as occupational advantages, perform-
ing apical surgery without magnification is no longer adequate or de-
Figure 3. Clinical cases requiring surgical endodontics. The cause of failure in fensible. It is disadvantageous for the treating endodontist as well as for
A and C is apical transportation, which is not easy to correct nonsurgically. (B) the patient. Some may claim that using 3⫻ or 4⫻ loupes is sufficient,
Shows well executed endodontics, and another attempt of nonsurgical retreat- however, clinicians who use the microscope would argue that the
ment would most likely fail. (D) Shows a failed traditional technique surgery. loupes do not provide enough magnification to detect crucial details. It
is interesting that there is a substantial difference in surgery outcome
between studies using the microscope (3, 19) and those that do not (20,
microsurgery as a treatment option. When we examine our treatment 21). Although these are not randomized controlled studies directly
options, the surgical approach is the more conservative treatment than comparing these two approaches, we believe that surgical outcomes are
the nonsurgical treatment for certain cases. A common example is a improved when the clinician can examine the resected root surface
tooth with acceptable endodontics and a new post and crown restora- carefully, and that omission of this most critical step in microsurgery
tion, but a persistent or enlarging periapical lesion (Fig. 3B). Breaking has a direct effect on the outcome of the surgery. Some may argue that
or disassembling the crown, removing the post and retreating the canals using loupes is good enough. However, the fact is that inspecting the
would be more dramatic, more time consuming, more costly and less resected root surface with the highest magnification of the microscope
predictable than a root-end microsurgical retreatment. This surgical is not even good enough. To completely see all the critical anatomical
retreatment approach has been shown to have a higher success than details of the root surface it has to be stained with methylene blue. Using
nonsurgical retreatment provided that periodontal conditions are not loupes is the first step and a welcome change from unaided vision, but
compromised (3). effective magnification and illumination requires the operating micro-
scope.
The Operating Microscope: Why is It Essential for
Microsurgery?
Microsurgery is defined as a surgical procedure on exceptionally
small and complex structures with an operating microscope. The mi-
croscope 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 (1–5, 18). 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 end-
odontic microsurgery in the following ways:
1. The surgical field can be inspected at high magnification so that
small but important anatomical details, e.g. the extra apex or
lateral canals, can be identified and managed. Furthermore, the
integrity of the root can be examined with great precision for
fractures, perforations, or other signs of damage.
2. Removal of diseased tissues is precise and complete.
3. Distinction between the bone and root tip can easily be made at Figure 4. A modern clinical environment in which the microscope provides not
high magnification, especially with methylene blue staining. only a clinical but also an ergonomic advantage.
Review Article
TABLE 2. Magnifications for different surgery stages for lasting hemostasis (1, 23, 24). Because a higher concentration of
Magnification Procedures epinephrine is used, there is a concern as to its effects on the systemic
circulation (25).
Low Orientation, inspection of the surgical site,
(⫻4 to ⫻8) osteotomy, alignment of surgical tips,
Some claim that the amount of epinephrine in an infiltration or
root-end preparation, and suturing block injection in dental procedures produces little or no systemic
Midrange Most surgical procedures including effects (26, 27). Others believe that the amount of epinephrine given as
(⫻8 to ⫻14) hemostasis. Removal of granulation local anesthetic causes systemic effects (25, 28, 29). Virtually all of the
tissue, detection of root tips, adverse effects associated with epinephrine are dose dependent. The
apicoectomy, root-end preparation,
root-end filling New York Heart Association suggested a maximal dose of 0.2 mg of
High Inspection of resected root surface and epinephrine for cardiac patients when used in conjunction with pro-
(⫻14 to ⫻26) root-end filling, observation of fine caine. This maximal dose is still referred to and has been used unoffi-
anatomical details, documentation cially as a factor by various authors to drive the maximum dosage for
other agent (30). Currently recommended maximum dosage of epi-
nephrine 1:50,000 in local anesthetics 2% lidocaine for adults for good
Misconceptions About the Operating Microscope hemostasis is 5.5 cartridges to reach 0.2 mg (31)
The introduction of any new tool or equipment, if it is designed to Although the systemic effects, such as pulse rate and blood pres-
produce significant changes, has always led to misconceptions, misin- sure, are minimal in response to the amount of epinephrine used in
terpretations and resistance. In the 1950s, neurosurgery, ophthalmol- surgical procedures, the study clearly demonstrates that the plasma
ogy, and ENT were done with loupes or even with unaided sight. This is level of epinephrine is elevated when a high dose is used (25). When a
unthinkable today. Of course, apical surgery is not nearly as complex or healthy patient was injected with eight cartridges of 2% lidocaine with
critical as these fields, but the size of the operating field and the size of 144 mg epinephrine, changes in blood pressure, heart rate, and plasma
the anatomy is not very different. norepinephrine levels were all elevated (25). It appears that virtually all
In every arena, neurosurgery, ENT, and ophthalmology, the pro- of the adverse effects associated with epinephrine are dose dependent.
cess of acceptance was, at first, marked by resistance. Fortunately, we Furthermore, the results of our preliminary study showed that the
embraced the microscope rather quickly and with enthusiasm. Since amount and concentrations of epinephrine used in endodontic surgery
1998, all postgraduate endodontic programs must teach the use of does not usually elicit dramatic and persistent systemic cardiovascular
magnification in accordance with the American Dental Association Ac- responses. This assessment is supported by the recent study by Vy et al.
creditation Standard for endodontic graduate programs (22). (31) who showed that placement of 2.25% racemic epinephrine satu-
The frequently asked question, “How powerful is your micro- rated in CollaCote collagen effects little to no changes in blood pressure
scope?” really addresses the issue of usable power. Usable power is the and pulse rate of human volunteers indicating again that cardiovascular
maximum object magnification that can be used in a given clinical effects by this hemostatic agent is minimal. The cardiovascular effects
situation relative to depth and size of the field. For example, with in- are minimal and short-lived and are well tolerated by the majority of
creasing magnification the depth of field decreases and becomes nar- patients, except patients with severe cardiovascular disorders or who
rower. Experience suggests that magnification above 30⫻ is of little have had cardiovascular surgery. Thus, the use of 1:50,000 epinephrine
value in periapical surgery because the slightest movement by the pa- with 2% lidocaine is recommended for local anesthesia in the majority
tient, sometimes even breathing, moves the field out of view and out of of cases. With severe cardiac patients, a consultation with his or her
focus. The surgeon then must repeatedly re-center and refocus the physician before the surgery is highly recommended and should be
microscope, wasting valuable time. Thus the belief, that “the greater the routine in the surgery protocol.
magnification the better” is a misconception. Table 2 shows suggested Because many anesthetics are vasodilators the use of anesthetics
magnifications for different surgery stages. without vasoconstrictors, such as plain mepivacaine (e.g. 3% Carbo-
As shown in Table 2, we do not believe that all surgical procedures caine), is not recommended as this will lead to excessive bleeding
have to be performed at high magnifications. For certain procedures, during surgery.
low magnification is better than high magnification, because the viewing
fields must be large enough, for instance, to properly align the ultra-
sonic tip. Mechanism of Vasoconstriction by Epinephrine
The microscope does not improve access to the surgical field. If Epinephrine binds ␣-1, ␣-2, ␤-1, and ␤-2 adrenergic receptors
access is limited for traditional surgery, it will also be limited when the located on the vascular smooth muscles. The ␣ -1 receptors are adja-
microscope is placed between the surgeon and the surgical field. How- cent to sympathetic nerves that innervate blood vessels. The ␣-2 recep-
ever, the microscope does create a much better view of the surgical field tors are distributed throughout the vascular system and are generally
by appropriate magnification and highly focused illumination. Because bound by circulating catecholamines. When epinephrine binds to the
vision is greatly enhanced, cases can be treated with a high degree of ␤-1 adrenergic receptors in the heart muscle, the heart rate, cardiac
confidence and accuracy. Those who use the microscope routinely contractility, and peripheral resistance increase. When the drug binds
wonder how they managed without it in the past. There is a maxim; to ␤-2 adrenergic receptors in the peripheral vasculatures, vasodilation
see better is to do better and we might add: to do it more easily. results. The ␤-2 receptors are prevalent in blood vessels that supply
skeletal muscles and certain viscera but are relatively rare in mucous
Hemostasis membranes, oral tissues, and skin. Ideally, for the purpose of endodon-
Local Anesthesia: The Epinephrine Misconception tic microsurgery, an adrenergic vasoconstrictor would be a pure ␣-ag-
The main purpose of anesthetics in clinical dentistry, in particular onist. Fortunately, the predominant receptors in the oral tissues are
endodontics, is for local anesthesia. In endodontic surgery, however, ␣-receptors, and the number of collocated ␤-2 receptors is very small
local anesthesia has two distinct purposes: anesthesia and hemostasis. (Fig. 5). Thus, the drug’s predominant effect in the oral mucosa, sub-
Thus, a high concentration of vasoconstrictor containing anesthetic, e.g. mucosa and periodontium is vasoconstriction. Because virtually all-
1:50,000 epinephrine, is preferred to obtain effective vasoconstriction adverse effects associated with epinephrine are dose and route depen-
Review Article
periapical surgery, the pulse rate of patients did not change with the
application of pressure to the bone cavity (36). Because epinephrine
used topically causes immediate local vasoconstriction, there is little
absorption into the systemic circulation and thus there are practically
no systemic effects.
Other hemostatic cotton pellets with epinephrine are Epidri (Pas-
cal Co.), that contain an average of 1.9 mg racemic epinephrine hydro-
chloride, and Radri (Pascal Co.) that has a combination of vasocon-
strictor and astringent. Each pellet of Radri contains an average of
0.45-mg racemic epinephrine hydrochloride and 1.85 mg of zinc phe-
nol sulfonate.
Before placing an epinephrine pellet all the granulomatous tissue
should be removed from the bone cavity. The first epinephrine pellet is
placed against the bone and is followed by packing the cavity with sterile
cotton pellets one at a time. Pressure is applied over these sterile pellets
using the back of a hand mirror or college pliers for about 2 to 4 min.
Figure 5. Schematic diagram illustrating the density of adrenergic receptors in
The sterile cotton pellets are then removed one at a time taking care not
blood vessels of the oral mucosa. (Reprinted with permission from color atlas
of Microsurgery in Endodontics, by S. Kim with G. Pecora and R. Rubinstein. to dislodge the epinephrine pellet. If bleeding still occurs, the proce-
W.B. Saunders Co., A Harcourt Health Sciences Company, 2001.) dure is repeated with a new epinephrine pellet until hemostasis is
achieved. The combination of both epinephrine and pressure has a
profound effect that usually results in immediate and profound vaso-
dent, clinicians should use the appropriate dose with an aspirating constriction. Epinephrine causes local vasoconstriction by acting on the
syringe. ␣-1 receptors present in the blood vessels wall, and the pressure aug-
ments this hemostatic potential. The epinephrine cotton pellet also pre-
Surgical Hemostats vents debris from getting lodged into the bone crypt during root-end
Topical hemostats or local hemostatic agents are useful adjuncts preparation and root-end filling. The pellet must be removed before the
for hemostasis. Once an incision has been made and the flap is re- final irrigation and closure of the surgical site.
flected, topical hemostats, in many situations, play an important role in
achieving hemostasis. They can be broadly classified by their mecha- Ferric Sulfate
nism of action (32): Another chemical agent used in hemostasis is ferric sulfate: Stasis
There are numerous agents on the market. Only some of the pop- (Cut-Trol, Mobile, AL), Viscostat, and Astringedent (Ultradent Products,
ular, effective and frequently used agents will be discussed (Table 3). Inc., UT). Ferric sulfate or ferric subsulfate is a hemostatic agent that
has a long history. It was first used in medicine in 1857 as Monsel’s
Bone Wax solution, which is 20% ferric sulfate. Even though the mechanism of
The use of bone wax (Ethicon, Somerville, NJ) as a local hemo- Monsel’s solution is still debated, agglutination of blood proteins results
static agent was first introduced by Horsley (33). In 1970, Selden (34) from the reaction of blood with both ferric and sulfate ions and with the
found bone wax to be an effective hemostat in periapical surgery. Bone acidic pH (0.21) of the solution (37). The agglutinated proteins form
wax contains a large percentage of highly purified beeswax and a soft- plugs that occlude the capillary orifices. Thus, in contrast to traditional
ening and conditioning agent (isopropyl palmitate). With bone wax, the hemostatic agents, ferric sulfate affects hemostasis through a chemical
hemostatic mechanism has essentially a tamponade effect. The wax, reaction with blood.
when placed under moderate pressure, plugs all vascular openings. The Ferric sulfate is easy to apply and there is no need to apply any
plug is formed partly of blood and partly of bone wax, which prevents pressure. A dark brown or greenish brown coagulum forms immedi-
further bleeding. The method of action is purely mechanical and does ately on contact with blood and the source of any persistent hemorrhage
not affect the blood clotting mechanism. can be located because of the color difference. Thus, any bleeding point
When using bone wax for hemostasis it should first be packed can be easily identified and hemostasis is achieved almost immediately.
firmly into the entire cavity, and then the excess should be carefully Although ferric sulfate is known to be cytotoxic and to cause tissue
removed to expose only the apex of the tooth. Following root-end filling, necrosis, systemic absorption of ferric sulfate is unlikely, because the
the wax should be removed. Studies have shown that bone wax causes a coagulum isolates it from the vascular supply. Care must be taken,
foreign body reaction if left in the surgical site. Ibarrola et al. (35) however, not to leave ferric sulfate solution in the bone because it has
showed that in rats the wax consistently produced inflammatory reac- significant adverse effects on osseous healing (38). Therefore, the sur-
tions. Bone wax residues have also been associated with sinus tracts that gical site must be thoroughly flushed with saline to remove the ferric
developed after surgery, suggesting that care must be exercised to en- sulfate completely so that there is no complication or delay in healing.
sure the complete removal of this material from the surgical site. There-
fore, bone wax is infrequently used in endodontic microsurgery. TABLE 3. Hemostatic agents by mechanism of action
Mechanical agents Bone wax
Epinephrine Cotton Pellet Chemical agents Vasoconstrictors (epinephrine)
This is a mechanical/chemical agent. Racellets (Pascal Co., Belle- Ferric sulfate
Biological agents Thrombin
vue, WA) are cotton pellets containing racemic epinephrine hydrochlo- Resorbable agents Calcium sulfate
ride. The amount of epinephrine in each pellet varies. For example, Gelfoam
each Racellet #3 pellet contains an average of 0.55-mg racemic epi- Absorbable collagen
nephrine. Each Racellet #2 pellet contains 1.15 mg of racemic epineph- Microfibrillar collagen
Surgicel
rine hydrochloride. It has been shown that when Racellet #2 was used in
Review Article
Thrombin
Topical thrombin USP (Thrombostat, Thrombogen) is a protein
substance that is produced in a conversion reaction from bovine pro-
thrombin. It is a potent dry powder that acts rapidly in an intrinsic
fashion to clot the blood fibrinogen directly. Thrombin USP is used
widely in the medical field to achieve localized hemostasis; however, its
use in endodontic surgery has not been investigated. The main disad-
vantage of topical thrombin is that it is difficult to handle and to deliver
to the bleeding site. It is also expensive.
Recommended Clinical Steps for Achieving Hemostasis

There are numerous ways to achieve hemostasis. With the abun-
dance of available hemostatic agents and with the introduction of new
products, the choice has to be based on objective evaluation. A good
agent achieves hemostasis within a short period of time, is biocompat-
ible, does not impair or retard healing, is reliable and works best for the Figure 6. Schematic diagram illustrating hemostatic techniques employed at the
particular surgical procedure and lastly, it is relatively inexpensive. With University of Pennsylvania. (Reprinted with permission from Color Atlas of
these purposes in mind, the following sequence is recommended to Microsurgery in Endodontics, by S. Kim with G. Pecora and R. Rubinstein. W.B.
Saunders Co., A Harcourt Health Sciences Company, 2001.)
achieve effective hemostasis during endodontic microsurgery.
Presurgical Soft-Tissue Management: New Concepts and Practice

Inject two carpules (maximum three carpules in special situa- The following management procedures have changed from the
tions) of 1:50,000 epinephrine containing local anesthetic, e.g. 2% traditional techniques. First, the semilunar incision, the most popular
Xylocaine, into multiple infiltration sites buccal/lingual and palatal flap design technique with anterior teeth, is no longer recommended
throughout the entire surgical field. Wait at least 15 to 20 min for the because of inadequate access and scar formation (39). Second, the
vasoactive agent in the anesthetic to constrict the blood vessels in the soft removal of sutures is done within 48 to 72 h, not a week (1, 5). Third,
tissues as well as in the hard tissues before making the first incision. new suture materials are monofilament, gauge 5 ⫻ 0 or 6 ⫻ 0 to
provide rapid healing (1, 5). Fourth, the papilla base incision (PBI) has
been developed to prevent loss of interdental papilla height with sulcu-
Surgical lar incisions (40). Fifth, flap retraction during the surgery is facilitated
by making a resting groove in the bone, especially during mandibular
A. Remove all granulomatous tissue, quickly and completely be- posterior surgery, to ensure retraction (1).
cause this tissue is highly vascularized and, therefore, bleeds Fundamentally, the flap designs are very similar to those of the
profusely. traditional techniques: the sulcular full-thickness flap, the muco-gingi-
B. Place an epinephrine pellet into the bone crypt followed by dry val flap and vertical releasing incisions (41, 42). The once popular
sterile cotton pellets until the crypt is filled. Apply pressure for 2 semilunar flap design and the Lüebke-Ochsenbein flap design are no
min. Remove all cotton pellets except for the first epinephrine longer recommended. In both the sulcular full-thickness flap and the
pellet. Continue with the surgical procedure and remove the epi- muco-gingival flap designs, the wider base of the flap to improve mi-
nephrine pellet before final irrigation and closure. crocirculatory perfusion was an unnecessary procedure, and it created
C. Small bleeders from the bone can be stilled by dabbing them with a lasting scar as a result of cutting the mucosal tissue across the fiber
a cotton pellet soaked with ferric sulfate solution. All of the ferric lines (1, 41). With the current method the base of the flap is as wide as
sulfate deposits must be carefully and thoroughly removed by the top, and the vertical incisions follow the vertical blood vessel align-
saline flush, as they are a major irritant to the tissues if left in-situ. ment. This facilitates nearly scar-free healing while still providing more
D. A large osteotomy site is filled with freshly mixed calcium sulfate than adequate access to the surgical site.
paste. After setting hardened calcium sulfate is carved out around In the sulcular full-thickness flap design, the main disadvantage is
the root. Although the paste is not designed for hemostasis per recession and shrinkage of the papilla (40, 43). Velvart (40, 44) pro-
SE, it is very effective agent for hemsostasis for a large bone crypt. posed the PBI for the marginal mucoperiosteal flap to prevent or min-
The calcium sulfate paste can then be left in the crypt because it imize loss of interdental papillary height. A recent article by Velvart and
is resorbable. Peters (2005) provides an excellent review on this subject (45).
Figure 6 summarizes these recommendations. It has been customary to remove 4 ⫻ 0 silk sutures after 1 wk. With
the microsurgery technique, monofilament sutures are removed within
48 to 72 h for best results (1, 5). This is enough time for reattachment
Postsurgical to take place and the suture removal is easy and painless (Fig. 7). After
Moist gauze compresses should be applied to the tissues before 72 h, the tissues tend to grow over the sutures, especially with mucosal
and after suturing to remove blood clots between the bone and soft tissues, and thus removal of sutures may be more uncomfortable.
tissues, to assure proper alignment of the flap and to reduce stress on Suture materials often used now are the thinner monofilament
the suture lines. polyamide with smaller needles. The 5 ⫻ 0 and 6 ⫻ 0 sutures are ideal
Effective and complete hemostasis is imperative in endodontic for microsurgery and polypropylene sutures (6/0 or 7/0) are also pop-
microsurgery for good visualization, a dry environment for placement of ular (44). The use of 4 ⫻ 0 silk sutures is no longer acceptable because
root-end filling materials, and a more efficient surgical procedure with the silk is braided and causes accumulation of plaque causing delayed
less blood loss. healing or secondary inflammation (1). The thinner and smaller mono-
Review Article
Figure 7. Micro-suturing with 5 ⫻ 0 and 6 ⫻ 0 monofilament sutures (top left); suture removal after 48 h (top right) and tissue healing 1 wk postoperatively.
filament sutures promote a cleaner surgical site and thus rapid healing. Osteotomy: Smaller is Better
With the incorporation of new materials, concepts, and technique mod- Does the size of the apical lesion make a difference? This is an
ification, healing after surgery leaves almost no scars. In this age, when argument that has been studied extensively, but is still an area of debate.
esthetics in dentistry is important, microsurgery also contributes to the Boyne et al. (46) in his study examined nine patients with 21 periapical
highest esthetic standards in this field. defects in the anterior region with at least one cortical plate remaining
intact. The sizes were divided into two groups of lesions ranging from 5
Atraumatic Tissue Retraction and the Groove to 8 mm and 9 to 12 mm. Biopsies were taken at 4, 5, and 8 months. It
Technique was found that 9 to 12-mm defects had herniation with fibrous tissue,
In the past, the importance of good and stable retraction was not while the smaller defects had complete bone regeneration. In 1970,
understood. Surgeons thought that retraction is the assistant’s job and Hjorting-Hansen (47) showed that cavity spaces up to 5 mm showed
paid little attention to the consequences and complications associated complete bone regeneration independent of anatomic site. Hjorting-
with poor retraction.
Hansen and Andreason (48) did a similar study on dogs. The results
One of the key factors in postoperative tissue swelling is because of
showed complete healing at 5 mm with one cortical plate intact.
frequent slippage of the retractor during surgery (1). This is also the
However, if both plates were removed, incomplete healing resulted.
main cause of transient parasthesia in the mandibular molar/premolar
The larger size lesions showed healing, but with fibrous tissue. The
region (1). To address this problem, retractors of several shapes and
sizes were developed to permit stable and nontraumatic retraction. authors concluded that the size of the lesion matters as well as the
These retractors have wider (15 mm) and thinner (0.5 mm) serrated removal of one, or both cortical plates. These studies suggest that
working ends compared to the standard retractors (1). Some are con- the larger the defect, the smaller the chance that complete healing
cave while others are convex to accommodate the irregular contours of will take place.
the buccal plates. The serrated tips provide better anchorage on the A recent study on healing, as evidenced by radiographic changes,
bone and are designed to prevent slippage during retraction. showed that there is a direct relationship between the size of the osteot-
In addition to contour specific retractors, a new procedure has omy and the speed of healing: the smaller the osteotomy, the faster the
been developed to protect the mandibular nerve and prevent postoper- healing. For instance, a lesion smaller than 5 mm would take on average
ative problems, such as parasthesia, when operating in the molar/pre- 6.4 months, a 6 to 10 mm size lesion takes 7.25 months and larger than
molar region near the mental foramen. A 15-mm long horizontal groove 10 mm requires 11 months to heal (3). Thus, the osteotomy should be
is cut into the water-cooled bone with a Lindemann bur or a #4 round as small as possible but as large as necessary to accomplish the clinical
bur. This groove must be made beyond the apex to allow space for the objective. There is a tendency during surgery to enlarge the osteotomy
osteotomy and subsequent apicoectomy. The groove permits secure towards the coronal margin, away from the apex. This tendency results
anchoring of the serrated retractor tip and secure, steady retraction of in excessive removal of healthy bone around the neck of the crown
the flap. As shown in Fig. 8, a safe and efficient way to make a groove easily causing a perio-endo communication. When this happens, the
above the mental foramen is to first identify the foramen, then carefully long-term prognosis for the tooth is poor. With the microsurgical tech-
cover it with the retractor and then make the groove just above it. Once niques, the size of the osteotomy is significantly smaller, just 3 to 4 mm
the retractor is in position within the groove, there should be no move- in diameter. This is just larger than an ultrasonic tip of 3 mm in length,
ment or slippage. yet allows the tip to vibrate freely within the bone cavity (Fig. 9).
Review Article
Figure 8. The Groove Technique: a small narrow horizontal groove is made just above the mental foramen. A KP#1 retractor is firmly seated in the groove protecting
the nerve during the osteotomy.
Distinction Between Bone and Root Tip Under the soft, and bleeds when scrapped with a probe (1). This step is essential
Microscope for keeping the size of the osteotomy small. If the initial osteotomy is
A major purpose of using the microscope during the osteotomy is prepared without magnified examination, the chances are that the os-
to clearly distinguish the root tip from the surrounding bone. As men- teotomy will be too large and thus violating one of the main advantages
tioned earlier, this differentiation is one of the most important advan- of microsurgery. If the root tip can not be seen, careful drilling and
tages of using the microscope (see Microscope section). It would be microscopic examination along with applying methylene blue stain,
ideal to locate the root tip precisely all the time. However, if the apical preferentially staining the periodontal ligament, allows root tip identi-
lesion has not fenestrated or if the lesion extends lingually, then locating fication as well as a small osteotomy.
the apex can be a real challenge, even for the experienced surgeon.
Once the access cavity has been prepared, the osteotomy must be ex- The Bevel Angle: Is it Necessary?
amined carefully to ascertain whether the root tip can be seen. The root Elimination or minimization of the bevel angle is one of the most
has a darker, yellowish color and is hard, whereas the bone is white, important benefits of microsurgery. With the traditional rotary bur, the
steep bevel angle of 45 to 60 degrees was recommended (49 –52). The
purpose of this steep bevel was simply for access and visibility (Fig. 10)
(51). In fact, with the traditional techniques beveling to this degree was
inevitable, since the surgical instruments were large. The following is a
comparison of bevel angles created by the traditional rotary bur tech-
Figure 9. The ideal osteotomy measures ca. 4 mm in diameter allowing a 3 mm

ultrasonic tip to move freely within the bone crypt. This by the microsurgical
osteotomy is compared with a much larger traditional size osteotomy. (Re- Figure 10. A comparison of a large osteotomy and acute bevel angle made by the
printed with permission from Color Atlas of Microsurgery in Endodontics, by S. traditional bur method (left) with a smaller osteotomy without bevel angle,
Kim with G. Pecora and R. Rubinstein. W.B. Saunders Co., A Harcourt Health made by the microsurgical method (right). The image at right is 10⫻ larger
Sciences Company, 2001.) than the left image.
Review Article
TABLE 4. Comparison of bevel angles created by traditional and microsurgical
techniques
Microsurgical Technique Traditional Technique
● No bevel or less than 10 ● Acute Bevel (45–60
degrees degrees)
● Expose few dentinal tubules ● Exposure many tubules
● Small osteotomy ● Large osteotomy
● Minimal loss of buccal plate ● Greater loss of buccal plate
● No danger of perio ● Great danger of perio
communication communication
● Easy identification of apices ● Frequent missing of lingual
apex
● No lingual perforation ● Easy lingual perforation
nique and the perpendicular preparation (no bevel) done with the
microsurgical technique (Table 4).
There is no biological justification for a steep bevel angle. It was Figure 11. Frequency of apical ramifications and lateral canals. A 3-mm apical
strictly for the convenience of the surgeons for apex identification and resection was needed to eliminate the majority of apical ramifications and
lateral canals. (Reprinted with permission from Color Atlas of Microsurgery in
for the subsequent apical preparation (1, 2). In fact, beveling causes Endodontics, by S. Kim with G. Pecora and R. Rubinstein. W.B. Saunders Co., A
significant damage to the very tissue structures that the surgery is de- Harcourt Health Sciences Company, 2001.)
signed to save, i.e. buccal bone and root. By diagonal resection, the
result of steep beveling, the buccal bone is removed along with a large
area of the root causing, in effect, a large osteotomy. Furthermore, aided vision or even with loupes. Only the high magnification of a mi-
beveling frequently misses the lingually positioned apex, causes elon- croscope provides the light and the magnification to completely see the
gation of the canal and reduction of the root diameter, thereby weak- anatomical details of the resected root surface (1, 3–5, 42, 53). One of
ening it (1, 5, 53). the fundamental drawbacks of the traditional root-end resection tech-
nique without magnification and microinstruments is the inability to
Root-End Resection manage and to adequately inspect the anatomical details of the root
How Much Should be Resected? surface. In contrast, with the bright illumination and the range of mag-
There is no complete agreement as to how much of the root has to nification of the operating microscope from 4⫻ to 25⫻, the resected
be resected to satisfy biological principles. Gilheany et al. (54) suggests root surface can be examined in great detail. Yet, a complete and critical
that at least 2 mm be removed to minimize bacterial leakage from the inspection of the resected root surface requires staining of the surface
canals. Our anatomical study of the root apex shows that at least 3 mm with a contrasting medium, such as methylene blue, that stains the PDL
of the root-end must be removed to reduce 98% of the apical ramifica- and pulp tissues selectively (4, 5). With the aid of micromirrors placed
tions and 93% of the lateral canals (1). As these percentages are very at 45 degrees to the surface, the reflected view of the root surface shows
similar at 4 mm from the apex, we recommend root-end amputation of every anatomical detail of the canal system, which is critical for a suc-
3 mm, since this leaves on average of 7 to 9 mm of the root, providing cessful surgery. This is equally important for surgical retreatment cases,
sufficient strength and stability. A root-end amputation of less than 3 mm in which this step also identifies the causes of failure of the previous
does, most likely, not remove all of the lateral canals and apical rami- surgical procedure. It is the inspection of the resected root surface,
fications, therefore, posing a risk of reinfection and eventual failure which shows why and how the traditional apical surgical technique was
(Figs. 11 and 12). highly inadequate.
As pointed out earlier, the anatomical details of the resected root
Anatomy of the Root Outline After Root-End Resection surface are complex. All types of shapes and forms can be found in the
The anatomy of the root outline varies greatly. It’s shape can be
oval, ovoid, reniform and various other irregular forms (51, 55). The
oval or ovoid shapes are frequently found in single roots while the more
complex shapes, e.g. reniform is found in fused premolar or molar
roots. In surgery, it is essential that the entire root-end be resected. It is
a frequent occurrence in failed surgical cases, that only the buccal
aspect of the root was resected leaving the lingual apex in situ. The result
is a continuous infection from the lingual apex (4). This situation is
more frequent in premolars and molars with fused roots and can be
avoided by staining the resected root surface with methylene blue (de-
tails in following section).
Inspection and Management of the Resected Root Surface;

the Most Important Step in Microsurgery!
Once a root tip is resected perpendicular to the long axis of the
root, proper identification of anatomical details and their management
are some of the most important and unique steps in microsurgery and
are critical for the success of the treatment (1). Unfortunately, this Figure 12. A digital image of a 3 mm apical resection on a maxillary premolar.
surgical procedure cannot be done adequately and precisely with un- (Photo by Dr. F. Maggiore, Germany.)
Review Article
Figure 13. Inspection of this resected root surfaces shows several types of apical configurations, isthmi and anatomies.
canal system. When cutting the root perpendicular to its long axis, techniques used in these studies were of the traditional methods. Re-
round, oval, horseshoe shaped, S-shaped, two to five small round and gardless, it is clear from these studies that placing root-end fillings
oval shaped canals and isthmuses, and so forth, can be observed (Fig. results in greater healing success. However, there are also some studies
13). This important step in microsurgery is not considered at all in the that report opposite findings. Rapp (59) found no significant difference
traditional surgical technique. in healing between teeth that were root-end filled and those that were
not. Further, August (60) reported that fewer of the cases with root-end
Consequences of Apical Curettage Without Root-end filling healed than cases with root-end resection only. Careful examina-
Resection and Root-end Resection Without Root-End Filling tion of these studies (56 – 60) shows many problems associated with
A survey of the literature does not provide any conclusion as to their procedures and conclusions: Firstly, the sample size is small lead-
which is the best option as many of these studies include the old surgical ing to underpowered results. Secondly, the studies were done with the
techniques and some studies are inadequate in terms of duration and old, traditional methods using amalgam as the root-end filling material.
number of cases observed (56 – 60). However, the following observa- As discussed earlier, the old methods had inherent problems not only
tions can be made: Because the major cause of periapical lesions is a with the resection angle but also with the placement accuracy of the
leaky apical seal with attendant egress of microorganisms and their root-end fillings (see Resected Root Surface). Therefore, the conclu-
toxins, the removal of the diseased periapical tissues by periradicular sions of these studies are less relevant for modern surgical endodontics.
curettage eliminates only the effect of the leakage, not the cause. Thus, Because there is no conclusive study indicating the correct ap-
elimination of the periradicular lesion alone will likely result in the proach we have to decide on the basis of the canal anatomy at the
recurrence of the lesion. Initially, there may be a cessation of symptoms root-end section. As shown in Fig. 13, one of the key steps in microsur-
and a radiographical improvement, but this is only temporary. As the gery is inspection of the resected root surface. This step reveals all the
initial healing surge plateaus, the slower but persistent pathosis pre- details and complexity of the root canal anatomy. The important ques-
vails, and the case will eventually fail again. Up to this point, there is total tion is can apicoectomy alone prevent any further leakage from the
agreement among endodontists, because a leaky root filling or an un- canal provided that the canal is obturated before surgery.
treated accessory canal or isthmus causes problems. For a failed non- The Toronto Study states (21) that nonsurgical retreatment fol-
surgical case, nonsurgical retreatment should be attempted first, pro- lowed by root-end resection without root-end filling is an acceptable
vided that the benefits of this retreatment outweigh the surgical alternative treatment option on the basis of eight cases, in which seven
retreatment. Apical surgery entails not just the removal of the diseased cases were successful. This report is of some concern. Certainly, some
tissue or the root tip, but most importantly resealing of the root canal cases will heal, especially if the size of the root-end resection is large.
system. When surgical retreatment is required, two important questions The reason is that the anatomic complexity decreases significantly coro-
should be considered: is root-end resection alone enough in cases nal of the apical delta. Thus, well cleaned and filled canals with such
where the root canal filing seems to be adequate, or is it necessary to extensive resection could work. However, the price is a short and weak-
refill the root-end in every case? ened tooth and a comparatively large osteotomy. In addition, this ap-
Altonen and Mattila (56) reported that teeth with root-end fillings proach would not work in posterior teeth where the anatomy is much
had greater healing success than those that were not filled, provided that more complex. More importantly, because of the relative short roots in
nonsurgical fillings were done. Lustman (57) and Rahbaran (58) also posterior teeth, root-end resections of more than 3 mm might substan-
observed better success with either amalgam or SuperEBA root-end tially compromise the strength and stability of the tooth. It is our clinical
filling materials than in the nonfilled groups. The materials and surgical experience as well as that of many others, who have practiced micro-
Review Article
called an isthmus (Fig. 14). An isthmus is a part of the canal system
and not a separate entity. As such it must be cleaned, shaped and
filled as thoroughly as other canal spaces. Surprisingly, isthmuses
were not even mentioned in dental textbooks or journals until 1983,
when Cambruzzi and Marshall (66) published an article on isth-
muses in a Canadian dental journal. Until 1990, evidence of a treated
and root-end filled isthmus is virtually absent from the dental liter-
ature.
Types
There are many isthmus types (Fig. 15). According to Hsu and Kim
(60), there are five different types. Type I was defined as either two or
three canals with no noticeable communication. Type II was defined as
two canals that had a definite connection between the two main canals.
Type III differs from the latter only in that there are three canals instead
of two. Incomplete C-shapes with three canals were also included in this
Figure 14. An example of a canal isthmus in the mesial root of the mandibular category. When canals extend into the isthmus area, this was named type
1st molar (type V) is presented. An actual clinical example is reflected in the IV. Type V was recognized as a true connection or corridor throughout
micromirror. (Reprinted with permission from Color Atlas of Microsurgery in the section.
Endodontics, by S. Kim with G. Pecora and R. Rubinstein. W.B. Saunders Co., A
Harcourt Health Sciences Company, 2001.)
Incidence
The isthmus is most frequently observed between two root canals
surgery for many years, which cases that were retreated nonsurgically within one root. Thus, the majority of posterior teeth contain an isth-
with a subsequent root-end resection without root-end filling frequently mus. At the 3-mm level from the original apex, 90% of the mesiobuccal
failed. roots of maxillary first molars have an isthmus, 30% of the maxillary and
mandibular premolars, and over 80% of the mesial roots of the man-
The Isthmus dibular first molars have one (1, 55). This high incidence of isthmuses
An isthmus is defined as a narrow strip of land connecting two in premolars and molars is an important consideration when perform-
larger land masses or a narrow anatomic part or passage connecting ing apical surgery. This is one of the reasons why apicoectomy alone,
two larger structures or cavities (61). The isthmus has been called without root-end preparation and/or root-end filling, especially in mo-
a corridor (62), a lateral connection (63), and an anastomosis lar teeth, usually fails.
(64). Weller et al. (65) described the canal isthmus as a narrow,
ribbon-shaped communication between two root canals that con- Identification
tains pulp tissue. In many cases, a tooth with a fused root has a In posterior teeth, root apices are usually round, but after a 3-mm
web-like connection between two canals and this connection is resection, roots are peanut shell shaped and usually show evidence of
Figure 15. Inspection of resected root surfaces of extracted teeth reveals many different types and shapes of isthmi. (A) Shows an infrequently seen round apex. (B)
Shows a modified type l. (C) has several apices with a type l isthmus. (D) Is a type II isthmus, (E) is a type IV, and (F) a type V. The classification is based on Hsu and
Kim (55). The majority of molar isthmi are types IV and V.
Review Article
Figure 16. A great number of complete (type V) and incomplete (type IV) isthmi are located between 3 and 4 mm from the apices of the mesiobuccal roots of maxillary
first molars. (Reprinted with permission from Color Atlas of Microsurgery in Endodontics, by S. Kim with G. Pecora and R. Rubinstein. W.B. Saunders Co., A Harcourt
Health Sciences Company, 2001.)
an isthmus. Methylene blue staining is the most effective means to iden- Ultrasonic Root-end Preparation
tify anatomical details, such as isthmuses. The conventional root-end cavity preparation technique using ro-
tary burs in a micro-handpiece poses several problems for the surgeon
Management
(1, 4, 5, 53, 67, 68):
Weller et al. (65) distinguished two types of isthmuses: the com-
plete and incomplete isthmus (Fig. 16). The management of a complete
1. Access to the root-end is difficult, especially with limited working
isthmus is relatively easy with the use of appropriate ultrasonic instru-
ments. However, the incomplete isthmus requires a careful approach space
with thin ultrasonic tips troughing along the incomplete isthmus (67). It 2. There is a high risk of a perforation of the lingual root-end or
is essential that the entire canal system, canal(s), and isthmus, be pre- cavity preparation, when it does not follow the original canal path
pared to a depth of 3 mm. 3. There is insufficient depth and retention of the root-end filling
material
Clinical Significance 4. The root-end resection procedure exposes dentinal tubules
A survey of numerous failed cases done with traditional methods 5. Necrotic isthmus tissue cannot be removed
clearly shows that the main cause of failure in the mesial roots of molars These clinical dilemmas were never questioned in the past, rather
is mismanagement or failure to manage the isthmus (1, 2, 55). Fre- it was an accepted fact, because the standard tools at that time were too
quently, the root-end filling is placed only into one canal, while bacteria large for the surgical site and the true complexity of the root-end anat-
and toxins are still present in the isthmus as well as the second canal. omy was not known. Many articles and textbooks of that time contain
Thus, the reported high success rate with apicoectomy alone, as re- extensive descriptions how to retro-prepare with burs. Figure 18 shows
ported in the Toronto study (21) are likely to only occur in teeth without a generation change in root-end preparation tools from burs to micro-
isthmuses. This appears unusual because, as mentioned previously, 80
burs to ultrasonic tips.
to 90% of molar roots have isthmuses (1, 55, 65). Thus the suggestion
The aim of the root-end preparation is to remove the intracanal
that nonsurgical retreatment followed by an apicoectomy alone would
solve molar surgical problems is ill advised. It is essential to identify and filling material and irritants and to create a cavity that can be properly
manage the isthmus when treating multi-rooted posterior teeth. filled. The ideal root-end preparation can be defined as a class 1 cavity
To summarize, the ready identification of isthmuses under the at least 3 mm into root dentine, with walls parallel to and coincident with
microscope, efficient and precise ultrasonic instrumentation and fi- the anatomic outline of the root canal space (67).
nally, filling with the best biocompatible root-end filling material, is in Richman first introduced the use of ultrasonics in endodontics in
our opinion, the best and most successful microsurgical approach (3, 1957, using a modified ultrasonic periodontal chisel scaler for root
19). Presented in Fig. 17 is a typical case that failed because of not canal debridement and apicoectomy (69). Eventually Carr (4) intro-
treating the isthmus, and healed subsequent to surgical management. It duced retrotips designed specifically for root-end cavity preparation
is our observation that the main cause of failure in mesial roots of during endodontic surgery. Several authors later reported superior op-
mandibular molars done with the bur and amalgam is the inability to erator control, decreased risk of perforation by increased ability to stay
treat the isthmus, thus causing the root-end filling to float at the buccal centered in the canal when using the ultrasonic retrotips as compared to
aspect of the canal while the lingual leaks. the microhandpiece (70).
Review Article
Figure 17. Failed traditional surgical case (A). High magnification of root-end preparation with an isthmus (B). Obturation of root-end in C with SuperEBA shown at
16⫻ magnification. Note elongated root-end filling covering two apices and connecting the isthmus (C). Radiograph immediately after surgery (D) and 1 yr
postsurgery (E), showing complete healing. (Reprinted with permission from Color Atlas of Microsurgery in Endodontics, by S. Kim with G. Pecora and R. Rubinstein.
W.B. Saunders Co., A Harcourt Health Sciences Company, 2001.)
Wuchenich et al. (71) compared the root-end cavities prepared iment design, because the previous study used demineralized and de-
with conventional handpieces or ultrasonic tips in cadavers in a SEM hydrated the teeth, which may have predisposed towards crack
study. They found that ultrasonics tips also made cleaner and deeper formation.
root-end cavity preparations, aiding retention of the root-end filling Layton (73) used smooth stainless steel tips also on extracted teeth
material and disinfection by removing infected dentin. to evaluate if the cracks were created during the root resection proce-
Despite the advantages of using ultrasonics, Saunders et al. (72), dure or after the root-end preparation with ultrasonic tips. The results
while experimentally using the ENAC system (smooth stainless steel of his study concurred with Saunders that ultrasonic preparations do
tips) on extracted teeth reported crack formation in the walls of the lead to increased number of cracks in the walls of the preparations. He
cavity, which may increase the chance of apical leakage. However, Lay- observed more cracks on the resected surfaces after root-end cavity
ton et al. (73) suggested that the cracks might be a result of the exper- preparation than after root resection only.
Layton also observed a higher prevalence of microfractures when
he used the tips at higher power settings. Walpington et al. (74) have
suggested using low to moderate intensity for 2 min to minimizes the
risk of root dentine microfactures.
Because both the Saunders and Layton studies were performed on
extracted teeth (72, 73), in which microfractures could possibly be
attributed to tooth desiccation, brittleness, and absence of periradicular
tissues. Min et al. (75) suggested the use of cadavers for the results to be
more clinically relevant. A study by Gray et al. (76) on cadavers reported
that the ultrasonic tips did not cause a greater than average number of
cracks. The number of cracks observed in his study seemed insignifi-
cant. It was suggested that the periodontal ligament might dissipate
stresses and thereby prevent cracking. In another experiment on cadav-
ers (77) an impression of the resected root-end was made with polyvi-
nylsiloxane and was examined under SEM; also to find no significant
cracks. An in vivo study (78) on 25 patients undergoing endodontic
surgery using the polyvinylsiloxane impression technique found only
one root-end showing evidence of a crack.
Most ultrasonic instruments used in prior studies were smooth,
Figure 18. Traditional root-end preparation instruments with burs (top and
center) and modern ultrasonic instrument (bottom). (Reprinted with permis- stainless steel tips. Diamond coated ultrasonic surgical instruments
sion from Color Atlas of Microsurgery in Endodontics, by S. Kim with G. Pecora have been introduced in recent years in hopes of minimizing dentinal
and R. Rubinstein. W.B. Saunders Co., A Harcourt Health Sciences Company, fractures through their ability to abrade dentine more quickly, thus
2001.) minimizing the time that the instrument is in contact with the root-end
Review Article
shown that MTA has the capacity to induce bone, dentin and cementum
formation in vivo (92–94). In comparison to amalgam and SuperEBA as
root-end filling materials, MTA consistently resulted in regeneration of
periapical tissues including periodontal ligament and cementum (Figs.
21, 22, and 23). Although the precise mechanisms of MTAs mineralized
tissue-inducing activity remain unknown, it is likely that MTA will have a
wider clinical application beyond the dental pulp and root canal ther-
apy. Preliminary results of a study assessing inductive properties of MTA
on bone and dentin (95) show that the cell cultures using animal and
human osteoblasts and dentinoblasts grown on MTA grew faster and
better than cells without MTA (Figs. 24 and 25). Based on the findings
from this study, we suggest that MTA stimulates osteo- and odontogenic
cell proliferation via intra- and extracellular Ca2⫹ and Erk dependent
Figure 19. Microsurgical root-end preparation of a maxillary canine with a KiS
pathways and that MTA promotes cell survival via the PI3K/Akt signaling
#1 ultrasonic diamond coated tip (16⫻).
pathway.
It may be premature to state that MTA is the ideal root-end
(79). Various studies (80-82) comparing the diamond-coated tips with filling material, however, results of experiments performed using
stainless steel tips have concluded that neither tip produced a significant animal models and in vitro laboratory methods, along with the mod-
number of microcracks. However, the diamond coated tips cut much ern cellular and molecular methods, provide unequivocal evidence
faster, and left a more grooved or rough cavosurface. It is not consid- that MTA has greater healing induction potential and is more bio-
ered a clinical problem, instead it may be an advantage. compatible than any other root-end filling material available to date
The most recent developments are the Zirconium coated and dia- (89, 92, 94, 95). Some clinical experimental results also agree with
mond coated tips e.g. KiS tips (1) (Fig. 19). In regard to diamond the scientific results (91). However, the use of MTA alone does not
coated tips, diamonds adhere to the surface of the tips resulting in a guarantee clinical success. MTA cannot overcome deficiencies in
slightly larger diameter, whereas Zirconium nitride is processed into techniques that are inherent in the traditional apical preparation.
the metal making the tip narrower. A drawback of the Zirconium coated Clinical studies show that healing of cases sealed with MTA is much
tip versus the rough diamond coated tip is its ineffectiveness in removing better, but not significantly different then IRM, provided that mod-
gutta-percha. This is mainly because of the surface smoothness. Navarre ern microsurgical or, at least, ultrasonic preparation techniques
et al. (79) compared the KiS tips with the stainless steel tips and con- were employed (19). Good surgical techniques and protocol are as
cluded that KiS tips remove gutta-percha from axial walls and prepare important for better results as are the materials.
ideal root-end preps faster than the stainless CT-5 tips. In summary, Given the development of contemporary microsurgical techniques
ultrasonic tips have fundamentally changed apical surgery. The histo- and tissue inductive root-end filling materials, the continued use of
logical section in Fig. 20 provides a graphical demonstration of the traditional surgical techniques with amalgam fillings has been ques-
advantage of using an ultrasonic instrument over a bur. Ultrasonic in- tioned (19)
struments are still being improved upon, and new, different types of
coating would make a difference in cutting efficiency while minimizing
microfractures. The search for the most efficient ultrasonic instruments Root-End Filling Material: Gray MTA (gMTA) and White
will continue, and their application together with the microscope and MTA (wMTA)
microinstruments will make endodontic microsurgery even more effec- Most of the research findings (88 –95) on MTA have been based
tive. on the gMTA. Recently, gMTA has been replaced by wMTA (ProRoot by
Densply) for reasons that are not clear. There are only few studies so far
Root-End Filling Materials: Is MTA the Best Material? that have made a direct comparison between the two types of MTA in
An ultrasonically prepared 3 mm class I cavity preparation must be their constituents, biocompatibility, sealing ability, and regeneration of
filled with a material that guarantees a hermetic seal. the original tissues.
In this section, the authors will not elaborate on the many different
kinds of root-end filling materials since this matter has been addressed
many times in this journal in recent years. Especially, a review article by
Torabinejad and Pitt Ford (83) provides an excellent review. There are
several root-end filling materials now used in conjunction with apical
surgery. Amalgam has been and still is to some extent a widely used
material. However, in the past decade amalgam has slowly given way to
ZOE containing materials, such as IRM and SuperEBA as a favorite
root-end filling materials. Numerous studies show that these ZOE con-
taining materials are superior to amalgam in terms of sealabiliy and
biocompatibility (84 – 87). More recently, mineral trioxide aggregate
(MTA) has been suggested as having many of the properties of the ideal
root-end filling material.
Although the exact composition of MTA is proprietary, the main
ingredients are tricalcium silicate (Ca3Si), tricalcium aluminate Figure 20. Histological images of root-end preparations in dogteeth by a bur
(Ca3Al), and tricalcium oxide (Ca3O2). Because of its superior sealing (left) and ultrasonic tip (right). The bur preparation nearly resulted in a lingual
ability and biocompatibility over conventional filling materials, MTA is perforation, while the ultrasonic preparation preserved the integrity of the root
gaining popularity among endodontists (88 –91). In vivo studies have apex because of the co-axial preparation within the root canal.
Review Article
Figure 21. MTA root-end filled apex (mesial root) of a dog tooth showed complete healing at 5 months postoperative (left X-rays). The histological pictures show new
bone formation at the surgical site (center) and the absence of inflammatory cells (right), suggesting a complete resolution of the pathology. The distal apex, showing
incomplete healing, is filled with SuperEBA (left X-rays).
Analysis of the chemical constituents of both types of MTA has age test through the root filling with gMTA and wMTA showed that there
shown that they are almost identical in their composition except for was no statistically significant difference between them although the
the absence of iron compound in the wMTA (96, 97). gMTA fillings had leaked in fewer cases (102).
Biocompatibility of gMTA and wMTA was compared by evaluating The tissue response was compared by subcutaneous implantation
cell attachment and osteogenic behavior. Perez et al. (98) demon- of dentin tubes filled with gMTA (103) and wMTA (104) and subsequent
strated that there was no initial difference in the cell attachment, but the histological examination showed that there was no obvious observable
cells on wMTA did not survive as long as on the gMTA. On the contrary, difference between the two. They both showed similarities in the bridge
Camilleri et al. (99) directly compared the biocompatibility using a cell formation and tissue changes, indicating that the mechanisms of action
culture method and concluded that the samples of two commercial of the wMTA and gMTA are similar.
forms of MTA showed good biocompatibility. Studies on wMTA have Faraco et al. tested pulp capping with gMTA (105) and wMTA
concluded that WMTA is biocompatible and has the potential to induce (106) on dog dental pulps and showed that both resulted in a healing
osteogenic behavior, although in some cases no direct comparison was process with complete dentin bridge formation in all the samples. Pari-
made with gMTA, (100, 104 –106). rokh et al. (106) also showed that there is no difference between the
The sealing ability was compared using the bacterial leakage test two. They both formed hard tissue barriers and caused minimal or no
on perforation repair sites. Ferris et al. (101) tested the ability of both tissue inflammation.
types of MTA to seal off the perforation site and showed that there was no Although additional studies are needed to test wMTA, the pub-
significant difference between the two materials. Also a bacterial leak- lished findings so far indicate that wMTA is comparable to gMTA.
Figure 22. Histological sections of dog teeth root-end filled with MTA show remarkable bone regeneration (yellow frame). At large magnification (right) numerous
PDL-like projections are seen from the bone toward the MTA filling. From the MTA side, numerous PDL-like projections with fibroblasts forming a columnar pattern
are seen (left). The regenerated PDL has the same width of ca 0.38 mm, as a normal PDL.
Review Article
Figure 25. MDPC23 odontoblasts grown on MTA proliferated significantly

faster (about 60%) than those in the control. This test was done using the MTT
assay.
Figure 23. The same preparation as in Fig. 22 shows newly generated cemem-
tum-like projections covering the MTA. At large magnification (right) a growing
cementum-like entity, closely linked to the MTA, can be seen. With time the
cementum-like projection will close over the MTA, forming a biologically than it appears on the radiograph (108). A thorough knowledge of the
barrier. anatomy of the region, as well as taking angled radiographs are essen-
tial. It is also essential that the vertical releasing incision is long enough
to expose the mental foramen after a careful dissection. Once the fora-
Surgical Sequelae and Complications: The Mental
Foramen and Sinus men is identified, a retractor is placed to protect the foramen and under
the microscope, a horizontal groove is cut just above the foramen (Fig.
Many clinicians avoid doing surgery on posterior teeth because
of possible parasthesia in the mandibular arch and sinus infringe- 8). Although injuring the nerve is extremely rare, transient parasthesia
ment in the maxillary arch. These anatomical entities should not be may occur even if the surgical site is far from the nerve. Inflammatory
a deterrent for surgery as there are well-tested techniques to man- swelling of the manipulated tissues may cause impingement on the
age them. mandibular nerve, resulting in transient ipsilateral paresthesia. Normal
sensation generally returns within few weeks. Thus, performing surgery
Mental Foramen Management on mandibular posterior teeth should not be of great concern, provided
Generally, the mental foramen is located below and between the that proper preparations are made. At our institution, there has been no
apices of the second premolar and the mesiobuccal root of the first case of permanent parasthesia in more than 450 mandibular molar
molar. More precisely, its most common location is inferior to the cases since 1992, when microsurgery was first taught and performed by
crown of the second premolar (62.7%) (107), and it is always larger endodontic graduate students.
Figure 24. Scanning electron microscope images of gray MTA (A), MDPC23 mouse odontoblast cells (B), and cells grown on MTA (C). MDPC23 cells without MTA
appear normal, of a round shape and attached to the plate surface (B). MDPC23 cells grown on gray MTA have a flat appearance, showing robust growth, suggesting
that MTA may stimulate cell growth. Electron dispersion analysis was used to differentiate cells from MTA by comparing the Ca2⫹ content.
Review Article
TABLE 5. Radiographic checkup of resected teeth in the maxillary posterior taken, there are usually no problems with a sinus perforation. A com-
region (n ⫽ 146) 6 – 42 months postoperatively parison study done by Prof. G. Watzek and his colleagues at the Univer-
Maxillary Maxillary sity of Vienna, Austria showed that there is no difference in terms of
Healing complete healing (89.2% vs. 85.3%) of cases with sinus perforation and
Sinus Exposed Sinus Not Exposed
Complete 33 (89.2%) 93 (85.3%)
with an intact sinus (Table 5).
Incomplete 3 (8.1%) 8 (7.3%)
None 1 (2.7%) 8 (7.3%)
Total 37 (100%) 109 (100%) Classification of Endodontic Microsurgical Cases
Because the outcome of endodontic surgery depends on the pre-
existing condition of the tooth, it is important to know that the proba-
Sinus Management bility of success depends on the given situation. Therefore, we propose
The sinus can be easily perforated when dealing with maxillary the following classification (Figs. 26 and 27):
posterior teeth. Sometimes it can be avoided with the careful execution
Class A represents the absence of a periapical lesion, no mobility
of the surgery. Sometimes it cannot be avoided, when the root-ends
and normal pocket depth, but unresolved symptoms after non-
extend into the sinus. When the sinus is perforated, the most important
surgical approaches have been exhausted. Clinical symptoms are
step is to prevent any solid particles, such as cotton pellets, root-end
the only reason for the surgery.
filling materials, and so forth, from entering the sinus cavity. The sinus
is capable of flushing away large amount of fluid but not solid materials. Class B represents the presence of a small periapical lesion together
Thus, flushing of the sinus with saline poses no problem. If the size of the with clinical symptoms. The tooth has normal periodontal prob-
sinus perforation is very small, a cotton pellet tied securely to a suture ing depth and no mobility. The teeth in this class are ideal can-
can be used as a barrier (1). If the perforation is large, however, a thin didates for microsurgery.
iodine gauze strip can be inserted into the sinus, leaving the end outside Class C teeth have a large periapical lesion progressing coronally
for ready retrieval, before continuing the surgery. Once the surgery is but without periodontal pocket and mobility.
completed, the cotton pellet or the iodine strip must be removed com-
pletely. The postoperative preparations should include a prescription of Class D are clinically similar to those in class C, but have deep
an antibiotic, such as ciprofloxacin or amoxycillin for 1 wk, postoper- periodontal pockets.
ative instructions to sleep with the head slightly elevated, to avoid nose Class E teeth have a deep periapical lesion with an endodontic-
blowing and to expect possible nose bleeds. When these precautions are periodontal communication to the apex but no obvious fracture.
Figure 26. Classification of endodontic microsurgical cases.
Review Article
postoperative reactions. In either case, if a small dose of ibuprofen or
dexamethasone provides postoperative comfort, it would be beneficial
to incorporate their use into the surgical protocol.
Lasers
Various laser systems were tried in endodontic surgery with lim-
ited benefits (112, 113). The CO2 or Nd/Yag lasers are not suitable
because they do not cut bone and dentin effectively (112–114).
Er:Yag lasers have also been used for apical surgery (115–117).
The authors claim that the Er:YAG laser causes no vibration and dis-
comfort while cutting bone and dentin and less damage to soft tissues
and bone, as well as less contamination of surgical sites. Outcomes of a
critical prospective randomized clinical trial has not yet been reported.
Clinical impressions from those who used the Er:YAG laser system for
apical surgery are mixed: (a) The Er:YAG system can be used for os-
teotomies and root resections but the procedure requires more time
than a preparation with burs. (b) While the Er:YAG laser may promote
Figure 27. A long-term 8 yr follow-up of a #19 using microsurgical techniques faster healing and more comfortable postoperative results according to
and gray MTA as root-end filling material. Complete radiographical and clinical the manufacturer, the root-end preparation cannot be done with the
resolution of the pathology with total absence of symptoms.
laser and the procedure still requires microsurgical ultrasonic prepa-
ration and filling. There are no convincing clinical and/or animal study
Class F represents a tooth with an apical lesion and complete de- results demonstrating significant advantages of using the laser over the
nudement of the buccal plate but no mobility. microsurgical techniques. Under these circumstances, we should be
cautious about changing our current surgical approach. If we incorpo-
Classes A, B, and C represent no significant surgical treatment
rate this laser system into our surgical armamentarium, we must be sure
problems, and the conditions do not adversely affect treatment out-
that it has a significant and distinct advantage over the existing tech-
comes. For instance, in the study by Rubinstein and Kim (3), cases in
niques. As of now, there are no articles published in peer-reviewed
these categories had 96.8% healing success after 1 yr. However, classes
journals that demonstrate this advantage. Research using randomized
D, E, and F present serious difficulties. Although these cases are in the
clinical trial methods with the laser system is urgently needed to provide
endodontic domain, proper and successful treatment requires not only
information as to whether the currently available laser system, Biolase,
endodontic microsurgical techniques but also concurrent bone grafting
is of significant benefit in endodontic surgery.
and membrane barrier techniques. These are true challenges even for
the endodontic surgeon who has excellent microsurgical skills, because
the causes of the problem are of combined endodontic and nonend- Treatment Outcome of Endodontic Microsurgery
odontic origins. The predictable and successful management of these There is an abundance of success and failure studies and review
cases is the true challenge. articles in endodontic surgery (3, 19 –21, 82, 118 –125). Does the
microsurgical approach provide better treatment results than the tradi-
Postoperative Reactions: Pain and Swelling tional techniques? Although relatively few surgical outcome studies use
Pain and swelling are common postoperative reactions after sur- experimental designs with the higher levels of evidence-based research
gical endodontic treatment. It is a common impression with the tradi- [e.g. randomized clinical trial (RCT)], many of the published studies
tional techniques that apical surgery is invasive and causes moderate to are cohort studies or case series and, clearly, future studies should be
severe pain and swelling and requires analgesics 1 day after the surgery designed to satisfy the Cohort and RCT requirements. Until then, we have
for a significant number of patients. Further, 23% of these patients are to make our clinical decisions on the basis of current knowledge. It
absent from work because of swelling and pain (109, 110). would be ideal to conduct a RCT using a group of traditional cases and
At the University of Pennsylvania, we examined and monitored another group of microsurgical cases. However, as stated earlier, it
postoperative pain and swelling in more than 150 patients undergoing would be unethical to conduct such a study, knowing that the failure rate
microsurgical endodontics. The patients were preloaded with 800-mg of traditional periapical surgery is very high. This sentiment is also
ibuprofen and continued on this drug for 2 days four times per day. The echoed by Chong and Pitt Ford (19) who performed an important RCT
preliminary results of this study clearly demonstrate that pain and swell- study in microsurgery. As pointed out in their work, conducting a clin-
ing were minimal. Occasionally, patients report some swelling but only ically reliable prospective study is extremely difficult, because outcome
minor pain. Similar results were obtained by Tsesis et al. (111). The depends on participant cooperation, over which the investigators have
difference between the Tsesis and our study is that Tsesis used small limited control.
doses (8 mg) of a corticosteroid (Dexamethasone) preoperatively and Thus, in this section we will mostly discuss the success of micro-
two single does (4 mg) 1 and 2 days postoperatively. Pain and swelling surgical techniques and compare them with the traditional techniques
were evaluated using the Verbal Numerical Rating Scale (VNRS) ranging using available and relevant published articles. Success or healing of
from 1 (no pain) to 10 (intolerable pain). The degree of swelling was surgical cases must be differentiated by pre- and postmicrosurgery pe-
expressed as none, mild, moderate, and severe. Of the 82 patients, riods. Table 6 contains data of recent studies.
64.7% did not report any swelling 1-day postsurgery. Only one patient
reported maximum pain of VNRS 4 and close to 80% of the patients Traditional Methods
reported VNRS 1, indicating no pain. These results may be attributed to The clinical success of traditional surgery, based on the absence of
the use of ibuprofen or dexamethasone, however, it may also be the symptoms and on radiographical healing, ranged from 44 to 90% for a
microsurgical procedures that are largely responsible for the mild to no certain period of time (126 –130). Such disparity could be explained by
Review Article
TABLE 6. A Summary of Selected Microsurgical Studies
Inclusion/
Teeth Art/ Follow-up
Author/Year Sample Size Study Design Exclusion Magnification Retropreop Retrofill Material Success Rate
PM/M Period
Criteria
Wang et al. 155 teeth 42A/58P 4–8 yrs prospective No No Ultrasonic Amalgam, 74%
(2004) Composite
Super EBA,
IRM or MTA
Maddalone and 120 teeth 62/30/28 3 yrs prospective No Loupes Ultrasonic Super EBA 92.40%
Gagliani
(2003)
Chong et al. 108 teeth 1 vs 2 yrs prospective Yes Microscope Ultrasonic IRM vs. MTA 87% IRM
(2003) 92% MTA
Schwartz - Arad 122 teeth 11.2 retrospective No No Bur Amalgam & IRM 44.30%
et al. (2003) months
mean
Von Arx et al. 39 roots in 25M 1 yr prospective Yes No Ultrasonic SuperEBA 88%
(2003) 25
molars
Wessen and 1,007 teeth all molars 5 yrs prospective No No Bur Amalgam 57%
Gale (2003)
Rubenstein and 59 roots 19/17/23 5–7 yrs prospective Yes Microscope Ultrasonic SuperEBA 91.50%
Kim (2002)
Rahbraran et al. 176 teeth 129/33/14 4 yrs retrospective No No Ultrasonic SuperEBA & 37.4% Endo
(2001) & Bur Amalgam 19.4% Oral Surg
Rud et al (2001) 834 roots 520M 1 yr retrospective No Microscope N/A Dentine bonded 92%
in 520 resin
molars
Zuolo et al. 114 teeth 39/24/39 1–4 yrs prospective Yes No Ultrasonic IRM 91.20%
(2000)
Testori et al. 302 roots 65/126 4.6 yrs retrospective No No Ultrasonic SuperEBA vs 68% Bur
(1999) in 181 mean vs Bur Amalgam 85% ultrasonic
teeth
Rubenstein and 91 roots 30/30/31 1 yr prospective Yes Microscope Ultrasonic SuperEBA 96.80%
Kim (1999)
Halse et al 474 teeth 1 yrs retrospective No No Bur Amalgam 68.70%
(1991)
differences in the study designs, sample sizes, the recall period, and the Testori et al. (20) reported that of 68% of the teeth treated with the
lack of clear and consistent evaluation criteria for clinical and radio- traditional techniques healed in 4.5 yr versus 85% with the ultrasonic
graphic parameters of healing. Other factors that can affect the progno- technique. This was a retrospective study and there were no stated
sis in periradicular surgery include patient systemic conditions, inclusion or exclusion criteria. Both authors found a difference of 17%
amount, and location of bone loss, the quality of any previous root canal between the two techniques. It is noteworthy that ultrasonic instruments
treatment or retreatment, coronal restoration, occlusal microleakage, versus burs alone resulted in such a significant difference. How much of
surgical materials and techniques, and the surgeon’s skills (128 –130). this difference was a result of the material used is not clear, as roots in
Considering these factors, a survey of the literature reveals a distinct the ultrasonic group were root-end filled with SuperEBA, while amal-
pattern in the treatment outcome by different techniques and methods. gam was used in the other group. The results with eugenol-based ma-
A classic study by Frank et al. (130) reported that 42.3% cases, terials in the above two studies are comparable with results reported by
that had been documented successful initially, failed after 11 to 15 yr. Dorn and Gartner (132). Many authors (3, 20, 120, 132) since then
From this result the authors questioned the use of amalgam and tradi- have given varied results with eugenol-based materials like IRM and
tional surgical methods using a handpiece and burs. The effects of SuperEBA and the use of ultrasonic tips. It is apparent from these results
several prognostic factors in surgery outcomes were examined by eval- that ultrasonic root-end preparation provides a significantly higher
uating previous studies. Despite many unexplainable results, one cor- treatment success, perhaps in the range of 17 to 30%, than the tradi-
relation was obvious: teeth with radiolucencies failed in significantly tional bur techniques.
greater numbers (129). Molven et al. (128) found that the efficacy of
the apical seal was the most important factor for successful apicoec- Ultrasonic Without Microscope
tomy. This would explain the low success obtained with the traditional Outcome studies need to be cautiously compared as there are too
surgical methods as described in this review. many variables in treatment protocol and methodology (3). To be
meaningful, any success/failure study has to be well controlled and
Comparison of Ultrasonic versus Traditional Method specific as to what it intends to study. A prospective approach is essential
Bader and Lejeune (131), Rahbaran et al. (126), and Testori et al. for a better understanding of the prognosis of surgical endodontics. This
(20) compared the healing of these two different periapical techniques will help in well-defined case selection and in the application of repro-
retrospectively, the traditional technique with rotary instruments, and ducible, evidence-based, contemporary surgical techniques, and oper-
the modern technique using ultrasonic tips. The Bade and Lejeune’s ator’s skills (82). There are four prospective studies recently published.
study (131) was a prospective RCT study: 80 teeth were assigned to four This, by no means, is meant as a comparison but as an acknowledgment
groups with two groups treated with traditional techniques and the other of a common theme found among them (3, 82, 118, 120). Von Arx et al.
two groups with ultrasonic root-end preparation. IRM was the sole (120) reported 88% success after 1-yr follow-up of 24 molars with 39
root-end filling material. The ultrasonic technique healing success of roots using ultrasonics and SuperEBA. He regularly found isthmuses in
95% was compared with 65% success with the traditional techniques. molars and managed them despite not using the microscope. His case
Review Article
Figure 28. An example of unusual apical anatomy of a #19. The tooth was retreated twice with persistent clinical and radiographical problems. Inspection of the
resected root surfaces at high magnification revealed three separate canals in the mesial root and an isthmus in the distal root. The case was performed under strict
microsurgical protocol with MTA as the root-end filling material. (Courtesy Dr. G. Guess, La Jolla, CA.)
selection criterion was exclusion of advanced periodontitis. The details Ultrasonics and the Microscope: The Complete
of the inclusion criteria are lacking in this case, however, this is an Microsurgical Approach
otherwise well executed and documented prospective study. Another Figure 27 shows a radiograph displaying the long-term success of
worthy prospective study is by Zuolo et al. (82). They selected lesions of a typical molar case performed with a strict microsurgical protocol
strictly endodontic origin (pockets less than 7 mm) and excluded using MTA as the root-end filling material. To the untrained eye the
through and through lesions or cases in which they found no buccal filling looks continuous, just somewhat larger. In contrast, Fig. 28
cortical plate. Healing after a 1 to 4 yr follow-up was 91.2% of 102 cases shows the way the microsurgical technique allows the surgeon to iden-
included in the recall. The study did not include the use of a microscope, tify the unique canal anatomy and how it can be managed correctly.
but fiberoptic light was used to transilluminate the root. Out of the 102 In this category, there are two published prospective works. Ru-
case, 9 cases failed and out of these 9 cases 6 were molars, suggesting binstein and Kim (3) evaluated the microsurgical techniques using only
a higher incidence of molar failure (85%). This result is similar to one root-end filling material, SuperEBA. They had strict criteria, select-
Testori’s (20) who used microsurgical instruments but not a micro- ing cases with pure endodontic lesions only. Ninety-four teeth (32 an-
scope. The authors also did not mention finding isthmuses in molars, teriors, 31 premolars, and 32 molars) were subjected to strict micro-
suggesting that they may not have identified them during the surgery. surgical procedures under the microscope, as described in this review.
Maddalone and Gagliani 2003 (118) showed overall healing of 92.5% The purpose of this study was to evaluate microsurgical endodontic
for 120 teeth with 28 molars. They used 4⫻ loupes, ultrasonic tips and techniques. Briefly, all apices were resected 3 mm perpendicular to the
SuperEBA root-end fillings. They did not have strict inclusion criteria long axis of the root. No bevel was made and the size of the osteotomy
but stated that they did not include cases with compromised periodontal was usually 4 mm in diameter. The resected root surface was stained
status. They compared their results with the works of Friedman et al. with methylene blue and was reflected in a micromirror for examination
(133), and commented that the latter had fewer successful cases, pos- under the microscope at high magnification (16-24⫻). The apical ca-
sibly because they did not use ultrasonics. Maddalone and Gagliani nals were prepared 3 mm deep with ultrasonic tips and were subse-
(118) made no mention of isthmuses in their molar cases. Recently, quently sealed with SuperEBA. Recall radiographs were taken at
Wang et al. (21) reported 74% healed cases of the 94 examined 3-months intervals for 1 yr. The resolution of periapical radiolucencies
teeth that were treated with ultrasonic tips and various root-end along with the reestablishment of the lamina dura as well as the absence
filling materials (amalgam with varnish, SuperEBA, composite of symptoms were considered for healing. After 1 yr, 96.8% of the cases
resin, and MTA). This seemingly low healing, compared to the other reported had healed (3), and recalls of the same cases after 5 to 7 yr
studies, may be a result of the use of amalgam and beveling., There showed a sustained healing of 91% (122).
was no mention of isthmuses in molar teeth, although 58 posterior In 2003, Chong and Pitt Ford (19) compared IRM versus MTA with
teeth having been examined. This suggests that the resected root the same technique for both groups. This RCT was designed to assess
surfaces were not inspected for isthmuses. These prospective stud- and compare the success of two popular root-end filling materials, MTA
ies support the premise that the treatment outcome can be signifi- and IRM. Because the same microsurgical techniques were used, this
cantly improved with the use of ultrasonic tips and biologically was an ideal way to evaluate the techniques as well as the materials. Both
acceptable root-end filling materials, even when not all of the mi- materials promoted high levels of healing in 24 months: 92% with MTA
crosurgical techniques are used. and 87% with IRM. The authors had strict inclusion and exclusion
Review Article
criteria: no pockets more than 4 mm deep and no mobility. Results of 11. Nair PN. New perspectives on radicular cysts: do they heal? Int Endod J
the studies by two different groups clearly demonstrate that the com- 1998;31:155– 60.
12. Nair PN. Non-microbial etiology: foreign body reaction maintaining post-treatment
plete microsurgical technique using the appropriate root-end filling apical periodontitis. Endod Topics 2003;6:114 –34.
materials provides a higher degree of success than any other techniques 13. Nair PN, Pajarola G, Schroeder HE. Types and incidence of human periapical
used in the past. lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1996;81:93–102.
14. Nair PN. New perspectives on radicular cysts: do they heal? Int Endod J
Summary 1998;31:155– 60.
Endodontic surgery has now evolved into endodontic microsur- 15. Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic failures.
gery. By using state-of-the-art equipment, instruments and materials Crit Rev Oral Biol Med 2004;15:348 –381.
that match biological concepts with clinical practice, we believe that 16. Nair PN, Sjogren U, Schumacher E, Sundqvist G. Radicular cyst affecting a root-filled
microsurgical approaches produce predictable outcomes in the healing human tooth: a long-term post-treatment follow-up. Int Endod J 1993;26:225–33.
17. Simon JH. Incidence of periapical cysts in relation to the root canal. J Endod
of lesions of endodontic origin. We must consistently learn and teach 1980;6:845– 8.
microsurgery to all endodontists so that they can treat nonsurgical as 18. Pecora G, Andreana S. Use of dental operating microscope in endodontic surgery.
well as surgical endodontic cases with equal ease and skill. With a high Oral Surg Oral Med Oral Pathol 1993;75:751– 8.
percentage of successful treatment outcomes of conventional endodon- 19. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of Mineral Trioxide
Aggregate and IRM when used as root-end filling materials in endodontic surgery.
tics together with high success of surgical endodontics almost all teeth Int Endod J 2003;36:520 – 6.
with endodontic lesions can be successfully treated. The challenge for 20. Testori T, Capelli M, Milani S, Weinstein RL. Success and failure in periradicular
the future will be the successful and predictable management of perio- surgery: a longitudinal retrospective analysis. Oral Surg Oral Med Oral Pathol Oral
endo lesions. Radiol Endod 1999;87:493– 8.
We must continuously run well controlled experiments, clinical as 21. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics: the
Toronto Study. Phases I and II: apical surgery. J Endod 2004;30:751– 61.
well as biological, on many new techniques and materials to meet the 22. Commission on Dental Accreditation of the American Dental Association. Standards
present and future challenges. On the basis of published research, we for Advanced Specialty Education Programs in Endodontics. 1998;(revised 2004).
believe that endodontic microsurgery with MTA is a predictable proce- 23. Buckley JA, Ciancio SG, McMullen JA. Efficacy of epinephrine concentration on local
dure to save teeth. We must assertively teach the future generation of anesthesia during periodontal surgery. J Periodontol 1984;55:653–7.
graduate students, and also train our collegues to incorporate these 24. Gutmann JL. Parameters of achieving quality anesthesia and hemostasis in surgical
endodontics. Anesth Pain Control Dent 1993;2:223– 6.
techniques into everyday clinical practice, similar to what periodontists 25. Troullos ES, Goldstein DS, Hargreaves KM, Dionne RA. Plasma epinephrine levels
did 15 yr ago with implants. and cardiovascular response to high administered doses of epinephrine contained
The preservation of our natural teeth must be our ultimate goal. in local anesthesia. Anesth Prog 1987;34:10 –3.
After all, when all is said and done, our natural teeth are always better 26. Holroyd SV, Watts DT, Welch JT. The use of epinephrine in local anesthetics for
than any man-made replacement. dental patients with cardiovascular disease: a review of the literature. J Oral Surg
Anesth Hosp Dent Serv 1960;18:492–503.
27. Malamed S. Handbook of local anesthesia, 1st ed. St. Louis: C.V. Mosby Co., 1980.
Acknowledgments 28. Dionne RA, Goldstein DS, Wirdzek PR. Effects of diazepam premedication and
We express our sincere thanks to Drs. G. Carr, G. Pecora, and R. epinephrine-containing local anesthetic on cardiovascular and plasma catechol-
amine responses to oral surgery. Anesth Analg 1984;63:640 – 6.
Rubinstein for pioneering and developing endodontic microsur- 29. Witherspoon DE, Gutmann JL. Hemostasis in periradicular surgery. Int Endod J
gery. Our special thanks to our graduate students, Drs. F. Setzer, M. 1996;29:135– 49.
Korli, J. Song, and I. Ping for helping us to complete this article. We 30. Jastak JT, Yagiela JA. Vasoconstrictors and local anesthesia: a review and rationale
would like to express our sincere gratitude to Dr. Mian Iqbal for for use. J Am Dent Assoc 1983;107:623–30.
revising the figures and Jutta Dörscher-Kim for editing. 31. Kim S, Rethnam S. Hemostasis in endodontic microsurgery. Dent Clin North Am
1997;41:499 –511.
32. Vy CH, Baumgartner JC, Marshall JG. Cardiovascular effects and efficacy of a hemo-
Supplementary data static agent in periradicular surgery. J Endod 2004;30:379 – 83.
Supplementary data associated with this article can be found, in 33. Horsley V. Antiseptic wax. BMJ 1892;1:1165.
the online version, at doi:10.1016/j.joen.2005.12.010. 34. Selden HS. Bone wax as an effective hemostat in periapical surgery. Oral Surg Oral
Med Oral Pathol 1970;29:262– 4.
35. Ibarrola JL, Bjorenson JE, Austin BP, Gerstein H. Osseous reactions to three hemo-
References static agents. J Endod 1985;11:75– 83.
1. Kim S, Pecora G, Rubinstein R. Comparison of traditional and microsurgery in 36. Besner E. Systemic effects of racemic epinephrine when applied to the bone cavity
endodontics. In: Kim S, Pecora G, Rubinstein R, eds. Color atlas of microsurgery in during periapical surgery. Va Dent J 1972;49:9 –12.
endodontics. Philadelphia: W.B. Saunders, 2001:5–11. 37. Evans BE. Local hemostatic agents. N Y J Dent 1977;47:109 –14.
2. Kim S. Principles of endodontic microsurgery. Dent Clin North Am 38. Lemon RR, Steele PJ, Jeansonne BG. Ferric sulfate hemostasis: effect on osseous
1997;41:481–97. wound healing: I. left in situ for maximum exposure. J Endod 1993;19:170 –3.
3. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery 39. Kramper BJ, Kaminski EJ, Osetek EM, Heuer MA. A comparative study of the wound
with the use of a surgical operation microscope and Super-EBA as root-end filling healing of three types of flap design used in periapical surgery. J Endod
material. J Endod 1999;25:43– 8. 1984;10:17–25.
4. Carr GB. Microscope in endodontics. J Calif Dent Assoc 1992;20:55– 61. 40. Velvart P. Papilla base incision: a new approach to recession-free healing of the
5. Carr GB. Surgical endodontics. In: Cohen S, Burns R, eds. Pathways of the pulp, 6th interdental papilla after endodontic surgery. Int Endod J 2002;35:453– 80.
ed. St Louis: Mosby, 1994:531. 41. Guttmann JL, Harrison JW. Surgical Endodontics. Boston: Blackwell Scientific Pub-
6. Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root-canal lications, 1991.
therapy (a review). Endod and Dent Traumatology 1994;10:105– 8. 42. Lubow RM, Wayman BE, Cooley RL. Endodontic falp design: analysis and recom-
7. Kerekes K. Tronstad L. Long-term results of endodontic treatment performed with mendations for current usage. Oral Surg 1984;58:207–12.
a standardized technique. J Endod 1979;5:83–90. 43. Zimmermann U, Ebner JP, Velvart P. Papilla healing following sulcular full thickness
8. Jokinen MA, Kotilainen R, Poikkeus P, et al. Clinical and radiographic study of flap in endodontic surgery. J Endod 2001;27:219.
pulpectomy and root canal therapy. Scand J Dent Res 1978;86:366 –73. 44. Velvart P, Ebner-Zimmermann U, Ebner JP. Comparison of long-term papilla heal-
9. Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjo B, Engstrom B. Retreatment ing following sulcular full thickness flap and papilla base flap in endodontic sur-
of endodontic fillings. Scand J Dent Res 1979;87:217–24. gery. Int Endod J 2004;37:687–93.
10. Gorni FG, Gagliani MM. The outcome of endodontic retreatment: a 2-yr follow-up. 45. Velvart P, Peters CI. Soft tissue management in endodontic surgery. J Endod
J Endod 2004;30:1– 4. 2005;31:4 –16.
Review Article
46. Boyne P, Lyon H, Miller C. The effects of osseous implant materials on regeneration 80. Peters CI, Peters OA, Barbakow F. An in vitro study comparing root-end cavities
of alveolar cortex. Oral Surg Oral Med Oral Pathol 1961;xx:369 –78. prepared by diamond coated and stainless steel ultrasonic retrotips. Int Endod J
47. Hjorting-Hansen E. Studies on implantation of anorganic bone in cystic jaw lesions. 2001;34:142– 8.
(Thesis) Munksgaard, Copenhagen, 1970. 81. Brent PD, Morgan LA, Marshall JG, Baumgartner JC. Evaluation of diamond-coated
48. Hjorting-Hansen E, Andreasen JO. Incomplete bone healing of experimental cavities ultrasonic instruments for the root-end preparation J Endod 1999;25:672–5.
in dog mandibles. Br J Oral Surg 1971;9:33– 40. 82. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical
49. Rud J, Andreasen JO. A study of failures after endodontic surgery by radiographic, prospective study. Int Endod J 2000;33:91– 8.
histologic and stereomicroscopic methods. Int J Oral Surg 1972;1:311–28. 83. Torabinejad M, Pitt Ford TR. Root end filling materials: a review. Endod Dent
50. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations Traumatol 1996;12:161–78.
and clinical techniques. Int Endod J 1985;18:8 –34. 84. Szeremeta-Brower TL, VanCura JE, Zaki AE. A comparison of the sealing properties
51. Gutmann JL, Pitt Ford TR. Management of the resected root end: a clinical review. of different retrograde techniques: an autoradiographic study. Oral Surg Oral Med
Int Endod J 1993;26:273– 83. oral Pathol 1985;59:82–7.
52. Gutmann JL, Harrison JW. Periradicular curettage, root-end resection, root-end 85. Bondra DL, Hartwell GR, MacPherson MG, Portell FR. Leakage in vitro with IRM,
filling. In: Guttmann JL, Harrison JW, eds. Surgical endodontics. Boston: Blackwell high copper amalgam, and EBA cement as retrofilling materials. J Endod
Scientific Publications, 1991:208 –213. 1989;15:157– 60.
53. Kim S. Endodontic microsurgery. In: Cohen S, Burns R, eds. Pathways of the pulp, 86. Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP. Effect of IRM root-end
8th ed. St Louis: Mosby, 2002:683–721. fillings on healing after replantation. J Endod 1994;20:381–5.
54. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage as- 87. Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP. Effect of Super EBA as a
sociated with root end resection and retrograde filling. J Endod 1994;20:22– 6. root-end filling on healing after replantation. J Endod 1995;21:13–5.
55. Hsu YY, Kim S. The resected root surface. The issue of canal isthmuses. Dent Clin 88. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end
North Am 1997;41:529 – 40. filling materials. J Endod 1995; 21:489 –92.
56. Altonen M, Mattila K. Follow-up study of apicoectomized molars. Int J Oral Surg 89. Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. Tissue reaction to implanted
1976;5:33– 40. super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a pre-
57. Lustmann J, Friedman S, Shaharabany V. Relation of pre- and intraoperative factors liminary report. J Endod 1995;21:569 –71.
to prognosis of posterior apical surgery. J Endod 1991;17:239 – 41. 90. Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral
58. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical out- trioxide aggregate as a root-end filling material. J Endod 1995;21:109 –12.
come of periapical surgery in endodontic and oral surgery units of a teaching dental 91. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J
hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Endod 1999;25:197–205.
2001;91:700 –9. 92. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP.
59. Rapp EL, Brown CE Jr, Newton CW. An analysis of success and failure of apicoec- Histologic assessment of mineral trioxide aggregate as a root-end filling in mon-
tomies. J Endod 1991;17:508 –12. keys. J Endod 1997;23:225– 8.
60. August DS. Long-term, postsurgical results on teeth with periapical radiolucencies. 93. Thomson TS, Berry JE, Somerman MJ, Kirkwood KL. Cementoblasts maintain ex-
J Endod 1996;22:380 –3. pression of osteocalcin in the presence of mineral trioxide aggregate. J Endod
61. Merriam Webster’s Collegiate Dictionary 10th ed. Springfield, Merriam Webster 2003;29:407–12.
1993. 94. Baek SH, Plenk H Jr, Kim S. Periapical tissue responses and cementum regeneration
62. Green D. Double canals in single roots. Oral Surg Oral Med Oral Pathol with amalgam, SuperEBA, and MTA as root-end filling materials. J Endod
1973;35:689 –96. 2005;31:444 –9.
63. Pineda F. Roentgenographic investigation of the mesiobuccal root of the maxillary 95. Shin S. In vitro studies addressing cellular mechanisms underlying the bone and
first molar. Oral Surg Oral Med Oral Pathol 1973;36:253– 60. dentin inductive property of mineral trioxide aggregate. Master thesis in oral biol-
64. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med ogy. (Thesis) University of Pennsylvania, 2004.
Oral Pathol 1984;58:589 –99. 96. Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford TR. The constitution
65. Weller RN, Niemczyk SP, Kim S. Incidence and position of the canal isthmus: part 1. of mineral trioxide aggregate. Dent Mater 2005;21:297–303.
Mesiobuccal root of the maxillary first molar. J Endod 1995;21:380 –3. 97. Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical differences between white and
66. Cambruzzi JV, Marshall FJ. Molar endodontic surgery. J Can Dent Assoc gray mineral trioxide aggregate. J Endod 2005;31:101–3.
1983;1:61– 6. 98. Pérez AL, Spears R, Gutmann JL, Opperman LA. Osteoblasts and MG-63 osteosar-
67. Carr GB. Ultrasonic root end preparation. Dent Clin North Am 1997;41:541– 4. coma cells behave differently when in contact with ProRoot MTA and White MTA. Int
68. Von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type Endod J 2003;36:564 –70.
of sonic and diamond-surfaced retrotip: a 1-year follow-up study. J Oral Maxillofac 99. Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibil-
Surg 1999;57:656 – 61. ity of two commercial forms of mineral trioxide aggregate. Int Endod J
69. Richman MJ. The use of ultrasonics in root canal therapy and resection. J Dent Med 2004;37:699 –704.
1957;12:12– 8. 100. Moghaddame-Jafari S, Mantellini MG, Botero TM, McDonald MJ, Nor JE. Effect of
70. Engel TK, Steiman HR. Preliminary investigation of ultrasonic root-end preparation. ProRoot MTA on pulp cell apoptosis and proliferation in vitro. J Endod
J Endod 1995;21:443– 8. 2005;31:387–91.
71. Wuchenich G, Meadows D, Torabinejad M. A comparison between two root end 101. Ferris D, Baumgartner JC. Perforation repair comparing two types of mineral tri-
preparation techniques in human cadavers. J Endod 1994;20:279 – 82. oxide aggregate. J Endod 2004;30:422– 4.
72. Saunders WP, Saunders M, Gutmann JL. Ultrasonic root end preparation: part 102. Al-Hezaimi K, Naghshbandi J, Oglesby S, Simon J, Rotstein I. Human saliva penetra-
2-microleakage of EBA root end fillings. Int Endod J 1994;27:325–9. tion of root canals obturated with two types of mineral trioxide aggregate cements.
73. Layton CA, Marshall G, Morgan L, Baumgartner C. Evaluation of cracks associated J Endod 2005;31:453– 6.
with ultrasonic root end preparations. J Endod 1996;22:157– 60. 103. Holland R, de Souza V, Nery MJ, et al. Reaction of rat connective tissue to implanted
74. Waplington M, Lumley PJ, Walmsley AD, Blunt L. Cutting ability of an ultrasonic dentin tube filled with mineral trioxide aggregate, Portland cement or calcium
retrograde cavity preparation instrument. Endod Dent Traumatol hydroxide. Braz Dent J 2001;12:3– 8.
1995;11:177– 80. 104. Holland R, de Souza V, Nery MJ, et al. Reaction of rat connective tissue to implanted
75. Min MM, Brown CE Jr, Legan JJ, Kafrawy AH. In vitro evaluation of effects of ultra- dentin tubes filled with a white mineral trioxide aggregate. Braz dent J
sonic root end preparation on resected root surfaces. J Endod 1997;23:624 – 8. 2002;13:23– 6.
76. Gray JG, Hatton J, Holtzmann DJ, Jenkins DB, Neilsen CJ. Quality of root end prep- 105. Faraco Junior IM, Holland R. Response of the pulp of dogs to capping with mineral
arations using ultrasonic and rotary instrumentations in cadavers. J Endod trioxide aggregate or calcium hydroxide cement. Dent Traumatol 2001;17:163– 6.
2000;26:281–3. 106. Faraco Junior IM, Holland R. Histomorphological response of dogs’ dental pulp
77. Calzonetti KJ, Iwanowski T, Komorowski R, Friedman S. Ultrasonic root-end cavity capped with white mineral trioxide aggregate. Braz Dent J 2004;15:104 – 8.
preparation assessed by an in situ impression technique. Oral Surg Oral Med Oral 107. Phillips JL, Weller RN, Kulild JC. The mental foramen: 1. Size, orientation, and
Pathol Oral Radiol Endod 1998;85:210 –5. positional relationship to the mandibular second premolar. J Endod
78. Morgan LA, Marshall JG. A scanning electron microscopic study of in vivo ultrasonic 1990;16:221–3.
root-end preparations. J Endod 1999;25:567–70. 108. Phillips JL, Weller RN, Kulild JC. The mental foramen: part 2. Radiographic position
79. Navarre SW, Steiman R. Root-end fracture during retropreparation: a comparison in relation to mandibular second premolar. J Endod 1992;18:271– 4.
between zirconium nitride-coated and stainless steel microsurgical ultrasonic in- 109. Meechan JG, Blair GS. The effect of two different local anaesthetic solutions on pain
struments. J Endod 2002;28:330 –2. experience following apicectomy. Br Dent J 1993;175:410 –3.
Review Article
110. Kvist T, Reit C. Postoperative discomfort associated with surgical and nonsurgical 122. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed 1 year after
endodontic retreatment. Endod Dent Traumatol 2000;16:71– 4. apical microsurgery. J Endod 2002;28:378 – 83.
111. Tsesis I, Fuss Z, Lin S, Tilinger G, Peled M. Analysis of postoperative symptoms 123. Rahbaran S, Gilthrope MS, Harrison SD, Gulabivala K. Comparison of clinical out-
following surgical endodontic treatment. Quintessence Int 2003;34:756 – 60. come of periapical surgery in endodontics and oral surgery units of a teaching
112. Wong WS, Rosenberg PA, Boylan RJ, Schulman A. A comparison of the apical seal dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol
achieved using retrograde amalgam fillings and the Nd:YAG laser. J Endod Endod 2001;91:700 –9.
1994;20:595–7. 124. Rud J, Rud V, Munksgaard EC. Periapical healing of mandibular molars after root-
113. Bader G, Lejeune S. Prospective study of two retrograde endodontic apical preparations end sealing with dentine bonded composites. Int Endod J 2001;34:285–92.
with and without the use of CO2 laser. Endod Dent Traumatol 1998;14:75– 8. 125. Halse A, Molven O, Grung B. Follow-up after periapical surgery: the value of the
114. Maillet WA, Torneck CD, Friedman S. Connective tissue response to root surfaces one-year control. Endod Dent Traumatol 1991;7:246 –50.
resected with Nd:YAG laser or burs. Oral Surg Oral Med Oral Pathol 126. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical out-
1996;82:681–90. come of periapical surgery in endodontic and oral surgery units of a teaching dental
115. Paghdiwala AF. Root resection of endodontically treated teeth by erbium: YAG laser hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2001;91:700 –9.
radiation. J Endod 1993;19:91– 4.
127. Danin J, Linder LE, Lundqvist G, Ohlsson L, Ramsköld L, Strömberg T. Outcomes of
116. Komori T, Tokoyama K, Takate T, Matsumoto K. Clinical application of the Erbium:
periradicular surgery in cases with apical pathosis and untreated canals. Oral Surg
YAG laser for apicoectomy. J Endod 1997;23:748 –50.
Oral Med Oral Pathol Oral Radiol Endod 1999;87:227–232.
117. Gouw-soares S, Tanji E, Haypek P, Cardoso W, Eduarso CP. The use of Er:YAG, 128. Molven O, Halse A, Grung B. Surgical management of endodontic failures. Indica-
Nd:YAG and Ga-Al-As lasers in periapical surgery: a 3-year clinical study. J Clin Laser tions and treatment results. Int J Dent 1991;41:33– 42.
Med Surg 2001;19:193– 8. 129. Harty FJ, Parkins BJ, Wengraf AM. The success rate of apicectomy. Br Dent J
118. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study. 1970;129:407–13.
Int Endod J 2003;36:193– 8. 130. Frank AL, Glick DH, Patterson SS, Weine FS. Long-term evaluation of surgically
119. Schwartz-Arad D, Yarom N, Lustig JP, Kaffe I. A retrospective radiographic study of placed amalgam fillings. J Endod 1992;18:391– 8.
root-end surgery with amalgam and intermediate restorative material. Oral Surg 131. Bader G, Lejeune S. Prospective study of two retrograde endodontic apical prepa-
Oral Med Oral Pathol Oral Radiol Endod 2003;96:472–7. rations with and without the use of CO2 laser. Endod Dent Traumatol
120. Von Arx T, Gerber C, Hardt N. Periradicular surgery of molars: a prospective clinical 1998;14:75– 8.
study with a 1-year follow up. Int Endod J 2001;34:520 –5. 132. Dorn SO, Gartner AH. Retrograde filling materials: a retrospective success-failure
121. Wesson CM, Gale TM. Molar apicoectomy with amalgam root-end filling: results study of amalgam, EBA, and IRM. J Endod 1990;16:391–3.
of a prospective study in two district general hospitals. Br Dent J 133. Friedman S, Lustmann J, Shaharabany V. Treatment results of apical surgery in
2003;195:707–14. premolar and molar teeth. J Endod 1991;7:30 –3.

Cirugía Endodontica

Uploaded by

Copyright:

Available Formats

Cirugía Endodontica

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cirugía Endodontica

Uploaded by

Copyright:

Available Formats

Review Article

Modern Endodontic Surgery Concepts and Practice:

Periapical Lesions: Can Complete Healing Occur with Nonsurgical

Recommended Clinical Steps for Achieving Hemostasis

Presurgical Soft-Tissue Management: New Concepts and Practice

Figure 9. The ideal osteotomy measures ca. 4 mm in diameter allowing a 3 mm

Inspection and Management of the Resected Root Surface;

Figure 25. MDPC23 odontoblasts grown on MTA proliferated significantly

Figure 26. Classification of endodontic microsurgical cases.

You might also like